Thoughts on Flight 3407, Revisited

It's been nearly a year since the Bombardier Q400 turboprop operated by Colgan Air as Continental Connection Flight 3407 crashed on approach to KBUF with the loss of 50 lives. I had some thoughts that I posted here in May of last year. Now, the NTSB has had a public meeting at which the Board approved a report that lays blame for the proximate causes of the accident at the feet of the crew, particularly the captain. The Board has published "a synopsis from [its] report [which] does not include the Board’s rationale for the conclusions, probable cause, and safety recommendations". The synopsis can be found at this link and makes for very interesting reading.

Back in May I observed that:

"It is looking ever more likely that Capt. Renslow and First Officer Shaw took actions that caused the airplane stop flying. The pressing question is, "Why?" Why did two experienced professional aviators take actions that were so completely wrong?"

The NTSB report synopsis concurs with respect to why the airplane stopped flying, stating in part:

• "The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall."
  
• "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."
  
• "The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation."
  
• "Although the reasons the first officer retracted the flaps and suggested raising the gear could not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training."

This is an inexplicable set of behaviors from professional aviators. But it seems to me that the vital question remains unanswered: WHY?

Let us stipulate that Capt. Renslow and First Officer Shaw were not a team of the quality of, say, Capt. Sullenberger and First Officer Skiles. Let us also stipulate that they had, by the time the critical moment arrived, introduced contributory factors to the developing Devil's brew: they were not well rested, they were lax in their duty to maintain a "sterile cockpit."

But these factors should not overcome the rule that is programmed into the mind of every pilot from his first hours in training: When the stall warning goes off (and make no mistake, the stick pusher is an emphatic stall warning) you PUSH!. If you PULL you will DIE!

In spite of this deep programming, this Captain PULLED. He pulled HARD, and 50 people died. Why did he do that? The NTSB's synopsis does not provide an answer.

Back in May, I wondered about this:

"...the possible impact on this accident of the well-known and widely viewed NASA Tailplane Stall video. ...The actions of pilots Beck and Renslow in the critical moments...are exactly the prescribed measures for reacting to a tailplane stall and exactly the wrong measures for reacting to an incipient stall of the main wing."

The NTSB first demurs, stating:

"It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery."

I very much look forward to learning the Board's rationale for that conclusion. Because they go on to say:

"The inclusion of the National Aeronautics and Space Administration icing video in Colgan Air’s winter operations training may lead pilots to assume that a tailplane stall might be possible in the Q400, resulting in negative training."

And they then promulgate the following Recommendation:

"Identify which airplanes ...are susceptible to tailplane stalls and then (1) require operators of those airplanes to provide an appropriate airplane-specific tailplane stall recovery procedure...and (2) direct operators of those airplanes that are not susceptible to tailplane stalls to ensure that training and company guidance for the airplanes explicitly state this lack of susceptibility and contain no references to tailplane stall recovery procedures."

If the first conclusion is supported by the facts, whence the second conclusion and the recommendation?

There are many more conclusions and recommendations in the synopsis of the Board's report. As I said, it makes for interesting reading. And there would appear to be lots more to come (from the NTSB press release on the 2 February public meeting):

"The Board will hold a public forum this Spring exploring pilot and air traffic control high standards. This accident was one in a series of incidents investigated by the Board in recent years - including a mid-air collision over the Hudson River that raised questions of air traffic control vigilance, and the Northwest Airlines incident last year where the airliner overflew its destination airport in Minneapolis because the pilots were distracted by non-flying activities - that have involved air transportation professionals deviating from expected levels of performance.

In addition, this Fall the Board will hold a public forum on code sharing, the practice of airlines marketing their services to the public while using other companies to actually perform the transportation. For example, this accident occurred on a Continental Connection flight, although the transportation was provided by Colgan Air."

These will be interesting proceedings. On the topic of "air transportation professionals" and "expected levels of performance", I recommend highly that you go read this post written by Dr. Tony Kern. It speaks well to this vital topic.