Seconds to Disaster: US Edition (6 page)

The Colgan Air crash on
February 12, 2009, occurred five miles out from Buffalo Niagara airport in
up-state New York. Compared to any single accident since commercial aviation
began it would have the most profound influence on aviation, and not solely in
the United States.

Most aircraft accidents occur
during what are called the “Critical Eleven Minutes”—within three minutes after
take-off, and eight minutes before landing. The loss of Colgan Air flight 3407
occurred during the approach phase of the Critical Eleven Minutes.

When aircraft fly high and
fast they are aerodynamically “clean”. However, during this eleven-minute
period when an aircraft is taking off or landing, it flies slower and has what is
termed a 'dirty' configuration. The aircraft is, of course, closer to the
ground and any obstacles surrounding the airport.

On takeoff, flaps and slats
are pushed out to the front and rear of the wing, making the wing surface
larger and increasing lift at the aircraft’s low speeds. On approach to landing,
spoilers may be pushed up on top of the wings to “spoil” the lift of air over
the wings and so help slow the aircraft down or increase the rate of descent. Slats
are then extended further, flaps again are pushed out and eventually the landing
gear hangs down. All of these essentials create enormous amounts of drag and
change the flying characteristics of the aircraft, making it less maneuverable.
In certain conditions, the buildup of ice can add weight and increase drag.

The demand on both the engines
and pilots is at its peak. If something goes wrong, or the conditions are
inclement, it can cause the workload to increase dramatically in an instant. The
reaction time of the aircraft is slower in this configuration, especially the
engines which may be running at idle on approach descent.

Below 10,000 feet, a sterile
cockpit rule is in force—there must be no non-essential chatter. As we shall
see it was a rule, along with many others, that was ignored the night of the
Colgan Air Flight 3407 crash, which also revealed a deadly litany of work
practices within the airline industry that had put tens of millions of lives at
risk for many years. 

The Bombardier Dash 8 Q400 descended in darkness amid a
mixture of wintry weather, its twin Pratt and Whitney turboprop engines throbbing
in unison. Captain Marvin Dean Renslow asked his co-pilot Rebecca Shaw to make
a radio call to operations in Buffalo, to inform them of their imminent arrival
in ten to fifteen minutes.

The forty-seven year-old
Captain Renslow lived with his wife, young son and daughter in Lutz, Pasco County,
Florida. He had joined Colgan Air in September 2005 and had since flown 3,379
hours with the company, 109 of those hours as Pilot in Command of the Q400
model.

Twenty-four year-old First
Officer Rebecca Shaw was working her dream job and that Thursday night was delighted
to be sitting with a captain who was jovial, friendly and outgoing. She had
accumulated 772 hours flying time on the Bombardier Dash 8. It was late evening;
the time 22:07 local.

The Buffalo Approach
controller cleared them to descend. Captain Renslow took the radio calls, while
Shaw pushed the PA button and made her public address to the passengers and
flight attendants.

“Folks, from the flight deck
your first officer speaking, uh, it looks like at this time we're about ten
maybe fifteen minutes outside of Buffalo. Weather in Buffalo is, uh, pretty
foggy. Snowing a little bit there it's not too terribly cold, uh, but, uh, at
this time I'd like to make sure everybody remains in their seats so the flight
attendants can prepare the cabin for arrival. Thank you.”

Shaw had slept little in the
last thirty-six hours, having commuted to work from the West Coast to the East
Coast, spending the night in the busy crew lounge where “one of the seats had
her name on it”.

Listening to her PA announcement
were forty-five passengers. They were under the care of two flight
attendants busy preparing the cabin for landing. Flight attendant Matilda
Quintero, a widow and breast cancer survivor, lived in Woodbridge New Jersey
with her ninety year-old mother and one of her two grown daughters.

Quintero usually worked short
flights to avoid long stays away from home and had swapped off a flight to
Europe so that she could be home that weekend. However, her preferred duty on
the Las Vegas sector which included an overnight was changed to the Buffalo
flight at the last minute.

The second flight attendant,
Donna Prisco, was a mother of four who'd started flying as a flight attendant a
year earlier and loved her new job. The two were an exceptional team and made a
distinct impression on all those who worked with or flew with them as
passengers.

