Author Topic: Aircraft crash in WNY  (Read 3925 times)

Offline CAP1

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Re: Aircraft crash in WNY
« Reply #45 on: February 14, 2009, 08:29:11 AM »
Very sad day in aviation, RIP to all onboard.

Here's the tapes from Buffalo ATC - callsign Colgan 3407

Abbreviated version
Download Crash - MP3 Crash by Colgan Free Music Hosting

Full version - 15 mins in they're cleared for the ILS 23
http://event.liveatc.net/kbuf/KBUF-Feb-13-2009-0300Z.mp3

Hearing the cheer in the FO's voice just minutes before they went down, then hearing ATC not being able to contact them again is gut-wrenching :( 

There was another Colgan crew cleared for the approach a few minutes after, and they asked the tower if they knew what was going on down there, I imagine they saw the fire, that had to be tough to stomach. 

Many pilots reporting icing conditions while in the approach area.  Not the time to speculate, but the NTSB said that after 15 degrees of flaps was selected, there was severe pitch down and roll.  Very likely that it was a tail stall, as a result of the ice it had accumulated.  In an icing situation like this it's usually always encountered when adding flaps.
That's what I'm thinking.  To recover from a tail stall the recovery actions are almost completely opposite of a wing stall, you want to pull the stick back to re-attatch the flow on the horizontal stab and maintain power or reduce power. Basically to recover from a tail stall you want to "undo what you just did".   

Since the thrust line on the Dash 8 is above the center of gravity - any sudden increase in power will cause a nose down pitching moment, that will be aggravated by the already compromised lifting surface of the horizontal stab as a result of the ice accumulation.  Like you said it's most likely to happen during flap extension, especially if you're close to the max speed for flap extension - as I'm guessing he may have been, trying to fly the approach a little faster because of the icing. 

dam.......

she had that"thank god this flight is almost done tonight" tone to her voice.

it seemed that it happened so fast that they weren't even able to make a mayday, or any other emergency calls.

Godspeed to them all. :salute
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Offline Casca

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Re: Aircraft crash in WNY
« Reply #46 on: February 14, 2009, 09:04:31 AM »
NTSB finding was that misconfiguration was a key component of the crash. Doesnt mean that the icing wasnt a major factor and that corrections werent called for. However the full deployment of the flaps and subsequent overspeeding/retraction directly caused the crash. I thought recommended procedures anytime ice was observed was to disengage AP and fly the approach manually. Even GA pilots are taught you never engage flaps with visible ice on the leading wing edges? I know U've got thousands of hours in all kinds of stuff...from the comparatively little I know it sure seems like some fundamental errors...assuming AP was engaged up till final.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

the loss of control, attributed to a sudden and unexpected aileron hinge moment reversal that occurred after a ridge of ice accreted beyond the deice boots while the airplane was in a holding pattern during which it intermittently encountered supercooled cloud and drizzle/rain drops, the size and water content of which exceeded those described in the icing certification envelope. The airplane was susceptible to this loss of control, and the crew was unable to recover. Contributing to the accident were: 1) the French Directorate General for Civil Aviation's (DGAC's) inadequate oversight of the ATR 42 and 72, and its failure to take the necessary corrective action to ensure continued airworthiness in icing conditions; and 2) the DGAC's failure to provide the FAA with timely airworthiness information developed from previous ATR incidents and accidents in icing conditions,3) the Federal Aviation Administration's (FAA's) failure to ensure that aircraft icing certification requirements, operational requirements for flight into icing conditions, and FAA published aircraft icing information adequately accounted for the hazards that can result from flight in freezing rain, 4) the FAA's inadequate oversight of the ATR 42 and 72 to ensure continued airworthiness in icing conditions; and 5) ATR's inadequate response to the continued occurrence of ATR 42 icing/roll upsets which, in conjunction with information learned about aileron control difficulties during the certification and development of the ATR 42 and 72, should have prompted additional research, and the creation of updated airplane flight manuals, flightcrew operating manuals and training programs related to operation of the ATR 42 and 72 in such icing conditions.
« Last Edit: February 14, 2009, 09:06:40 AM by Casca »
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Offline SFRT - Frenchy

