CRW Overrun Transcript
 

This is not going to enhance public or industry perception regional pilots...

http://www.ntsb.gov/Dockets/Aviation...022/439435.pdf

Think about what you're saying on the hot mike...

I didn't have time to read it 100% just yet but I did read from takeoff roll to overrun and then some.

We all agree that it's not appropriate to move the flaps from the current setting to the desired takeoff setting while barreling down the runway. But, if all of this did actually take place before V1, I wonder how they ran out of runway. Maybe just didn't get on the brakes quick enough.

Please correct me if I am wrong, but if you have the parking brake set while waiting out a delay, you can engage in conversation normally...

It is a shame to see a self-induced incident. My only real problem with what they did prior to takeoff was not taking the time to get back into the game after the delay. Once they started moving, the conversation should have stopped, and they should have double checked all settings. I have had more almost-f'ed-myself moments following a ground hold than any other time. You really almost need to start your flight over from the beginning, as if you were at the gate. We are creatures of habit, and a ground delay often forces us to break up our normal flow. After a few missed items under similar circumstances, I now take the last five minutes of a delay to go through the flight plan and the FMS pages, and read the departure pages again.

I know people will be critical of the phone calls prior to getting the actual situation under control, but in all fairness the captain said he did not know what to do. Making at least one call could be seen as a positive step towards ensuring everyone's safety. That said, he ended up getting too wrapped up in the calls and seems to be unaware of most of what was going on in the cabin and outside.

Good judgment comes from good experience, and good experience comes from bad judgment. Lets try to use the examples of bad judgment in this case enhance our good experience and good judgment. I would rather learn from everyone's collective mistakes than make all the same mistakes myself down the road. Everyone made it out of this one ok, so lets skip the personal attacks and harsh criticisms, and point out specific things we can learn from.

not only that but adhering to sterile cockpit - now we've all done it, but sometimes its good to have a reality check to remind us how important it is to be focused on what you're doing and not going on with the small talk. I really thing some changes need to be made though - especially with pay and schedules. Its hard to be all business and focused when you're doing 8 legs a day and getting paid crap and treated like crap. Professionalism starts to fly out the window with your sanity. Add any kind of distraction in the cockpit or in your personal life and it can spell disaster. So many accidents go back to fatigue, lack of focus, small talk and not realizing whats happening (ala buffalo etc), not just because of training, hours etc. It can happen to anyone - granted proper training and experience can help prevent or correct things that go wrong nobody is invincible. Its amazing how things go from small talk to OH MY GOD WHATS HAPPENING?! Be safe everyone. Just my humble thoughts.

Spot on - well said.

There's no doubt that the Capt was in shock and had frozen up....not surprising in the least....it would happen to many of us in that kind of stressful situation.

However, there are two things to aid you if you ever find yourself in this kind of situation. First, most Flight Ops Policy Manuals that I have seen have some sort of Post Accident/Incident checklist that will help you get the aircraft secured and the passengers safely taken care of. It will tell you who to notify and what items to safeguard. Second, keep the ALPA Accident/Incident Hotline card in your wallet and call the number....follow the advice on the back of the card and do not discuss the nature of the difficulty with anyone, including out loud while the CVR is running. There will come a time to discuss what happened, but not while you're under that kind of stress and shock.

It is tough to tell when exactly they made the decision to abort but the flaps were moved and V1 was called 5 seconds later and then the master warning went off 2 seconds after the V1 call. The "sound of engine RPM decrease" was not until 11 seconds after the V1 call.

True, and they were talking about G-rated subjects...it could have been worse.

But the timeline does not make it clear when they were taxiing and when they weren't...based on the checklists I think they mostly stuck to sterile cockpit.

I was referring to what was said after the plane came to a stop...the CA was pretty much frozen with indecision. The FO kept prompting him to something...

In any situation like that, notify ATC, secure the airplane, and make an evacuation decision. A few choice expletives would be in order, but after that stick to business.