They were taking care of,
among others, Alison Des Forges, a human rights activist and world-renowned
expert on Rwanda. She was on her way home from a public debate with a member of
the British Parliament.

Also on her way to Buffalo was
Beverly Eckert whose husband was killed in the 9/11 attacks. She had met with
President Obama the previous week and he called her “an inspiration.” Among
them was off-duty Captain Joseph Zuffoletto, travelling as a passenger.

It was now 10:09 p.m. and the
pilots were well into the approach. Captain Renslow bantered with Shaw.  “How
are the ears?”

“Uh they're stuffy.”

“Are they poppin?”

“Yeah.”

“Okay. That's a good thing.”

“Yeah. I wanta make ‘em pop.”

The two of them laughed. Shaw
had been feeling under the weather and had considered calling in sick for the
flight. “Is that ice on our windshields?” she asked.

“Got it on my side. You don't
have yours?”

“Oh yeah, oh, it's lots of
ice,” she replied.

The Bombardier Q400 has
sophisticated anti-icing devices on the leading edge of its wings as well as
parts of its tail and horizontal stabilizer.
[53]

The propeller blades
themselves are fitted with an electrical de-icing system. The crew had
activated the anti-ice system eleven minutes after takeoff.

Automatic weather information
issued by the airport at Buffalo was reporting a blustery night in a visibility
of 3 miles in light snow and mist, with the temperature a chilly 1 degree. Not
threatening but less than ideal conditions demanding a higher workload of the
crew.

The aircraft leveled off at
four thousand feet and Shaw once again broached a subject they had explored
throughout the flight—how some of her co-pilot colleagues had complained about
a slow company progression to captain.

“No, but all these guys are
complaining. They're saying, you know, how we were supposed to upgrade by now
and they're complaining. I'm thinking you what? I really wouldn't mind going
through a winter in the northeast before I have to upgrade to captain.”

“No, no.” Captain Renslow
replied.

“I've never seen icing
conditions. I've never de-iced. I've never seen any....I've never experienced
any of that. I don't want to have to experience that and make those kinds of
calls. You know I'd have freaked out. I'd have like, seen this much ice and
thought, oh my gosh we were going to crash.” Shaw then answered a radio call
from Buffalo Approach who continued to vector them towards the localizer for
their approach on runway 23.

At 10:15 p.m. Captain Renslow
reduced the engine power and called for gear down as they were told to contact
Buffalo Tower. “Colgan thirty four zero seven, contact tower one two zero point
five. Have a good night.”

Along with the ice threat, winds
buffeted the aircraft but these conditions were not exceptional. Level at 2400
feet now, the autopilot was still engaged and the crew had their approach
clearance. The aircraft was on a typical flight path with the flaps set at 5
degrees.

Immersed in murky cloud, the
Q400's landing lights illuminated moisture that flashed by either side at 180
knots as they headed towards runway 23. Everything was in place for a normal
approach and landing, except for one important detail—the speed was dropping.
The Q400 requires 20 knots of airspeed to be added to the approach speed in the
event of icing but this standard item had not been done.

A double chime sounded,
indicating the landing gear was now down and locked. “Gear's down,” confirmed
Shaw.

The combination of landing
gear along with the flatter pitch of the propellers turned the aircraft from
less than clean, due to some ice, to “dirty”. These items added drag and the
speed reduced rapidly from 170 knots to 149 knots, a slow speed for the flaps set
only to five at that point.

Captain Renslow called, “Flaps
fifteen, before landing checklist.”

At this point Shaw paused for
three seconds and only put the flaps to ten. Perhaps she noticed the already
ominous speed reduction as she began to say
,
“Uhhh” before both control
columns began to judder—a mechanism fitted in some aircraft and
called
a
“stick-shaker” that warns pilots they are flying at a dangerously slow speed.

The automation reached the
point where it could no longer cope and the autopilot-disconnect horn sounded.
The horn continued to blare out a warning for the remainder of the flight.

The flaps were still on their
way out and were only passing 6.7 degrees as the speed dropped to a dangerously
low 126 knots. Then, for reasons that will never be known, Captain Renshaw
pulled back on the control column: an act in itself that decreased the speed
further as he increased the pitch of the aircraft, up to 30 degrees and so now
the wing's angle of attack came even closer to the stalling angle. He did
increase the power a little to 70 percent of total torque power; however, the
Bombardier Q400 could go to 130 percent of total torque in an emergency, so it
had plenty of power remaining to help take it away from a stall situation.

