When Pilots treat the Aircraft Like a TOY! | Air Crash Investigation

This video has been brought to you in conjunction with Skillshare. You will now find a link in the video description below with a special offer just for you. It is late in the afternoon of October 14, 2004. An almost empty Bombardier CRJ 200

aircraft

with only two

pilots

on board is in an extremely serious situation during the climb, as several major pitch changes have been felt and at this moment The

aircraft

is at its maximum altitude in a fully developed stall and a bank to the left with more than 80 degrees and both engines. failed, but it was not the aircraft or the aircraft systems that caused this situation.

This is the shocking but unfortunately true story of Pinnacle Airlines Flight 3701. Pay attention. The beginning of the story that led to the

crash

of Pinnacle Flight 3701 actually began earlier on October 14, 2004. The

crash

ed plane, which was a CRJ-200 bomber, was supposed to fly from Little Rock to Minneapolis with passengers on board. board, but

when

the flight crew lined up the plane on the runway at Little Rocky and safely prepared for takeoff, they received a message broadcast and the akash message had to do with a right engine air bleed system, so Initially, the engineers were struggling to find the problem with the engine, so they called more mechanics to help them.

While this was happening, the passengers were rerouted to different flights that took them towards Minneapolis, which meant that after a few hours,

when

the small crease had been found and rectified, the plane was still on the Little Rock apron, but the airline needed that plane to fly the next day from Minneapolis, so now they needed to get that plane to Minneapolis, so they called in a reserve crew. The crew that was called to operate the flight consisted of a captain who was 31 years old, had 6,900 hours of total time and 973 hours on the CRJ 200. He was a happily married family man with mostly good training comments, along with him I was 23 years old. former first officer, had been flying for pinnacle for just over six months at which time he had 761 hours of total time 222 in the crj 200 and was described as a really happy and positive person who was very happy with his position at pinnacle both The

pilots

were transported as passive crew members on a flight from Detroit, they arrived at Little Rock around 8:36 p.m. and were described by people who met them on the ground as being in good spirits and well rested. and, according to the captain's wife, these two pilots had not flown together before, before we continue, I just want to point out a little bit about these types of positioning flights, so they are quite rare, obviously, because the airline doesn't care.

I like to fly empty. plane and that's why there is always a feeling of doing something special when you are operating a positioning flight there is no cabin crew on board there are no passengers on board and that is why you also as a pilot have to do some extra things like you have to operate aerial stairs, if you have them, you have to make sure the kitchens are secure, no trolls are moving and you need to set up the front slides in case of evacuation, there are very rarely time pressures. On a positioning flight like this one, for example, the crew only needed to get the plane to Minneapolis for use the next day and so it was probably pretty good and in a festive spirit for the operation and other things.

What you also have to remember is that when you are operating an empty flight like this, the airplane is not handling like it normally does, you are much lighter, so the performance will be different and you will be able to do things that you normally can't know this, This actually poses some pretty significant threats because the way an aircraft is operated must be exactly the same whether it is operated with or without passengers or cabin crew. Well, that's just to take the crew into account. They received their briefing materials, flight plans that planned to climb to a cruising altitude of 33,000 feet, and the weather along the route looked pleasant with only a layer of cloud partially covering the departure airport, but it was clearing as they moved north at 21:21.

CRJ 200 took off from the Little Rock airport and it became apparent almost immediately that this aircraft was not flying like it was supposed to because just five seconds after takeoff, at an altitude of about 450 feet, the first of several workshops appeared very large pits. The inputs came from the cockpit, the first caused a lateral g-load of 1.8 g and tilted the attitude up to 22 degrees nose up and caused a climb of 3,000 feet per minute. This was done very quickly, followed by a shaker vent and then a stick push event, such as when the airplane pushes the nose forward, followed by full forward movements on the yoke that leveled the airplane and caused a side load. of approximately 0.6 g.

