The International Cessna^® 170 Association

Just before the crash, while on approach, the first officer on Colgan 3407 was remarking about how he hoped to have a seasons experience in the northeast's icing weather before he had to upgrade to Captain...as he had no previous experience in icing conditions in the 1600 hours flying he'd done in AZ prior to his hiring.
Then.. the CVR recorded him saying:
"I've never seen icing conditions. I've never deiced. 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'dve freaked out. I'dve have like
seen this much ice and thought oh my gosh we were going to crash."

Next he said:
"but I'm glad to have seen oh— you know now I'm so much more
comfortable with it all."

The captain responded (with regard to his own icing experience) somewhat later:
"oh yeah— I'm so glad. I would've— I w— I mean—. I would've been been
fine. I would have survived it. there wasn't— we n— never had to make
decisions that I wouldn't have been able to make but...now I'm more
comfortable."

Unfortunate final comments. They stalled/crashed on that iced-up approach.

The entire transcript: http://www.ntsb.gov/Dockets/Aviation/DC ... 418693.pdf

Not that it makes any real difference, but the first officer on that flight was a 24-year-old woman with 2200 hours total time and 772 in type. http://en.wikipedia.org/wiki/Colgan_Air_Flight_3407

John

Familiarity breeds contempt. These comments, made just moments before their stall-warnings activated ....point to that sort of acceptance/rationalization of flight in icing-conditions. Just because one has seen ice before... never makes the next experience just as OK. EVERY TIME you fly with ice...you are a TEST pilot, regardless of any previous test-pilot's certification flights in that model aircraft that were approved by some bureacrat in an office in OKC.

The guys that shared this photo with me are believers!

I think what I found the most disturbing was the fact that the flight crew observed the ice build up, commented on it and yet did not seem to recognize the danger associated with it. Considering the conditions the Colgan flight crews are expected to operate in it is irresponsible to not provide them with the training required to deal with significant icing. I still remember a small commuter hiring low time instrument rated commercial pilots to place in the right seat because the second pilot was cheaper than an auto pilot.

It is not yet known if icing was a causal factor in this accident. The FDR indicated the icing systems were operating and I am sure NTSB will check the hardware to ensure there were no hard faults which takes time. The airplane is certified to fly in known icing which means it has been designed, engineered and flight tested to be able to maintain safe flight characteristics in those conditions. There is a level of icing that the deice/ant-ice will not be able to handle and when encountered, the crew must take action to escape. 121 air carriers give ground and flight training to their crews for that purpose. I would not go so far as to label pilots as test pilots when operating properly certified airplanes in icing conditions and I can tell you there are no beauracrats in OKC involved in that process. There are engineers and test pilots who work in the aircraft certification office for transport category aircraft who perform those functions.
Regarding the CVR, the transcript reveals a compromise of sterile cockpit procedures which will cause a distraction from monitoring duties of both pilots. When you operate an airplane using an autopilot, and especially in hazardous conditions such as icing, both pilots have a duty to pay strict attention to what is happening. The pilot flying uses/programs the autopilot to fly/control the airplane and must always be just ahead of it to avoid mistakes. The pilot not flying does not have the responsibility of aircraft control and is supposed to actively monitor the "situation" (big picture) and to actively monitor the pilot flying performance to make sure control inputs are per the plan. Pilot not flying duties include active call outs for any non standard condition from excessive ice/hazardous wx, a flying pilot deviation from an aircraft limitation/clearance/SOP, or any condition affecting safety. This is both taught, practiced, and tested in airline training and qualification programs. The CVR records of this flight are very concerning because the nature of the conversation is not consistent with acceptable cockpit discipline and the results indicate that both crewmembers were completely unaware of the flight condition that ultimately led to a stall and a fatal accident.
There has been talk of low paid pilots and inexperience. While these may be relevant factors, high paid experienced pilots are not immune. I have a friend who was jump seating from Hawaii in a DC-10 operated by a major airline with a highly experienced crew years ago. As they descended to an intersection southwest of San Francisco with a crossing and speed restriction, the non flying pilot did not properly set the auto throttles and the fully loaded airplane leveled off with near idle thrust set. Neither pilot or FE caught it and the stick shaker came on. Another jump seat occupant (senior captain) screamed "Airspeed guys, Airspeed!!" It took the flying crew more than a few seconds to figure it out and finally someone slammed the thrust levers forward averting a potentially disasterous problem. That little "incident" was probably never reported or investigated but it kind of makes you wonder doesn't it? This flying business is serious. Whether your buzzing around on a beautiful spring day in a Cessna 170 or trying to make your living in a commuter plane flying in ice you have to pay attention to what is happening around you and take it seriously.