Nevertheless, Captain Renshaw
never demanded more than 80 of that 130 percent.

The automatic stick-pusher
physically pushed against the control column in an attempt to increase the aircraft’s
speed. Captain Renslow overrode it by increasing his backward pull on the
stick. The Airspeed now dropped to 100 knots. Only seven seconds had passed
since the stick shaker indicated an imminent stall.

The aircraft was now pitched
up at an angle of 23 degrees. The nose fell and they rolled right to a bank of
110 degrees. Captain Renslow uttered, “Jesus Christ”  and Shaw put the
flaps handle back to zero and said, “I put the flaps up.” She then asked: “Should
the gear be up?”

“Gear up, oh shit.” There was
an increase in the ambient noise in the cockpit. In a chilling moment, Captain
Renslow realized it was over. “We're down.”

Rebecca Shaw's microphone
relayed to the voice recorder her last words at 10:16 p.m. and 51 seconds—only
25 seconds had passed since the first indication of a problem via the
aircraft's stick shaker. “We're—” she said, followed by a scream.

Two seconds later the recording
stopped.

All forty-five passengers
and the four crew died, along with one victim on the ground.
Fifty deaths, as we shall see in the following pages, happened needlessly and
at root, because of an industry’s relentless pursuit of profit.

Yet because of those
preventable deaths a profound examination of aviation law was on the
horizon—one that in essence, some would claim, reveals a long-standing and
almost criminal disregard for human life within the aviation industry in
America, and worldwide, for over six decades.

The Colgan Air crash is
now considered a Loss of Control or an LOC accident. It is one of at least ten
LOC accidents in the last ten years accounting for close to
one thousand
five hundred deaths
over that period.

But can the blame be simply
placed one hundred percent on the pilots? And if not, what else contributed to
this tragedy?

On May 12th at the National Transportation
Safety Board’s hearing on Flight 3407, the mindset of Colgan Air was slated and
a litany of problems revealed within the company that continue to exist in
aviation. The crash evidence would educate the North American public's
perception of the aviation industry and how it is managed and administered—and it
would reveal much about the industry’s pilots, their work habits, and their
lot.

In fact, the evidence would
shake aviation administrators to the core and invoke changes in US law, changes
that would send a momentous wake-up call to aviation worldwide—a wake-up call,
we contend, that many outside of the US are still choosing to ignore.

The disturbing evidence
presented showed that Captain Renslow and his co-pilot Rebecca Shaw were
probably flying while suffering from fatigue.

But was fatigue a factor in this
crash?

The board revealed both pilots
at the controls of flight 3407 lived far from their base of operations in Newark
and commuted quite some distance to get there. This did not appear to be of
their own choosing, but the low salaries paid, and the fact that the airline
was continually closing and opening new bases put the pilots in this position.
Barbara Hersman of the National Transportation Safety Board said, ‘I think it
would be a challenge to expect people, within 60 days, to relocate. Especially
if they're getting paid $16,000 a year.’

Mr. Morgan, a representative
of Colgan Air disagreed. “It is what works for the airline to put
airplanes in places where they need to be flying and we try to adjust our bases
as best we can, but we first and foremost have an airline to run”.

First and foremost don’t they have passenger safety to
consider? “Passengers Deserve Better,” Chesley Sullenberger told ABC News
reporter Brian Ross during one of his many in depths investigative reports into
pilot fatigue. The image below is a screen capture, when a pilot secretly filmed
tired pilots trying to catch up on sleep in crash-pads and operations centers,
notably in La Guardia, New York.

As the hearing progressed
it quickly became clear how these two pilots worked in an environment of chronic
pilot-fatigue. It’s a situation experienced by many pilots worldwide.

First Officer Rebecca Shaw had
moved back to Washington State on the west coast to save money by living with
her parents. To continue employment with Colgan Air it meant her having to
constantly commute across the US continent.

Safety board member Kitty
Higgins commented: “Fatigue has been compared to essentially being drunk. It
has the same effect on an individual as alcohol… when you put together the commuting
patterns, the pay levels… I think it's a recipe for an accident and that's what
we have here.”

