Try as they might, regional airlines just can’t seem to avoid the glare of public scrutiny. The latest controversy, involving the fatal crash of a Pinnacle Airlines CRJ200 on October 14 last year, has once again forced the industry to defend its safety record. This time, however, the airlines can’t blame the hubbub on the rantings of politicians or ex-DOT Inspectors General. Rather, they find themselves pitted against perhaps an even more powerful foe– namely, the Air Line Pilots Association.
One hour before the start of the June 13 through 15 NTSB public hearing on the crash, ALPA leveled some pointed criticism at Pinnacle’s “safety culture” and implied that the growth of the industry and the transition from turboprops to jets has resulted in a more widespread safety problem.
“This environment means that pilots often have less time to gain first-hand experience with an aircraft before assuming command,” said ALPA air safety chairman Terry McVenes in a statement. “Carriers like Pinnacle must provide comprehensive operational training to compensate for this lack of hands-on experience and to better prepare [their] pilots for the transition to jet aircraft.
“Pinnacle Airlines…has failed to put critical safety reporting programs in place that could help detect and correct safety issues before accidents occur,” added McVenes. “Carriers around the world rely upon cost-effective, non-punitive and confidential safety-reporting programs such as Flight Operational Quality Assurance (FOQA) and the Aviation Safety Action Plan (ASAP) to help ensure that air travel remains the safest mode of transportation. For more than a year, ALPA has repeatedly requested that Pinnacle Airlines put both these programs in place.”
FOQA involves collecting data from an airplane’s FDR with a laptop computer to determine whether a flight crew exceeded any limitations established in an airline’s manuals, typically during non-revenue flights. Safety auditors can download the information on command, allowing them to track a pilot’s every move.
ASAP, along with the Aviation Safety Reporting System and the Voluntary Disclosure Program, encourages airlines and employees to report violations to the FAA. Under the program, the FAA classifies those infractions as administrative actions and waives legal sanctions for violations already reported by the airline.
“The ironic thing is that the pilots have to agree to these programs,” said Regional Airline Association president Deborah McElroy. “And in many cases the reasons the carriers don’t have them in place is because the pilots haven’t agreed to it.”
According to Pinnacle vice president of marketing Phil Reed, the airline had in fact approached ALPA two years ago for permission to institute FOQA, but the union never responded with a side letter. Not until after the hearings did ALPA formally respond, said Reed. “They [had] chosen not to respond for whatever reason,” said Reed. “But the fact that they indicated that it had never been addressed is just improper.”
McElroy said a number of regional airline CEOs and safety directors share her irritation with ALPA’s “irresponsible activity” and believe the union violated regulations that limit public comments from participants in an ongoing investigation. “It’s really shameful that ALPA would make those comments,” she said. “It’s not appropriate given the fact that they are a party to the investigation. It is solely the NTSB’s jurisdiction to determine what caused the accident.”
As one might expect, ALPA did its best to deflect responsibility from the pilots, who, during a repositioning flight from Little Rock to Minneapolis, took the 50-seat jet to its service ceiling of 41,000 feet to, in the words of the captain, “have a little fun.” According to information extracted from the flight data and cockpit voice recorders, the pilots changed seats, ignored stick-shaker warnings, failed to declare an emergency immediately and waited too long to request a vector to an alternate airport.
The flight data recorder (FDR) data showed that the airplane maintained 41,000 feet for three-and-a-half minutes before the stick shaker activated. Over the next 20 seconds the stick shaker and stick pusher activated four times, after which the airplane entered a 32-degree nose-down pitch attitude and an 80-degree left bank. About a second later the FDR stopped recording, but the cockpit voice recorder (CVR) continued to run.
Once the FDR started recording again at FL290, it indicated zero oil pressure and fuel flow to both engines. But the pilots at first reported only a single engine failure, and didn’t report a dual flame-out until they reached 11,000 feet. Only then did they ask for a vector to “any airport.”
“How do you train for such a scenario?” asked Reed. “I don’t know how you do it... We told [our employees] that we were of course saddened by the loss of our crew, but that we were also extremely disappointed in the fact that they had stepped so far outside the basic parameters of operating an aircraft. It was just unfathomable.”
