Plane Answers: NTSB glosses over fatigue in the Colgan crash

by Kent Wien on

As a pilot, I feel the National Transportation Safety Board (NTSB) has failed me. They’re tasked to investigate accidents and report on them so the aviation community can hopefully avoid similar mistakes. They also submit recommendations to the FAA for changes they feel will make air travel safer.

But I have to question the impartiality of the NTSB after seeing the outcome of the Colgan 3407 investigation.

Yesterday the NTSB came out with a report on the Colgan 3407 accident in Buffalo, New York last year that puts the blame squarely on the captain.

CAPTAIN’S INAPPROPRIATE ACTIONS LED TO CRASH OF FLIGHT 3407 IN CLARENCE CENTER, NEW YORK, NTSB SAYS.

Clearly, the captain reacted to a reduction in airspeed in a way that is contrary to everything we’re taught as pilots. But what caused this?

The NTSB sought to find out just why this reasonably experienced captain would respond in such a manner. Training records were examined, toxicology reports were submitted and everything that was said by the crew during the flight was analyzed.

Glossed over in the report was the fact that both the captain and first officer had very little sleep over the previous 24 hours. The NTSB says the captain had ‘reduced sleep opportunities’ and attempted to rest in the company crew lounge. Apparently the attempts at sleeping there weren’t effective since the captain logged on to a company computer at 3:10 in the morning.

The first officer likely had a full day near her home in Seattle before commuting on an ‘all-nighter’ to her base in Newark. She also tried to get a nap in at the crew lounge in the morning as well.

But one of the investigators in the Colgan accident, Robert Sumwalt refuses to allow for the possibility that fatigue was even a contributing factor in the accident, saying “…just because the crew was fatigued, that doesn’t mean it was a factor in their performance.”

Incredible.
Numerous studies have concluded that significant sleep deprivation is equivalent to operating while under the influence of alcohol. The British Medical Journal concluded that “after 17–19 hours without sleep, performance on some tests was equivalent or worse than that at a BAC of 0.05%. Response speeds were up to 50% slower for some tests and accuracy measures were significantly poorer than at this level of alcohol. After longer periods without sleep, (up to 28 hours) performance reached levels equivalent to the maximum alcohol dose given to subjects (BAC of 0.10%).”

It’s illegal to drive a car in the U.S. with a blood alcohol content at or above 0.08 to 0.10%.

The role of fatigue was mentioned during an NTSB hearing on the Colgan accident. Board chairman Deborah Hersman argued that several issues, including the crew’s sleep deficits and the time of day the accident took place, were factors and said that fatigue was present and should be counted as a contributing factor to the crew’s performance.

But the view of board member and former USAirways pilot Robert Sumwalt prevailed. He concluded that fatigue wasn’t a factor in the accident. It didn’t stop them from detailing the role it played in Colgan 3407 (PDF LINK)

So if nicotine is found to cause some cancer, but its role in a person’s life expectancy cannot be determined, should we rule it out as a possible factor in a lung cancer death?

The British Medical Journal study concluded that fatigue does affect performance, finding that, “getting less than 6 hours a night can affect coordination, reaction time and judgment” and poses “a very serious risk” to drivers.

It was precisely this reaction time and judgment that are to blame in the Colgan accident. I’m sure if you had asked Captain Renslow about the proper response in a stall, he would have been able to recite the steps verbatim. But that night, he was operating in a fog caused by a lack of quality sleep for the past 36 hours.

And the copilot, Rebecca Shaw, after commuting across the country all night before starting her day, misinterpreted the stall for possible icing conditions that she thought was affecting the tail and so she retracted the flaps during the recovery, exacerbating an already difficult recovery.

Most pilots expected sleep deprivation to play the leading role in the Colgan 3407 accident. The industry has averaged nearly an accident a year for the past twenty years with fatigue listed as a contributing factor. Could this have been the first case where a lack of sleep was actually considered the cause of a crash?

If a lack of sleep can affect affect coordination, reaction time and judgment, how conclusive does fatigue have to be, to be considered a cause in an accident that lists improper reactions and judgement as the main factors?

This time the NTSB isn’t even attaching fatigue as a ‘contributing factor’ in the Colgan accident, even though they went on to say in the report:

All pilots, including those who commute to their home base of operations, have a personal responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight.

There is no doubt in my mind that, if a BAC of, say, .08% were discovered in the pilots’ blood that the NTSB would list this as the cause of the accident and close the case.

I’ve always been a proponent of the NTSB. They look at human factor trends and educate us on ways to avoid them. As a fresh 20 year-old pilot, I even defended the local NTSB office in a KOMO4 TV news report when their numbers were reduced.

