Learning from others mistakes

May 12th, 2009 → 8:22 pm @ Geek Pilot

The NTSB is in rare form right now with Colgan 3407. In the past, these inquiries and meetings about crashes took at least a year to come together. Somehow they are having these meetings just 3 months after the crash. The media is making a big deal about the Captain having failed 5 checkrides. Most of the population has no idea what a checkride is and how easy it is to fail one for something VERY minor. A pilot trains for many hours and sometimes months for a single hour to day long event called a checkride. One small mistake (depending on the examiner) and it’s game over. My wife gets this. Most people do not. They think “5 failed checkrides?!?!!? OMG Why was he hired?”.

Learning from other people’s mistakes is something I not only encourage….but practice! I watch many TV shows on TV about air disasters (Seconds From Disaster and Air Emergency are my two favorites!). I also read a lot of books on airline history. Amazon.com has a huge selection of such books. I buy them used for under $10 a piece. I really liked Hard Landing.

I’ve spent the day reading documents from the NTSB about Colgan 3407. I have read the cockpit transcript, viewed the animation video and more.

The Cockpit Voice Recorder (CVR) is one device that is sometimes in the back of my mind. If I ever have a “bad day” at work and don’t come home….what will be my last words? What will investigators, fellow pilots…my wife….read on the transcript? Eh.

I am going to post two links. They both work! I say this because the NTSB site is being bombarded right now and I had to hit reload SEVERAL times in order for the pages to load.

To view an animation recreation of the accident go here:

http://www.ntsb.gov/events/2009/Buffalo-NY/AnimationDescription.htm

To read to CVR transcript go here:

http://www.ntsb.gov/dockets/aviation/dca09ma027/418693.pdf

Stefan

I read the transcript yesterday… I am not a pilot (trying to be though) but I do understand “checkrides” and agree that failing 5 is not that bad, depending on when they where or what the reasons were… I will only say that I hope that the flight crew, passengers, and the person on the ground are resting in peace… You will all be missed… As another pilot that blogs says, he will not judge or pick them apart, as you will soon make the same mistake or a worse one as they did!
http://pilotian.blogspot.com Ian

That animation just makes me want to crindge
Stefan

PS As you said, we learn from the mistakes and move on… I can’t believe I forgot that!
bobm

Very few people have in tested in a fashion where the outcome of their descision is one of life or death. Some have taken the right action and survived, some the wrong and died. Sadly, some have taken other lives as well as theirs. For some, their actions really don’t matter for they are so screwed, the outcome is nearly certain. Yet others recieve some sort of divine or ordained repreive that lets them survive despite themselves.

You will never know for sure how you will react when it really, really matters. You won’t know until you are in that position and suddenly you realize you are in a defining moment with your very existence, or the existence of others is on the line. At least the Colgan crew continued to fight until the end. Sadly their actions will be second guessed for a long time. Many of the accusers are speaking without the knowledge of how they will react in that critical situation.

The transcript was a chilling read, with a wierd crew dynamic and a tragic outcome. How the mud will fly.
Ajin

I was thinking could they have averted the stall after the stick pusher kicked in? or it was too late already (low altitude)? or atlest when the stick shaker kicked in?

meaning if they would have done:

1) They were at 2200ft when the stick pusher pushed the nose down, so
2 Engine full power
3) Gear up
4) Full flaps down (guess it will improve lift at low speed? maybe bad idea? increase drag too?)
5) Try to maintain the nose down angle (the normal degree) and not exceed into steep pitch down angle and try to regain speed for the current flap setting
6) Once they gained speed, level off… then try to slowly climb

Could these action have saved the flight or they were doomed because of their low altitude stall?

I feel the biggest mistake the pilot made was to fly in Autopilot into know icing conditions and also be distracted with non essential talks at low altitude (bad cockpit culture)…they were worried about ice build up.. they should have been more vigilant, maybe if flying pilot had his/her and on the yoke then he/she might have been able to react more quickely when the stick shaker kicked in???

Since i am not a pilot (wanting to be one soon) i have already started to learn to have proper attitude towards rules and proven safety regulations… i too love the program “Air Crash Investigation”

Its a really good program and i guess all pilots & wanna be should watch them and learn from the mistakes!

the most heartbreaking incident was the “Tenerife” airport disaster… such a experienced Capitan aware of the situation around having make such a bad decision.. even after being warned by the more alert co-pilot… atlest the world learned a big lesson here with such a high price… atlest they implemented “Crew Resource Management” to avoid such situation in future….
JeB

My heart goes out to all 50 people. May they rest in peace.

I somehow feel that the lack of regulation, Colgan’s poorer standards, the pilot’s low rest, reduced pay, lack of experience, bad weather, and poor economy all contributed to the incident.

Just saying all the fault belongs to the cockpit crew (some media) isn’t seeing the entire picture.

***********************

QUESTION: As a regional pilot, do you have to do recurrent training every 6 months or 1 year to keep you proficient on emergency procedures? If so, how often do you have to go to recurrent training? Also could you write about your experiences with that?

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