US regional Colgan Air has proposed adding cockpit voice recorder data to its flight operations quality assurance programme in the aftermath of a fatal 12 February 2009 Colgan Bombardier Q400 crash in Buffalo, New York. The incident has turned attention to the crew's breach of sterile cockpit procedures.
Speaking at a National Transportation Safety Board inquiry that is also focusing on the pilots' training, scheduling, low pay and level of fatigue, Colgan vice-president of safety Daniel Morgan noted that the CVR proposal "is in its infancy".
However, Colgan has already requested that its pilots union, the Air Line Pilots Association (ALPA), review the feasibility of using CVR recordings as part of an enhanced quality assurance programme.
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In a recent letter to Mark Segaloff, chairman of the Colgan unit of ALPA, company vice-president flight operations Harry Mitchel wrote: "Today's flight operations quality assurance data deals only with the FDR [flight data recorder] information. This is excellent data that provides powerful safety enhancements - but has certain limitations, only a visual representation.
"If one could overlay the recording from the CVR to provide sound, not only for flightdeck communications, but also for the numerous other sounds generated within the flightdeck, the safety management system would immediately move to much higher level of safety. The power of data cannot be over-emphasised."
Sterile cockpit rules require pilots to refrain from non-essential activities during critical phases of flight. A transcript of the crashed Q400's CVR indicates that for a large portion of the flight, the pilots chatted casually about life on the line. During the final three minutes of the 12 February flight, with ice building on the aircraft, the crew discussed their lack of previous experience during icy conditions, NTSB member Lorenda Ward pointed out.
At 22:12:05 of the transcript, first officer Rebecca Shaw admitted: "I've never seen icing conditions. I've never de-iced. ... 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've freaked out. I'd have, like, seen this much ice and thought, oh my gosh, we were going to crash."
Shortly thereafter, the crew received a stick-shaker stall warning. Capt Marvin Renslow reacted as if startled and failed to respond appropriately, according to Colgan executives. "That crew was not ready to respond to the stall warning," says Colgan manager of flight standards Dean Bandavanis.
The aircraft stalled and went out of control on approach to Buffalo's Runway 23 and crashed into a house about 9km (5nm) from the airport at 22.17, killing all 49 on board and one person on the ground.
During the hearings, NTSB members repeatedly questioned whether the combination of low pay, long commutes and fatigue created a recipe for disaster. Crew training also continued to be in the spotlight, as Renslow had failed check rates in his records.
Colgan executives present at the hearing say the carrier's FAA-approved training programme provides comprehensive training on the stall warning system during initial Q400 ground school as well as annual recurrent ground school.
Seeking to clarify reports to the contrary, they say a pilot receives hands-on experience in the flight simulator on the proper response to stick-shaker activation.
"Captain Renslow and first officer Shaw did know what to do, had repeatedly demonstrated they knew what to do, but did not do it. We cannot speculate on why they did not use their training in dealing with the situation they faced," says Colgan.
Colgan's Mitchel says that, not long after the accident, the carrier's standardisation department "put a full blitz out" to reinforce sterile cockpit procedures.
Source: Flight International