The NTSB has done as much as the FAA to ensure safe flying for the masses. I don’t understand why they’ve been reluctant to properly address the role of fatigue in a number of accident reports.

Perhaps it’s because airlines are terrified at the thought of reducing the 16-hour duty day further, which could lead to the recall of a few pilots at each company. Airlines point to a policy that allows a pilot to call in ‘fatigued’ if they don’t feel rested. But we don’t allow pilots to self diagnose when they’re too drunk to fly-we simply have limits on how much time must pass before they can fly.

So the fatigue policy, while helpful, isn’t the only way to ensure pilots are well rested on their next flight. Furthermore, Colgan unilaterally put new restrictions on the use of fatigue calls by its pilots.

But the FAA was confident enough that fatigue was a causal factor in the Colgan Dash 8 accident to start acting before the final NTSB report has been issued. They are working on new limits that will reduce the duty day for pilots, which includes both flight time and the time sitting around in airports between flights.

To appease the industry, the FAA may have to agree to a slight increase in flight time limits-the number of hours a pilot is allowed to be in the air in a day-currently 8 hours for a two-pilot crew-to secure improvements to the current 16 hour duty day for pilots.

I applaud the FAA’s decision to take on this cause after their previous 1995 attempt failed. At least the FAA seems to recognize that, for most pilots, it’s not the number of hours flown in a day, but it’s the amount of time on duty, and during what time of day a pilot is on duty that affects our safety.

Because there’s no way we’ll solve the fatigue issue if we continue to deny it leads to accidents.

Do you have a question about something related to the pointy end of an airplane? Ask Kent and maybe he’ll use it for the next Plane Answer’s Plane Answers. Check out his other blog, Cockpit Chronicles and travel along with him at work. Twitter @veryjr

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Drunk pilot arrested in London

by Tom Johansmeyer on

After (another) pilot was found drunk in London this week, the issue of pilot inebriation has become a frequent discussion topic. Since 1997, 11 commercial pilots, on average, have tested positive for alcohol every year. According to FAA regulations, pilots can’t fly with a blood alcohol content of above 0.04 percent (it’s 0.02 percent in Great Britain). Last year, 13 pilots tested positive, making 2008 slightly above average.

The FAA conducts more than 10,000 random alcohol tests every year, says spokeswoman Laura Brown. This is approximately 10% of the total, as there are around 100,000 commercial pilots in the United States.

The latest culprit, Erwin Washington of United Airlines, was arrested at Heathrow Airport on Monday, when he was suspected of being drunk in the cockpit — members of his crew reported him to the authorities. Washington could lose his license as a result. Two other U.S. pilots have been arrested in England on charges involving alcohol in a little more than a year.

Though an intoxicated pilot is obviously a danger to the passengers, the National Transportation Safety Board says that no airline in the United States has crashed because the pilot was drunk.

[has video]

Irony: NWA pilots land late because of scheduling discussion

by Tom Johansmeyer on

The investigation into the overshooting Northwest Airlines flight continues. The National Transportation Safety Board has found that the pilots were distracted by conversations and the use of personal laptops when flying 150 miles past Minneapolis. One of the topics being bandied about was scheduling, though I suspect it didn’t involve the impact of a late arrival because of a missed airport.

According to the NTSB, “The pilots said there was a concentrated period of discussion where they did not monitor the airplane or calls from (air traffic controllers) even though both stated they heard conversation on the radio.” In the report generated by its investigation, the NTSB continued, “Both said they lost track of time.” Meanwhile air traffic controllers and airline dispatchers were trying to contact Flight 188 for more than an hour. Neither pilot realized something was amiss until they were asked about it by a flight attendant.

Delta was pretty quick to announce that the pilots were involved in activities not related to flying and that they could be fired for it. For now, the fliers are suspended pending the results of the government’s investigation (and one by the airline itself).

Plane Answers: “Chit-chat” did NOT doom Colgan flight 3407

by Kent Wien on

Welcome to Gadling’s feature, Plane Answers, where our resident airline pilot, Kent Wien, answers your questions about everything from takeoff to touchdown and beyond. Have a question of your own? Ask away!

Allow me to invoke some commentary in lieu of today’s usual Plane Answers post.

So much has been written about the Colgan Dash 8 accident in Buffalo, NY. As I’ve written before in a “Pilots are either Heroes or Villains” post, I am a reluctant commenter during accident investigations. But the NTSB has released a tremendous amount of information already and I feel the need to shed some light on what the Colgan pilots may have been dealing with before the tragic accident.

We’ve heard that the captain reacted incorrectly by pulling up instead of pushing forward, that he didn’t have much experience in the Dash 8 Q400, that he and the first officer were discussing non-essential topics during the sterile period and that the captain had flunked a number of checkrides while learning to fly. We also heard about their long commute before work and the lack of sleep each pilot had before the trip.

