Monday, June 20, 2005
Pinnacle Pilots Were Having 'Fun' When Engines Stalled
Shortly after Pinnacle Airlines [PNCL] Flight 3701 took off on Oct. 14 from Little Rock, Ark., the two pilots on the re-positioning run began a series of maneuvers that pushed the envelope on the Bombardier [BBD] CRJ 200, taking it to 41,000 feet, its service limit. The pilots' joy-riding antics may have contributed to the aircraft's crash outside Jefferson, Mo., and to their deaths upon a fiery impact.
The pilots told ground controllers they were having "a little fun" when questioned why they were flying so high.
Without pinpointing the cause of the accident, the National Transportation Safety Board (NTSB) last week held a three-day fact-finding hearing on what was the first domestic crash of a regional jet and of the General Electric [GE] engine that powered the plane.
In the first of two-parts, Regional Aviation News in this edition is focusing on the pilots, Pinnacle's training and the changes the carrier has implemented since the crash. The next installment will focus on the aircraft and the engines.
Capt. Jesse Rhodes and First Officer Peter Cesarz were the only ones aboard the flight, which was to move the aircraft from Little Rock to Minneapolis. The aircraft had been pulled out of service early on Oct. 14 because of a right engine bleed air sensing loop. The loop was replaced and the aircraft returned to service and scheduled for repositioning.
The plane crashed when both GE engines stalled shortly after the crew reached 41,000 feet. The crew tried to restart the engines four times during a seven-minute descent, but without success.
However, even as the aircraft was gliding back to earth, the crew did not tell air traffic control (ATC) that both engines were out until 15 minutes after the engines stalled, or six minutes before the crash.
NTSB lead investigator Lorenda Ward in her report noted that if the crew had immediately informed the ground controllers of the true extent of the emergency, they could have made it to one of six airports that could have handled the aircraft operating as a glider. In the end, the plane tried to reach Jefferson City Memorial Airport, which was just outside the best glide range due to changes in the airspeed, she said. The plane crashed in a residential area about two miles short of the runway.
"I have no idea why they could not declare an emergency earlier and then get all the assistance they could," said Terry Mefford, Pinnacle's chief pilot. "It was a terrible event. I could not put myself in their place. I will not speculate."
Rhodes, 31, had 6,750 total flight hours, including 1,724 as a pilot in charge. Cesarz, 23, reported 565 total pilot time hours, including 200 accumulated in the six months prior to the accident.
As the NTSB was investigating the pilots' background and training, investigators questioned ground school and simulator instructors as well as other pilots to determine if Pinnacle had policy guidelines in place to report emergencies to ground controllers. While the pilots reported no "stigma" associated with declaring an emergency, providing the ground controllers with detailed information did not seem to be a priority.
One simulator instructor relayed to investigators that when training pilots on ATC communications, he advised the pilots not to "overload" the controllers with "too much unneeded information, such as specifics to the aircraft systems." Others indicated that they were to talk to the controllers when they had time to talk.
Prior to the accident, Pinnacle did not provide specific training on how to deal with a dual engine failure, said Thomas Palmer, the carrier's flight standards manager. Such a failure was not dealt with in the simulators.
Instead, Pinnacle required the pilots to memorize the procedures on dealing with a dual engine failure. As a "memory item," pilot candidates would be quizzed and tested on these procedures in the training course.
Since the accident, Palmer said Pinnacle has added dual engine failure scenarios to the simulator training sessions. "When we looked back at it, we probably should have had it in the training, but we had not looked into it because it was not a high probability. Now that we have had one, we have added it to the crew training."
In addition, since the accident, Palmer said the carrier has added stall training to its course work. "We continue to review the training program. We have made additions to the program to include high-altitude flying and lock ups."
Bombardier told the NTSB that this was the only flight that ever had double engine failure because the turbines locked up.
Mefford in his testimony said Pinnacle's pilot training program was "quite good. I went through it myself. As chief pilot, I have always been looking for improvements, but our core program has been quite good."
As part of the training program, Pinnacle offers new hires eight hours of crew resource management training, which includes human interactions, workload management, team building, first officer assertiveness and accident communications. Captains-in-training take a two-hour refresher version of the course. Mefford told the NTSB that Pinnacle is now reevaluating the curriculum. "We felt it could be a factor in this crash."
Pinnacle has also changed the way it monitors the pilots during non-revenue flights, Mefford said. "Because of this, we download the flight data equipment [recorders] so the pilots know that someone is watching them."
Earlier, Mefford told investigators that he had hoped any deviations during a repositioning flight would come out in a flight safety report or a crew communication report.
After the accident, Mefford told the NTSB that he heard rumors of a "410 Club," for pilots trying to fly at 41,000 feet during repositioning flights.
On Oct. 22, Pinnacle issued an "alert bulletin" restricting all flights to less than 37,000 feet. "Flight crews are not to accept or request ATC clearance above this altitude," the bulletin stated. In addition, the pilot not flying the plane is now required to call out each 1,000-foot mark after reaching a transition height of 29,500 feet.
A second bulletin, issued on May 17, required that the aircraft fly at speeds greater than 250 miles per hour (mph) after reaching 10,000 feet. "Climbing at speeds less than 250/.70 Mach may lead to reduced climb performance and most importantly may lead to an unsafe margin above stall." ?
>>Complete transcripts and preliminary reports are available at
http://www.ntsb.gov.<<;
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