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Pinnacle Flight 3701 Ntsb Determines Cause  
User currently offlineAirfoilsguy From , joined Dec 1969, posts, RR:
Posted (7 years 11 months 2 weeks 2 days 5 hours ago) and read 5816 times:

Looks like they are blaming the pilots for this one. Its too bad this had to happen but it shows what happens when you don't follow proper procedure.

10 JAN 2007 NTSB determines cause of fatal CRJ crash in Jefferson City
The NTSB has reached its probable cause statement and safety recommendations regarding the October 14, 2004 accident at Jefferson City involving a CRJ accident: The National Transportation Safety Board determines that the probable causes of this accident were (1) the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover, in part because of the pilots' inadequate training; (2) the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; and (3) the pilots' failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the engine cores to stop rotating and resulted in the core lock engine condition. Contributing to this accident was 1) the engine core lock condition, which prevented at least one engine from being restarted, and 2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating. (NTSB)


http://aviation-safety.net/news/newsitem.php?id=1757

http://www.ntsb.gov/publictn/2007/AAR0701.htm

[Edited 2007-01-11 17:14:00]

[Edited 2007-01-11 17:14:28]

23 replies: All unread, jump to last
 
User currently offlineAvConsultant From United States of America, joined Feb 2006, 1360 posts, RR: 2
Reply 1, posted (7 years 11 months 2 weeks 2 days 5 hours ago) and read 5742 times:

Quoting Airfoilsguy (Thread starter):
1) the engine core lock condition, which prevented at least one engine from being restarted, and 2) the airplane flight manuals that did not communicate to pilots the importance of maintaining a minimum airspeed to keep the engine cores rotating. (NTSB)

Basic airmanship should have ensured prevented this.

These investigations reveal peer review. I have not seen any of these reports.


User currently offlineAirfoilsguy From , joined Dec 1969, posts, RR:
Reply 2, posted (7 years 11 months 2 weeks 2 days 5 hours ago) and read 5708 times:

I finally found the transcript for the flight recorder. It is rather sobering.

http://www.ntsb.gov/events/2005/Pinnacle/exhibits/CVR_Factual.pdf


User currently offlineLTBEWR From United States of America, joined Jan 2004, 13199 posts, RR: 15
Reply 3, posted (7 years 11 months 2 weeks 2 days 4 hours ago) and read 5657 times:

The NTSB preliminary report is especially critical about the unprofessional behavior of the pilots and makes clear that pilots not operate aircraft so close to their limits. It also goes on to recommend pilot training, including from the airlines programs, to include prevention of such incidents in the future, how to reduce the risks of such stalls, how to get out of them if possible (including simulator training) and for all normal operations limits to apply to ferry, repositioning and non-revenue flights.
Additional recommendations also included improvements in some of the flight recording equipment to improve the details and accuracy of it.
It's a shame that these pilots chose to act in such an unprofessional and dangerous matter and ending up killing themselves. But for some stroke of luck, this a/c could have crashed into a home, an apartment building or a chemical plant and killing many more on the ground. These guys definately should have been nominated for a Darwin Award. Sadly, in death they will remembered as fools for stupidly seeking a thrill.


User currently offlineAvConsultant From United States of America, joined Feb 2006, 1360 posts, RR: 2
Reply 4, posted (7 years 11 months 2 weeks 2 days 4 hours ago) and read 5597 times:

Quoting LTBEWR (Reply 3):
But for some stroke of luck, this a/c could have crashed into a home, an apartment building or a chemical plant and killing many more on the ground. These guys definately should have been nominated for a Darwin Award. Sadly, in death they will remembered as fools for stupidly seeking a thrill.

Well said, we're very fortunate others were not killed. What a bunch of jackasses!!


User currently offlineSkibum9 From United States of America, joined Nov 2001, 1229 posts, RR: 0
Reply 5, posted (7 years 11 months 2 weeks 2 days 4 hours ago) and read 5573 times:

Just wait. Someone on this board will try to argue against this finding, saying something like the pilots had no blame in the incident and it was all Pinnacle's fault for training, Canadair for the manuals and GE for the engines.