But how much did these facts play a part in the accident? We’ll never know exactly what each pilot was thinking, but when you combine the transcripts with the NTSB recreation, a picture emerges that’s a little more complicated than what’s being reported.

According to the transcripts, the flight from Newark was completely normal until the start of the approach. Checklists were accomplished, altimeters were set, approach briefings were done. There was a fair amount of conversation, but this was mainly while above 10,000 feet. There may have been discussions with their company about where the aircraft would park after landing, but it’s hard for me to determine if this was before or after they flew below 10,000 feet.

The press latched on to the ‘chit-chat’ these pilots were having before the accident. The cockpit voice recorder was installed years ago as a safety device, but it’s sadly being used to satisfy the morbid curiosity of the public. Do we really need to hear the conversations that took place on the ground in Newark before this flight?

Much of that talking while approaching Buffalo revolved around icing and their prior experience in ice. In the last four minutes before the captain asked for the gear to be put down, there was only a single, three-sentence statement made by the captain in response to the co-pilot’s concern with her lack of icing experience.

The Approach

After that, nothing was said for the next two minutes, until the chain of events that would cause this accident would begin.
“Gear down.” The captain called.

The co-pilot responded by lowering the gear and pushing two knobs called condition levers forward. Just two seconds later, the approach controller told her to contact the tower. The co-pilot immediately looked down to change to the tower frequency, while acknowledging the controller. After she had spun some dials to enter the tower frequency in the VHF control panel, she looked at the gear handle to call out that it had extended completely-that it was now down and locked.

Two seconds later, the captain called for the flaps to be lowered to 15 degrees. Before even having a chance to look up and check on the flight’s progress she needed to move the flap handle from 5 to 15 degrees.

In the 22 seconds that it took for the co-pilot to put the gear down, push the condition levers forward, change the frequency, verify the landing gear position and select flaps 15, the airplane had slowed from 180 knots to 133 knots and the stall warning system activated.

She was relying on the captain to fly the airplane or, in this case, monitor the autopilot, while she performed her non-flying pilot duties. Every pilot has been in this situation before, where rapid-fire actions can take the non-flying pilot’s attention away. But usually being out of the loop for twenty seconds isn’t enough to cause a problem. Up to this point, she had done everything right.

Now let’s think about what the captain may have been dealing with:

He was in level flight at 2,300 feet with the flaps set to five degrees. He may have been tired, and so he likely felt like letting the autopilot take care of intercepting the final approach course. The autopilot was holding the altitude and heading and since the Dash 8 Q400 doesn’t have any autothrottles, he was manually setting the power to the proper setting to maintain a speed of about 180 knots.

At one point, the speed picked up to 186 knots. He pulled the power back slightly to let it settle at 180 knots which took about 6 seconds.

A few seconds later he called for the gear to come down. The co-pilot brought the gear down and pushed the condition levers forward. The condition levers essentially control the pitch of the propellors. Pushing them forward drives the prop blades to a finer pitch, resulting in a higher prop RPM, but also more drag. These levers are procedurally moved forward so maximum thrust is available in the case of a missed approach. So putting the gear down and the condition levers are two actions that will result in a significant amount of drag.

But somehow, the captain was distracted. He had just pulled the power back prior to calling for the gear to come down. He didn’t touch the throttles for the next 27 seconds, which means there was no way he had glanced at his airspeed for that half-minute. He could have been checking to see if there was any more ice accumulating or glancing at his approach plate.

The point is, he had become distracted and the co-pilot was out of the loop while she accomplished her required duties. The motion of the gear coming down and the condition levers coming forward meant that there was little time to react with the throttles.

This wasn’t the first time a pilot failed to notice a loss of airspeed while on approach. In fact, less than two weeks later another accident occurred while flying an approach on autopilot. Turkish flight 1951 which crashed short of the runway in Amsterdam was equipped with an autothrottle system, but it had failed at 1950 feet, when it reduced the power to idle slowly without the crew noticing.

In an age when the flying public seeks comfort by thinking airplanes just land themselves, it appears that a reliance on automation may have led to two separate accidents in the month of February alone. Autopilot use is generally encouraged by many airlines as a way to reduce a pilot’s workload.

But I’m certain that if the autopilot had been off in either accident, the pilots would have found it difficult to maintain altitude as the airplane slowed, which would have made it immediately obvious that more power was needed.

In both of these cases the autopilot masked this, making it easier to become distracted.

