This Pilot Didn’t Follow Standardized Work?
“The commuter plane that crashed near Buffalo was on autopilot until just before it went down in icy weather, indicating that the pilot may have ignored federal safety recommendations and violated the airline's own policy for flying in such conditions, an investigator said Sunday. Federal guidelines and the airline's own instructions suggest a pilot should not engage the autopilot when flying through ice. If the ice is severe, the company that operated Continental Flight 3407 requires pilots to shut off the autopilot.
“You may be able in a manual mode to sense something sooner than the autopilot can sense it,” said Steve Chealander of the National Transportation Safety Board, which also recommends that pilots disengage the autopilot in icy conditions.
Automatic safety devices returned the aircraft to manual control just before it fell from the sky, Chealander said.”
Is this a case of “should not” or “must not”? If the airline “requires” the autopilot to be shut off in “severe” ice, what is the definition of “severe,” I wonder?
If policies and guidelines were not being followed, this seems like less of an “accident.” If the airline required pilots to follow certain rules, what are they doing on an ongoing basis to make sure the rules are being followed? Are they doing anything to “audit” the process or do they just wait for something bad to happen?
This has to be more systemic than just one pilot making an unfortunate fatal error this one time. Some news reports have pointed to problems in the training processes… which is a management responsibility.
There is some speculation that the pilot reacted incorrectly when an automated “stick pusher” system kicked in (ironically, this automation is supposed to HELP, but reports say that pilots often react to it the wrong way… again, this seems systemic and not just this one time).
The safety board, among other issues, is looking into why Colgan's training programs apparently stop short of allowing pilots in simulators to feel the stick-pusher activate, according to people familiar with the issue. The device is intended to automatically prevent the plane from going into a stall by pointing the nose down to regain speed. Safety experts worry that unless pilots understand and feel what happens when the stick-pusher goes into action in a simulator, they may not react properly when it activates during an in-flight emergency.
In a statement, Colgan said its training programs “meet or exceed the regulatory requirements for all major airlines,” adding that in the wake of the Buffalo crash, it has “specifically re-examined our procedures for this aircraft.”
Do we really understand why this problem happened?
What can we do to prevent from happening again?
- What could have prevented this the last time?
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