ATSB

Australian Transport Safety Bureau Lee Rosier 2012

Semester 1, 2012, ERT

Safety Management Systems

Mr Abraham

AIRCRASH INVESTIGATION: PINNACLE AIRLINES FLIGHT 3701

The series of events that led to the crash of Flight 3701 will be analysed using Reasons Swiss cheese model of accident causation.

Lee Rosier

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Semester 1, 2012, ERT

Safety Management Systems

Mr Abraham

1. Introduction
Pinnacle Airlines flight 3701 crash On the 14th of October, 2007 an preventable disaster occurred involving a Bombardier CL-600-2B19, N8396A. Pinnacle Airlines Flight 3701 crashed into a residential area about 4 kilometres south of Jefferson City Memorial Airport in Jefferson City, Missouri, while on a transit flight from Little Rock National Park in Arkansas to Minneapoliss St Paul International Airport. Both engines flamed out during the flight after a pilot-induced aerodynamic stall where the critical Angle of Attack (AOA) for the craft was exceeded due to the pilots inappropriate flying (Quade, 2002). Neither engine was restarted. The safety issues which led to the crash will be analysed in this report. These include flight crew professionalism; flight crew training in the areas of high altitude climbs, stall recognition and recovery, and double engine failures (NTSB, 2007; p iiii). These led to the deaths of the pilot and the first officer

2. Analysis
Reasons Swiss Cheese Model of Causation Reasons Swiss Cheese Model of Accident Causation groups every event and circumstance that leads to an accident into one of four categories: 1. Unsafe Organisational Influences; 2. Unsafe Supervision; 3. Unsafe Conditions; and 4. Unsafe Acts. (Colorado Firecamp, 2000) The following analysis of the Pinnacle Airlines disaster groups the contributing factors into these categories, so that causation can be determined.

2.1 Organisational Influence

Resource/Acquisition Management
Human Resources Training High Altitude Training

Climbs to high altitude were absent from Pinnacle Airlines simulator training, which may have led to the impractical climbing procedures used. If the organisation had training procedures in place
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the pilots probably would have climbed less aggressively and not lost so much speed. Stall Recognition and Recovery Training Most stall training in the industry, including Pinnacle Airlines, focuses on restarts with a minimum altitude loss as nearly all stalls occur at a low altitude (NTSB 2012, p56). This meant that the pilots were not properly trained to cope with the high altitude stall they were faced with.

Organisational Climate
Culture
Values and beliefs 410 club (to join you fly at 41,000ft)

The 410 club is part of the organisations culture. It is deemed an achievement to reach 41,000ft. This is shown by several comments captured by the Cockpit Voice Recorder. The first officer states; Man we can do it. Forty-one it. Later at 2151:51, the first officer says; theres four one oh my man. The first officer then laughs and says, this is great. If the culture of the organisation did not include the 410 club the accident would never have occurred.

2.2 Unsafe Supervision

Supervisory Violations
Authorised unnecessary hazard

Air Traffic Control (ATC) authorised the unnecessary and hazardous climb. The original flight plan indicated that the cruising altitude was 33,000ft, however, at 2135:36 the pilots requested to climb to 41,000ft, approval coming 37 seconds later. If the ATC had not authorised the climb the aerodynamic stall would never have occurred.
Failure to provide correct data

Manual not comprehensive. It did not specify minimum speed after stall.

2.3 Unsafe Conditions

Substandard Conditions of Operators
Adverse Mental States Misplaced motivation

The crews misplaced motivation to join the 410 club The crew were motivated to reach 41,000ft despite the hazards. Because the pilots were improperly motivated they did not take required care when operating at an aircrafts maximum operating altitude.
Physical/Mental Limitation Lee Rosier Page 4

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Incompatible intelligence/aptitude Pilots complacency resulting in swapping seats, and possibly

causing confusion regarding their roles. The pilots did not have the requisite knowledge to climb to and operate at such a high altitude. This is repeatedly in evidence from not realising the urgency of the matter after the stickshaker and pusher kept activating; not sustaining the minimum velocity of 240 knots after the engines flamed out; to their failure to report the nature of emergency as soon as it was recognised. Also, the pilots did not fully understand the effect of altitude on the aerodynamics and performance of the aircraft (NTSB 2007). The crew simply did not have the knowhow to operate at 41,000ft.

2.4 Unsafe Acts

Errors
Skill based Errors Inadvertent use of flight controls Incorrect use of autopilot vertical speed mode.

The vertical speed mode is used for climbing. It keeps the aircraft climbing at a constant speed. The flight crew, however, used it for staying at 41,000ft. The automation they should have used is the airspeed mode, which keeps the aircraft at a certain airspeed (NTSB 2007, p70). The improper use of automation led to the aircraft reaching 41,000ft without enough speed.
Over controlled the Aircraft

Overriding of stickpusher. The pilots response to the stickpusher is the epitome of over-controlling the aircraft. The stickpusher is an essential safety resource and should not be overridden. The stickpusher would have saved their lives if they had not over-controlled it..
Decision Errors Improper Procedure

Improper climbing procedure. The pilots did not follow the correct climbing procedure as they ascended too steeply, so steeply in fact that the stickshaker and pusher went off after the first pitch-up manoeuvre (NTSB 2007, p1). If the pitch up manoeuvres were less aggressive the aircraft may have been able to sustain flight at 41,000ft.
Wrong Response to emergency Lee Rosier Page 5

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The pilots failed to report the nature of the emergency in a timely manor It is procedure to report the nature of the emergency as soon as it is known. The pilots knew that it was a double engine flame out straight away as shown by the captains statement at 2155:33, double engine failure. The Captain told the ATC that, we had an engine failure up there ATC did not find out that it was a double engine failure until 2209:02 almost 15 minutes after the failure (NTSB 2007, p5). If the ATC had known that it was a double engine failure, the pilots could have been instructed correctly.

