Author Topic: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)  (Read 7667 times)

Offline Baradium

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NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« on: April 12, 2010, 04:31:59 AM »
Some of this stuff is a bit dry, but this gives a good insight into an accident chain once you wade through the pieces and put together what happened.

main docket http://www.ntsb.gov/Dockets/Aviation/DCA10IA022/default.htm (list of links below are from this source)

CVr transcript: http://www.ntsb.gov/Dockets/Aviation/DCA10IA022/439435.pdf

Operational factors (includes crew interviews): http://www.ntsb.gov/Dockets/Aviation/DCA10IA022/439314.pdf

FDR Data: http://www.ntsb.gov/Dockets/Aviation/DCA10IA022/437790.pdf 

Survival factors:  http://www.ntsb.gov/Dockets/Aviation/DCA10IA022/439387.pdf   (includes pictures)


Note that all items are in pdf format.         

"Well I know what's right, I got just one life
In a world that keeps on pushin' me around
But I stand my ground, and I won't back down"
  -Johnny Cash "I won't back Down"

Offline Baradium

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #1 on: April 12, 2010, 04:34:00 AM »

A bit of information on CRJ systems.    Many CRJ-200s have two takeoff flap settings availible,  flaps 8 and flaps 20 (some CRJs do not have the flaps 8 setting).    Flaps 20 gives you a reduced ground roll compared to flaps 8, while flaps 8 gives you better second segment climb.   As a reasonably advanced jet, the CRJ-200 also has a takeoff configuration warning system.  This system checks items such as trim, spoilers, and flaps.   When a given parameter is not met it will verbalize with a message such as "Config trim."  Flaps have to either be at 8 or 20 degrees to avoid a "config flaps message.   GLD (ground lift dumping) spoilers are auto deploy and deploy when certain conditions are met.   They are N1 less than 40%,  and 2 of:  wheel speed greater than 16, weight on wheels, or radar altimeter less than 5 ft.

EDIT:  Also of note is that another aircraft from this same company rejected a takeoff and stopped 500 ft from the end of the runway around 2 weeks after this incident.
« Last Edit: April 12, 2010, 05:10:59 AM by Baradium »
"Well I know what's right, I got just one life
In a world that keeps on pushin' me around
But I stand my ground, and I won't back down"
  -Johnny Cash "I won't back Down"

Offline undatc

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #2 on: April 12, 2010, 06:11:52 AM »
Got a cliff notes version?

On the NATCA BBS, there is a rumor flying around the the CRJs dont fly headings correctly and could be as much as 20 degrees off.  Something that is screwed up in their nav software, know anything about it?
-the content of the previous post does not represent the opinions of the FAA or NATCA, and is my own personal opinion...

Offline Baradium

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #3 on: April 12, 2010, 06:38:07 AM »
Got a cliff notes version?

On the NATCA BBS, there is a rumor flying around the the CRJs dont fly headings correctly and could be as much as 20 degrees off.  Something that is screwed up in their nav software, know anything about it?


Cliff notes:   Crew was about as unsterile as they could be on taxi.  Talking about corvettes and the like.    Set flaps 8 with flaps 20 speeds set and on a short runway.   Captain (seems it was captain, report doesn't actually say flat out they were moved just "sounds similiar to flap handle movement") noticed flaps were wrong as they were going down the runway and hit the flap lever to change them to 20.  Flaps being out of 8 and 20 while in transit resulted in a "CONFIG FLAPS" message since flaps weren't in a takeoff position.  Captain attempted to initiate an abort after V1 was reached due to the message that he caused.   Late abort and apparent lack of use of any reverse thrust resulted in the aircraft ending up in the EMAS.   

This airport is a pretty exciting looking one... emas is very close to a VERY steep dropoff.   It's one airport I wouldn't want to do a normal abort on... let alone something like what they did.   Without an emas there would have been fatalities.    BTW, there is a picture of the aircraft in the emas included in the safety factors link.  I don't believe there is yet an emas on the other end of the runway either... so good thing they were going that direction for the takeoff...