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Re: Aircraft crash in WNY
« Reply #47 on: February 14, 2009, 09:37:54 AM »
NTSB finding was that misconfiguration was a key component of the crash. Doesnt mean that the icing wasnt a major factor and that corrections werent called for. However the full deployment of the flaps and subsequent overspeeding/retraction directly caused the crash. I thought recommended procedures anytime ice was observed was to disengage AP and fly the approach manually. Even GA pilots are taught you never engage flaps with visible ice on the leading wing edges? I know U've got thousands of hours in all kinds of stuff...from the comparatively little I know it sure seems like some fundamental errors...assuming AP was engaged up till final.

I'm sorry Humble, I don't want to come accross as "I have xxxx hours, u don't I know shut up". I love reading what others have to offer even if it's the intercontinental missile theory. I just like to see people here get their ideas/fact straight about aviation.
Here's the NTSB report you are talking about : http://www.bluecoat.org/reports/NTSB_96_Roselawn_ATR.pdf ... There's no mention of "full flpas, nor misconfiguration was key". The flaps 15 did cause ice to accumulate beyond the boots, but nothing wrong having them there anyway.

3.2 Probable Cause
The National Transportation Safety Board determines that the probable causes of this accident were
the loss of control, attributed to a sudden and unexpected aileron hinge moment reversal that occurred
after a ridge of ice accreted beyond the deice boots because: 1) ATR failed to completely disclose to
operators, and incorporate in the ATR 72 airplane flight manual, flightcrew operating manual and
flightcrew training programs, adequate information concerning previously known effects of freezing
precipitation on the stability and control characteristics, autopilot and related operational procedures
when the ATR 72 was operated in such conditions; 2) the French Directorate General for Civil
Aviation’s (DGAC’s) inadequate oversight of the ATR 42 and 72, and its failure to take the necessary
corrective action to ensure continued airworthiness in icing conditions; and 3) the DGAC’s failure to
provide the FAA with timely airworthiness information developed from previous ATR incidents and
accidents in icing conditions, as specified under the Bilateral Airworthiness Agreement and Annex 8
of the International Civil Aviation Organization.
Contributing to the accident were: 1) the Federal Aviation Administration's (FAA’s) failure to ensure
that aircraft icing certification requirements, operational requirements for flight into icing conditions,
and FAA published aircraft icing information adequately accounted for the hazards that can result
from flight in freezing rain and other icing conditions not specified in 14 Code of Federal Regulations
(CFR) Part 25, Appendix C; and 2) the FAA’s inadequate oversight of the ATR 42 and 72 to ensure
continued airworthiness in icing conditions.




3.1 Findings

1. The flightcrew was properly certified and qualified in accordance with applicable regulations
to conduct the flight.

8. The flightcrew’s actions would not have been significantly different even if they had received
the available AIRMETs.

9. The flightcrew’s actions were consistent with their training and knowledge.

37. The flightcrew’s failure to increase the propeller RPM to 86 percent and activate the Level III
ice protection system in response to the 1533:56 caution alert chime was not a factor in the
accident.



Even GA pilots are taught you never engage flaps with visible ice on the leading wing edges? I never flew anything big, nor a jet, so I have limited knwoledge. All I know with boots is the planes I currently fly for my cargo airline, being the lil C402B that has boots, and a 16,000 lb turboprop with boots. Nor the FAA directives to us, our company SOP nor the flight manual prohibit from using flaps in icing.

There is an excellent NASA video about flaps in icing. You have two types of icing, the "regular icing" that accumulates on the plane, kills your airflow & add weight. In this type, the plane will stall the "regular way", due to those factors, u are advised not to land full flaps in case of you not having enought power available to maintain flight.
The other type is the tricky one, kind of called "tail icing" by some. This one is caused by changing the angle of attack/ airflow due to flaps extention. This type of icing will cause the nose to go down like a regular stall, BUT any attempt of typical remedy by the pilot by reducing the angle of attack by putting the nose down will INCREASE the stall. To correct that NASA states to "undo what you have done".

