Figure: Q400 Indicated Airspeed Display, from NTSB AAR-10/01, Figure 1.

Eddie Sez:

I think of this crash every time I get on a commuter airliner as a passenger. First, what really happened:

  • Two inexperienced pilots put themselves on duty after long commutes and inadequate rest, sleeping either on an airplane while commuting or in the airline's pilot lounge.

  • The pilots activated a VREF switch used for icing conditions that raised the pilot display low speed cues and stick shaker speed.

  • The pilots were disengaged during the approach, talking idly while failing to notice the low speed cues and getting behind in normal briefings and approach call outs.

  • When the stick shaker went off, because of the VREF switch, the aircraft was a good 20 knots above stall speed.

  • The captain pulled up aggressively and put the airplane into a stall.

  • The first officer retracted the flaps, deepening the stall.

  • The aircraft fell almost straight down, killing all on board and one on the ground.

Had the pilot, at any time until just about the last few moments, simply pushed forward on the controls, the airplane would have recovered. Some, including the Air Crash Investigations film, make the case that these pilots would have performed better if not fatigued. Perhaps. But a more experienced or better trained pilot would have never got the airplane into that situation and would not have put the airplane into the stall after the stick shaker went off.

I think the professional aviator class is filled with pilots that don't have a basic understanding of aerodynamics and why airplanes actually fly, how to get an airplane out of a stall, or the need to focus on the task at hand when flying an airplane:

  • Aerodynamics — Not everyone who drives a car understands what is going on between the gas pedal and the tires but every pilot should know the difference between the relative wind and the chordline of a wing. See Basic Aerodynamics / Lift for more about this.

  • Stall Recovery — When a highly cambered wing is stalled there is only one way to get it out of the stall and years of simulator practice trying to hold every inch of altitude needs to be unlearned. See Basic Aerodynamics / Angle of Attack for more about AOA. As a result of this mishap the stall recovery training most American pilots receive is changing. See Abnormal Procedures / Stall Recovery for more about this.

  • Sterile Cockpit — Though the NTSB report doesn't spend much time on it, these pilots chatted idly while on an instrument approach and failed to notice the many cues they had telling them their speed was heading south. See Normal Procedure / Sterile Cockpit for more on this topic.

But there is one more factor that I think everyone has missed. When pilots who have never stalled a large airplane are trained exclusively in simulators, having an abnormal situation outside of the box can come as a shock. When in a panic, our brains often jump to an instinctual reaction (pull back on the yoke) and fail to think things through. The best way to deal with this is to desensitize oneself against the fear in a real airplane. More about this: Pilot Psychology / Panic.

What follows are quotes from the relevant regulatory documents, listed below, as well as my comments in blue.


Accident Report


Narrative

[NTSB AAR-10/01, ¶1.1.]


Analysis

[NTSB AAR-10/01, ¶1.17.1]

[NTSB AAR-10/01, ¶2.2.1]