Or, as Ernest K. Gann wrote in Fate is the Hunter, "In this game we play for keeps".

My previous comments were intended to remind everyone that engineering test pilots help in the certification process that bureacrats document in nice, comfortable offices. Neither the certification testing nor the office-job are guaranteed to duplicate what line-pilots experience in actual flight conditions.

This crew was operating on autopilot and clearly unaware of the flight-control feedback the autopilot-operation masked. They likely had no warning that their normal approach-speeds would be inadequate under those conditions and both pilots discussion-points were to the effect that they had little previous experience in icing conditions prior to the Colgan job... yet their luck so-far in avoiding death on-the-job aparently led them to a feeling of false-confidence with regard to ice.

In other words: they were complacent about ice due to lack of experience and an associated lack-of-respect for the experimental nature of EVERY FLIGHT IN ICING CONDITIONS. I am disappointed that anyone would suggest that because an airplane has passed icing certification requirements that flights in icing conditions could be considered ordinary or routine, if the aircraft were operated according to it's certification, regardless of the individual nature of every flight. I believe this attitude contributes to the complacency which many pilots develop in line-operations. as a former demo and production-test pilot (albeit non-engineering) for a major manufacturer who has flown on icing test flights, I know it to be untrue. Airplanes fly predictably only in icing conditions which exactly duplicate the certification tests. All other conditions are EXPERIMENTAL TEST CONDITIONS. How many icing certification tests do you imagine were flown on actual approach just a few hundred feet above the ground with the autopilot engaged? Yet that is how this airplane, and many many others are actually operated, and done so by pilots even less-experienced than the accident flight.

I predict that investigators will critique those dead pilots for discussing icing conditions ...while in icing conditions.... as being off-topic and in violation of the sterile-cockpit-rule.... and pat themselves on the back thinking they have truly addressed a causal factor of this accident. B.S. with CAPITAL LETTERS.

At the risk of criticism for so stating it prematurely, ... in my opinion: The cause of this accident was ice accumulated beyond the capability of the aircraft, and the flight crew's failure to recognize it due to a combination of inexperience, a rationalized lack of respect for it (possibly due to a combination of past luck coupled with inadequate/ineffective training), and their continual use of the autopilot in icing conditions (which masked the aircraft's actual precarious condition.)

The victims of this accident along with airline crews and passengers deserve a thorough investigation and it is too early to make any conclusions based on information that has been released by the press. NTSB investigations are not secret in our country and the information we are recieving through the media is interesting and provacative. Perhaps the airline industry itself will be the first beneficiary of this process because the performance of the crew, the circumstances of their employment, and the organizational influences that are being reported have a direct relationship to aviation safety and there are huge lessons already being learned. Having said that, it is a big mistake to jump to conclusions in considering the cause of an accident of this complexity. The process takes time and involves establishing facts and eliminating potential "causes" following a thorough investigation. Regarding icing, this airplane is capable of flying in icing conditions and does so on a routine basis. The night of the accident, another Colgan Q400 and many other airline aircraft landed safely in Buffalo after flying through essentially the same weather as the accident aircraft. The NTSB will certainly evaluate all parts of the deicing system to determine if there were any faults that occurred prior to impact and we can not draw any conclusions until this process is complete which will take at least a year. I do not understand George's assertions that flying in icing conditions is some kind of "test pilot" scenario. I flew for a large regional airline for 25 years and experienced icing conditions during the winter in a variety of airplanes but learned that icing is a hazard that can be managed by both company management (dispatch & maintenance to be specific) and individual flight crews. I think that the airline accident record supports my position. Regarding FAA certification and, again with all due respect to George, the process is not beauracratic. It is a design and engineering process that meets a safety standard which is recognized world wide. Of course it is applied in the real world to weather which is subject to extremes such as evidenced by the picture George posted. For those of you who do not fly professionally, please understand that airline flight crews are trained to fly in icing conditions. They have extensive preflight planning and are taught and tested to recognize hazardous icing conditions and take evasive action when necessary. All weather flying is safe. This accident was an anomoly and it will take a careful investigation to determine what happened so we can fix it. Some of you may remember Roselawn where an American Eagle ATR 42 crashed due to ice accretion. That investigation determined a fault in the design of the aircraft's wing deice boots that has since been corrected. We need to let the same process take place in this instance. In the days after that accident, so called "experts" were spreading similar blame before the facts came in.
We are near the end of an extraordinary cycle in commercial aviation that has seen the regional airline industry and the regional jet take over a huge percentage of airline capacity in this country. It started in the end of the 90s and accelerated after 9/11 and it has been accomplished with argueably the best safety record in aviation history. There have been some good and not so good regional airlines but this record speaks volumes for their management and their mostly younger and probably "inexperienced" pilots and mechanics. We should also mention that the industry has greatly benefited from the lessons learned by the legacy airlines in the 70s AND 80s most particularly in human factors and safety risk management. I believe that general aviation can also benefit from these lessons but I recommend we listen and learn rather than pound our chests and act like we already know it all.