Now there was no indication why this happened because unfortunately no data copied from the voice recorder was saved from the beginning of the flight, but from the flight data recorder we know that this was the first of three such entries, a which we'll get to in a second, the plane continued to climb and at time 2125. Then, about four minutes after takeoff, when the plane reached about fourteen thousand feet, the external pilot was activated and after that, both transcripts of the Air traffic control and flight data recording show that the pilots now swapped seats meaning the captain moved from the left seat to the right seat and the first officer moved to the left seat why we don't really know but What we do know is that shortly after this the external pilot was disconnected and the second pitch command was recorded from the east cockpit.

At this time, they applied 2.3 g of vertical load, which gave a climb rate of approximately 10 000 feet per minute, the plane continues to climb and right after this there are recordings of the rudder cyclical movements left and right, so they started left, then right. left, then right again, this gave some lateral loading to the plane within the aircraft's performance limits, but definitely not something you would have ever felt as a passenger and not something you would normally do anyway, the crew continues climbing and at 24,600 feet, the last pitch input felt this time is a 1.87 g load and that gives about 9,000 feet per minute in climb rate.

This is indicative of pilots who are testing things right, they are doing things now that they would never do when they have passengers or cabin crew on board, such as testing the limits of what the aircraft can do. The plane now continues to climb to its planned cruising altitude of 33,000 feet, but somewhere around here the flight crew decides yes. it would be a good idea to see if they can get up to the maximum certified ceiling of the crj-200 which is 41,000 feet, then they contact our traffic control, request flight level four one zero and their traffic control sees that there is no traffic above from them. so they clear them up to this level um somewhere around here is also where the cockpit voice recorder transcripts start recording so from here we know that the pilots were laughing right they were in a festive mood in the cabin there are a lot of expressions like oh man, oh brother, that's 41, uh, I can't believe he's tall, uh, although it seems like a normal thing and a lot of laughter and things like that definitely indicate that the mood in the cabin is different from what would be in In a normal commercial flight, the autopilot mode that pilots use to climb up to 41,000 feet will be really important to this story.

They're using a mode called vertical speed and what vertical speed does is kind of like the name implies. maintains a certain rate of climb a certain vertical speed this is a mode that we normally use very rarely when operating at high altitude because it will climb with that vertical speed and it will sacrifice speed to maintain that vertical climb rate and this is exactly what happened as well that from about 37,000 feet the pilots enter a climb rate of 500 feet per minute maintaining that climb rate is fine as long as the confidence of the engines can sustain it well because the external throttle will move the thrust to maximum and then maintain 500 feet per minute and if the thrust is not enough the speed will start to decrease and this is exactly what happened.

They started with a speed of 203 knots, which is mach 0.63, and as they continued to climb, the speeds continued to get lower and lower. and lower so that when they reach 41,000 feet the speed was now 163 knots and mac point 57 now why is this important? Well, this turns out to be the most dangerous thing they've done so far because if you know your aerodynamics, you should know that as the speed gets slower and slower, if you want the plane to continue flying, the angle of attack of the wing, like the The angle that the wing has against the oncoming air must increase, you must have more and more angle. of attack to create the same type of lift at lower speeds;

However, when you do that, the pressure difference between the bottom of the wing and the top of the wing will increase and that will increase the vortices that are created on the wingtips now those vortices also come with something called induced drag, so what this effectively means is that as the plane continues to go slower and slower, especially at high altitude, but the air is very thin, this induced drag will get bigger and bigger and the plane could end up. In a situation that we pilots refer to as being on the back of the drag curve, essentially that means that as the plane goes slower, the drag will increase, so we will go even slower and it will go increasingly slower and unless you have enough confidence in the engine to accelerate the plane and reduce drag well, the plane will eventually stop, it will not return to this speed on its own and another problem you have when you are at these altitudes is that the air is very thin.

As confidence in the engine is greatly reduced, the engines will not be as effective up there, so we are very careful when operating at higher altitudes because of this, this is something we are constantly on the lookout for when we go up and this is why Vertical speed is a state of mind that can be very dangerous and in fact this is probably the most dangerous thing I have done up to this point, although all the other things they have done are much more spectacular than the pilots on this flight . They don't seem to recognize this problem, instead they are really excited to have joined the 41k club.