I am all for getting paid more and I thing we should be. However, if we can't do the job professionally now, why do you think paying us more money will make us more of a professional?

who did he call first?
 

don't mean to sound rude.. but while this guy was panicking and on his cell phone...did he ever stop to check on anyone else but himself? Bad stuff...full on conversations in the flight deck on the cvr. Where was the F/O in any of this ? It took one read to to see the flaps eight even after they'd both briefed a 20 dept. Sucks and i understand the frustrations but wow ... the situational awareness was really lacking.
I like the F/A comment about the story the pax were about to get from the capt. post runoff. Oh well... another obvious lesson for us.

excellent stuff... thank you DD

stuck pig
 

I'm curious, did the company take any action against the crew?

16:19:19
CAM-2 parking brake?
16:19:21
CAM-1 sh— should I set it? I guess yeah.

I found a tad bit of comic relief in that, only because no one was injured.

The only thing worse than going off the end of the runway would be having the plane roll away while deplaning ;)

Or not having the overrun and going off the cliff. Not sure which end they went off of.

I have no idea, but just by reading the CVR I assume they are gone, especially after the Colgan incident. Not mentioning the sterile cockpit, then failing to follow and adhere to the checklist (wrong flap setting). Then instead of aborting trying to set the flaps to the proper setting while rolling down the runway at take off thrust. Then after that (never flew a CRJ or even a jet) but aborting after V1 for a config warning, I would assume was against procedure as well.

Reading that transcript is sobering, as it was just another flight, and just another convo like any of us have had prior to departure, and then in just 2 seconds it all went wrong. Just kind of a wake up call of how much can go wrong, in such a small amount of time, and the consequences of it.

Things to take note of. The captain did initially call for flaps 20 at 16:08:44. Unfortunately the FO put in flaps 8 and the error was not caught in the subsequent checklists. For those unfamiliar with the CRJ, flaps 8 is the most used flap setting.

Based on the CVR there is a ten second or so gap between V1 and power reduction, but only the the FDR can confirm the accuracy of that. I am unsure as to why they got a spoiler configuration warning....any ideas?

It is also worth noting that the FO did not call Vr.

Reading CVR reports like this one makes my stomach churn. We have all had some moronic conversations at work that we would not like anyone to hear....so I hope that no one holds the content of their discussion against them. Only that they should not have been so involved as to lose situation awareness.

I have heard many stories of successful flaps 8 takeoffs, when the flap setting should have been 20. It is a mistake that a lot of crews have made. Changing the flap setting during takeoff roll, not so much.

I thought the crew did pretty well at staying calm at the end of the runway. Just imagine the 10,000 thoughts running through your head in a moment like that. With the most blaring one being that your career is quite possibly over. I am not sure how I would handle that. I imagine most people would go into full shock.

As mentioned before, it is always better to learn from the mistakes of others. We can all learn from this accident.

And remember, pull the damn CVR circuit breaker before you go into CYA mode!!!!

Have done two aborts one low speed (less than 40kts) and one highspeed (over 100kts). Both times we got a CONFIG SPOILERS after the abort was initiated.

When you idle both thrust levers the spoilers come up if you are above I think 30kts (not really sure). The logic must sense the high thrust setting and the spoilers being up and give the warning.

Thrust levers physically at auto causes spoilers to deploy. Actual fan speed above 77.9% causes the config warning. The engines don't spool down as fast as you bring the levers back, therefore for a split second you get the config warning.


It looks like this crew tried really hard to kill themselves and were saved by the complete luck of having EMAS at the end. Any other airport and this would've been another Colgan 3407 aftermath.

That is what I thought...forgot the specifics and I wasn't about to look for the book.

I don't see anything wrong with having a conversation while waiting for a PDC with the brakes set, although getting your stories straight would probably be better done outside of earshot from the CVR.

Because if you lose your airline pilot job and you can replace your income by working sales, or construction, or the equivalent then it makes it a little less likely to attract and keep professionals. Can a doctor or a dentist say the same thing? Despite what many people say, pay is a motivator. It is for me. And it is for most people.