Harlow and all...please do not misunderstand what I am addressing as a discussion... not a proclamation....not an argument. It's a discussion intended to reinforce a healthy respect for ice in all.

"...the performance of the crew, the circumstances of their employment, and the organizational influences that are being reported have a direct relationship to aviation safety and there are huge lessons already being learned..." While this is certainly a well-constructed elucidation, it does not address the fact that this type of accident has occurred over and over and over again...in the same industry...for over 60 years ....despite the authorities "certifying" the planes and pilots.

I am not suggesting we leap to a conclusion. I am suggesting we take greater caution and expedite departures from icing conditions whenever/whereever they are encountered. Just because an airframe was once "certified" does not make it "...capable of flying in icing conditions ... on a routine basis..." My comments are intended as a wake-up call and return-to-reality that icing is never routine and that individual encounters are unique...not necessarily predictable.

The picture I posted is an example of the many things that can occur to make the "routine" .... nothing like routine! A proper preflight can demonstrate the anti-icing system on an airplane is working just fine. Then in actual conditions (by the way, the SAME conditions in which both aircraft and flight crew were "certified" airworthy...) the system failed to keep the ice off the airplane. That was only one photo of that aircraft. I have more of the other wing, tail, etc. which continues to demonstrate the validity, or lack of, a "certified" system. (One which was run past all those bureacratic paper-shufflers that sit safely behind desks telling pilots that airplanes will fly reliably in ice. Harlow, I am not talking about YOU. I am talking about all the people who participate in the paperwork side of the certification process until they begin to believe their own crap that airplanes are safe to fly in ice.)

My remarks are also intended to point out that because "...airline flight crews are trained to fly in icing conditions...." does not insulate them from the common errors of assumption that because they've survived previous encounters, they are somehow insured of success in subsequent encounters. Based upon their recorded conversation, that is precisely the attitude which seemed to exist in the Colgan cockpit, only moments before they screamed and died,... and one which I hope to dispell in this discussion.

The mere repetition of that phrase ""...airline flight crews are trained to fly in icing conditions...." is onerous to me. NO! WRONG ATTITUDE!
Airline and other pilots SHOULD be taught NOT to fly in ice!
Yes... taught how to deal with it should they encounter it, but they should be TAUGHT to avoid it, deal with it when avoidance didn't work, and exit it.

Of course, the same old managerial forces will continue to influence things. Airlines will hire inexperienced crews, pay them as little as possible (while complaining that qualified pilots are hard to find), and dispatch them into ice on a "routine" basis.

I'm not pooh-pooh-ing training and the discovery and application of correct operating practices for specific airframes. That's all well-and-good... but only as a temporary measure for the purposes of exiting icing conditions. (Notwithstanding the reporting-guidelines mentioned in the AIM,... ALL ice is SEVERE ice! Every level of ice on an airframe...from heavy rime and thick clear, to light frost .... has been the cause of fatal accidents in aircraft. EVERY LEVEL. There is no such thing as "light or moderate" ice, in my opinion.)

I also have what some might consider "experience" in flying icing conditions. I have flown professionally for over 38 years in commuter-airline, gov't, corporate, and factory test-flight work. I participated in the actual icing certification tests of the airplane pictured above as a factory pilot. I have many hours of line-operations in icing conditions.
Only a healthy respect for ice, and a firm personal-policy incorporating a determined goal of avoidance and exiting all ice, will satisfy me.
It seems to me that it's the folks who claim they can fly in ice, that are pounding their chests.

