Safety Pilot: A personal and systemic failure

May 1, 2010

For the general aviation pilot who might be contemplating an airline career, the Colgan Air Q400 (Dash 8) accident in Buffalo in February 2009 may have some far-reaching consequences. An ATP certificate or some academic/experiential equivalent is under consideration for new hires. The accident has rightfully rattled more than a few cages and the FAA recently closed an advanced notice of proposed rulemaking to allow public comment on the need for additional certification for new air carrier pilots. Perhaps we really don’t need more rules, just better application of the existing ones.

If Colgan-type accident scenarios were more common, additional certification might be warranted, but fortunately these are outlier events. The precursor conditions, however, are not. The failures at Buffalo were both individual and systemic.

The NTSB is correct to hold the captain accountable for a disastrous mistake in basic airmanship. Neither he, nor the first officer, was paying attention as the Q400 slowed while on autopilot during a night IFR approach. As the stall drew near, the autopilot kicked off; the stick shaker—and then the stick pusher—activated exactly as designed. The captain, who was the pilot flying, mishandled the controls by pulling the aircraft into the stall. One theory is that he thought the aircraft was developing a tail stall, where the correct action is to pull. Unfortunately, this was nothing more than a basic wing stall. Or, perhaps it was just a startled response to a completely unexpected pitch change, where the primal and completely wrong reaction was to pull. Few situations in training allow one to get into a stall without realizing that the edge is near. Developing that critical awareness is what keeps aircraft flying and is the premise behind the FAA’s emphasis on stall avoidance. Recovery is the last line of defense when awareness fails. Pilots should be trained and tested in accordance with the practical test standards. It is a virtual certainty that some are not.

Before the accident Colgan claimed no requirement to teach stick-pusher or -shaker procedures to transitioning crewmembers. It’s essential that whenever a pilot transitions to a new aircraft, big or small, he or she becomes familiar with its stall characteristics and/or any safety systems designed to prevent them. That’s common sense.

On both the personal and systemic level, the cockpit voice recorder and the first officer’s cell phone records reveal that sterile cockpit procedures were not followed. Most crews self-police and that usually works. It’s unprofessional and dangerous to discuss anything but flight-essential matters when any aircraft, GA or airline, is close to the ground.

The system failed by allowing this captain to take command in the first place. His flight check record was dismal before he even started with the airline and wasn’t exactly stellar after that. The system also failed in letting the fatigue debate drag on for so long. It is idealistic to think that anyone (GA or airline pilot) can function safely and consistently at the end of an exceptionally long day. Both the captain and FO had long commutes in addition to their regular duty time. That’s a nasty little secret that no one has realistically addressed.

Much of the proposed rule has to do with improving the knowledge of new pilots, especially in areas of inclement weather. Not a bad idea, although the first officer’s supposed lack of experience in icing conditions had little to do with this accident. According to Colgan, she had more than 30 flights in icing conditions.

A proposed change that first officers should have an ATP, and at least 1,500 hours flight time, is ironic in that both pilots had well in excess of that. The compromise position now appears to be around the 800-hour mark. There is an inherent Catch-22 about the airline business. Everyone wants you to have experience, but many pilots can’t get the appropriate experience unless they get hired. I’m a bit skeptical that one can substitute flight hours in light, unprotected GA aircraft for the heavy-weather flying that is the staple of regional airline work.

Ditto for academics. The college/university and flight school training environment is somewhat limited in what can be done with nonairline tools and within the students’ economic reality. More RJ or turboprop simulator time will help, but what really makes the difference is exposure to real weather in real-world operations—experience difficult and expensive to get outside the airlines. Many airline-pilot hopefuls leave college or flight training with $100,000 or more in loans, to get absurdly low pay as new FOs in an unstable industry.

How about seasonal Initial Operating Experience (IOE) until new pilots gain sufficient experience? By investing in more training captains, IOE for a low-time pilot (less than 1,500 hours) might be in the neighborhood of 100 hours with a check airman, rather than the current 15 to 25 hours—and it might be season specific.

The Buffalo accident revealed poor flying skills, poor economics, and poor supervision, with systemic fatigue and training concerns. Most of this was caused by a casual attitude and complacency inside the cockpit and well beyond. No one was minding the store during a night instrument approach! There were so many opportunities to prevent the accident. For all pilots, a professional attitude is every bit as critical as the attitude of the aircraft. Is still more regulation preferable to accountability and common sense? I think not.

Bruce Landsberg was named ASF president in 2009.