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Flagship 3701Flagship 3701

A lack of common sense snowballs into a fatal accidentA lack of common sense snowballs into a fatal accident

I do not like to criticize other pilots, especially in print, particularly when they cannot speak for themselves. But every once in a great while, there is an event that can be discussed only using harsh criticism.

I do not like to criticize other pilots, especially in print, particularly when they cannot speak for themselves. But every once in a great while, there is an event that can be discussed only using harsh criticism. The crash of Pinnacle Airlines (call sign "Flagship" and now doing business as Northwest Airlink) flight 3701 on October 14, 2004, is such an example. The flight was a Part 91 repositioning flight from Little Rock, Arkansas, to Minneapolis-St. Paul International Airport in Minnesota. Airlines often use the less restrictive Part 91 operating rules to ferry airplanes throughout their systems as necessary. It is common practice to expect — and demand — that pilots operate the equipment and the flights that are flown under Part 91 the same way they do under Part 121, even though there are no passengers on board.

The crew of Flagship 3701, a Bombardier Canadair CRJ 200, did not, and they paid for it with their lives.

The captain, age 31, was an airline transport pilot with 6,900 hours of total flying time, of which 5,055 hours were flown as a pilot in command. He had 973 hours on the Canadian-built CL-65 regional jet, with 150 hours as a CL-65 pilot in command. The first officer (FO), age 23, had 761 hours of total flying time, including 222 hours as a CL-65 second in command.

The crew rode as passengers into Little Rock, arriving at 8:36 p.m. local time. Flagship 3701 departed at 9:21 p.m., and signs of trouble began to occur almost immediately. At an altitude of only 190 feet agl, the crew initiated an extreme pitch up of the aircraft that peaked at 22 degrees of pitch; standard takeoffs in the Canadair Regional Jet 100/200 using the takeoff mode of the flight director are done at approximately 15 degrees of pitch. While an empty CRJ may indeed climb at 22 degrees of pitch, there is never a reason for a pilot to use so much elevator input as to risk a stall. As with many turbine aircraft, the CRJ200 is equipped with a two-part, computer-controlled stall-protection system. In the event of an impending stall, a stick shaker activates. The shaker does just that — it vibrates the control column. If the pilot does not take the proper corrective action, or if the situation deteriorates, then a stick pusher activates. The stick pusher produces a strong, forward movement of the control column, with enough force to pry the control column from an unprepared pilot's hands. At this point, the airplane is trying to protect itself, doing what it can to prevent a full stall from developing.

Only five seconds after rotation, the crew of Flagship 3701 made a control input that was severe enough to activate both the stick shaker and -pusher. Almost all vertical load factor was removed from the airframe. The cockpit voice recorder (CVR) records only the most recent 30 minutes of conversation, so we do not know the crew's response to this highly unusual, nonstandard development. We do know that at 9:25 p.m. and 14,000 feet, the flight data recorder indicated the crew switched seats. At 15,000 feet, approximately six minutes after takeoff, the crew initiated a second pitch up maneuver so severe that it produced a rate of climb of 10,000 feet per minute. A minute later, one or both of the pilots began a series of aggressive, and unnecessary, rudder inputs. At 9:32 p.m., the crew was level at 24,600 feet, when a third pitch up was recorded on the flight data recorder, which produced a rate of climb that briefly peaked at 9,000 feet per minute. The NTSB said the various pitch-up maneuvers had "likely exceeded the aircraft's flight envelope." By 9:52 p.m. — only 31 minutes after rotation, the CRJ was level at 41,000 feet (flight level 410), but at considerable cost to its performance.

There is an FAA limitation that has been in place for some time on the minimum airspeed during a climb above 10,000 feet that requires a crew to fly no slower than 250 knots or 300 feet per minute. When one of the two climb parameters can no longer be met, the airplane is to be leveled off and allowed to accelerate before continuing the climb, or a descent is to be initiated. During the climb, the airspeed had declined from 203 knots at 37,000 feet to only 163 knots at 41,000 feet. During the last 4,000 feet of the climb, the crew set a rate of climb of 500 feet per minute in the autopilot.