As far as headings.   The DG slave function for our instruments (auto slewing to maintain correct mag position) seems to use an averages type function to avoid sudden swings for magnetic interference.  But, this means that if you're on the ground and going to take off from an area with a lot of mag anomolies (such as terminal or other metal structures close to the runway)  you can end up with a heading well off from the runway.    My company has a procedure to disable our magnetic slave functions on specified runways at certain airports where this exists as this has previously caused headings to be off that far on takeoff or soon after takeoff as the system tries to adjust itself  (or off from the start if you didn't have it correctly set).   By turning off our magnetic slave function and going to DG only mode for takeoff on those runways we can limit any error.

As far as in flight.... you guys know that we fly headings and not courses, right?   ;)     

I will say that the other day I did have my DGs make a fairly decent sized swing in cruise flight, but it was right after we'd made our transition back to mag mode so it was still trying to settle itself I think.   Generally it seems to be pretty good at matching up with our standby magnetic compass.
"Well I know what's right, I got just one life
In a world that keeps on pushin' me around
But I stand my ground, and I won't back down"
  -Johnny Cash "I won't back Down"

Offline undatc

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #4 on: April 12, 2010, 06:56:28 AM »
Sounds like you hit the problem on the nose.  I'll post it up on the BBS and see what they think.

And yes, when I need to sequence some aircraft, I will usually use, "turn 30 degrees left" instead of the "fly heading".  Since our winds are pretty crazy outta the North, some aircraft may be crabbed past the heading I would want them to be, so the turn XX degrees seems to work better.
-the content of the previous post does not represent the opinions of the FAA or NATCA, and is my own personal opinion...

Offline Baradium

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #5 on: April 12, 2010, 07:30:16 AM »
Sounds like you hit the problem on the nose.  I'll post it up on the BBS and see what they think.

And yes, when I need to sequence some aircraft, I will usually use, "turn 30 degrees left" instead of the "fly heading".  Since our winds are pretty crazy outta the North, some aircraft may be crabbed past the heading I would want them to be, so the turn XX degrees seems to work better.

I would always advise that if you want to use a heading to  ask present heading first.   It's not really uncommon to have 100kt winds in the flight levels.    Otherwise, degrees left or right is a good way to do it. 

Also,  remember that our true airspeed speed changes as we descend.   It's a pet peeve of mine when we are given "max forward speed" or "greater than 310 kts" or the like and then a mandatory descent that is earlier than normal.   You're making us go slower as we get lower and we burn tons more fuel both as we go faster and lower.   So not only do you make us burn more fuel because we are going fast, you are making us burn even more by descending us early too.        A close second behind that would be when we are sent back and forth between fast and slow speeds.     I also suspect some controllers issue earlier descents to attempt to get us going slower... I'd just as soon be given a slower indicated and be able to stay high and burn less gas myself.   Especially these days when the airlines aren't giving us as much extra fuel (we call it contingency fuel, the fuel that is above out burn and reserve levels).
"Well I know what's right, I got just one life
In a world that keeps on pushin' me around
But I stand my ground, and I won't back down"
  -Johnny Cash "I won't back Down"

Offline Artoo

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #6 on: April 12, 2010, 05:39:10 PM »
Haven't read the docs yet, but I flew as a passenger into Chuck Yeager Airport 2 summers ago, and hadn't done my homework, when I saw the terrain coming up as fast as it was outside my window seat I was a little unnerved.  I remember thinking to myself "These crazy WV people built a friggin airport on a friggin mountain (or what they call mountains)".  I'm an inexperienced student pilot and would have no problem putting a GA aircraft on the runway there, but I can't imagine managing that type of heavy metal with a fixed amount runway with no room for error at the end.

http://yeagerairport.com/images/aerials%209-2-09%20017.jpg

http://en.wikipedia.org/wiki/File:20090121_0693_Yeager_Airport.JPG
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Offline Rooster Cruiser

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #7 on: April 12, 2010, 08:05:17 PM »
From the outside looking in, it appears that there IS a widespread lack of discipline and leadership in the cockpits at many of these smaller carriers; but when you have 300 hour CFI's being mentored by 1800 hour captains that were hired as 300 hour CFI's to be mentored by 1800 hour captains, well, it's not hard to see how the proverbial experience gene pool could be watered down a bit. 