 Colgan management insisted fatigue was not a
problem at their company.

This remark is often echoed
over and over by aviation industry management worldwide. Because changes to
work patterns could cost money, and because first and foremost many airlines
are profit driven, safety comes second. The NTSB’s chairman, Rosenker, said of
Colgan Air: “I am concerned about the winking and nodding that I have seen in
some of the policies of the company, your company, and crew members, and I
don't believe it is only within your company or those crew members.”

Other damning revelations were
made by the NTSB.

The experience level in the
cockpit was also questioned. (An issue we will re-examine when we return to the
Air France Flight 447 crash later.)

There is an informal rule in
commercial aviation known as the “Two thousand hour rule”. To ensure a balance
of experience, the combination of the two pilot's experience in that type of
aircraft should amount to at least two thousand hours. This would ensure inexperienced
pilots only flew with experienced pilots.

Captain Dean Renslow and his co-pilot
Rebecca Shaw had less than a thousand hours on type between them.

Was lack of training for the
pilots a factor? Why didn’t Captain Renslow have adequate training on the
aircraft's stall warning and recovery? (A situation, as we shall see, that was
similar to the lack of training experienced by the crew of Air France Flight
447.)

The NTSB asked why the pilots
were trained for stalls in the simulator up to the point, but not including, when
the automatic stick-pusher actually pushed down on the control column, a
situation which meant Captain Renslow was not physically familiar with this
procedure of stall recovery.

In response, a Colgan Air
manager said he would have to read about it.

Was the FAA complicit? The safety
board was concerned as to why problems at Colgan Air were missed in previous
audits.

A year before the accident an
FAA inspector, Christopher J. Monteleon, highlighted
deficiencies after a Colgan Air assessment. He was suspended and given a desk
job.
[55]

This revelation of the FAA’s
actions led New York Times aviation analyst Bob Miller to suggest: “Now
it's beginning to look like there's some complicity with the FAA and Colgan
Airlines in the operation and training of that aircraft.”
[56]

So what has changed?

On October 14
^th
2011, the US House of Representatives passed a bill forcing the FAA and
airlines to boost regional airline safety through enhanced training and hiring
requirements and by initiating fatigue countermeasures.

“This bill raises the safety
bar for all US airlines,” said Capt. John Prater, president of the Air Line
Pilots Association, Int’l (ALPA). “Now, every airline will have an incentive to
hire the best-qualified candidates and provide their pilots with the
high-quality training they seek and require to maintain the highest possible
standard of safety.”

While the US has begun to lead
the way in its recommendations, many of the dangerous practices highlighted
still exist in aviation internationally.

As for Colgan Air, its
management faced no charges; in fact, they produced a report in which they put
the blame one hundred percent on the crew. It has to be asked: was the disaster
a damning indictment of a company’s reckless disregard for safety, ostensibly
in the pursuit of more profit?

Might this mindset doom the
aviation industry to yet more tragic disasters? Perhaps, unless a fair and
equitable balance is found between cost, passenger and crew safety, and company
and shareholder profit.

In the wake of the Colgan Air
crash of February 2009, experience levels of new pilots to the US industry were
increased from 250 hours of piloting a real airplane, to 1,500 hours, before
they could obtain a license to fly with an airline. The quality of their 1500
hours and what level of supervision and development is still open to debate.

In Europe the introduction of
a new license allows airlines to have pilots with less than 250 hours flying
experience entering the cockpits of commercial airliners. The safety margin is
being cut so close that it could even prove fatal.

Despite the world becoming a global
village, despite instant communications, many of the lessons learned from accidents
and incidences fail to travel well.

Pilot fatigue must be tackled.
Is overworked, cheap labor in the cockpit conducive to a safe flight? Long
commutes forced on pilots have to be curtailed. Finally, training beyond simple
box-ticking must be introduced if the industry wishes to avoid future
catastrophes by putting passenger and crew lives at risk.

But until airlines and
regulators agree to truly put the passenger first, and the recommendations
proposed after the Colgan Air crash are adopted worldwide, many more aviation
disasters are only waiting to happen.

And many millions of passengers’ lives will continue
to be put at risk.