On a side note about icing, I did encounter severe icing in both the Turbo prop and the 402. In the Metro, at 17000ft the IAS went down from 180 to 130, but I could maintain flight there. In the 402, a couple of times each winter we can't maintain altitude. Once this year I droped from 13,000 to 9,500, ice accumulated from clear wings to not flying in less than 2 min. The other time, I was 10000, diped down to 9000. Sucks when the MEA is 10K  :uhoh Those 402B have the tiptanks, those are the killers. I noticed the 402C without the tiptanks have significant improvement in the ice.

About those boots, on my planes they are powered by vaccum pressure like my instruments but at 18 PSI, they are ususally rendered ineffective by multiple tiny cuts/holes in the boots.

Dawger already covered all that ... rock on dude ... I'm going back to honoring Vday I guess :D
« Last Edit: February 14, 2009, 09:40:23 AM by SFRT - Frenchy »
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Offline humble

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Re: Aircraft crash in WNY
« Reply #48 on: February 14, 2009, 10:01:50 AM »
I have no issues at all with anything, ....all my comments are based on what I've read specific to this. Obviously its a big topic amongst the guys who fly turboprops. Almost invariably every senior pilot (5,000+ hours PIC in turboprop) specifically comments to misconfiguration as the primary cause separate from all other findings. All these guys are hitting on everything said here but with a lot of speculation on crew decisions. Unequivocally feeling that 1) flaps should never have been deployed with known icing. 2) AP should have been off (no mention yet from NTSB) to avoid a sudden release to manual flight in a unstable configuration and also to provide sensory feedback to the pilot. From everything I can find its pretty clear that any icing condition on a turboprop will maximize issues with faulty decision making. Obviously more will come from NTSB but if it was a tail stall due to ice then the real cause is 100% pilot error for deploying flaps at low alt in those conditions.

Going back to the earlier crash, its specifically mentioned (on various pilot BBS's) that the actual cause of the uncommanded roll excursion was the retraction of flaps due to an over speed warning on decent. The crash itself was due to failure to recover from unusual attitude (busted the wingtips over stressing the AF). ....this is typical from a bunch of pilot BBS's...

No! On the Roslawn accident the F/O 'deselected' flaps! He had selected flaps in the holding to stay under max holding speed (Mistake!). When he got the clearence to descend, he forgot flaps and got a flaps overspeed warning. He then reduced flaps, and the roll upset begun.

« Last Edit: February 14, 2009, 10:17:20 AM by humble »

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Offline Wingnutt

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Re: Aircraft crash in WNY
« Reply #49 on: February 14, 2009, 10:16:10 AM »
I listend to the 30+ min ATC recording and right after the plane quit responding there was a lot of chatter from other aircraft saying they were building ice, also they brought them in at only 2300,   so slow shallow approach + building ice perhaps could have caused a rather abrupt "fall out of the sky" kinda stall, and at low altitude like that it would have been almost instant.. which makes more sense than an engine failure..   If an engine had failed they would have at lease had time to get a distress call out.

Offline Casca

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Re: Aircraft crash in WNY
« Reply #50 on: February 14, 2009, 10:21:23 AM »
Obviously more will come from NTSB but if it was a tail stall due to ice then the real cause is 100% pilot error for deploying flaps at low alt in those conditions.

Humble, I don't have any beef with you but you keep heading down this "pilot error" road pretty doggedly.  You applied it to Roselawn, in error, and you seem to be anticipating it in the current case.

The phrase "pilot error" is virtually meaningless if we consider anything more than the vaugest outlines of an accident or incident.  There is no element of correctability in "pilot error".  It can't be fixed.  Now if one says pilot errror, because the pilot had insufficient training;  or pilot error because the pilot was drunk; you have something that can be addressed.  So when you prospectively assess "100% pilot error" in this case permit me to disagree with both your phraseology and methodology.
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Offline Dawger

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Re: Aircraft crash in WNY
« Reply #51 on: February 14, 2009, 10:57:13 AM »
Humble,

It is a common error to assume the last event in the accident chain is the one that should have been avoided and therefore caused the accident.