The Stall

When the stick shaker activated on Colgan flight 3407, the autopilot turned off automatically. Somehow the captain let the nose of the airplane reach nearly 30 degrees, and even though he correctly responded with full power, it wasn’t going to prevent the continued loss of airspeed as long as he had the nose pointed up between 20 and 30 degrees.

The co-pilot had been thinking about ice for the last half of the trip because of the build-up she had seen earlier, and this might have been going through her mind as she heard the stick shaker activate at the exact moment she was moving the flap handle from 5 degrees to 15. She very well may have associated her flap selection with the stick shaker, and if a movement in the flight controls results in something going wrong, I could see most pilots tempted to move the flap handle back where it was before the problem began (in this case, back up).

This is exactly what she did, which made the recovery much more difficult for the captain, since an extra 20 or 25 knots would be needed to fly at the reduced flap settings. Bringing the flaps up is also a recovery technique in high-wing turboprops that encounter enough ice to stall the tail. So this may be further proof that she was convinced tail-icing was their problem.

The captain may have also thought tail icing was his problem and the reason the nose wanted to drop, completely misreading what the ‘stick pusher’ was trying to tell him. Reports have indicated that the captain had watched the NASA video on tailplane icing recoveries during training just a few months earlier. This is a video which will definitely leave a lasting impression on any pilot.

Considering the lack of sleep both pilots had, it’s easy to come up with a scenario where a misdiagnosis of the problem–deciding between a tailplane stall or traditional stall–led to the accident.

The Aftermath

Non-essential chatter wasn’t a factor in this accident since the pilots had been quiet for more than two minutes prior to the airplane slowing. The NTSB will likely look at the training these pilots had received and how fatigue may have played a role in the accident.

It’s been verified that a lack of sleep can be equivalent to drinking while on the job, so the NTSB will likely factor this into their final report. And perhaps some attention will be given to the audible alerts pilots receive with specific attention given to how accurately they’re interpreted and how long the reaction time is with various warnings.

The airplane manufacturers may determine that a warning prior to the stick shaker is warranted. A “caution, too slow!” warning may be all that’s needed.

But first, training and procedures need to be considered to avoid this scenario. A great deal of time is spent during recurrent training on FAA mandated scenarios and emergencies that become repetitive. A program that introduces an even wider range of failures and scenarios in the simulator might be a better way to prepare pilots.

The NTSB will also likely criticize the turnover that has resulted from commuter airlines that see themselves as a stepping stone to the majors. An airline that decides $16,000 a year is an acceptable salary for a pilot might have to rethink their strategy as the flying public recognizes the need to continue to attract the best pilots possible.

This accident could become a catalyst for a number of changes that have been needed for a while. Proper crew rest, adequate training, and upgraded safety warnings could be around the corner. Let’s hope so.

Do you have a question about something related to the pointy end of an airplane? Ask Kent and maybe he’ll use it for next Monday’s Plane Answers. Check out his other blog, Cockpit Chronicles and travel along with him at work.

Helo pilot grounded because of in-flight porn star tryst

by Tom Johansmeyer on

Definition of good sex: you’re willing to come back for more
Definition of great sex: you’re willing to piss away your pilot’s license
Definition of unforgettable sex: “great” sex with a porn star

David Martz is stupid enough to make receiving oral sex unpleasant. How? He was videotaped(!) on the receiving end of a passenger’s lips while flying a helicopter around San Diego. If this is some flyboy version of “put out or get out,” it may have made more sense not to let the camera roll.

What the LA Times doesn’t tell you is that Martz is Motley Crue drummer Tommy Lee‘s helicopter pilot … and his passenger was none other than porn star Puma Swede (link to Wikipedia, safe for work).

The National Transportation Safety Board is out for satisfaction – much like Martz, ironically – and pushed to have his license revoked. Going down over San Diego (the helicopter, not the passenger) could have led to lost lives and plenty of property damage.

According to the NTSB, the blowjob itself wasn’t the problem. Pilot and passenger were busted because the video showed both unfastening their seatbelts … apparently much more dangerous than unfastening buttons. The giver’s body blocked the receiver’s access to the controls. Puma Swede, however, says that the whole incident didn’t take long (sorry, Martz). So, maybe the safety folks are being a bit tough on the fast-shooter.

The ruling handed down deprives Martz of his license for one year, though he can appeal the NTSB decision in federal court. Before the 2005 BJ, this pilot’s license was suspended twice and revoked once. But, he stayed out of trouble until being thanked for the spin four years ago.

Believe it or not, Martz almost got away with hit. He received the aerial bliss on May 29, 2005. This year, though, the video popped up on the internet, arousing suspicion and ultimately leading to action.

After the jump, check out a YouTube-friendly version of the video that grounded Martz, and an interview with the lovely Puma Suede.