What was the outcome for the crew with PSA?

I guess in contrast with some of the other threads in the forums these days the real question is, were these pilots fairly low time? What was their training background? Were there any fatigue issues with the crew?

I wonder what would have happened had the F.O. NOT moved the flaps while in a t/o configuration. The warning ultimately caused them to abort the t/o at a speed that caused them to overrun the runway but not by much. I'm not sure of the runway length but I would imagine they would have been able to lift off before they reached the end had neither of them noticed the flaps were not set correctly. But if this was a relatively short runway or a runway with some clearance issues at the departure end, things may have been pretty bad. I know one way is a little hilly and one way there is a big drop off. Gotta wonder what that would have done to get the FAA moving with some changes.

Just some food for thought.

FMI:

CD List Of Contents

Captain
Total time: 9,525 hours
CL-65 time: 4,608

FO
Total time: 3,029 hours
CL-65 time: 1,981

According to the report, no training problems, no failures, and no fatigue issues.

Well, from the CVR ...
It was the captain who moved the flaps. Based solely on the speed book, it looks like their data was based on flaps 20, but the FO had flaps 8 in his head. How much of an actual difference is there between flaps 20 and flaps 8 speeds when the numbers come across the ACARS? Based on the speed book, there is only about a 10 kt difference. According to the FDR, the highest recorded ground speed was 142 kts. :eek:

I for one hope they didn't get canned for it. Yes there were definite things wrong with what they did but could happen to many of us. And you can bet they'd never make that mistake again - and will probably take sterile cockpit and checklists (and double checking) more seriously from now on. Probably more seiously than just about anyone now. Retrain - life goes on. And thank god no lives were lost. Airplanes can be repaired and replaced, egos and pride are done some good by being bruised (or severely beaten!) sometimes. They learned their lessons - and did it for many of us who read the CVR as well.

I wasn't saying they got canned. Nor do I think they should be. I have no idea what happened to them.

I just think a lot of us don't treat this job with the respect it deserves 100% of the time, myself included of course. There are things we can all do to improve.

You're joking right? The CA said "I don't know what to do" after they went off. ALPA to the rescue.

This illustrates why whenever I respond to a checklist, I physically touch the item being called out and verify its position.

For flaps I always point to the flaps required on the performance, and then move to the lever to verify they agree.

The decision to abort was made several seconds after V1. Let's remember what V1 is. We're committed to fly after we have heard V1. The speed was 142 knots. The airplane would have flown just fine at flaps 8, flaps 20, or anything in between. The airplane would have flown just fine even though it was yelling 'config flaps' at the crew. The decision to abort so long past V1 sealed their fate.

With that being said, I think it could have happened to many of us. They have paid a huge price. Get them retrained and get them back in the cockpit. And let's all take 'sterile' more seriously. But most important I beleive is proper checklist discipline. I see too many people just read/or recite from memory the checklist, and say from memory the proper response, without actually verifying the checklist item.

Let us all learn from it.

It think it's more than checklist usage.

Part of CRM is effective communications which includes active listening. Both appeared to have missed something. The CA called for Flaps 20, but the FO set 8. For whatever reason, the word "Twenty" that entered his ear did not get processed correctly by the brain, and therefore the brain didn't tell the hand to more the switch a little more. The FO called that he had set Flaps 8, and the CA confirmed this. Neither processed what had been said vs what was supposed to have been said/done.

So here is my question: with the FAA all hot and bothered about runway incursions, why is this practice of completing so much "inside" work while the aircraft is moving an FAA-approved procedure?

All of this is done while the ac is moving. The FO is inside with the ACARS and setting the PFD. The CA has to look inside to set the bugs and look at the speed card (to verify the correct weight is selected). This is where the flap setting should have been caught, twice. Seems like some of this could have been completed before the aircraft came off the gate.

For those of you who think "oh it could happen to any one of us", your looking at this the wrong way and to be honest it is quite disturbing.

Look at the recent history of your Regional or Commuter accidents.