Tailwinds!!!
User currently offlineLowrider From United States of America, joined Jun 2004, 3220 posts, RR: 10
Reply 6, posted (7 years 11 months 2 weeks 2 days 4 hours ago) and read 5529 times:

One issue I am surprised no one has mentioned was the fact that they lied about the extent of the emergency to ATC. They said that they had an engine out, not a dual engine failure or both engines out. I don't know if Pinnacle taught these guy about minimum climb speeds, but if they did, it is safe to say that neither one paid attention in class that day. What a waste.


Proud OOTSK member
User currently offlineAirfoilsguy From , joined Dec 1969, posts, RR:
Reply 7, posted (7 years 11 months 2 weeks 2 days 4 hours ago) and read 5510 times:

Quoting Lowrider (Reply 6):
One issue I am surprised no one has mentioned was the fact that they lied about the extent of the emergency to ATC. They said that they had an engine out, not a dual engine failure or both engines out.

I always wondered why they did this. Is there some kind of report that needs to be filed by ATC when a plane has a duel engine failure that doesn't need to be filed if only on engine fails? Maybe they were trying to avoid this.


User currently offlineBurnsie28 From United States of America, joined Aug 2004, 7564 posts, RR: 8
Reply 8, posted (7 years 11 months 2 weeks 2 days 3 hours ago) and read 5448 times:

Quoting Airfoilsguy (Thread starter):
Looks like they are blaming the pilots for this one.

Every flight in the end leads to pilot error, it may not be the first factor but in the end is an overall cause.



"Some People Just Know How To Fly"- Best slogan ever, RIP NW 1926-2009
User currently offline2H4 From United States of America, joined Oct 2004, 8956 posts, RR: 60
Reply 9, posted (7 years 11 months 2 weeks 2 days 3 hours ago) and read 5420 times:
AIRLINERS.NET CREW
DATABASE EDITOR




Quoting Burnsie28 (Reply 8):
Every flight in the end leads to pilot error, it may not be the first factor but in the end is an overall cause.

Not at all. How do you explain terrorist attacks? How about animals running out onto the runway directly in front of the airplane in fog or darkness?

Not every accident is a result of "pilot error", nor is "pilot error" a factor in every accident...


2H4





Intentionally Left Blank
User currently offlineYYZYYT From Canada, joined Apr 2005, 999 posts, RR: 0
Reply 10, posted (7 years 11 months 2 weeks 2 days 3 hours ago) and read 5399 times:

There was a very good thread about this a long time ago, after the transcripts and the pilots' antics were first disclosed to the public. In particular, a good discussion of the pilots decision to climb to FL410 and the engine restart procedures. Oh, and a lot of speculation / opinion as to who should/would be found responsible....

http://www.airliners.net/discussions...general_aviation/read.main/2167624


User currently offlineAirfoilsguy From , joined Dec 1969, posts, RR:
Reply 11, posted (7 years 11 months 2 weeks 2 days 3 hours ago) and read 5383 times:

Quoting Burnsie28 (Reply 8):
Every flight in the end leads to pilot error, it may not be the first factor but in the end is an overall cause.

Every mishap is the result of error on someones behalf but not always the pilots. True, alot of mishaps have a factor of pilot error but nobody is perfect. With all that the pilots have to do in the flying of an airplane it is almost imposable for even the best of flights to go completely perfect. During the investigative process EVERYTHING that happens prior to a crash is pointed out. There is usually something the pilot did or didn't do that can be a contributing factor in a crash but not the whole reason the plane crashed.


User currently offlineJdl1527 From United States of America, joined Aug 2006, 52 posts, RR: 0
Reply 12, posted (7 years 11 months 2 weeks 2 days 2 hours ago) and read 5351 times:

Quoting 2H4 (Reply 9):
Not at all. How do you explain terrorist attacks? How about animals running out onto the runway directly in front of the airplane in fog or darkness?

