NTSB: Pinnacle crash exposes cultural, systemic safety flaws
A lack of professionalism, discipline and knowledge exhibited by the two pilots flying the Pinnacle Airlines Bombardier CRJ200 that crashed in Jefferson City, Mo., on Oct. 14, 2004, directly led to the tragedy that took their lives, the NTSB has determined after more than two years of investigation.
During a public hearing in Washington, D.C., on January 9, the Safety Board didn’t let the airline and the regional airline industry as a whole escape reproach altogether, however. Board members questioned the integrity of the safety culture at Pinnacle and the effectiveness of the 1997 “One Level of Safety” rule and issued recommendations to make mandatory several existing voluntary safety programs.
The accident occurred when, during a repositioning flight from Little Rock to Minneapolis, the pilots took the 50-seat jet to its service ceiling of 41,000 feet to, in the words of captain Jesse Rhodes, “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.
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 time 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 no oil pressure or fuel flow in either engine. To avoid disciplinary consequences, in the opinion of the board, the pilots at first reported only a single engine failure and didn’t report a dual flameout until they reached 11,000 feet. Only then did they ask for a vector to “any airport.”
Although it doesn’t expect to issue the final report for “several weeks,” the NTSB summarized its findings in a synopsis that listed the pilots’ unprofessional behavior, deviation from standard operating procedures and poor airmanship as the direct cause of an in-flight emergency from which they could not recover. The Board cited the pilots’ failure to prepare for an emergency landing soon enough, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites, and their failure to achieve and maintain the target airspeed in the double engine failure checklist, which caused the airplane’s engine cores to stop rotating and resulted in a phenomenon known as core lock.
The Board also listed as contributing factors inadequate training for high-altitude stalls and the failure of flight manuals to stress the importance of maintaining a minimum airspeed to keep the engine cores rotating.
More specific operational and procedural errors included the flight crew’s inappropriate use of the vertical speed mode during the climb, which allowed the airplane to reach 41,000 feet in a critically low energy state. According to the Board’s synopsis, that blunder showed that the pilots did not understand how airspeed affects airplane performance and did not realize the importance of conducting the climb according to published charts.
Board members laid much of the blame on the captain, for not ensuring that first officer Peter Cesarz achieved the 300-knot or greater airspeed required for the windmill engine restart procedure and for failing to demonstrate command authority by taking control of the airplane and accelerating it to at least 300 knots. The findings concluded that the first officer’s limited experience in the airplane might have contributed to the failed windmill restart attempt because of a possible reluctance to command the degree of nose-down attitude needed to increase the airplane’s airspeed to 300 knots.
But aside from all the technical errors, perhaps most damning of the NTSB’s findings centered on the conclusion that the pilots made the decision to perform aggressive pitch-up and yaw maneuvers during ascent and operate the airplane at its maximum operating altitude (41,000 feet) for personal, not operational, reasons.
“I think what is particularly disturbing about this accident is that the crew was intentionally noncompliant with the procedures,” said Board member Robert Sumwalt. “But I can’t help wondering why this crew–an otherwise decently performing crew–would think that on [that] night they could go out and do the things that they did…I would suggest that a safety culture is when an organization establishes an absolute expectation that employees will do the right thing even when no one is watching.”
Asked by Sumwalt to list Pinnacle’s safety programs, NTSB senior human performance investigator Dr. Evan Byrne reported that Pinnacle had established a system under which crewmembers could file flight safety reports, which management placed into a database and investigated. However, said Byrne, the “formality or level of maturity of the program itself for following up or tracking these reports from crews was not complete, or had not yet matured.” The company had also established a telephone safety hotline, but according to testimony from Pinnacle employees, no one ever used it to report a safety concern.
Later, Sumwalt seized on Byrne’s findings that at the time of the accident Pinnacle hadn’t yet established an Aviation Safety Action Plan (ASAP) or Flight Operations Quality Assurance (FOQA) program. ASAP encourages airlines and employees to report safety concerns by requiring the FAA to waive legal sanctions for violations already reported by the airline. 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.
“I find it interesting that Northwest Airlines, the parent company, did in fact have a robust FOQA and ASAP program at the time of the accident, but its wholly owned subsidiary, Pinnacle, did not,” said Sumwalt.
Sumwalt also cited reports of a so-called “410 Club” at Pinnacle, members of which, according to testimony, climbed to Flight Level 410 during repositioning flights. The board found no evidence that management knew of the club before the accident or that the pilots involved in the Jefferson City crash explicitly aspired to belong to it, but Byrne opined that a FOQA program would have detected and discouraged such unusual flight plan deviations.
“At the time of the accident, Pinnacle Airlines lacked at least two elements of a safety culture–an informed culture and a reporting culture,” said Sumwalt. “And I would suggest that lacking these elements, while they did not cause the accident, they may have enabled the accident.”
Soon after the NTSB held its first public hearing on the crash, in June 2005, the Air Line Pilots Association publicly criticized Pinnacle for not instituting ASAP and FOQA programs. However, a Pinnacle spokesman claimed that the airline asked for permission from ALPA to institute FOQA in 2003 but that the union didn’t respond until after the Jefferson City hearings. At the same time ALPA claimed it had “repeatedly requested that Pinnacle Airlines put both these programs in place” for “more than a year.”
One of the Board’s recommendations would require that, apart from instituting a FOQA program, Part 121 carriers review FDR data from nonrevenue flights. In fact, accceptance of FOQA itself within the pilot community is far from universal, as many fear that the information gleaned from flight data recordings could lead to punitive action, even though an FAA rule explicitly bars such use except in cases of deliberate or criminal acts.
“I realize that in the industry having flight data recorders produce information that can be used in disciplinary action with pilots is contrary to what the labor unions would like to see,” conceded the Board’s newest member, Steven Chealander, who suggested that the Board remove the reference to FDR examinations from its recommendations.
Since the crash Pinnacle has instituted both an ASAP and a FOQA program. Its simulator training now includes high-altitude stall and stall buffet margin demonstrations and training for double engine failures at 35,000 feet. The NTSB has recommended that the FAA and the industry at large collaborate on improving training syllabuses for high-altitude operations in regional jets to ensure that pilots understand the airplanes’ performance traits and aerodynamics. It also recommends that the FAA require pilots to practice high-altitude stall recovery technique in the simulator.
In fact, in adopting high-altitude training, ASAP and FOQA, Pinnacle has become an exception within the regional industry. Houston-based ExpressJet remains the only other regional airline to have instituted FOQA, while no fewer than 16 majors conduct the audits. Meanwhile, only 16 out of 43 RAA member airlines have adopted ASAP programs, according to board member Kitty Higgins. “There is a difference between what’s happening at the regional carriers and what’s happening at the major airlines,” she said.
As they stand now, however, the NTSB’s formal recommendations only “strongly encourage” that all Part 121 carriers adopt ASAP and FOQA programs. Chealander, for one, suggested during the meeting that the Board change the verbiage to “require.” Other recommendations as now written, such as those pertaining to new voluntary line operations safety audits (LOSA) and safety management systems (SMS), do ask the FAA to mandate compliance. Not in widespread use among regional airlines, LOSAs employ jumpseat observers during revenue flights to collect safety data. An SMS manages safety risks through a methodical and explicit set of rules and processes instituted throughout an organization, theoretically reducing the number of isolated safety decisions.