Thursday, February 4, 2010

Blaming the pilot gets us nowhere


The Airline Pilots Association is furious about the probable cause issued by the National Transportation Safety Board in the crash of Continental Express flight 3407, (Colgan Air) and not just because the labor union exists to look out for the best interests of its members. No, ALPA is outraged because in determining what happened to Continental Express flight 3407, the NTSB focused on a symptom and ignored the cause.



Following a hearing on February 2, the board determined that the pilots of the flight, Capt. Marvin Renslow and First Officer Rebecca Shaw, mishandled a stall, and despite the fact that there was time to recover, failed to do so, causing the crash.

The NTSB's hearing was lengthy and detailed including discussion of crew training, fatigue, company policies and hiring practices. But at the end of the day, according to the board's finding of probable cause, responsibility for the accident falls to Renslow and Shaw.

In a statement later, ALPA president John Prater pointed out what should be obvious to the board because its a basic truth in accident investigations; there is no one cause.

"The Board has missed a valuable opportunity to highlight the many factors that combined to cause this tragedy," Mr. Prater said.

The full NTSB probable cause statement follows below, but in summary, the board cites four actions, lapses actually, the crew's failure to monitor airspeed, its failure to observe discipline in the cockpit, the captain's failure to monitor the flight and the airline's operating procedures for flights in icing conditions.

It's a list that heaves buckets of blame on the pilot. Okay, he's not qualified by many measures - the most dramatic being a record of failed check rides and an inability to focus on the task at hand as seen from a cockpit voice recorder transcript that demonstrate this guy's mind was everywhere but on the flight.

The larger question, one that begs examination, is how was he in the cockpit in the first place? How does a succession of first officers work with a pilot who's flying skills and lack of professionalism are so apparent without passing along their concerns? How does his employer fail to note these shortcomings?

John Gadzinski, an airline pilot and fellow member of the International Society of Air Safety Investigators told me once - and I'm going to paraphrase here because truth be told, we were drinking at the time - that an airline's commitment to safety can be easily determined by answering this simple question. Is there a gap between its policies and its practices?

Colgan repeatedly states that safety is a top concern and yet, here's the gap. Colgan claimed to have a policy prohibiting pilots from overnighting in crew lounges yet it was a well known fact that commuting pilots did just that. Colgan claimed use of personal electronic devices was prohibited and yet the 24-year old first officer on the flight not only felt free to send text messages but when she did so, the captain failed to say anything to her about it.

Sterile cockpit? We'll that's not just a Colgan "policy" its an F.A.A. requirement. On the night of the crash, Flight 3407 had an hour-long taxi out at Newark Liberty Airport while waiting takeoff. Virtually the entire time was spent in conversation, but only sixteen minutes of talk was about the flight.

Its just not believable that this kind of cockpit behavior was unknown to Colgan. Getting to the heart of why that was the case is entirely relevant to determining why this plane crashed. Its bigger than Mr. Renslow and Ms. Shaw. Its bigger than Colgan too. There's a crisis here, but you'd never know it by reading the probable cause statement.

Sure, its recognized by the safety board to the extent that it plans two public events, one to study pilot training and standards and another to look into "code-share" operations.

Whether the effect of future discussions will be as effective as something more comprehensive emerging within the powerful emotional atmosphere of a crash hearing remains to be seen.

In discussing the danger of Mr. Renslow's loquaciousness, NTSB member Robert Sumwalt said he squandered time he did not have. Waiting too long to address the problems in the regional airline business risks the same fate.

PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the low-speed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.

10 comments:

Joe d'Eon said...

"No, ALPA is outraged because ... the NTSB focused on a symptom and ignored the cause"

Well, sort of. The NTSB focused on "direct" causes, and the results they came up with sound correct to me. What you're saying is that there are factors that contributed to the existence those direct causes in the first place, and I agree. Completely.

You call for "something more comprehensive " to solve the problem. I would like to know what you propose as a more comprehensive solution.

Editor said...

Dead pilots always get blamed because they can't defend themselves. To lay blame at the door of FAA or the company risks upsetting someone who can argue otherwise (which might reveal how incompetent many investigations are).

And let's not forget that the NTSB's mission is not to make aviation safer - it is to look like the gov'ment is doing something.

As for what needs to be done - competent and transparent investigations, free of outside influence and politics, would be a start.

Craig said...

I don't want to pick a fight, but it is the NTSB's mission to make aviation safer - many of their recommendations the FAA ignores. The NTSB is actually separate from the FAA so that they can be free from outside influences and politics, in theory. I see that you're speaking from a cynical viewpoint of the politics involved, which can never be completely removed from the subject.

I agree with the NTSB's findings, and I agree that the duty/rest rules needs to be more conservative. 'Flight Discipline' will become a term all jet pilots will learn in the future IMO. Tony Kern wrote a great book by the same name, recommended from this fellow professional pilot. (CRJ200 CA, US Airways Express)

Dan said...

I'm no huge fan of the NTSB, but I've not been that impressed with ALPA either. There job is to protect the pilots at all costs. As a former Safety Director, ALPA blocked investigations all the way. If you want to read the CVR to listen to what happened, you're not allowed. If you want to monitor data that the airplane collects for identification of deterioriating systems or even improper procedures some pilots use when transitioning in order to target flaws in the TRAINING, ALPA refuses. During an emergency egress due to smoke in the cabin, the pilot volunteered the chain of events that occurred which really helped identify the cause of the smoke. A week later, the ALPA rep said it didn't happen that way and we couldn't use the information. Unfortunately the condition of the airplane corroborated the pilots version and he hadn't done ANYTHING wrong. But ALPA still wanted to cover his ass. I'll believe a pilots union when I see it. And the problem is that most pilots don't are good folks and very conscientious. But those union guys don't give a damn.