George,
ICan't help but agree with your position that no two icing conditions are the same. I had my ass chewed off a couple of times by management when I wouldn't go on account of forecast likely icing cotitions. I always made it a point to avoid any known icing and if inadvertant icing was encountered, made every effort to get out of it in the most expedient way even if I had to declare an emergency. In my oinion, any pilot who will willingly fly into known icing conditions in any type of airplane, depending on either anti icing or deicing equipment to keep things safe, is either ignorant or has a death wish.

George and BL, I don't want to argue with you guys but I feel like I have to defend the industry I spent a great deal of my life a part of. I flew for a scheduled regional airline with bases up and down the west coast and for 4 years had a base at Washington Dulles. In the winter, we encountered icing conditions on a routine basis. When I started in the 70s I didn't know anything about icing conditions and I flew equipment that, while certified for icing was marginal at best. In the 80s and 90s, I flew equipment that could handle light to moderate icing conditions and received very effective training on the ground and in simulators that prepared us to recognize icing and deal with it safely. I never went looking for icing and, as George recommends, I would always find a safe way through or out of it. I never recall a company manager pressuring us to fly through icing in my 25 years. They used to spend lots of money getting us the best airplanes and equipment to handle the conditions we flew in every day. I do remember our dispatchers cancel flights if there were reports or forecasts of serious icing or conditions that we could not handle. We were drilled on problems associated with autopilots and icing conditions and actually had two serious incidents at our company both involving Embraer Brasilias. In both cases, it was pilots not flying by our SOPs that caused the problems, not the icing which would have been flyable had they paid attention. In my 25 years, I experienced two times where I really got scared, once in a Twin Otter between Reno and Sacramento and once in a Shorts 360 between Santa Rosa and Arcata. In both cases, we accumulated more ice than the system could shed and we were unable to maintain altitude with full power. In both cases the previous leg along the same route an hour earlier was uneventfull which shows how fast dangerous conditions develop and really supports what George is saying. Both times I was fortunate to be able to descend to a lower altitude and warmer temperatures. I don't think that is a bad record. In my later years I got to fly pressurized turboprops and jets that could fly above icing and weather. We had a large fleet of those airplanes and the problems involving icing conditions were minimal. Am I missing something here? I fully agree with George that icing is dangerous, but do I understand you to say we should never knowingly enter it? If that were so, the airline industry would come to a complete stop in the winter and in some locations, year round. We would not be able to take off for example if we knew we would pick up ice on climbout and get it again on descent. Regarding pilot experience, we used to hire pilots with 1500 hours, sometimes less and they would go at least a year before becoming captains. During this year they were exposed to weather and other hazards and the vast majority became successful captains and many went on to fly for the majors. I am sure that quite a few of them now complain about new inexperienced pilots such as the fo on Colgan's flight, while forgetting that all of us were in that category not so long ago. Don't we all start out inexperienced?
Incidentally, safe flight in icing conditions depends on proper maintenance of equipment. Pilots need to test deice/ant-ice equipment before flight and monitor it during flight. We need to follow manufacturer recommended published procedures in the AFM. I recommend use of products such as icex on pneumatic boots to help make them more effective. Is the picture that George posted show an airplane that had a defective leading edge deice system, maybe an alcohol weeping wing? One section of the wing has significant build up while the inboard seems cleaner. If a system is not properly maintained, it won't work. Anyway, this is an interesting discussion and I fully agree you need to be carefull in icing conditions but I would not go so far as to say we should NEVER fly in it.

voorheesh wrote:George and BL, I don't want to argue with you guys but I feel like I have to defend the industry I spent a great deal of my life a part of. ... .

Yes, let's all remember we are only having a gentlemen's discussion... nothing personal in this...

I think it's dangerous for your reputation to attempt to defend what this industry has done in many cases. This industry is famous for repetitous errors.

voorheesh wrote:...They used to spend lots of money getting us the best airplanes and equipment to handle the conditions we flew in every day. I do remember our dispatchers cancel flights if there were reports or forecasts of serious icing or conditions that we could not handle. ...

That's a fine memory to have, but in fact I doubt that the pilots were appraised of all the facts behind-the-scenes of the operation. The company-position will likely be more concerned with money and profitability and positioning more than the workload of pilots fighting ice. And companies believe the salesman's hype about how well-equipped for ice particular aircraft are....and continue to believe it, having spent their money on it.... seeing reluctant pilots as being lazy and troublesome. (Then some chest-thumper sucks up and announces HE will go! ...putting additional pressure on peers.) What were the administrative specifics of those cancelled flights? Too few pax? Too high operational costs for de-icing fees at the other end for the number of pax? Too high a probability of equipment being caught, cancelled by pilots, stuck somewhere out-of-position? Those are more likely the reasons for most airlines to cancel flights.