High jinks

Once level, the crew engaged in a conversation about the thrill of being so high. Apparently, at the time, there was an unofficial "410 club" at Pinnacle, consisting of those crewmembers who had taken the CRJ to its maximum certified service ceiling.

The CRJ also was on the backside of the power curve, meaning that the engines could no longer produce sufficient thrust to overcome a state of very low energy and high-induced drag. At 9:54:07, the captain voiced the first words of concern, stating, "We're losing here. We're gonna be...coming down in a second here." About three seconds later, the captain stated, "This thing ain't gonna...hold altitude. Is it?" At 9:54:32, the crew requested a lower altitude from the controller, but it was too late.

At 9:54:36, the stick shaker activated again. The airspeed was now 150 knots, and the pitch was almost twice what it should have been. In a ten-second span between 9:54:45 and 9:54:54, the shaker and pusher each activated three times. In trying to recover the aircraft, the crew induced a 29-degree nose-up pitch attitude, followed by a 32-degree nose-down attitude with a left roll of 82 degrees. Both engines ceased operation, and at 9:55 p.m., the crew declared an emergency; they did not fully recover from the stall until they had descended to FL340.

The CRJ produces electricity using the engine-driven generators. In normal operations, the auxiliary power unit (APU), which also has a generator, is not used unless one engine generator is deferred. Moreover, the APU generator cannot be used above FL370, and it cannot even be started above FL300. When the aircraft suffers a total loss of normal AC electrical power, which this one did when both engines failed, a ram air turbine called the air-driven generator (ADG) deploys just below the FO's window. The ADG supplies emergency electrical power to a limited amount of equipment, including the FO's flight instrument display screens on the left side of the cockpit. Because the crew had switched seats, the less experienced FO, who was in the captain's chair, was now the pilot flying.

It took approximately 30 seconds for the captain to first verbalize the double-engine failure, and it took approximately a minute and a half after the double-engine failure had occurred before the crew initiated the first item on the double-engine failure memory item checklist. The checklist was poorly executed from the start. Being in the wrong seats did not help, and the ADG, which is an extremely noisy distraction, probably made it difficult to hear.

The double-engine failure checklist calls for an immediate airspeed of 240 knots, which provides a modicum of glide performance and also keeps the engines and the ADG propeller rotating. As a result of the aerodynamic upset and the poor airspeed management, the engines experienced what is called core-lock. In simple terms, that means that the core of the engine, which must be rotating for a successful engine start, had stopped in both engines. Below 21,000 feet, the checklist has the crew accelerate to 300 knots for an airstart, which forces ram air through the engine to achieve the necessary core engine speed for a successful start. Instead, the highest speed achieved was 236 knots. The captain reminded the FO at least twice to accelerate, and the NTSB concluded that the relative inexperience of the FO probably gave him some trepidation about pitching the nose over as far as was necessary to achieve the required speed. The checklist clearly states that the acceleration from 240 to 300 knots can take up to 5,000 feet.

Because of the failure of the crew to accelerate properly, the airstart procedure failed; the core engine speed readings for both engines remained at zero. The only remaining option was an APU-assisted start below 13,000 feet, which would leave precious little time to prepare for a crash if the attempt failed. There was no discussion about choosing a potential landing site.

Too little, too late

Upon descending below 13,000 feet, the crew tried four starts with the APU, and none was successful. The core engine speed readings were still zero. At 10:08 p.m., the crew had switched back to their proper seats. At 10:09, a full 14 minutes after the event began, the crew finally acknowledged to ATC that they had not lost just one engine, but two, and asked for vectors to the nearest airport. ATC had queried the crew several times about their status, and were told each time by the crew to stand by. Now they were at 9,500 feet agl and losing 1,500 feet a minute. Their last restart attempt occurred at 5,000 feet. ATC had given them a heading toward Jefferson City airport, in Jefferson City, Missouri, but it was to be too little, too late.

The crew spent the last minutes trying to find the Jefferson City airport with the help of the controller. They crashed in a residential area at 10:15 p.m. 2.5 miles south of the airport.

