Aviation / Current

The Procedures Factor

Last February, while delving into the NTSB report on the crash of CO 3407 in Clarence Center, New York (a Colgan Q400 on approach to Buffalo International Airport’s Runway 23 on 12 February 2009), one of this blog’s authors uncovered a shocking misstep on the part of the FAA in 1999 that played a major role in the deaths of 50 people. 2009, unfortunately, had another crash that can be directly attributable to severely deficient stall recovery procedures.

William Langewiesche’s recently penned/typed a thought-provoking Vanity Fair piece, “The Human Factor,” which explores the crash of Air France 447 in detail. He traces the development of sophisticated aircraft systems, whose rollout concurred with a dramatic drop in aviation-related fatalities but completely misses the ticking time bomb that killed 50 people in February 2009 and another 228 in June of that year:

Stall phenomena are covered during the initial A320 type rating, according to the same philosophy of the manufacturer and the operator. They are not reviewed during the long haul passage, in CCQ 330, or during recurrent training.

At the time of the accident, the immediate actions were: simultaneously reducing angle of attack and applying TOGA thrust from the first signs of the stall (Stall warning / buffet onset). A minimal loss of altitude was expected.

See if the astute reader notices why 2009 stall recovery procedures today (or at least after August 2012) would be considered borderline psychotic:

(c) Stall warnings for the specific airplane.

(d) Reducing AOA is the proper way to recover from a stall event. Pilots must accept that reducing the airplane’s AOA may often result in altitude loss. The amount of altitude loss will be affected by the airplane’s operational environment (e.g., entry altitude, airplane weight, density altitude, bank angle, airplane configuration, etc.).  At high altitudes, stall recovery may require thousands of feet.

Altitude loss in the thousands of feet might be required to recover from a stall…especially if the stall occurs at a high altitude. Circa 2009 turbine aircraft stall training emphasized minimizing altitude loss—from this blog eight months ago:

What Procedures Caused This Crash?

This is the question the author feels that all accident investigators should ask first and foremost.  Naturally, questioning the procedures of powerful businesses and governmental organizations is not a common occurrence in this country.  Nevertheless, the NTSB really should have recognized that this is not at all appropriate:

Stall profile Entry into stall During stall Exit from stall
Landing stall 180 knots and minimum altitude of 5,000 feet AGL [(Above Ground Level)] with flaps at 35°, gear down, and power at flight idle  PF maintains altitude and Heading PF calls “stall,” advances power to rating detent, and calls “check power, flaps 15” PM calls “positive rate” PF calls “gear up.” PM calls “Vfri”

PF calls “flaps 0”

PF adjusts power tomaintain 180 knots 

Maintain altitude.  Essentially, air carrier training emphasized “powering out” of a stall—maintaining (or possibly increasing) pitch attitude so as to avoid any altitude loss or gain.

The FAA approved Colgan’s stall recovery procedures, procedures which did not bother to even mention a requirement to reduce pitch. Air France, to its credit, doesn’t omit reducing angle of attack in the French airline’s stall recovery procedures, but emphasizing altitude and heading control is extremely hazardous considering controlling heading and altitude isn’t possible unless the flying pilot first breaks the stall.

Okay, question for the regulators: what gives?

AC 120-109 is from August 2012—three and a half years after the Colgan crash.  I’m going to go out on a limb, and postulate the complete revamping of air carrier stall recovery procedures (more of a back to basics—after all, “lower the nose” is not news to pilots) wasn’t related to the investigation of CO 3407.  The NTSB did not argue that stall recovery procedures should be completely rewritten as a result of the February 2009 crash, though the NTSB was clearly aware of the problem:

Also, on July 29, 1997, the NTSB issued Safety Recommendation A-97-47 as a result of the ABX Air accident in Narrows, Virginia.  Safety Recommendation A-97-47 asked the FAA to do the following:

Evaluate the data available on the stall characteristics of airplanes used in air carrier service and, if appropriate, require the manufacturers and operators of flight simulators used in air carrier pilot training to improve the fidelity of these simulators in reproducing the stall characteristics of the airplanes they represent to the maximum extent that is practical; then add training in recovery from stalls with pitch attitudes at or below the horizon to the special events training programs of air carriers.

Not exactly “lower the nose,” but the NTSB in 1997 came extremely close with “pitch attitudes at or below the horizon.”  The FAA in response generated the inadequate stall recovery standard in effect from 1999 to 2012:

The FAA further stated that, to address the recommendation, it would revise the practical test standards to require pilots to adjust pitch, bank, and power to recover from an approach to stall and would add a note indicating, in part, that airspeed and/or altitude loss is critical at low altitudes and must be kept to an absolute minimum.

Ah—absolute minimum for altitude and/or airspeed loss. Got it.

Moreover, the NTSB had eventually given up altogether on pursuing improvements in stall recovery training:

On November 19, 1999, the NTSB stated that the ability of simulators to faithfully replicate an airplane’s actions in some stall and stall recovery regimes could be improved. The NTSB noted that generic simulator modules that were developed for some highly variable events have provided useful and necessary training for pilots. The NTSB pointed out, as an example, microburst and windshear simulator training, which provides realistic and effective training to pilots on specific models, even though an actual encounter is likely to be significantly different. The NTSB stated that it was disappointed that the FAA did not make changes to improve the fidelity of simulators in reproducing stall characteristics to the maximum extent feasible. The NTSB added that airline pilots need to be afforded this type of training so that they are fully prepared to recover stalled aircraft. As a result, Safety Recommendation A-97-47 was classified “Closed—Unacceptable Action.”

Ouch. Could it be argued had the FAA taken Safety Recommendation A-97-47 seriously the 278 people killed by CO 3407 and AF 447 probably wouldn’t have died in 2009?


One thought on “The Procedures Factor

  1. Pingback: Five Years After the Fall: The Atlantic Angle of Attack | In The Corner, Mumbling and Drooling

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