The crash of Colgan 3407

N200WQ, the accident airplane. Photo taken on approach at YYZ on Oct. 5, 2008, courtesy of Michael Fast and airliners.net



I've seen my share of reports on aviation accidents caused by human frailties.

There was the 1972 Eastern Airlines crash in the Everglades that occurred when a crew became so distracted by a burnt-out landing gear bulb that they were unaware the auto-pilot had disengaged and their L-1011 had begun a gentle descent into the swamps.

There was the crash of a United Airlines DC-8 that occurred near Portland Ore. in 1978, when the pilot, circling because of a potential landing gear problem, ran out of fuel. His FO had brought their fuel crisis to his attention; the captain chose to ignore it.

No less than the worst accident of all time was caused by an impatient KLM 747 pilot, who, despite the objections of his co-pilot, commenced his takeoff roll in heavy fog without clearance from air traffic control and smashed into a Pan Am 747 taxiing on the same runway, killing 583 people.

You can blame these accidents on denial, arrogance, whatever. In the end, though, the pilots knew how to fly the planes.

I'm not so sure about the pilot of Colgan 3407.

I'm hesitant to rip a flight crew, especially the deceased pilot-in-command who oversaw a terrible crash. Seems like bad karma. But reading the NTSB preliminary report, there's really no way to argue around the clear-cut evidence.

Gross incompetence cost 50 people their lives near Buffalo, N.Y.

(Not ice, as was originally and continuously lamented as the culprit in knee-jerk media reports. But when it comes to aviation news, is there another kind?)

The inattentive crew of 3407 let a bad situation fester, then when the warning bells alerted them to the situation at hand, they did the exact opposite of what they should have done to correct the problem. That's no exaggeration.

It wasn't a complicated solution, either. The fixes were things my flight students could describe and accomplish after three or four lessons in a Cessna 172. Again, I'm not exaggerating.

But it never should have gotten to that point aboard Colgan 3407, a Dash-8. As I have said a few times here, it's not one thing that causes an accident, but a chain reaction of four or five different problems that, had any been resolved differently, the accident chain could have been broken.

Colgan 3407 is no different.

Let's look at the accident chain:

The fatigue factor

1. It begins with a departure from Newark that's more than five hours late, which means a flight crew that's been on duty much longer than expected by the time they take off circa 9:30 p.m.

Fatigue, according to the NTSB report, will be a topic addressed when the board convenes in May to discuss the accident. I'm glad to hear that, because crew fatigue is a topic that gets brushed aside too often by the FAA, which although it has rules about mandated rest periods and maximum work hours, does nothing to actually enforce them.

Fatigue, you may remember, was also cited as a factor in the last major U.S. plane crash, when a Comair flight took off from the wrong runway in Lexington, Ky.

Pilots need protection from draconian schedule-makers and dispatchers, and also from their own employers. You've never met a group of employers as outright hostile to their indentured servants/employees as the regional airline companies.

It's one of the reasons I chose to abort my aviation career before takeoff; I really don't want to work for an employer who has no respect for me.

The Colgan crash is another example as to why more stringent government intervention and oversight is needed when it comes to crew fatigue. The airlines aren't going to police themselves.

Sterile cockpit

2. According to NTSB officials who have reviewed the cockpit voice recorder (CVR), the crew ignored FAA rules about maintaining a "sterile cockpit" during their approach and descent into Buffalo.

A sterile cockpit, you ask? Below 10,000 feet, commercial pilots can only talk about essential flight topics. This keeps the focus on the task at hand during departure and arrival phases of the flight, when mistakes and oversights are magnified.

(Ever wonder why you have to keep your electronics off early and late in flights? It's so operations-critical communications aren't disrupted below 10,000 feet).

Although there's no sterile-cockpit requirement for private pilots, I taught my students to adopt a similar tactic.

We weren't ever really above 10,000 feet AGL, but my rule of thumb for students was that once they contacted approach and/or copied the ATIS information (a broadcast of local weather and airport conditions), then the chatter stopped and concentration commenced.

I'm sure that the crew of Colgan 3407 isn't the only one to kind of shrug its shoulders at the sterile cockpit requirement -- on the contrary, I'd guess the rule is treated with a grain of salt by thousands of crews every day.

But when you study the accident chain of 3407, it has to be considered the second step, because there's no other way to really conceive of how they got to No. 3 without it.

Low and slow

3. So here comes 3407 into the Buffalo area, and the crew is ostensibly chatting away unaware that the airspeed is slowly bleeding off ... slowly bleeding off ... until the stick-shaker activates and warns of an oncoming stall.

That was one of the more elementary rules broken that night: Don't get low and slow.