Christine Negroni said...

Dan, You will find that CVR transcripts and even FDR data can be obtained from the NTSB investigation when the docket is published. The internet has allowed access to these documents online, which is a tremendous help now eliminating the need to travel to DC or request a paper copy from the federal publishing house.

Grumpy said...

As an Air Safety Investigator of some 50+ years, neither the NTSB nor its predecessor CAB learned to distinguish between "Probable Cause" and a description of What Happened. "Causes" are difficult to determine, because there are dozens of definitions of "cause," most of them legalese. Were the Investigation Agencies to discard their infatuation with "causes" and concentrate on What Happened, both immediately and historically, then they might be able to identify an audit trail of behaviors that led to the accident.
For example, elimination of the SO by the two-person cockpit eliminated the opportunity for junior pilots to learn from their seniors by observing and listening. Every Captain to whom I've spoken who's old enough to have ridden side-saddle attributed significant learning to that time, much of it in the practice of CRM (and much of that negative). Furthermore, the generation of airline managers who had risen from operational ranks has given way to management by bean-counters, who do not value the "informal education" process that goes beyond "the book." The value of that knowledge was proved by US 1549.
Analyses of most recent air carrier accidents/incidents show that either their initiations, or the crew responses, demonstrated serious shortfalls in knowledge that we once would have considered basic airmanship and equipment knowledge. In the long run, it has been the aggregation of numerous changes in attitudes toward the roles of crew liveware, compounded by an early prediction that automation would relieve workload, that has led to inexperienced and ill-trained FOs who lacked the learning opportunity afforded by being an SO. No amount of training-to-the-book in a classroom or simulator can take the place of being there.

That's an obvious factor, but you'll never hear it from the NTSB the FAA, ICAO, or any other government agency; because it puts their judgment at risk. With "Cause"!

Robert Scott said...

I have to agree with the points made very well by 'Grumpy' and add below a extract of an email that I recently wrote on the subject. Aircraft have not suddenly become more difficult to fly, nor has that nasty CO2 removed some of the lift from the luft. The fact of the matter is that we have many inadequately trained and managed pilots in cockpits these days and until that changes, neither will the accident rate.

Another point that is becoming very obvious, at least to me, is that many of the 'Loss of Control' accidents / incidents are nothing more than examples of very poor basic piloting skills. The fact that control is subsequently lost is not surprising, especially for anyone who went through basic RN / RAF training and had the consequences of poor scan, overbanking, inability to fly on 'limited panel' etc, drummed into him. Granted, Airbus aircraft in particular, have characteristics that require a different approach in certain flight regimes and degrees of automation, but the one thing that runs loud and clear through the accidents offered for consideration is that often a perfectly serviceable aircraft was lost because the crew either forgot (or had never known) how to fly their aircraft in anything other than optimum conditions.

I respectfully suggest that is where we should be focussing at least some of our attention.

My reference to RN / RAF training is because that is my background, for which I have often been very grateful. However, I am very aware that pilots trained in other environments have the same skills, having also enjoyed robust training courses where the basics were drilled into them.

What is painfully apparent is that many of today's pilots do not have those skills. Somewhere along the way training courses were pared back to the minimum so that an overreliance was placed on management of 'the system' rather than pure piloting skills. The correct balance lies somewhere in the middle as those of us now in the later stages of our careers are well aware.

If we were to hold another conference I think it should focus on the loss of those skills and attempt to quantify the arguments in terms of types of accidents vv time devoted (or allowed by management) to honing essential handling skills.

These concerns are not new. They started with the L1001. "What the !@&$ is it doing now"? However, in those days we were more concerned with embarrassment at hitting the wrong switch than being unable to fly the aircraft if it had a failed ASI, it was night, etc, etc. Nowadays the pilots are in their comfort zone when everything is working well but poorly equipped to deal with an abnormal situation. Mind you, a rider to that should be that there are also examples of stunning airmanship, such as the DHL incident.

Many of today's young pilots have an enviable mix of good handling skills and a thorough understanding of the automatices, but I would suggest that there are at least as many more whose handling skills are suspect, in many cases because of lack of practice and not lack of interest.

If we have pilots who can't fly without everything working perfectly we have to deal with that issue before we start preparing more massive tomes that will gather dust on pilots' bookshelves.

I think that is where the focus should be and would form the basis of an interesting - and valuable - conference.

Robert Scott said...

P.S. For 'l1101' read L1011.

My apologies.

Anonymous said...

I firmly agree with Mr. Scott, after 28 years in the cockpits of commercial and military a/c it would seem the situation with the fully automated a/c and the fly by wire systems and also not direct control of the flight surfaces have led to the loss of abilities of modern day pilots to fly the A/c by hand when all else fails. The United DC10 crash in Iowa is an example of design failure with regards to being able to manually fly the A/C.
Our younger pilots may be managers of computers and all the new gimmicks that have been used to supposedly make the job easier but I submit they have caused a serious decay of pilotage skills.

suchan shah said...

Great content in you blog.