Aircraft Accidents and Lessons Unlearned XIII: Colgan Air 3407

We get caught up in emotional circumstances; feelings can confuse cognitive reasoning – we lose perspective.  We elect officials, vote for laws, protest/support, e.g. Immigration, Gun Control, Tax Reform and many more emotion-packed topics.  Sarcasm and insults are indicative of how we talk; we have mastered the art of the ‘verbal drive-by shooting’.  As the Road to Hell is being paved with good Intentions, Passion becomes the enemy of Safety.

Colgan Air (doing business as (dba) Continental Express), flight 3407, crashed near Buffalo, New York (NY), on February 12, 2009.  The Bombardier DHC-8-400 suffered an aerodynamic stall while on instrument approach into Buffalo Niagara International Airport, crashing into a house in Clarence, NY, increasing the death toll.  Accident investigations, e.g. Colgan 3407 and American flight 587, become highly charged, emotionally, when additional lives are lost on the ground; the media exploits the tragedy of added lives, weaving the facts into readily available 24/7 coverage.  This corrupts the environment surrounding the investigation, heightening the urgency for answers, which in turn, result in fixes that are short-term only.  For these reasons, the solutions must come from the head, not the heart.

Political representative Senator Chuck Schumer (NY) and safety advocate Chesley ‘Sully’ Sullenberger, stood with the Families of Continental Flight 3407 as they pushed for passage of the Airline Safety and Federal Aviation Administration Extension Act (ASFAAEA) of 2010.  The tragedy of this Act’s ratification was not limited to the accident that brought it to fruition.  It was what it did not do: fix major culture problems.  The ASFAAEA gave emotional responses to real problems, solving very little.

It must be understood, that the aviation industry is chock full of ‘experts’, including those who will tell you that they are experts if you didn’t know it already.  The Danish Physicist Niels Bohr stated, “An expert is a man [person] who has made all the mistakes which can be made in a very narrow field,” (Italics added).  By Mister Bohr’s standards, no one qualifies as an expert in aircraft accident investigation; it is an inexact science, at best.  That assessment is true because aviation is diverse.  Airlines differ from General Aviation; crop dusters are unlike air taxis, whose operations do not resemble medical helicopter operations.  Each of these separate aviation cultures cannot be captured by one mindset.  FedEx is as different from UPS as is United from American.

Investigators are passionate … about their jobs, but not the accident.  They cannot misuse their passions that cloud their search for answers.  Factual reports funnel Facts into Analysis, which leads to smart and effective recommendations and fixes.  Accident investigators must have a deep understanding of what the industry is about, how it works, how it does not work and how to fix it – to really fix it.

What is alarming from the Colgan 3407 Accident Report AAR 10/01 is what was missed.  FINDING number 11 states: The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.  It is understandable for this miss because ‘startle and confusion’ can only be credited to analysis – not fact.  However, these points cannot be ignored.  Analysis of a cockpit voice recorder, married to flight control movements found on the flight data recorder, is as close as investigators familiar with the aircraft, the pilots’ training and the flight conditions before the accident, can get to the facts.  The NTSB’s Human Performance specialists, who investigate human behavior, are incredibly talented; I’ve worked with them on several occasions; they know their stuff.  This statement describes the do-or-die moment, the pivotal juncture in Colgan 3407’s disaster; it is the point in time that the Captain’s training – or lack, thereof – failed to kick in; when he should have aborted the approach and gone around.  It is the moment when the pilots should have recognized their limitations.

However, this FINDING ends up being a throw-away; its impact is passed over in favor of ‘flight hour calculations’ and other events.  Total flight hour calculations are never a true indicator of experience and talent.  I doubt any commercial pilot would suggest that all flight crew members with more than, e.g. 1500 flight hours are indisputably competent; no airline crew member would make that fantastic suggestion.  Experience cannot be measured by yoke time.  My feeling is, it is better measured by competent training; in this case, training to understand one’s limitations.

The Captain of Colgan 3407 should have given himself both time and altitude, simply because he could.  His plane was not on fire, his fuel was adequate, the flight was not in immediate danger.  Instead he and the co-pilot allowed themselves to be dragged into confusion.  Is this the first-time Colgan flight crewmembers were paralyzed by astonishment?  It is not.  If only the NTSB recognized that this event had happened on another Colgan flight, a mere six years earlier.