They're discussing this room and back again and how cool it is, and at this point they're also being switched from one air traffic controller to another. the other one, the new air traffic controller, asks them what plane they are flying and when they answer that they are flying a crj-200, the air propulsion controller basically says oh, I've never seen them that high before and the captain answers to that, well, we don't have any passengers on board, so we decided to have a little fun and come here and this is actually our duty limit, so that kind of highlights that there was no operational reason for the crew to go up to 41 000 feet the only reason they did it was because they wanted to try something you know, join the 41k club the captain asks the first mate if he wants something to drink the first mate makes some jokes about checking if the liquor cabinet is locked, but then he orders a pepsi, the captain goes to make the pepsi for the first officer when he comes back, it seems like he's starting to realize that this is not a good position because he says um we're, we're losing here, um, We will be going down in seconds and this, this thing is not going to maintain altitude, right? and the first officer responds with that, can't you, man?

I greased it here, but it won't stay. What this indicates is exactly what we were talking about before that they are now so far behind on the endurance curve, even though the confidence is in maintaining speed and altitude. It continues to decelerate and this is what they are seeing in the speed recorded at 2154. The captain contacts air traffic control and asks them to obtain a lower altitude, perhaps a flight of a 3-9-0 or 3-7 -0, but only a few seconds later. He calls the first stick jerk event occurring when the airplane reaches 150 knots indicated airspeed.

This is done followed by another four lever shake events and four sticky pusher events for each of these, each time the lever pusher is activated the nose is pushed down. to gain speed in the air, but almost immediately afterwards, the nose rises again to maintain altitude, this results inthat the speed keeps getting lower and lower and the aircraft's angle of attack attitude increases. and higher and the highest indicated attitude was 29 degrees nose up at 41,000 feet when that happened, on the fifth stick shake and fourth stitch pusher, the airplane goes into an aerodynamic stall and that happens, both Engine one and engine two shut down almost simultaneously and the airplane pitches with the left wing down, pitches up to 82 degrees to the left and pitches down with 32 degrees nose down in the next 14 seconds, the pilots enter the controls and manage to control the plane, but are losing 7000 feet in the process during the recovery procedure, the captain had time to call our traffic control, said we declared an emergency reserve and then focused on actions of the first officer in the left seat.

Air traffic control returns and gives them a clearance to descend to 24,000 feet, which the captain recognizes as this happens, the adg, the air-powered generator, which is similar to a rat, a ramar turbine on an airbus is running. deploying in the airstream, we can hear that on the cockpit voice recorders because it produces quite a bit of airborne noise and about 20 seconds after the initial stall, someone in the cockpit shouts that we have no engines and the captain responds with a double engine failure. Then the captain quickly begins to act on the double engine failure checklist. that he has some memory items, one of those memory items is making sure that the plane's airspeed does not drop below 240 knots.

That's not written very clearly on the checklist, it just says airspeed 240, it doesn't. Clearly specify that that is the minimum and this will be one of the changes that will come out of this accident eventually because as they are descending now they are not maintaining 240 knots, they are maintaining a speed less than between 170 and 200 knots um indicated that the failure checklist of the dual engine tells the crew that if they are between 21,000 feet and 13,000 feet to consider a windmill start and the beginning of that checklist is that you need to maintain 240 knots to stabilize there and when you are ready to try to start the engines with a windmill, since by using the airflow of the plane's speed to rotate the engine components, to start them you need to tilt the plane forward to reach an indicated speed of at least 300 knots. so the captain is reading this and he tells the first officer to move forward, okay, give me 300 knots more forward, the first officer does it right, he pitches the plane forward about five degrees with the nose down, but every time he He does it, he continues.

It is necessary to bank the plane again so that the highest speed the plane reaches during this maneuver is 236 knots, which is less than the necessary minimum of 240 and you will understand why this is so important later in this video, now that the captain is dealing with the twin engine checklist, the cabin altitude alert goes off because the way the pressurization system is built on modern airplanes is that it uses engine bleed to pressurize the airplane and of course, If you have lost both engines, it means that there is no bleeding available now to pressurize the cabin, so while they are going through the checklist, now descending, the cabin altitude has steadily increased until they are now in a position at the one who needed to put on the masks.