The NTSB touched on several other issues in its report. The training that Pinnacle pilots received in high-altitude operations received a lot of scrutiny. The training at the time consisted almost entirely of classroom work, with no high-altitude air work done in the simulators.

Also, Pinnacle's simulator training did not include a double-engine failure drill, which I found to be very surprising. Because of the loss of the display screens on the FO's side of the airplane — a result of the electrical load shedding — the captain has to fly the airplane and work the radio while the FO performs the checklist until the APU can be started and normal power restored. This situation is ideal for the FO — all he does is the checklist. For the crew of Flagship 3701, the captain was forced to try both to complete the checklist and to keep an eye on an inexperienced FO until the APU was started. The report does not say whether the autopilot — which was available — was used during the descent.

Checklists

Compounding the problem was the captain's inability to perform the checklist properly. According to interviews, the captain had a history of doing a poor job of checklist performance in the simulator during training, and that habit was evident during the accident flight, especially with regard to managing the airspeed, using standard phraseology, and stating the completion of a checklist.

Much was made of engine core lock as a contributor to this accident. First discovered in the CF34 engines in 1983, a test profile was developed for new airplanes to fly to determine whether the engines were susceptible to core lock. GE, the engine manufacturer, testified that as long as an airspeed of 240 knots was maintained, the core would continue to spin. The board also criticized the quality of the Quick Reference Handbook (QRH) checklist in use at the time. Specifically, the board targeted some of the semantics about the required airspeed to be used. Being familiar with the airplane and the QRH, it is my opinion that the QRH then in use was very understandable. As much trouble as the captain had previously demonstrated in following the checklist, it is more likely that his rushed approach to the situation, combined with being in the wrong seat, led to his poor performance of the checklist itself. Had he been sitting in his own seat, it's probably a fair bet that this experience in the airplane would have made him more comfortable achieving the necessary rate of descent to maintain airspeed.

But all that aside, this accident, like all, started at one end of the accident chain and progressed toward its final conclusion. From the first shaker/pusher activation right after takeoff to the decision to switch seats to the onset of the stall itself and the botched execution of the double-engine failure checklist, this was a textbook example of how not to fly an airplane. The crew violated a number of FARs, they exceeded the performance envelope of the airplane, and they failed to ask for the help that could have saved them.

The NTSB was harsh in its causal statement of the accident: "The National Transportation Safety Board determines that the probable causes of this accident were (1) the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots' inadequate training; (2) the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and (3) the pilots' improper management of the double engine failure checklist, which...resulted in the core lock engine condition. Contributing to this accident were (1) the core lock engine condition, which prevented at least one engine from being restarted, and (2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating." The board also faulted the crew "for...evidence [that] showed that the pilots' tone in the cockpit was unprofessional and that their attitude was inconsistent with the demands associated with, and the precision required for, flying a high performance turbojet airplane...the pilots' overall actions during the accident flight were not consistent with the degree of discipline, maturity, and responsibility required of professional pilots."

The lessons

Professionalism is much more than just getting paid for performing some act. It is an attitude, an approach to your job, an adherence to procedures and protocols. The NTSB acknowledged that pilots may be tempted to fly outside the rules on ferry flights because they feel that they can get away with it, and Pinnacle has taken steps to address this problem, as noted in the accident report. Whether the airline left the high-altitude training out of the syllabus in order to save money or time or because it didn't feel it was necessary, it was an omission that certainly contributed to the confusion of the crew.

The crew showed a lack of professionalism from the start, beginning with the first pitch up after takeoff. They switched seats, which put them in a position of possibly having to have at least one pilot (the FO) fly the airplane from a seat to which he was not accustomed. In the event of an emergency, such a lack of common sense can snowball into a real problem. It created problems in following checklists. Keep in mind that checklists can't work if they are not properly executed, whether from memory or using a book.

This may not be a typical general aviation accident, but from pilots getting ready to pursue the world of very light jets to those who just want to get the most they can from their flying, it has lessons for all of us to heed.

Chip Wright of Hebron, Kentucky, is a regional airline captain.

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