1. SOPs

2. Pinnacle Airlines Flt 3701 14 th Oct 2004

3. Objectives By the end of this session you will be able to:  Identify the factors that led to the loss of Flt 3701  Understand the importance of  Adhering to SOPs  Demonstrating professional behaviour in the management of a flight

4. Overview 1  14 Oct 2004, Bombardier CL600 (CRJ 200 model) N8396A  Pinnacle Airlines Flt 3701, Operating as Northwest Airlink  Positioning flight (no Pax) from Little Rock to Minneapolis  Company planned altitude for this flight was 33,000ft

5. Overview 2  54 minutes into the flight the aircraft crashed in a residential area following a double engine flame out at 41000ft destroying the aircraft and killing both pilots  Weather, navigation equipment, fatigue, hypoxia and aircraft maintenance not an issue

6. Flight Profile - Take Off and Climb 5 secs 190’agl Pitch 22º 1.8G 3000 fpm Stickshaker Stickpusher 14,000’ AutoP 15,000’ AutoP Disengaged Pitch 17º 2.3G 10,000fpm Rudder Inputs 4.2ºL, 6ºR, 0.4ºR then 7.7 ºR 24,600’ Pitch >10º 1.87G 9000fpm FL370 to FL410 AutoP VS Mode 500fpm climb T/O Flight Plan Alt FL330 1 2 3

7. Handout – Abridged CVR  Read the handout (timescale 15 minutes)  Assess the following:  Attitude to the management of the flight  Appreciation of the potential threats to the flight  Use of SOPs and inter-crew communication  ATC communication and phraseology.

8. Flight Profile -Descent FL370 203kt 150kt AoA 7.5º FL410 163kt AoA 5.7º AoA 12º AoA 27º A/C stalls FL420 74kt Stickshaker Left roll 82º Recovered 178kts, 200kts, 236 kts Engines flame out Windmill start zone (21,000 – 13,000ft) Need 300kts 4 APU restarts V Minimum 240 kt now required Stickshaker Stickpusher Stickshaker Stickpusher Stickshaker Stickpusher Stickshaker Stickpusher

9. C.A.M. TimeLeft Audio PanelRight Audio Panel 21:21 to 21:24CaptainFirst Officer 21:25 to 22:06First OfficerCaptain 22:09 to 22:14No informationFirst Officer

10. NTSB Probable Causes of the Crash  Pilots’ unprofessional behaviour, deviation from SOPs and poor airmanship which resulted in an emergency they were unable to recover from  Pilots’ failure to prepare for an emergency landing in a timely manner  Pilots’ improper management of double-engine checklist.

11. SOPs

12. SOPs Team Exercises  As a team discuss and complete your group task.

13. Objectives/Benefits of SOPs?  Standards agreed prior to the flight so that maximum crew performance can be achieved  Set limits or acceptable tolerances  Improve communication  Create logical order, enhances workload management  Increase situational awareness  Specify prioritisation of duties (roles & responsibilities)  Improve cross-checking and monitoring  Allow inter-changeable crew composition  Facilitate conflict resolution  Support better error management in the cockpit.

14. Disregard /Deviation from SOPs  Corporate culture (management commitment to SOPs)  Ineffective or unclear company policies (schedules, costs)  Insufficient emphasis on strict SOP adherence during training  Insufficient vigilance (fatigue), distractions and interruptions  Task saturation resulting in degraded multi-tasking ability/ overload  Incorrect management of priorities (lack of or incorrect decision making for time-critical situations)  Absence of cross-checking, crew co-ordination or effective backup  Personal desires or constraints (press-on-itis)  Complacency and overconfidence.

15. Objectives Revisited By the end of this session you will be able to:  Identify the factors that led to the loss of Flt 3701  Understand the importance of  Adhering to SOPs  Demonstrating professional behaviour in the management of a flight.

16. QUESTIONS