There is a bit of ambiguity in the cockpit voice recorder and flight data recorder about when the masks were actually put on, but the masks were put on during this time. With all this happening, the captain continues to insist that the first officer go down and also accelerate, but this does not really happen and the captain does not insist other than the fact that the plane is now descending to about 29,200 feet and up to this point the electrical power has been supplied by the adg's air driven generator but at this point I am following the dual engine failure checklist and the captain decides to turn on the apu's auxiliary power unit and that is important because the apu will be able to provide full electrical power to the aircraft and also, more importantly, will be able to provide pneumatic power.

In case the wind start is not successful and it is necessary to make an APU assisted restart attempt later I also want to point out at this point that the plane is almost at ten thousand feet and even if they do not have two engines at thirty thousand feet they have a pretty good glide distance, well they have a large area around them that they could reach given the speed and altitude they have and within glide distance they have about six airports at this point, this serves as a good reminder that If you ever find yourself in a situation like this, if you are a pilot, dividing the rules in the cockpit is very important, the pilot who flies in a situation like this has to assume the worst, that is, we have lost both engines, we may not be able to do it. restart them, so what will my plan be and contact the air traffic control point towards an airport that is within their obvious glide distance?

You probably stay a little high and just aim for that, start preparing dishes, start briefing yourself quietly so you can get into one of these airports now the pilot monitoring on the other side has to focus on running the checklist with precision trying to start at least one of the engines because if they manage to start one engine they will have a There are many more options and much more time available, but in this case this crew seems to be completely focused on simply trying to start the engines correctly. The first officer maintains a largely inclined northeast course and there are no discussions about which airport to choose.

They are not going or talking to air traffic control or giving them any kind of indication about the severity of the problem, but at this point air traffic control calls the aircraft and asks them what their status is, what type of failure and emergency have. We're actually declaring because remember up to this point they've only declared an emergency and they've also told traffic control to wait, which means your traffic control will assume that they're very busy and they're working through the checklist and they're unlikely to come in and you know you're going to potentially cut them off, but here at traffic control you think time, you know, has passed too long, they need to know a little more about what's going on, so you ask them and the captain returns. and what the captain says is that well, we have had an engine failure up here and now we are trying to descend to restart the other engine, this is not true, yes, they have had an engine failure but they have also had a second. engine failure and the difference between an aircraft flying with one engine and wanting to restart the other and a line of aircraft without any engine is huge, one is an immediate emergency, the other is fine in the control situation, so the controller comes back and says, you understand controlled flight on one engine and there is no response from the captain to that question as the plane continues to descend now the captain tries to restart the engines using the apu, he makes four separate restart attempts, two on each engine, all of them with no success in rotation n2 is stuck at zero, not moving at all and since they are now approaching thirteen thousand feet, they request a further descent from air traffic control.

Air traffic control comes in and asks them: do you need to land? and the captain just says No, we're still trying to restart this engine, so at this point as low as 13,000 feet, air traffic control still doesn't know that they're dealing with a plane that has no engines and the captain still appears to be trying to hide the fact that they have been put in this situation at time 2208, the captain is heard on the voice recorder saying change, the first officer responds with yes and then there are some rearranging sounds on the voice recorder of the cockpit indicating that the pilots are now returning to their original seats, so the captain returns to sit in the left seat, the first officer in the right seat and, from this point, the captain is in control of the aircraft and the first officer takes care of the checklist and talks to our traffic. control and when the first officer calls air traffic control the first thing he does is state that they are actually having a twin engine failure and that they need to vector to the nearest airport immediately since the plane is passing at about 9000 feet now with air.

Traffic control is very aware of what is happening, the crew is asking for help to get to the nearest available airport and that is identified as Jefferson City, which is right across the street, the problem is that even though Jefferson was within range of glide when they were at 30,000 feet and when there are 20,000 feet since they have been maneuvering since they have been trying to restart the engines and have not focused on maintaining the best planing speed which would have been 170 knots Jefferson City is now out of the glide range, but they haven't really figured it out yet, they still haven't figured out that the first officer is asking a traffic stop to get the Jefferson City tower frequency and also the ILS frequency so he can tune to it and At this point they are still in the cloud, well the cloud cover over Jefferson City is about 5,000 feet, so they continue to descend now the captain is calling for the vectors to rotate to settle on the centerline, which will eventually they make, but when they break. out of the clouds at about 5000 feet, then the captain asks where the runway is, the first officer sees the runway and points it out to the captain and the captain says we're not going to hit this runway and there's a road or something like that , they look around.