During the last decade the Regional Airline business had such a huge expansion that they hired and promoted some to captain before they had accumulated enough experience as an FO under a grizzled veteran to acquire the discipline and humility necessary to handle the responsibility being handed them (50+ trusting souls in the back of a $20 million airplane).  As recently as 5 years ago I was predicting that accidents/incidents like this would happen due to the watered down experience level and lack of professional conduct that can be attributed to it.

I can't help but imagine visiting a new hire or recurrent class and saying this:

Jefferson City MO
Lexington KY
Buffalo NY
Charleston WV
????? ??

Pay attention to the task at hand.

Talk about your job and life some other time.

There are people in the back of the airplane that expect nothing less.

RC








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Offline Rooster Cruiser

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #8 on: April 12, 2010, 08:08:42 PM »
Apparently the captain was on his cell phone to his ALPA rep before the passengers were even evacuated!  They had not yet gone through the shutdown checklist nor conducted the evacuation, but the Capt was already starting damage control with his union.  This was caught on the cockpit mike.   ::unbelieveable:: ::complaining: ::banghead::

RC
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Offline undatc

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #9 on: April 13, 2010, 03:48:10 AM »
Also,  remember that our true airspeed speed changes as we descend.   It's a pet peeve of mine when we are given "max forward speed" or "greater than 310 kts" or the like and then a mandatory descent that is earlier than normal.   You're making us go slower as we get lower and we burn tons more fuel both as we go faster and lower.   So not only do you make us burn more fuel because we are going fast, you are making us burn even more by descending us early too.        A close second behind that would be when we are sent back and forth between fast and slow speeds.     I also suspect some controllers issue earlier descents to attempt to get us going slower... I'd just as soon be given a slower indicated and be able to stay high and burn less gas myself.   Especially these days when the airlines aren't giving us as much extra fuel (we call it contingency fuel, the fuel that is above out burn and reserve levels).

The art of sequencing is a wonder to behold.  If you get a chance to visit a center do it.  Try taking CRJ7/2 B735/6/7/8/9 B752/3 and various biz jets (or even a P180, a turbo prop that performs like a jet in cruise and acts like a C150 in the descent), all at different altitudes, and funneling them all into a nice pretty line, with winds that change at different altitudes, and give the next controller 7 miles in trail, with the fastest and lowest guy in front.  Its tuff, i've watched controllers that have been on the boards for 30 years screw it up.  Every controller has their own way of doing it, some like to vector hard to begin with, then slap speeds on them to maintain the spacing.  Others (like me) like to start 200 miles out with mach .01-.03 differences and small 5/10 degree turns to set it up.  Most of the time it works pretty well, but a random departure, or someone that you didnt see coming at you, can screw the pooch.

There is also the last min controller break that screws it up.  When you've been working for 30 min to set up a nice line, and you get out on break as it all is about to fall in place, the next controller may say WTF and start cranking guys around.

Most of the time, we start descending guys so they can go faster for us.  When you have a 737 at FL 400 they top out about mach .76.  But if I can get him down to say about Fl320 I can get him up to about .80 which is a huge help.

And the last  jab I'll take (just for kicks), would you rather be low fast burning gas and #1, or high slow saving gas and #5.  Your choice, I'll make it work.
-the content of the previous post does not represent the opinions of the FAA or NATCA, and is my own personal opinion...

Offline undatc

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #10 on: April 13, 2010, 03:51:25 AM »
From the outside looking in, it appears that there IS a widespread lack of discipline and leadership in the cockpits at many of these smaller carriers; but when you have 300 hour CFI's being mentored by 1800 hour captains that were hired as 300 hour CFI's to be mentored by 1800 hour captains, well, it's not hard to see how the proverbial experience gene pool could be watered down a bit. 