Pilot Training ‘Enhancements’
Although Reed denied that the accident prompted Pinnacle to change its training regimen, the airline has, in his words, “enhanced” the program to include “some basic improvements in different approaches and use of the simulators and that type of thing.” Specifically, simulator training now includes high-altitude stall and stall buffet margin demonstrations. The airline has also begun simulator training for double engine failures at 35,000 feet and has imposed a ceiling of 37,000 feet on its CRJs.
Hired by Pinnacle in February 2003, the flight’s captain had flown a total of 6,900 hours and 5,500 hours as pilot-in-command since earning his private pilot license in 1991. He had accumulated 973 hours in the CRJ and 150 hours PIC time in that type, all with Pinnacle. One of his previous employers, Trans States Airlines, fired him after two years on the job for abuse of sick leave privileges, failing to keep in contact while on reserve duty and attending a training event with another airline while still employed by Trans States.
Upon his hiring at Trans States in 1998, the captain failed both his oral test and simulator check ride for the Jetstream 41, including approaches to stalls. He received his first officer qualification later that day. In 1995 he twice failed FAA checkrides for a multi-engine CFI rating. After earning that credential on his third try, it took him two checkrides to gain his CFI instrument endorsement. He also failed his first ATP checkride in a Beech 1900, later achieving that rating after his second try in August 2000.
The first officer had flown a total of 761 hours and 222 hours as copilot in the CRJ. Although he failed his first checkride for his multi-engine commercial certificate, he passed his re-check the next day and won praise for his good attitude and piloting skills from his simulator instructor.
On the other hand, a Pinnacle sim instructor expressed “concerns” about the captain during periods four and five of his upgrade training, particularly over his failure to follow checklist procedures. He also said that the captain would sometimes use the incorrect checklist, misstate the status of an item, read a checklist item and not accomplish the task or take action on a system opposite the one he read from the checklist.
The instructor told investigators that he had sometimes seen such deficiencies in first officer training but rarely from a captain in upgrade training. Although he said the captain flew the airplane “just fine,” the instructor named decision-making and judgment as the pilot’s biggest weaknesses.
Another simulator instructor, however, expressed satisfaction with the captain’s judgment and reported no instances in which he rushed checklists. A check airman who tested the captain for an operating experience upgrade said he displayed proficiency, judgment, initiative, leadership and deliberate and thoughtful actions.
Whatever the case, the captain undeniably possessed plenty of experience, and Reed refused to accept the notion that Pinnacle’s “culture” might have bred a generally cavalier attitude toward safety among its pilots.
“The question that ALPA posed is ‘Do we have a culture of safety?’ The answer is clearly we do,” said Reed. “And how do we know that? Because we have a certificate hanging on the wall that says [so]. Goodness knows how many times over the course of the last seven or eight years since this management team has taken over that this airline has been exposed to outside reviews by the Department of Defense, by code-share partners, by the CSET [Certification, Standardization and Evaluation Team]. During none of those has there been any significant finding or one that indicated a culture of safety didn’t exist.”
Safety Investigations
In fact from Jan. 1, 1998, to Oct. 21, 2004, the FAA filed 59 violations against Pinnacle, seven of which involved fines. In late 2002 Pinnacle’s newly appointed certificate management unit (CMU) supervisor said that the company appeared “disrespectful” of the FAA, that it didn’t pay much attention to agency requests and that its training program needed better oversight and updating. After the CMU supervisor placed new principal inspectors in place, Pinnacle agreed to adjust its attitude and work closely with them.
In October 2002 that same supervisor said that CSET inspectors should not have accepted Pinnacle’s answers to some of their findings during a December 2001 evaluation, and that they improperly accepted promises rather than actual corrections. Pinnacle subsequently satisfied all the outstanding issues and the team issued its report in September 2003.
In June 2003 a Department of Defense survey team found that the company’s emergency response plan did not include DOD notification procedures. However, the company immediately fixed the problem and met all the rest of the survey team’s standards.
Meanwhile, the NTSB continues its investigation into the crash, turning its attention to a theory that the CRJ’s GE CF34 engines may have suffered core lock, a phenomenon that can happen after the core of a multi-spool jet engine stops spinning due to insufficient airspeed or airflow. Cooling of the core and outer spool at different rates causes different rates of contraction, resulting in binding until the temperatures return to equilibrium. At 300 knots a so-called windmill restart can achieve rotation, but beginning at descent through 20,000 feet the CRJ’s glide speed never exceeded 170 knots.