I'm not going to argue the point that extending the flaps in an airplane covered in ice is a risky proposition. Doing it with the autopilot on is much riskier still.

However, the true cause of the accident reaches much farther back in the accident chain.

I'll describe what I mean.

A pilot I know ran out of gas in a light twin flying cargo. I'll describe the event backwards so everyone can see how an accident chain is built.

He ran out of gas and crashed 1 mile short of the runway on his second ILS approach.

He allowed ATC to vector him many miles and put him at the back of the line. (Last chance to avoid running out of gas)

He missed his first ILS in 800 overcast. I suspect the low fuel situation was making him nervous.

He flew from an airport 70 away from his final destination where he had a chance to fuel but he was running late.

He flew from an airport 30 miles away to land at the airport 70 miles from his final destination. He could have fueled there too but he was running late.

He started the trip at the airport that was his final destination. He could have fueled there but he was late for work.

He had 3 airports where he could have fueled but instead, because he was late, he took a chance. In the end his reluctance to declare an emergency and let ATC vector him on his second approach put him in the weeds short of the runway but if he left his house 30 minutes earlier that day none of the rest of the chain of events occurs.

There is a similar chain in the Roselawn accident. In fact, there are some pretty off the wall accusations about that particular flight but I won't speculate about those affecting the outcome.

I flew across Lake Michigan a few hours after the accident at Roselawn in Beech 18 from Kenosha to Wilmington, Ohio. I went over Detroit to stay out of the weather that downed the ATR. I did not find out about the accident until the next day.  I remember the weather system. It was evil, evil enough for me to avoid completely back when I would fly through anything.

Now, an ATR has a lot better ice protection equipment than a Beech 18 but that leads to complacency. And I suspect in that accident and in the one this week that complacency is deadly. Many pilots believe modern aircraft can survive any icing encounter and have no qualms about remaining in icing conditions.

It just isn't true. While lowering flaps on an ice covered airplane is a bad idea, it is an even worse idea to let the ice build in the first place, trusting the anti-ice and de-ice systems to save your bacon. It will build everywhere not protected by a system and sometimes where it is protected.

The number one priority is to avoid letting the ice build. Does that mean we can't operate in winter? Of course not. But pilots need to be aware that checklists and procedures are to fix problems that could not be avoided.

The dictum to not lower flaps when iced up assumes you did your level best to avoid the ice in the first place. It is not a free pass to fly in circles in icing nor is a guarantee that airframe icing won't make your airplane unflyable.

Fly through the icing layers, not in them. Icing rarely extends more than a couple thousand feet thick in any particular layer. Most of the time it is only a few hundred feet thick, usually near the top of a particular cloud layer. When I expect icing on approach I tell ATC exactly what I want to do and why I want to do it.

A combination of weather reports, pilot reports and experience make it fairly easy to figure out where an ice free layer is where we can start the approach and then plan a continuous descent from that non-icy level to the approach minimum.

And I do all that and I fly an airplane with excellent ice protection. I would never consider flying a holding pattern at an altitude where I was building ice. I won't fly at an altitude where I'm picking up ice for more than a couple minutes before I'm on the radio explaining why I need higher or lower immediately.

Ice is like wind shear used to be. Flying through conditions that had microburst/windshear potential close to the ground used to be routine but a series of accidents changed all that.

I suspect we are about to see icing get much the same treatment.

« Last Edit: February 14, 2009, 11:22:23 AM by Dawger »

Offline trigger2

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Re: Aircraft crash in WNY
« Reply #52 on: February 14, 2009, 02:30:38 PM »

no......we're at one.

the one in the hudson wasn't a crash. that was a perfect landing, considering the circumstances.

Perfect landing considering circumstances, yes. A downed aircraft making an emergency landing after taking damage and/or losing control of the aircraft due to outside forces, yes. Downed aircraft (crashes, this was a crash, a well controled one, very much so, perfectly executed) seem to come in threes, we're at 2...