Not every accident is a result of "pilot error", nor is "pilot error" a factor in every accident...

Amen

My father always told me that there are old pilots and there are bold pilots but there are no old bold pilots.

I guess that we can all me thankful that these two pilots mis-actions and unprofessional attitudes did not cost anyone on the ground their life's.

We should all take this as a lesson as to that these two did not die in vein.


User currently offlineAvConsultant From United States of America, joined Feb 2006, 1360 posts, RR: 2
Reply 13, posted (7 years 11 months 2 weeks 1 day 22 hours ago) and read 5172 times:

Quoting Airfoilsguy (Reply 7):
Maybe they were trying to avoid this.

I think they were trying not to draw attention to themselves. An pax jet (empty or not) with a dual engine failure will draw a lot of attention.


User currently offlineAvConsultant From United States of America, joined Feb 2006, 1360 posts, RR: 2
Reply 14, posted (7 years 11 months 2 weeks 1 day 22 hours ago) and read 5166 times:

Quoting YYZYYT (Reply 10):
after the transcripts and the pilots' antics were first disclosed to the public.

When I read the transcripts all I could think of was "Beavis and Butthead"


User currently offlineWjcandee From United States of America, joined Jun 2000, 5339 posts, RR: 23
Reply 15, posted (7 years 11 months 2 weeks 1 day 15 hours ago) and read 5037 times:

Well...

Here's the thing:

There is no doubt that the two pilots showed poor airmanship in "greasing" it to the altitude that they did, arriving behind the power curve, and not recognizing the myriad signs that the thing was about to stall. However, they *did* use the autopilot to effectuate the climb, apparently unaware that the autopilot in climb-rate mode would happily put them at the altitude behind the power curve; apparently, this autopilot was not supposed to be used in certain modes above a certain altitude, and they either did not remember this or were never taught it.

Once they stalled, they also appear first to have gone into ass-covering mode by not revealing the dual-engine-out, and poor CRM by not dividing up the work between attempting a restart and finding a safe place to land dead-stick, which they initially had *plenty* of time to do. However, it is completely-comprehensible that they got tunnel-vision trying to do the relight, expecting that they would be able to do so. It is also the case that the Pinnacle checklist was confusing in numerous respects. Among other things, it could have been read to say that you can't attempt an APU restart above a certain altitude -- which is not the case; you can attempt such a restart -- so when the windmill relight failed, they actually intentionally descended to a lower altitude to attempt the APU restart. It is unclear why the APU restart failed as to at least one engine. However, airmanship was also involved here, because they never pointed the nose down enough to achieve enough airspeed for the windmill relight, even though they appear to have thought that they had. Here, the characteristics of the GE engines (requiring very high airspeed for windmill relight) also played a factor: they're great at not sucking in FOD, but that very characteristic makes them require a high airspeed to windmill-relight.

These guys screwed up big time in getting into the position that they found themselves. But they did not deserve to die for it, and I think that to jeer them on this forum is really undignified. They were two scared guys, who when put into a position I hope that none of us finds ourselves -- regardless of why they got there -- were less-than-optimally-served by their training, their equipment, and their checklist. At the last moment, when they realized that they were not going to make the airfield (and they did almost make it), they steered their plane away from houses and then died.

We can learn from the airmanship mistakes that got them where they were. We can learn from the airmanship mistakes that contributed to their inability to relight their engines and to have a safe place to land. But we should also recognize that they were, by all accounts, amiable guys, and we should respect them for attempting, in their final moments, to minimize the harm on the ground.

PS The investigation also revealed a certification problem with the CRJ, which is that the aircraft can't windmill-restart below an unusually-high altitude, because of the velocity necessary to accomplish the restart. You can APU-restart below that altitude, but, amazingly, SOP was that you could MEL the APU. Accordingly, if you ever found yourself in the unlucky situation of having a dual-engine flameout anywhere below a certain altitude, you die (or at least you can't relight either engine). I would be curious as to whether you can still MEL the APU on the CRJ.