OK, so the Brasilia was certified to fly in ice. The pilots were certified and trained. Why do you suppose they refused to follow SOPs they knew to have their safety in mind? Death wishes? Or more likely an inner-drive to please and to accomplish the mission, which most pilots have lying in their subconscious...waiting to quietly bite them. It's all too easy to condemn others whose luck caught up with them from our armchairs. I seriously doubt those Colgan pilots would have continued do what they were doing if they could have looked forward three minutes. But they were victims of their past flights that didn't crash in ice. They drank the comforting Kool-Aid served by the hostess of past-experience.

voorheesh wrote:...new inexperienced pilots such as the fo on Colgan's flight...

Let's keep in mind that it was the Captain on that flight who bears the ultimate responsibility for the matter, and HE sat there and mirrored the same complacent attitude of the FO, actually saying out-loud "...oh— you know now I'm so much more comfortable with it all." .... #%#^$# DEAD IDIOT! How did he come by that attitude? I'll tell you: He bought into the same B.S. that so many pilots buy into when they accept the claims that airplanes and companies and ATC and FAA and other pilots make....that it's OK to fly in icing conditons, until they segue into sitting there on autopilot driving along thru the stuff for two hours! He'd drunk the Kool Aid.
The FO, had she not also drunk the Kool Aid, would have been a lot smarter without the experience, as proven by her remarks only three minutes before she died, "I'dve have like
seen this much ice and thought oh my gosh we were going to crash." The Kool Aid and her captain's complacency made her stupid.

Never fly in ice? No, that's not what I said. But I will not launch into continuous icing conditions. If I cannot have a way to climb up out of it, or detour around it, or get quickly below it, .... I will not take the flight.

The pic I posted? It was a fully certified, operational system that failed in flight. Just like a single engine pilot should always consider an engine failure.... Just like a multi-engine pilot should always consider an engine failure.... Just like an overwater pilot should always consider an engine failure... a pilot contemplating flight in icing conditions either needs to have an alternative to flying in ice (exiting or detouring).... he'd better consider the possibility of anti-icing system failure!

(That pic is not a commentary on any particular type of anti-icing system. ALL anti-icing systems have failure-modes. Preflight inspection demonstrated that aircraft to be fully operational. MOST of the TKS system handled the workload, but preflight inspection does not PROVE anything! A pnuematic de-ice boot might inflate just fine on the ground. But I've personally had them rip off the airplane when they were activated in fight against relative wind. TKS systems may "weep" just fine on the ground, but that's no guarantee they'll properly distribute fluid in FLIGHT. Hot wings may pass a pressure-test on the ground...but bleed valves FAIL in flight all the time! Think about THAT next time you consider taking a flight in icing conditions.

Make it YOUR PERSONAL attitude that ice is only to be penetrated THROUGH.... NOT FLOWN IN ....IF you have a properly equipped airplane.

George, now I understand what you are saying and I agree with you. It is ok to fly into icing conditions in a properly equipped and maintained aircraft but you must have an exit strategy and you do not launch into continuous icing conditions that do not leave a way out. Thats more like the way my company operated and it is good advice. I can tell you have had your dose of management influence and I see that as a factor in the Colgan Air crash. The V.P. of safety defends 16 hour duty/8 hour flight days and makes comments such as "we expect our crews to show up well rested etc.etc" But then they only pay them enough to barely eat and won't give them a hotel room unless they are on a trip away from their base. This is talking out of both sides of the mouth. A good director of safety should be presenting management with risk analysis material that includes ways to make sure crews are rested. The crews are responsible for making life style decisions such as living in Seattle and working out of Newark which will undoubtedly cause fatigue and degrade performance. These "cultural" factors are imbedded in the airline industry and it is very sad that so many people have to die to bring them out in the open. I am hopefull that the FAA and the industry will address these issues with the same enthusiasm we did CRM and training when I worked. By the way I enjoyed my first, last and every flight in between during my days in the regionals and wouldnt hesitate to do it all over again. Harlow

Yes, I also thoroughly enjoyed the commuter airline experience. (Especially as back-then, penicillin would cure ANYthing.)