2.5 Summary
This analysis makes it apparent that the crash resulted from holes in each of the defence layers. Factors at each of the defence levels contributed to the outcome. If any one level had been complete the crash may have been avoided, as per the Swiss Cheese Model.

3. Evaluation
Pinnacle Airlines flight 3701 crash could easily have been averted. If proper procedures were followed and due care was taken the two pilots would have had an uneventful flight.

3.1 Contributing Safety Factors

The main contributing factor in this accident was the pilots lack of professionalism. The pilots wanted to operate at the CJR-200 maximum altitude for personal, not operational, reasons. The climb was not part of standard procedure. There are charts demonstrating how the jet is supposed to be handled during climbs. The charts were clearly not referred to as the pitch up manoeuvres were too aggressive and resulted in the stall from which they were unable to recover. The lack of training undertaken by the pilots must also have played a part. The pilots improperly managed the double engine failure checklist, probably because of confusion from the role reversal. The engines cores stopped rotating because the minimum speed of 240 knots was not

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maintained. The resultant locking of the engines cores was the reason for the APU assisted restarts being unsuccessful. The final contributing factor to this air crash was the pilots failure to recognise that an emergency landing needed to be prepared in a timely manner. The first thing the pilots failed to do after the double engine failure was to communicate the exact emergency the instant they knew it. They should have asked about landing options and would have been able to direct the aircraft in that direction while attempting to restart the engines.

3.2 Other Safety Factors

Further compounding this set of circumstances, the flight manual did not specify to pilots that it was important to maintain a minimum airspeed to keep the engine cores rotating. This was a big factor because if the cores had still been rotating when the APU assisted restarts were attempted, the engines may well have restarted. Also, the lack of high altitude training led to a lack of experience in required speeds, and emergency procedures. This is evident from their inability to fully recognise the urgency of their situation, until it was too late. Following the accident, Pinnacle Airlines made a couple of adjustments to the training regime. Firstly they provided pilots with the opportunity to practice double engine failures, and the procedures and airspeeds surrounding them. Furthermore, Pinnacle Airlines now provides pilots with more coaching regarding the importance of maintaining professionalism at all times during flight. These parameters have been put in place to minimise the likelihood of future accidents resulting from unprofessionalism and ignorance of procedures and required minimum speeds.

3.3 Findings
The Pinnacle Airlines flight 3701 disaster occurred due to a number of factors that allowed the holes to line up in the Swiss Cheese Model. Although neither the aircraft nor the pilots were impaired in any way, there were big holes in each category. The hole in organisational influences was made by the lack of pilot training regarding high altitude climbs practice and stall recognition, and the specified minimum speeds to prevent engine lock up were not included in the flight manual. The supervision hole was positioned where the pilot failed in maintaining due
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supervision of his craft. The hole in the conditions could be found with the pilots in the wrong seats, which apparently caused some confusion about their respective roles. Finally, the actions category was riddled with holes, including climbing too quickly, using autopilot vertical speed mode incorrectly, not maintaining critical speed, and not alerting ATC in a timely manner.

4. Recommendations
The improvements made because of flight 3701 greatly enhanced safety in the company. In line with Reasons model, further organisational advances could be made by allowing more simulations of stalls with greater instruction, and by revising manuals so that they are thorough in their detail. The importance of the climbing procedures needs to be emphasised to make sure future pilots do not make the same mistake as these two. In terms of supervision, professionalism needs to be demanded of all pilots during all flights, this would also serve to close holes in the unsafe acts category. Pilots are not to stray from operational or procedural requirements. These improvements would minimise the likelihood of a similar crash occurring in the future, by closing holes at three of the levels in Reasons model.

5. Conclusion
The crash of Pinnacle Airline Flight 3701 was a senseless and unnecessary accident which highlighted a number of holes in organisational and procedural levels within the company. By addressing these safety issues the likelihood of future accidents could be reduced. The accident led to a number of procedural changes that should prevent such an incident from occurring in future. This accident also illuminated the way in which poor discipline and a lack of training can affect a crews ability to make correct decisions, creating a multiplier effect and resulting in disaster.

Lee Rosier

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Semester 1, 2012, ERT

Safety Management Systems

Mr Abraham

Bibliography
Colorado Firecamp 2000, The Human Factors Analysis and Classification SystemHFAC The Swiss cheese model of accident causation, viewed 31st of May 2012, <http://coloradofirecamp.com./swiss-cheese/references.htm> NTSB 2007, Crash of Pinnacle Airlines Flight 3701 Bombardier CL600-2B19, N8396A Jefferson City, Missouri October 14, 2004, viewed 28th of May, <http://www.ntsb.gov/doclib/reports/2007/AAR0701.pdf > Quade 2002, Static, Dynamic and Accelerated Stalls, viewed 31st May 2012, <http://futurecam.com/stalls.html> The Flying Engineer 2012, Cockpit Design: EPR v/s N1 indication, viewed 28th of May, <http://theflyingengineer.com/flightdeck/cockpitdesign-epr-vs-n1-indication/>

Lee Rosier

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