User currently offlineAPFPilot1985 From , joined Dec 1969, posts, RR:
Reply 16, posted (7 years 11 months 2 weeks 1 day 15 hours ago) and read 5025 times:

Quoting Wjcandee (Reply 15):
I would be curious as to whether you can still MEL the APU on the CRJ.

According to the MMEL you can


User currently offlineDispatchguy From United States of America, joined Jan 2006, 1253 posts, RR: 2
Reply 17, posted (7 years 11 months 2 weeks 1 day 12 hours ago) and read 4977 times:

Quoting Wjcandee (Reply 15):
These guys screwed up big time in getting into the position that they found themselves. But they did not deserve to die for it, and I think that to jeer them on this forum is really undignified. They were two scared guys, who when put into a position I hope that none of us finds ourselves -- regardless of why they got there -- were less-than-optimally-served by their training, their equipment, and their checklist. At the last moment, when they realized that they were not going to make the airfield (and they did almost make it), they steered their plane away from houses and then died.

We can learn from the airmanship mistakes that got them where they were. We can learn from the airmanship mistakes that contributed to their inability to relight their engines and to have a safe place to land. But we should also recognize that they were, by all accounts, amiable guys, and we should respect them for attempting, in their final moments, to minimize the harm on the ground.

The perfect point to be made...



Nobody screws you better than an airline job!
User currently offlineAvConsultant From United States of America, joined Feb 2006, 1360 posts, RR: 2
Reply 18, posted (7 years 11 months 2 weeks 1 day 7 hours ago) and read 4913 times:

Quoting Wjcandee (Reply 15):
But we should also recognize that they were, by all accounts, amiable guys, and we should respect them for attempting, in their final moments, to minimize the harm on the ground.

I'm sure the Darwin awards have been littered with amiable people. Either way, these 2 guys killed themselves and perfectly good airplane in their words - "let's have a little fun".

I have "ZERO" respect for these guys actions. We have a enough bad shit in this industry beyond our control, we don't need the public thinking these antics are common occurances. It's still fresh, we live in a society where the media writes themselves as "Experts". We know this not the case, but John and Jane Doe who travel once a year do not realize this. Then you hope a politician does make this a soapbox.

This is a PR nightmare for everyone because 2 guys
"wanted to have a little fun."


User currently offline2H4 From United States of America, joined Oct 2004, 8956 posts, RR: 60
Reply 19, posted (7 years 11 months 2 weeks 1 day 7 hours ago) and read 4881 times:
AIRLINERS.NET CREW
DATABASE EDITOR




Quoting AvConsultant (Reply 18):
I have "ZERO" respect for these guys actions.

I have "zero" respect for their more childish actions that night, but I have considerable respect for the actions they took to minimize harm on the ground.


2H4





Intentionally Left Blank
User currently offlineD L X From United States of America, joined May 1999, 11573 posts, RR: 52
Reply 20, posted (7 years 11 months 2 weeks 1 day 7 hours ago) and read 4856 times:

Quoting AvConsultant (Reply 18):
I have "ZERO" respect for these guys actions.

DId they deserve to die?



Send me a PM at http://www.airliners.net/aviation-forums/sendmessage.main?from_username=NULL
User currently offlineWjcandee From United States of America, joined Jun 2000, 5339 posts, RR: 23
Reply 21, posted (7 years 11 months 2 weeks 1 day 3 hours ago) and read 4768 times:

Quoting AvConsultant (Reply 18):
We have a enough bad shit in this industry beyond our control, we don't need the public thinking these antics are common occurances

I totally agree. Indeed, what this accident exposed was that it was relatively common at some commuter carriers to "have a little fun" during repositioning flights. While Pinnacle's Chief Pilot expressed shock when he found this out, it apparently was a dirty little secret in the industry. The CRJ sure as hell isn't going to be at FL410 with any passengers on it, so how else could Pinnacle have had a Forty-Thousand Club if the pilots weren't screwing off on repo flights? Dispatchers obviously knew about this, or they weren't following their flights. One Chief Pilot said that most bad conduct among his guys occurred during repositioning flights. It seems like pilots were treated like amiable rogues when they wanted to have fun with the aircraft, and everybody looked the other way because nobody thought that it might be dangerous.
In short, it turns out that this sort of stuff was more common than people imagined -- the goofing off with the a/c, at least.

