Colgan Air Crew Was Crash Waiting To Happen

If an engineering education teaches one anything, it's that proper process begets beneficial results. The reverse case is scarily evident in the transcripts of the Colgan Air disaster, where a discombobulated crew was a disaster, waiting to happen, which did.

Alexander Wolfe, Contributor

May 13, 2009

6 Min Read

If an engineering education teaches one anything, it's that proper process begets beneficial results. The reverse case is scarily evident in the transcripts of the Colgan Air disaster, where a discombobulated crew was a disaster, waiting to happen, which did.What can one say about an airline crew which, even in ideal flight circumstances, was probably on the margins of competency? It's precisely for such people that the concept of a "sterile cockpit" was created. Focus on the multitasks at hand, and not on extraneous [non-pertinent word deleted], and maybe, just maybe, you'll be able to checklist your way through to stability, if a mid-air wrinkle arises.

Not this crew.

As a long-time aviation buff, my first post-crash thought was one that's probably familiar to a lot of similarly inclined folks. Namely, I was hoping the NTSB wouldn't be so quick to scapegoat the crew. However, in listening to the transcript of the Feb. 12 crash, outside Buffalo, NY, of Colgan Air Flight 3407, the crew's culpability is glaringly obvious. So much so that it'll set back for a good decade the idea that safety investigators need to cast a really wide net before reflexively alluding to "pilot error," as they've historically been wont to do.

The thing that leaves one shaking one's head is that this isn't even a canonical case of "tunnel vision," where, if the Capt. Marvin Renslow and co-pilot Rebecca Shaw had mentally stepped back from the situation, they might've come up with the correct response. (Like if Swissair Flight 111 had landed expeditiously, rather than trying to dump fuel and stow cabin cutlery; though I realize it's a rare pilot who'd attempt to put down with full tanks. The pilot of the Air France Concorde which crashed following takeoff in Paris in 2000 presumably did "think different," since his in-flight decisions spared a serious number of ground casualities. And of course we have Sully, who combined application of procedure with gut instinct in a way we can only envy.)

There was no any of the time with Colgan, as you see in the cockpit transcript quoted below. Things devolved so quickly that the account of the conversation is devoid of "[non-pertinent word]," which is the reference used by the FAA in place of the epithets emanating from the crew as a plane proceeds to fall out of the sky.

I'm not sure if it's a fair assessment, but it's my belief in any case that what happened in Colgan was in some loose but direct way destined by Airline Deregulation Act of 1978. By this I mean that, in the old days, pilots used to be able to make a nice living. (OTOH, if you add up profits and losses of the airline business since the days of the Wright Brothers, it's never actually made a dime, but that's another story. For which you should read the works of John Newhouse.)

Nowadays, though, to be a pilot for a regional often means accepting the job even though it doesn't provide a real living. Which, I submit, weeds out a cohort you'd rather not lose. Into the vacuum come people who perhaps love flying with a passion which outstrips their skills set. On another day, in another cockpit, Renslow and Shaw would have bantered their way through to a bumpy but successful landing.

But procedures, and sterile cockpits, aren't there for the sunny day. (For non-aviation folks like you and me, this means putting the damn cellphone away while you're driving -- or using Bluetooth instead -- and backing up your hard drives. )

OK, now here are two portions of the transcript, which I downloaded from the National Transportation Safety Board site (as opposed to glomming off of the Wall Street Journal). The first show the crew's recognition that there's ice on the wings, but instead of acting on that information, they joke. The second snippet is the end game of the flight.

22:10:22.6 HOT-2 is that ice on our windshield? 22:10:25.6 HOT-1 got it on my side. you don't have yours? 22:10:28.7 HOT-1 * [sound of whistle] 22:10:30.5 CAM [sound of click] 22:10:32.3 HOT-2 oh yeah oh it's lots of ice. 22:10:47.5 HOT-1 oh yeah that's the most I've seen- most ice I've seen on the leading edges in a long time. in a while anyway I should say. 22:10:51.4 HOT-2 oh *. 22:10:57.7 HOT-2 yeah that's another thing. all the guys- @ came in to our when we interviewed and he said oh yeah you'll all be upgraded in six months into the Saab and blah ba blah ba blah and I'm thinking you know what. flying in the northeast I've sixteen hundred hours. all of that in Phoenix how much time do you think actual I had or any in in ice. I had more actual time on my first day of IOE than I did in the sixteen hundred hours I had when I came here. 22:11:21.0 HOT-1 [sound of laughter]

22:15:32.8 HOT-2 roger. 22:15:59.5 CAM [sound similar to decrease in engine power] 22:16:04.1 HOT-1 gear down...loc's alive. 22:16:06.2 CAM [sound similar to landing gear handle movement] 22:16:07.4 CAM [sound similar to landing gear deployment] 22:16:14.9 HOT [sound of two double chimes] 22:16:21.2 HOT-2 gear's down. 22:16:23.5 HOT-1 flaps fifteen before landing checklist. 22:16:26.0 CAM [sound similar to flap handle movement] 22:16:26.6 HOT-2 uhhh. 22:16:27.4 CAM [sound similar to stick shaker lasting 6.7 seconds] 22:16:27.7 HOT [sound similar to autopilot disconnect horn repeats until end of recording] 22:16:06.4 APP Colgan thirty four zero seven contact tower one two zero point five. have a good night. 22:16:11.5 RDO-2 over to tower you do the same thirty four zero seven. CAM [sound of click] 22:16:31.1 CAM [sound similar to increase in engine power] 22:16:34.8 HOT-1 Jesus Christ. 22:16:35.4 CAM [sound similar to stick shaker lasting until end of recording] 22:16:37.1 HOT-2 I put the flaps up. 22:16:40.2 CAM [sound of two clicks] 22:16:42.2 HOT-1 [sound of grunt] *ther bear. 22:16:45.8 HOT-2 should the gear up? 22:16:46.8 HOT-1 gear up oh #. 22:16:50.1 CAM [increase in ambient noise] 22:16:51.9 HOT-1 we're down. 22:16:51.9 CAM [sound of thump] 22:16:52.0 HOT-2 we're [sound of scream] 22:16:53.9 END OF TRANSCRIPT END OF RECORDING

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Alexander Wolfe


Alexander Wolfe is a former editor for InformationWeek.

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