In 2003, I investigated both Air Midwest 5481 and Colgan 9446, both, dba, US Air Express; I investigated several other regional airlines flying those colors since, as well.  I found multiple problems with the Express carriers that differed from the US Air mainline operator.  The Operations investigators’ findings in 2003 were that Colgan 9446 accident’s probable cause was similar to Colgan 3407’s in 2009: pilot fixation on a problem.  In Colgan 9446’s case it was a reverse elevator trim; their problem-solving was limited by paralyzing confusion and restricted by a low altitude.  It had nothing to do with the pilots’ accumulated flight hours, which were more than adequate.  9446’s flight crew didn’t fly out of the situation; instead they fought the aircraft all the way to the scene of the accident.  If the NTSB compared these two Colgan (Regional) accidents, they would have found more than coincidence.  Both Colgan flight crews, despite which Regional name they flew under, became fixated at low altitudes.

Another astonishing element about the Colgan 3407 accident report was what was not a Finding, namely: What effect does the mainline airline, e.g. Continental Airlines, have on its Regional support airline’s operations, e.g. Continental Express, aka Colgan?  Himself, a former mainline pilot for US Air, Captain Sullenberger would agree that there are vast cultural differences between mainline Operators and their Regionals in regards to: pilot training, flight schedules, hiring practices, employee turnover, training contractor utilization; all of which may have played an important part in, not only Colgan 3407, but also Colgan 9446 and Air Midwest 5481.

Accident report AAR 10/01 boasts twenty-seven Recommendations; perhaps two or three have any teeth or even sound like fixes.  NTSB Board Members shared their ‘expert’ opinions, views that amount to bureaucratic myopia.  Chuck Schumer’s heartfelt support for the ASFAAEA managed to boost his political standing.  Meanwhile emotions ran high; the aviation industry did not benefit in the short term; it gained less in the long term.

In fact, matters are worse.  The ASFAAEA was intended to right the interpreted wrongs that were cherry-picked from the Colgan 3407 accident report, AAR 10/01.  The motivations by the Families of Continental Flight 3407 and, I believe, public figures, like Captain Sullenberger, were in earnest.  They, driven by passion, worked hard to right a wrong; their integrity cannot be challenged.  The ASFAAEA was designed to prevent the hiring of unqualified flight crewmembers (pilots); blocking them from sitting at the controls minus the adequate experience.  But, can ‘adequate experience’ levels be accurately measured?  If so, how?  Is it better to focus on an ambiguous quantity (hours) as opposed to focusing on quality (all training)?

This is how the political game is played on both sides of the aisle: play for time; distract with sidebars; allow those, like the Families of Continental Flight 3407, to claim victory.  Then, after an adequate period of time, give them a chance to forget.  Cynical?  Absolutely, even bordering on conspiracy theory.

Enter – very quietly – Department of Transportation/FAA NOTICE N8900.463, which is now, as of April 24, 2018, National Policy.  The Subject of this NOTICE is: Use of a Complex Airplane During a Commercial Pilot or Flight Instructor Practical Test.  The purpose of this NOTICE is to supplement a commercial pilot’s training requirements using equipment that is not, technically, up to the previous standard.  Is this a break from the intention of the ASFAAEA?  In a time that training needs to be improved, is the FAA lowering the bar, instead of raising it?  Is this a policy letter that the Chuck Schumers and Chesley Sullenbergers should be aware of?

What path to safety are we taking?  We have allowed ourselves to be lulled into a false security, focusing on a narrative that’s based in complacency.  It has been reported that these have been aviation’s safest years, that Major accidents are a thing of the past; we have figured this safety-thing out, folks.  No need to worry.  Time to move onto the next best idea.  Hey, is that a squirrel?

The Lessons Unlearned this month are: pay attention to all the Findings in an accident report; learn all you can from history; pay better attention to the Culture and wait, no matter how long it takes, for the other shoe to drop.  The time is past when we should be reacting to problems; we must instead be proactive.  However, if all the industry can do is react, then safety cannot bog down in passion; it must be driven by facts.  Otherwise, aviators become drowning persons who can’t swim; we flail our arms and exhaust ourselves, before slowly slipping below the surface.  Then, all we manage to continue being … are victims.

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