Quoting AvConsultant (Reply 18):
Either way, these 2 guys killed themselves and perfectly good airplane

Actually, I think that the goofing off killed the airplane, but it didn't kill the pilots. That is, the goofing off caused damage to the aircraft, which was more serious (frying an engine) than these guys initially probably realized. What they did know is that if their antics were uncovered, they were going to get fired or at least suspended. It was their ass-covering by trying to fix the problem on their own without declaring an emergency that really put them in a coffin corner: by the time they realized that neither engine would light -- in part because of their incompetent efforts to do so -- they were too low to dead stick it to anywhere.

While the demeanor of these guys was shockingly unprofessional, and their actions surprisingly incompetent, merely wishing to try flying the a/c at 40,000 wasn't by-itself what got them killed. The aircraft can fly that high. It just takes a lot more planning and piloting skill than was exhibited by these guys to get there ahead of the power curve and stay there. These guys seem to have acted as if you could just set the autopilot for FL400 and Whee!! Instead, the autopilot got them there and did everything it could to stay there, while the aircraft was basically yelling at them that what they were trying to do wasn't viable. What was very troubling to me was their reaction to the signals the aircraft was sending. They kind of giggled over it, kind of a "look what the plane's doing; it's not going to be able to hold the altitude very long". How exactly did they think that the aircraft was going to advise them that it could no longer fly? Was the autopilot going to reset itself for a lower altitude and then smoothly fly to that altitude? NO. What was going to happen was that the aircraft was going to stall and only then was the autopilot going to disconnect, handing them a dark aircraft with two engines out, in a dutch roll and basically out of control. That they expressed no inkling of this as a possibility was perhaps the most disconcerting fact of all.


User currently offlineDispatchguy From United States of America, joined Jan 2006, 1253 posts, RR: 2
Reply 22, posted (7 years 11 months 2 weeks 18 hours ago) and read 4630 times:

Quoting Wjcandee (Reply 21):
Dispatchers obviously knew about this, or they weren't following their flights

One thing is with FAR 91 REPO flights, the dispatcher, other than crunching numbers for a fuel plan, and filing the flight plan, shares no real 121-style opscontrol responsibility with the crew - at most 121s (and all I worked at) the flight plan is info only, and if the crew does something stoopid, like auger it in somewhere, its his dime. I would always remark the flight plan "FAR 91 REPO -FPLAN INFO ONLY" or something to that effect which was our (FSDO approved) absolving ourselves of any dispatcher responsibility to the flight.

Since it (the FAR 91 op) doesnt have the responsibility attached that a 121 does, about all I concerned myself with was OOOI times; I'd check to see if he was airborne and on my ASD, but flight following a 91 op wasnt a priority, but the crews all knew if they had problems, suggestions, requests for sports scores, etc, dispatch was always at the other end of the radio.



Nobody screws you better than an airline job!
User currently offlineAvConsultant From United States of America, joined Feb 2006, 1360 posts, RR: 2
Reply 23, posted (7 years 11 months 2 weeks 6 hours ago) and read 4539 times:

Quoting 2H4 (Reply 19):
I have considerable respect for the actions they took to minimize harm on the ground.

I think these two were so overwhelmed with what occurred, at night and trying to save their asses- harm to the ground was the least of their worries. Once they were below 3000' they started losing airspeed and along for the ride.

Quoting D L X (Reply 20):
DId they deserve to die?

It's not a matter if they deserved to die; we're responsible for our actions. Some people are smarter than others and sometimes smart people do stupid shit.


I guess now BBD will be forced to include in the manual if you go to 410 or whatever, could cause death.


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