One of the key things we're all taught -- pretty much from the first time we step in the airplane -- is to nail target airspeeds at low altitudes, because there's simply a lower margin for error when you're approaching the airport. In airspeed, you're flying closer to the stall speed of the plane ... finally approach speed is generally 1.3 times stall speed; In altitude, there's less leeway for recovery from a mistake.

On their approach, Colgan was at approximately 1,500 feet MSL, a little low, according to the report, and they got slow enough to where they stalled the plane.

This is ultimately a little more complex, and maybe we'll save for another post discussions about cross-controlled stalls, the horizontal component of lift, how g-force affects stall speeds and stall-spin accidents.

For now, moral of the story is simple: don't get low and slow.

That's what they did. They got low and slow, and it's the next chain in the accident.

Stall recovery

4. Back to our troubled plane. The stick shaker activates, warning of an oncoming stall.

The proper response in this situation is to initiate a stall recovery by 1) lowering the nose 2) applying full power and 3) retracting flaps in stages. There might be some small variations to this in jets, such as holding the nose steady instead of lowering it, but the general concept is the same.

When it came to step one, the PIC of Colgan 3407 did the exact opposite. He raised the nose.

In explaining why that's important, I need to back up and explain a few things:

You shouldn't mistake a stall for the engines quitting; in aviation-speak, a stall is code for the wings are no longer producing lift.

A stall is an aerodynamic event.

Ever stick your hand out the window and let it float in the wind? It's floating on the same aerodynamic principles that allow airplanes to fly. Lift is being created.

Lift in airplanes is affected by a lot of factors: air density, surface area of the wing, air speed and angle of attack -- the angle at which the wings meet the wind.

This oversimplifies things a little, but pilots can control the amount of lift being produced largely through two factors: airspeed and angle of attack.

(OK, when you start adding flaps and spoilers and such, they can also control the surface area of the wing, but I'm trying to keep it simple).

The faster you go, the faster the wind goes over the wings. More lift is produced.

The more "tilt" there is to the wing, the more lift is produced. If you plotted this on a graph, the amount of lift being produced would grow steadily as the angle of attack increases.

Think back to your hand out the window of the car. The more you tilt your hand upward, the more your hand wants to rise through the air. Until you reach a point where you tilt your hand so far, it plops like an anvil.

In aviation speak, that point is called the critical angle of attack. That is, the angle at which there's so much tilt to the wing, that air no longer flows smoothly around the surface. It's at this point the wing stops producing lift.

Each plane has a particular angle of attack that, if exceeded, lift ceases and the plane will stall. In most planes, the critical angle of attack is between 17 and 21 degrees.

Although airspeed plays a significant factor in stalls, it's ultimately the angle of attack that plays the most important role in the lift/stall equation.

So back to 3407.

The stick-shaker activates, enough of an event on its own to merit an investigation. The recovery procedure is simple, simple enough that my students all know it by the end of their fourth lesson.

The first two steps in stall recovery account for airspeed and angle of attack, controlling those two key things that help control lift: Power increases airspeed and the nose is lowered so that the critical angle of attack is not exceeded and air begins again flowing smoothly around the wing surfaces.

But does the captain of 3407 lower the nose, (also known as relaxing the back pressure)? Or does he maintain his current pitch, which is the proper procedure in some planes?

Nope, he yanks back on the yoke applying 25 pounds of force and pulls the Dash-8 to a plus-30 degree pitch attitude, way beyond the critical angle of attack.

This significantly worsens the stall, and with only 1,500 feet of altitude to play with, there's just not enough room for a recovery.

Raising the nose is a crazy response. It's so contrary to what's ingrained in a pilot's head from one of his earliest lessons. His response is the aviation equivalent to saying "Well, I saw that light was red, officer, so I stomped on the accelerator."

It's hard to fathom that a professional flight crew with thousands of hours of flight time and many more in a simulator erred so very, very badly.

Conclusions

I hope that I'm wrong. I hope that when the final NTSB report comes out that there's some unforeseen problem that's not in the preliminary report that explains all this.

I hope that I can come back with a post that says, "You know what? I really whiffed on my Colgan analysis and here's the extenuating circumstance that no one caught the first time around."

I'd much rather hear those things, because an accident of such simplicity scares the hell out of me.

When I think of my family and friends flying around the country and the possibility of something catastrophic occurring, I think it'd be easier to accept if a fan blade cracked because of metal fatigue or if the plane rolled after a mysterious uncommanded rudder deflection.

But this business with a bungled stall recovery? The 50 people killed by something so simple deserved much better.