1. Buffalo, complete pilot error
2. Lexington, Pilot eror
3. Those two guys who took a CRJ too high and flamed both motors and every other word was "dude".
4. The ALPA poster boy who never came near an F-16 but claimed to fly them.

Im sure there's more but those come to mind. The level of Maturity between a Mainline cockpit and a Regional is astounding and Sulley is the perfect example. Calm, cool, get the Pax off.

As for me, when I see something like this over run, my first and last thought is "That will NEVER happen to me".

Just another reason to avoid RJ's until you guys decide to police yourselves. Your reputation is suffering.

Surf Hard,

Nada

Please...if you can't multi-task, ya don't belong in a cockpit. Why don't we take care of ALL checklists and ALL duties before we ever move the aircraft? Because it's silly and inefficient. And I don't know about y'all but my head doesn't think that slowly.

They screwed up; they aren't the first and won't be the last...we'll always find another creative way to kill ourselves. Just don't let yourself be that idiot.

I agree that pay can be a motivator, but I don't think it makes a professional. Take our military personnel for instance. Most (not all) are very well trained professionals and they don't get paid near what their civilian counterparts do. However, they still get the job done and they get it done to a level that most civilians wouldn't have the discipline to.

Essentially, what was said about pay and professionalism would mean that the Captains at the airlines and the most senior pilots are more of professionals than junior guys, or First Officers.

Over the past few years almost everything that has gone against us in this industry has been our faults. With respect to negative press. Imagine you are up for a promotion at a non-aviation related job and one of the sales reps that reports to you (whom you've been counting on) completely botches a fairly large account. Then you go to your boss and say that if you were paid more and if he gives you this promotion, you would be more serious about your job and you wouldn't have let your rep make the mistakes that he/she made. Do you think you are going to get a raise? All of the most recent accidents in our community have been mostly impart by pilots not being professional, being negligent and breaking sterile cockpit. That doesn't work for us when we are trying to raise the professionalism bar.

As far as the level of professionalism = the level of pay and taking your job more seriously, do senior Captains at the Majors never break sterile cockpit? Do they not let their bellies hang out of their shirts? Do they not unbutton that top button of their shirt? Do they not wear cowboy boots? Do they not eat in front of the passengers? Do they not bash their own companies on the shuttle going over to the airport while the traveling public takes the same ride?

And even better, do you think that the public doesn't notice when a Novice regional airline First Officer or Captain walks past a Delta Air Lines pilot and says "Hello" and he doesn't even got a nod back in return? Yeah, that whole mentoring thing that the FAA has been passing around isn't going to work with this.

I guess what I am trying to say is that pay can be a motivator, but it really has nothing to do with professionalism. The hurdles and checks that may be involved to reach a job with higher pay is what allows a person to hold a job that requires a certain level of professionalism. There are many, many doctors and nurses that are working for free in places like Haiti that are still professionals.

Great post, Nada...I agree completely.

I have always thought that this was a week area in the Checklist.
The captain has to look at the FMS and read out the flap setting.
The F/O just does it. So lets say he makes the mistake of going to flaps 8 instead of flaps 20. (like what happened).
There is no checking of the setting after the Captain calls for Flaps 20 Taxi check. It is never double checked with the FMS again. You only confirm that the flaps are actually where they are. 8 degrees green.....

Just like the media only reporting on one side of the big picture.

So there have been no problems at the Majors?

Nobody landed on a wrong taxiway last year?

None of the Majors where involved in runway incursions?

Nobody overflew their airport because they fell asleep on the flight deck?

You should feel lucky that ALPA goes to bat for you in a way that they don't for the Regionals.

Take Sully out of the picture and you have nothing. And let's not kid ourselves, the outcome of his story is more unlikely than you winning the PowerBall 5 times before you retire.

But, the best part is that the overrun material really did it's job. Charley West going off the end and the only thing hurt is a few ego's, a few scared folks and a little airplane damage. Thanks, Airport Manager, FAA, NTSB, and whatever industry folks saved these folks with this great application of modern tech. :)