They themselves see a straight line of illuminated road a little to the left so the plane leaves the center line of the runway in Jefferson City and turns onto this road at time 22 14 46 the captain is heard on the voice recorder copious say let's continue The equipment prepared, I don't want to enter any house here now, that has some importance to me because, as a pilot, I know that if you are going to make an emergency landing on dry land, taking out the equipment is crucial for the equipment to absorb some of the forces of the impact and the fact that they choose not to do so to extend their glide and try to avoid houses shows that the captain is now focused on trying to avoid casualties on the ground (the last thing heard on the recorder of copied voice is that we are going into houses and then there are several alerts from the ground proximity warning system followed by impact noises at 22 1506 the plane cuts some trees and a garage before impacting the ground within a populated area .

It flips over and bursts into flames upon landing. Both pilots are lost on impact, but fortunately no one on the ground was injured. The aircraft

investigation

team quickly arrived on scene in Jefferson City and began trying to gather updated information and information on what could have caused this and very quickly they were able to find the cockpit voice recorder in good condition and blow up the recorder. of data and from there they were able to build a pretty clear picture of what had been happening, obviously the main focus was on the way the pilots had acted until they stalled at 41,000 feet, but there were some questions that needed to be answered : one, why the pilot piloting the first officer in this case acted the way he did when faced with disturbed warnings;

Did the plane's engines shut down when the plane stopped and why couldn't they get the engines running again? Now let's get into the technical aspects of this right after this message from my sponsor. I also want to take a few seconds. I'm here to especially thank the sponsor of this episode, which is Skillshare. Now I know you're watching this because you're a curious person, a lifelong learner, someone who constantly wants to improve and better understand the world around you, and in that case. Skillshare is definitely something you should check out. Well, they have thousands of high-quality video courses and pretty much anything you can imagine.

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To answer the first question about why the first officer acted as he did when he confronted thestall warnings, they had to go back to the Pinnacle Airlines training organization and the training organization made it very clear that the way the crews trained to handle imminent stalls were behaving was to avoid going into a fully developed stall, so use the shaker or the appearance of vibrations as a first indication of stall and act accordingly to try to get the aircraft out of the stall increase speed decrease the angle of attack as soon as possible, but what also became clear to the

investigation

team was that this type of training was rarely performed at high altitudes; it tended to be done at around 10,000 feet in different configurations and a lot of emphasis was placed on this type.

The objective of the training was to try to rectify the stall situation, increase airspeed and reduce the angle of attack, but also minimize the loss of altitude and this was common throughout the industry at the time of the accident. It was thought that the losses would occur mainly because the aircraft was part of the approach traffic pattern and therefore terrain would be a major issue, so once the threat of immediate stall was well resolved then it was necessary minimize altitude loss and also to around ten thousand feet. and underneath the engines are very powerful, the engines have the ability to almost pull a plane out of a stall, that's not what happens at 41,000 feet, but the engines have very little excess thrust available, so as a consequence After this accident, airlines around the world began practicing more high-altitude stalls and emphasizing the importance of really putting the nose down and keeping it down until airspeed has recovered, using the engines nice and slow and smooth to get there. .the speed increases and only once the speed increases again and the plane is not sold, can you start thinking about regaining altitude, not before, now this brings us to the problems with the engines and when it comes to why the engines actually shut down, ie.

It was pretty easy to understand because the airplane was in such an extreme position at 41,000 feet with a pitch attitude of 29 degrees and a really very low speed, what really happened was that the airflow going into the engines was seen. severely disrupted, causing the compressor to stall and basically not enough air being pumped into the combustion chambers to sustain the flames, so the flame from both engines came from the extreme attitudes the aircraft found itself in during the displacement, but this still doesn't explain why the engines wouldn't restart properly, it's one thing if they shut down, but if you're at 41,000 feet you should have enough time to try to restart the engines and then use the apu to turn it on, but in this case doesn't matter. what the flight crew was doing n2 the high pressure compressor and turbine just weren't moving properly n2 was stuck at zero and no matter what they did it wouldn't spin why is that ok?