Sky savages

On Monday morning's flight from Seattle to Denver, I frequently thought of the great Seinfeld episode "The Chinese Restaurant" where George Costanza yelled in frustration "We're living in a society here!"

It was the latest flight in which I've observed that airline travel generally turns fellow citizens into cretins who think they're in the land of the lawless in their little aluminum tubes at 35,000 feet.

In the spirit of returning some decency to air travel, here are two new rules for that would make things more enjoyable for everybody:

1. Just because the seats recline, that doesn't mean you should plop into your rearward neighbor's lap.

I once broke up with a girl, partially because when it came to this topic, she assured me that she'd use her God-given right to recline on any and all flights, despite whatever hardships it might cause the person behind her.

Such a statement, to me, reflected her true colors. And then she was gone.

Look, I know the seats recline, but they were designed 30 years ago in an era when a tightly regulated industry had the luxury of providing ample leg room, space to read a newspaper and stale lasagna.

Airlines have since shaved nearly a foot off the available space per passenger, destroying any semblance of comfort. Please don't wreck the already-limited space for the poor soul behind you. It's just common courtesy.


2. You shouldn't need a forklift to hoist luggage into the overhead bins.

The savagery in the skies is getting worse.

Fees for checked bags is the culprit.

When oil prices peaked and airlines freaked, they started charging their pax to check their luggage. This, in turn, caused nobody to check their luggage and instead attempt to wedge their belongings into overhead bins.

It's become open warfare for that coveted space.

Savvy flyers know this means you need to get onto the plane ASAP, and thus need to jockey for position in line and wait with bated breath as they call out rows for boarding.

But if you get on board late, you know what? You lose.

Don't argue with the flight attendants. Don't start re-arranging the bags of others who came before you. Don't attempt to wedge your over-sized bag in with hydraulic jacks. Please just give up, check your bag and the front of the cabin and stop pouting.

It wouldn't be popular, but airlines need to start strictly enforcing their rules on acceptable size of carry-on luggage.

Babyville

Some thoughts on birth and the baby as we enter week seven of parenthood.

The name

True story. One day, at least a year before we seriously considered attempting pregnancy, I found myself standing in the shower spontaneously pondering baby names. Mrs. VFR and I hadn't discussed anything of the sort in months.

But there I stood, rinsing shampoo out of my hair, and the name "Eliza" popped into my head. I immediately loved it. It fit predetermined criteria. Old, but not Mabel. Classic, but not overly popular.

It was more than the fact it merely passed those initial tests. It had this intangible: It just clicked right away. It sounded right. Eliza VFR. Yes.

I filed this nugget away and proceeded with getting ready for my day, thinking I'd unearth that thought again many months down the road. While I was drying off, Ericka came in to ask me a question. When she was done, she said:

"By the way, I was thinking of baby names for some reason. What do you think of the name Eliza?"

We never really considered anything else.

Numbers game

A little background on the mushier side of my marriage: Ericka and I often say "123" to each other, which is code for "I love you."

This is a little tradition that started on her side of the family. When her brother, Bullfrog, was a fierce southpaw on the mound in high school, her mom would always shout "I love you!" to him from the stands, much to his embarrassment.

He told her to stop; she wouldn't budge.

They eventually compromised on 123. One. Two. Three. I. Love. You. Bullfrog allowed her to shout this from the stands, and it quickly became a family trademark that carried over into our marriage.

It's important to us. Our wedding rings are inscribed on the inside with "One. Two. Three" and our wedding date.

So you can imagine our joy when Eliza was born, two days late, on January 23. 1/23.

Darth Vader visits

For the months leading up to the birth, we did a ton of research on natural birth versus C-section and the general labor process. Ericka concluded that she wanted as natural a birth as possible.

There were a lot of reasons for this, but the crux of it was that she wanted to avoid a C-section, unless an emergency required one.

From our studies, we knew that epidurals can often slow down the labor process, leading antsy doctors to administer the drug Pitocin, which speeds it up. Pitocin can also put undue stress on the awaiting baby, thus creating the sudden need for a C-section.

That cycle was burned into our minds. Epidural = Pitocin = C-section.

She was open to the epidural, but was going to give it her best shot without one. And I was slated to be her advocate during the hospital "experience." Her doula. Her voice of reason. This was the great birth plan.

Here's how it actually went down: My poor wife endured 55 hours of labor by the time they finally induced her, which caused her contractions to exponentially increase in severity.

She rolled around on the birthing ball and soaked in the jacuzzi in our room in hopes of soothing the daggers shooting into her stomach. But nothing really dulled the pain. More worrisome, she wasn't dilating. At all. All this pain, and no gain.