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Offline CAP1

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Re: Aircraft crash in WNY
« Reply #53 on: February 14, 2009, 03:31:24 PM »
Perfect landing considering circumstances, yes. A downed aircraft making an emergency landing after taking damage and/or losing control of the aircraft due to outside forces, yes. Downed aircraft (crashes, this was a crash, a well controled one, very much so, perfectly executed) seem to come in threes, we're at 2...



i agree it was a downed aircraft, but it was by no means a crashed aircraft. the pilot had total control of his aircraft right up to the water landing.

 misinterpretations like this is what makes people that don't know/understand aviation think that flying is dangerous.

 not trying to be argumentative, just saying my view........
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Offline Cobra516

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Re: Aircraft crash in WNY
« Reply #54 on: February 14, 2009, 04:09:13 PM »
Here's an excellent video about tail icing from NASA with some in-flight tests at various flap configurations with simulated tail-ice.

http://video.google.com/videoplay?docid=2238323060735779946
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Offline Serenity

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Re: Aircraft crash in WNY
« Reply #55 on: February 14, 2009, 06:46:37 PM »
i agree it was a downed aircraft, but it was by no means a crashed aircraft. the pilot had total control of his aircraft right up to the water landing.

 misinterpretations like this is what makes people that don't know/understand aviation think that flying is dangerous.

 not trying to be argumentative, just saying my view........

The point being made though isn't that flying is dangerous, it is that it seems that "incidents" with aircraft appear to come in threes, (Which is a thought that has struck me before) and we are currently on our second incident. That means historically, the evidence says we are likely to experience one more "incident". Whether that is a CRJ landing without a nose-wheel, or a 747 nosing into the ground from 30,000ft, we are likely (Based solely on the pattern these incidents have followed in the past) to see one more "incident" soon.

And I must say, with all this talk of icing, I am mighty glad to be flying in Hawaii... all we have to worry about are commercial pilots asleep at the stick.

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Offline CAP1

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Re: Aircraft crash in WNY
« Reply #56 on: February 14, 2009, 10:27:31 PM »
The point being made though isn't that flying is dangerous, it is that it seems that "incidents" with aircraft appear to come in threes, (Which is a thought that has struck me before) and we are currently on our second incident. That means historically, the evidence says we are likely to experience one more "incident". Whether that is a CRJ landing without a nose-wheel, or a 747 nosing into the ground from 30,000ft, we are likely (Based solely on the pattern these incidents have followed in the past) to see one more "incident" soon.

And I must say, with all this talk of icing, I am mighty glad to be flying in Hawaii... all we have to worry about are commercial pilots asleep at the stick.

http://kgmb9.com/main/content/view/4199/40/

i understand that......that was just a comment i made, 'cause the media has been pissin me off lately, with their "sensationalizing everything bad.

 i get what ya mean about these things being in threes too. it seems to happen with everything bad.


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Offline Cobra516

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Re: Aircraft crash in WNY
« Reply #57 on: February 14, 2009, 11:29:29 PM »
There was a British Airways jet that collapsed the nose gear on landing
http://forums.jetcareers.com/general-topics/82479-british-airways-crash-landing.html

Also a Southwest airline 737 had a fire in the right engine shortly after takeoff from McCaren Intl. near Las Vegas
http://www.ktnv.com/global/story.asp?s=9837292

and a Baron crash in North Houston. 
http://www.msnbc.msn.com/id/29171370/#storyContinued

Bad week for aviation. :(
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Offline Serenity

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Re: Aircraft crash in WNY
« Reply #58 on: February 15, 2009, 12:03:21 AM »
i understand that......that was just a comment i made, 'cause the media has been pissin me off lately, with their "sensationalizing everything bad.

Agreed there 100%. Anything that will scare the public is a newscaster's wet dream. Its despicable.

Offline ebfd11

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Re: Aircraft crash in WNY
« Reply #59 on: February 15, 2009, 01:54:19 AM »
one of the passengers on that flight was a 9/11 widow, i cant remember her name but she was one of the most prominent members of that group.

 Also all i can say no matter what .. I hope and pray that the famlies the best and just how sorry i feel for them. RIP
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