CAL3407, Commuting Pilots and a Personal Confession

Aviation in itself is not inherently dangerous.  But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect.

— Captain A. G. Lamplugh

A chain of events, often called an error chain, refers to the concept that a number of contributing factors, rather than one single event, typically lead to an accident.  Breaking just one link in the chain could yield vastly different results, which is exactly why pilots recognize the importance of following the rules, regulations and procedures that govern how they operate their aircraft.  However, it's often overlooked that the chain of events begins long before a pilot steps into the cockpit. 

Continental Express Dash 8 Q400

The February 2009 crash of Newark to Buffalo bound Continental 3407 (operated by Colgan Air) is a good example   The accident has resurfaced in the news lately as the final  results of the crash investigation recently went public and new FAA regulations designed to combat the root causes of the accident are soon to be enacted.  The NTSB investigation of this accident identified a series of facts, events and actions by the crew and the airline that lead to the accident.  All links in the chain.  The flight crew failed to monitor airspeed.  Both pilots failed to adhere to sterile cockpit procedures.  The Captain had no hands-on simulator training to teach stall recovery techniques and the first officer complained of being sick and spent the entire night before this fateful flight commuting to work and napping on the floor in crew ops.  Remove any of these from the equation, break the chain of events, and the end result might be quite different.  But the link in the chain I'm focusing on today started the night before the accident.  

The NTSB focused much of its attention on fatigue as a contributing factor to the crash. Records indicate that on the day of the accident, the captain logged into the company’s crew scheduling computer system at 3 am and 7:30 am, and that the first officer commuted to Newark on an overnight “red-eye” flight and sent and received text messages on the day of the accident.  Should they have been resting during this time?

The pilots reported for duty at 1:30 pm on the day of the accident and the schedule called for Flight 3407 to take off at 7:45 p.m. and arrive in Buffalo at 10:21 p.m.  While the flight was pushed from the gate at 7:45 p.m., the crew did not receive taxi instructions until 8:30 p.m. and the tower did not clear 3407 for takeoff at 9:18 p.m.  At the time of the crash, both pilots were operating on very little sleep and had been on duty for 8 hours and 47 minutes.  Not a particularly long duty day by any means, but both pilot's actions prior to sign-in, specifically the FO's commute, turned what should have been a normal day into a deadly one.

                                            There but for the grace of God, go I...

                                                                 ---John Bradford

Since I got my first commercial pilot job in 1992 until now, I’ve commuted six times for a total of 5 years, 9 months between my home in Texas to pilot bases in Corpus Christi, Atlanta, Miami and St. Louis.  Everyone who commutes does so for different reasons, but regardless of the circumstances, commuting is hard on everyone involved.  But while it comes at a cost, commuting also affords a significant up side as it allows pilots to live just about anywhere, regardless of where they work.  If you love Colorado, but you’re based in New York…great!  Have your house in the mountains if you want, because all you have to do is drive to the nearest airport and fly to work for free.  Pilots and Flight Attendants alike have what are known as reciprocal agreements with other airlines, so if your employer doesn’t fly from your city of choice to where you need to go, just hop on another airline…the ride is still free of charge.  Also, if the flight is full, there’s an extra seat or two in the cockpit specifically provided for the FAA to observe pilots at work, but if the seat is not in use by the FAA, it’s available as an extra seat for a pilot on a full flight.  Similar seats exist in the cabin for Flight Attendants.  

My longest stretch as a commuter took place over a 4 year period when I was based in St. Louis, Missouri and lived in Dallas, Texas.  After a particularly ugly merger just prior to an especially difficult time in history for the airline industry, I was forced out of my base in Texas and assigned a position in STL.  The airline was shrinking and furloughing pilots at an alarming rate and I was unsure whether my job would exist next month much less next year.  Pilots were engaged in what we commonly referred to as a “death march” in which we were repeatedly displaced from one base to another before being furloughed.  In my case, I first expected to be displaced to STL.  After a few months in STL, I expected to be displaced to New York, our junior base.  A few months later I fully expected to be furloughed from the company all together.  With deep roots in Texas, a nice home, a good school for the kids and a support structure if things got worse, I elected to commute.