When the ntsb questioned the engine manufacturers, they discovered that these particular engines, the CF-34-1 and three engines, had had problems with the in-flight engine start procedure during certification testing, meaning that if If the engine core was allowed to go to zero, it could face something called core lock and what Basically, core lock has to do with an air seal inside the high pressure turbine. Now this air seal directs air flow and cooling inside the engine and because it does that, it has to be very, very tight and the way it is. built has a rotating part and a static part, now the rotating part has some teeth that grind small grooves in the smoother static part around it and generally during normal final operation the margins are really very tight, what What can happen if the engine is running at a really high temperature and then suddenly cools down, is that the surrounding softer static material will cool faster than the rotating part of the air seal and when that happens, the rotating part can move out of the grooves that have been ground and into new material into the soft material and at the same time, the softer material, as it cools faster, contracts around the rotating part, which greatly increases the friction inside If allowed to come to a complete stop, this can actually lock the engine until the internal components have cooled enough to release each other and That's why remember how I said earlier in the video that it was so important that the outside airspeed is kept at a minimum of 240 knots, that's because at 240 knots there is enough air running through the core of the engine to keep this air seal rotating while it cools and then when it has cooled properly begin to restart the engine.

I don't have a problem, but as you know on this particular occasion, since the pilots forced the plane up to 41,000 feet and allowed the airspeed to decrease so slowly, that meant the engines were running at almost full power, heating them up a lot without turning on. There was a lot of cooling air running through the core, so one of the engines actually ran 300 degrees off its maximum redline temperature, the other was just below the redline and when the pilots finally got it the plane got upset where it was 29 degrees and the plane stopped fine, then the engines were red hot and then suddenly they shut down cooling very quickly since they are at really cold temperatures that we have at 41,000 feet, then the plane descended to a lower speed, which this core allowed. locked up and this is what happened, these engines were completely locked up, no matter what the pilots did after that point they would not start spinning, the only thing that would allow them to start spinning was more time to let the internal components cool down.

They cooled enough for them to release each other and then they would have been able to restart the engines. Because of this, an airworthiness directive was sent to all users of CF-34 engines to inform them of this. potential for core locks in certain situations and there were also FAA mandates to General Electric to try to update the way these air seals were built to minimize the risk of core locks like this occurring in the future, so which this brings us to At the end of the final report and what the ntsb considers the probable cause of the accident, the national transportation safety board determines that the probable causes of this accident were a deviation from the unprofessional behavior of the pilot of the standard operating procedures and poor flying ability, resulting in an in-flight emergency from which they were unable to recover in part due to inadequate pilot training; two, the pilot's failure to timely prepare for an emergency landing, including communicating with our traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites, and the inadequate management of three pilots of the checklist of dual engine failures that allowed the engine cores to stop rotating, causing the core-locked engine condition that contributed to this accident, were one of the core-locked engine conditions that prevented the at least one engine being restarted and two airplane flight manuals that did not communicate to the pilots the importance of maintaining a minimum speed to keep the engine cores spinning.

I know this video might trigger some feelings in you, like anger, disappointment, shock and awe, that's not the reason. I Chose to Make This Video I chose to make this video because it highlights a really important point: how important it is to stay professional no matter what kind of situation you find yourself in, even if you're in a position where no one ever will. Find out how he was operating or what he was doing, it could still have an impact, it could still have consequences, so try to be as professional as possible. There are also some really important learning points in this video about the aerodynamics of high altitude operations and also some technical systems.

And that's why I always make these videos well. Each of these videos from my series on aviation accidents and incidents, of which you can see more here. I'll try to highlight something that's really important, something that made the world of aviation a little safer. after the accident, although it may have been really tragic when it happened and I hope that you find these videos interesting and that they teach you something even if you are not in the aviation industry and if you do, please share these videos on social media, but also make sure You have subscribed to the channel and highlighted the notification bell so you know every time I send new videos.

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