During the last decade the Regional Airline business had such a huge expansion that they hired and promoted some to captain before they had accumulated enough experience as an FO under a grizzled veteran to acquire the discipline and humility necessary to handle the responsibility being handed them (50+ trusting souls in the back of a $20 million airplane).  As recently as 5 years ago I was predicting that accidents/incidents like this would happen due to the watered down experience level and lack of professional conduct that can be attributed to it.

I can't help but imagine visiting a new hire or recurrent class and saying this:

Jefferson City MO
Lexington KY
Buffalo NY
Charleston WV
????? ??

Pay attention to the task at hand.

Talk about your job and life some other time.

There are people in the back of the airplane that expect nothing less.

RC










The same thing is happening the in the ATC ranks.  You look around the the face of ATC is mine.  the young 20 something controller, newly certified and scared to death that you have (at times) a couple thousand lives in your hands.  Very humbling when I heard that for the first time, looked at my scope and estimated that I had roughly 2500 peoples lives in my hands.
-the content of the previous post does not represent the opinions of the FAA or NATCA, and is my own personal opinion...

Offline G-man

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #11 on: April 13, 2010, 04:40:03 AM »
Undac...

Cannot believe you have to deal with all that crap---Me....I just stay low, squawk 1255 and talk to no-one, unless I get within 5 nauticals....
Life may not be the party we hoped for---but while we're here--we might as well dance..........

Offline Baradium

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #12 on: April 13, 2010, 06:14:56 AM »

And the last  jab I'll take (just for kicks), would you rather be low fast burning gas and #1, or high slow saving gas and #5.  Your choice, I'll make it work.

The problem is we can't always be low and fast.

Once we get down to FL300 and lower we don't really gain much speed, even if we had some buffer at FL300.  Take me down to 240 and lower and my max indicated is going to be a slower TAS than I was doing at cruise at FL300.  So starting us down early "so we can speed up" actually ends up making us go slower over the ground, which messes the whole thing up.   The biggest difference I can make as far as time at a fix is to make the descent as steep as possible.

Giving me max forward speed and a mandatory descent to 11,000 is the type of thing I'm talking about.  If you want me to get to the front of the line, let me stay in the 20's as long as I can.  It might cost 100kts or better over the ground between 11,000 and my cruise altitude at barber pole.
"Well I know what's right, I got just one life
In a world that keeps on pushin' me around
But I stand my ground, and I won't back down"
  -Johnny Cash "I won't back Down"

Offline Baradium

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #13 on: April 13, 2010, 06:47:19 AM »
From the outside looking in, it appears that there IS a widespread lack of discipline and leadership in the cockpits at many of these smaller carriers; but when you have 300 hour CFI's being mentored by 1800 hour captains that were hired as 300 hour CFI's to be mentored by 1800 hour captains, well, it's not hard to see how the proverbial experience gene pool could be watered down a bit. 

During the last decade the Regional Airline business had such a huge expansion that they hired and promoted some to captain before they had accumulated enough experience as an FO under a grizzled veteran to acquire the discipline and humility necessary to handle the responsibility being handed them (50+ trusting souls in the back of a $20 million airplane).  As recently as 5 years ago I was predicting that accidents/incidents like this would happen due to the watered down experience level and lack of professional conduct that can be attributed to it.

I can't help but imagine visiting a new hire or recurrent class and saying this:

Jefferson City MO
Lexington KY
Buffalo NY
Charleston WV
????? ??

Pay attention to the task at hand.

Talk about your job and life some other time.

There are people in the back of the airplane that expect nothing less.

RC

You get what you pay for.   These days people will give anything for a dollar off on their plane ticket.  When I was in new hire at my current company they asked that we not wear our uniform if we went to apply for wellfare... because the company thought it was embarassing.  Nevermind that I thought it was embarassing that we qualified for it in the first place.    Companies that pay and treat employees well are put at a major disadvantage to the ones that don't becuase the passengers don't care and just buy whoever is cheaper anyway.  That means the mainline carriers contract with the cheaper regionals.   Regionals that do anything to better themselves have to cost more... which means they don't get the flying.