So the prospect of intervention was on the horizon when Ericka looked at me, and in a dark, low voice that sounded like Darth Vader, she said: "I want ... an epidural."

I assumed my role as advocate. "OK, let's slow down and talk about that," I said. "We can do that. Just remember that could slow things down, and --"

"NOW!" she bellowed.

"OK, just remember that it could --"

"NOW!" Darth Vader said.

Heil, epidural

I arranged the epidural.

A few minutes later, an anesthesiologist named Dr. Swastik arrived.

I kid you not. That was the dude's name. I wondered why he never changed it. I also wondered if my baby would someday display an irrational obsession with marching band and Meister Brau.

(Poor guy. I mean, seriously, now he's got some wise-ass cracking on him in a blog entry when all he did was deliver a fantastic epidural).

I left the room for about a half hour while Dr. Swastik administered the epidural. When I came back, Darth Vader had departed and my wonderful, smiling wife had returned.

Crowning achievement

The epidural not only defeated the pain, it allowed Ericka's body to relax to the point where she dilated. It occurred quickly, and in no time, she was ready for the home stretch.

She was feeling no pain, so much so, that we were having very nice conversations with our doctor in between pushes.

We did not know if the baby was a boy or girl, and we discussed our naming options with our doc at this point. We told him we had our girl name picked out for sure, but that we had three boy options.

When we were on the break before the second-to-last series of pushes, we finally got around to talking about what I did for a living. When I told him, he said, "Oh, so you must know Reako."

"Indeed I do," I said, and we had nice conversation about the general state of affairs on the local sports scene.

At this point, the doc said, "OK, you can see the head now." And he pointed in the general direction of this pointy, bluish-gray mass with white goop protruding from Ericka's down-theres.

It looked like a moonscape.

I had no doubt that the doc had indeed pointed to a head and that he knew what he was doing, but I concluded in my own mind that I must be looking in the wrong area.

"I delivered one of Reako's kids," the doc then said, jumping back to the earlier part of our conversation, as we geared up for a final push. (This was later verified).

Minutes later, the baby was born. I was stunned silent by the magnificence of this miracle process. The doc looked at us and said, "I guess you don't have to pick a name!"

Crying commenced. I cut the cord. Nurses placed the baby on the warming table. I watched as they poked and prodded her while the doctor patched up my wife.

At that moment, Eliza opened her eyes for the very first time. Her first sight was a proud papa. She stared right at me, and her steely blue eyes melted my heart.

Die Bambi!

Those of you who are already parents may remember placing your precious cargo in the car for the first time and driving away from the hospital as if you had a Ming vase balancing on a toothpick in the back seat.

I was no exception. I have never driven more slowly or been more on the lookout for soccer moms driving Ford Navigators while blabbing on their cell phones.

We weren't more than two blocks from the hospital when I saw an oncoming car careening off snow banks and hurtling toward us. It looked like the make and model Bluto drove at the end of Animal House.

A few minutes later, after dodging that wreck, we approached Pleasantville on a nice, country road when all of a sudden, a damned deer jumped out of the woods and into our lane. You may remember that I've already had a previous encounter with a deer this year.

I had no choice but to lock up the brakes.

At the last second before impact, Bambi jumped out of our lane and into the east-bound one. Just in time to get whacked by another vehicle.

My nerves were shot for two straight days.

Things I've learned

I know that a few of my readers are going to be proud parents any day now, so I'd like to pass along a few tidbits I've learned in seven fantastic weeks. I hope they're useful.

- Babies R Us is an evil place, filled with fear-mongers who prey upon your worst parental nightmares. All their advertising essentially comes down to this: "You're a bad, dangerous parent if you don't have this crappy, overpriced piece of plastic we'd like to sell you."

- If you have a birth plan, be flexible with it. Like I mentioned above, Ericka went in fairly determined to not have an epidural, because it could lead to the C-section. As it turned out, she probably avoided the C-section by having the epidural.

- We squirreled away a little dough specifically for baby expenses in the early months. OK, we didn't, but we thought about doing so. If you've had similar thoughts, save double what you planned. It's not just the big things. It's the series of little things on top of the big things.

- Three consecutive hours of slumber can indeed be classified as "a good night's sleep."

- There's an overabundance of information out there on birth and babies. Take it all with a grain of salt. Ask questions of your doctors, but realize that if you asked 10 different doctors the same question, you'd probably get 10 different answers. I'm not exaggerating. Trust your instincts. It ain't rocket science. They're either tired, hungry, gassy or sitting in their own waste. There's an outside chance they're sick, but that's why you've got a thermometer.

- Being Papa VFR is the greatest thing ever. Enjoy it.