It is a tremendous credit to the pilots at the regionals right now that there haven't been a lot more instances like this or worse.   The professionalism and integrity is a very big part of it.

You've got guys making essentially minimum wage or less doing all they can to keep the operation safe.   The average regional pilot has a lot less experience, a lot less pay, a lot less rest and a lot more work than a pilot at a major.  Professionalism is all that keeps everything working together.   


There is a whole lot more going on here than just young pilots.  Unfortunately, some guys have a hard time acting like professionals when no one thinks of them as such.   The company doesn't care, the public sure as hell doesn't care.  But the majority of the pilots at the regionals work hard and maintain their ethos regardless out of professionalism.  The companies only care if it's legal.  It's completely left to the pilots to keep it safe.


This accident and its lack of professional conduct wasn't because of lack of experience.  It was because of lack of professionalism.   I'm going to guess that you haven't read the operational factors section yet (if you've read any of these at all, I know it's a lot to wade through).  The FO in this case had 3,500 hours.  Almost 2,000 in the CRJ and 1,000 of PIC (don't know what the PIC was in).  He had been F/E on C-5 galaxies and was still active in the Air Guard as a "training and education manager."    The CA had 9,500 hours and was a check airman.   The CA had just started his 11th year with the company.

So you've got a captain who's been around over 10 years and an FO who has military training and a decent amount of flight time.   I think this is pretty far off from your idea of an inexperienced crew Matt.   There are pilots at mainline carriers with less experience than the FO had.    They were complacent, that's it.     Add to that... if the captain had not touched the flaps, continued with the config warning he caused or promptly aborted instead of making changes on takeoff roll they would have taken off or aborted fine and we'd have never heard about it.  And still most won't.   Honestly, how many of you knew about this before reading it here?   This incident happened in January. 


I know a lot of people are caught in the talking during taxi (which I also didn't like one bit), but I'm a bit held up by the decision to do a post V1 abort for a config warning you caused yourself (and thus should know what it is about).   But in either case I don't believe that it's actual lack of experience that is the cause. 


As late as it is I think I'll call it a night at that, while I can still hope that I've made some sense.
« Last Edit: April 13, 2010, 06:58:58 AM by Baradium »
"Well I know what's right, I got just one life
In a world that keeps on pushin' me around
But I stand my ground, and I won't back down"
  -Johnny Cash "I won't back Down"

Offline Rooster Cruiser

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Re: NTSB docket for CRJ runway overrun at KCRW (Charleston, WV)
« Reply #14 on: April 13, 2010, 07:06:07 AM »
Quote
It's completely left to the pilots to keep it safe...

This accident and its lack of professional conduct wasn't because of lack of experience.  It was because of lack of professionalism.   I'm going to guess that you haven't read the operational factors section yet (if you've read any of these at all, I know it's a lot to wade through).  The FO in this case had 3,500 hours.  Almost 2,000 in the CRJ and 1,000 of PIC (don't know what the PIC was in).  He had been F/E on C-5 galaxies and was still active in the Air Guard as a "training and education manager."    The CA had 9,500 hours and was a check airman.   The CA had just started his 11th year with the company.

That makes it even worse, Baradium.  A 9500 hour check airman, and a 3500 hour FO acting like a couple young punk kids.  Completely complacent to the point of distraction.  Then after they come to a stop, the Capt is on the phone to the CP and ALPA rep while the CVR is still rolling.  Never mind the 32 other souls in the back... someone will see to them, i'm sure.

These guys were sure setting the standard, weren't they?

Let me put it a different way:

"Hello ALPA?  This is Captain Sullenberger.  Yeah, I'm down in the middle of the Hudson River.  What do you think I should do now?"

RC
"Me 'n Earl was haulin' chickens / On a flatbed outta Wiggins..."

Wolf Creek Pass, by CW McCall