For a typical three day trip, I usually flew a sequence that signed in around noon on the first day, which meant I could commute to work on the same day my trip was scheduled to start.  This kept me from having to travel on a day off, but it also meant that I was already well traveled and tired when I signed in for the first leg of my trip.  The first flight from Dallas to St. Louis left around 6am and I could put my name on the standby list using an online check-in system 4 hours before departure at 2am.  I did my best to get in bed early and get a good night’s sleep, but with young children in the house and a wife who likes late night TV, you can imagine how that went.  In spite of my efforts, I rarely made to bed before 10.

When traveling as a non-revenue passenger, the seats in the cabin are first come first served.  In other words, the first person on the standby list gets the first seat and if there isn't an open seat at departure time, you don't go.  There was always a lot of competition for seats, so it was important to get my name high on the list.  I would be at my computer with everything loaded just waiting to hit enter at exactly 2am.  I had my watch set EXACTLY to company time so I wouldn’t be more than a few seconds off.  I would hit enter at exactly 2am and hope for the best.  Usually, there would be at least 4 or 5 names on the standby list during the first 30 seconds we were allowed to sign up.  Timing was everything.  

After putting my name on the list, I would go back to sleep until I had to get up to start my commute.  So let me think out loud while I do the math…flight leaves at 6…be at the airport by 5…leave the house at 4…I’m a diva and I like to have 45 minutes to get ready, so…set the alarm for 3:15 and go back to sleep.  That’s right, I slept from 10pm to 2am then from about 2:15 until 3:15 if I was lucky…that’s not much rest to prepare for what could be a very long day, but it’s what I did almost every time I commuted to work.

Once at the airport, the stress of commuting was just beginning.  When I arrived at the gate, I would assess the competition.  The flights to STL were almost always full, so seats in the main cabin were scarce and difficult to get.  As I mentioned before, the seats in the cabin are first come first served, but the aforementioned cockpit jump seats are awarded in order of seniority.  So, I would find the other pilots (there were usually at least 3 of us at this point) and compare numbers to see who was going to get the cockpit seat and who would be crossing their fingers in hopes that some paying passenger forgot to set his alarm.

As a direct result of the commute, the first day of a trip was almost always the most difficult.  I remember telling myself if I could just get through this first day and get a good night’s sleep at the layover hotel, the rest of the trip would be easy.  I remember one trip in particular that I flew with some regularity.  I would start my day with the commute described above and a sign-in time in STL sometime around noon.  My first flight was from STL back to Dallas at around 1pm.  After a short break, the second leg was a flight from Dallas to Chicago with another short sit before the third and final leg to Seattle.  Day one was a 13 hour duty day that ended in Seattle at about 1am body time…and that’s only if everything went as planned.  Add bad weather, maintenance and equipment delays to the mix and things could get much worse. 

In hind sight, I’m not proud of days like that.  I think I owe the flying public and my fellow crew members more of myself.  I rationalized my actions by convincing myself it was all in the name of normalcy for my wife and kids.  It was a significant hardship, but the truth is, it was a choice.  Furthermore, the trip I described above wasn’t my worst, just an average commute.  Many were far worse and a few were a little better. 

Continental 3407 crashed at 10:47 p.m. Feb. 12 while on approach to the Buffalo, New York. The plane, flying in an ice storm, pitched up violently as it neared a stall, then rolled over and crashed.  There were many links in the chain that led to this accident, but according to the NTSB, one contributing factor was the First Officer’s commute.  FO Shaw had flown a "red-eye" flight to Newark before Flight 3407 and allegedly spent no time in bed the night before the accident.  She can be heard on the cockpit recordings complaining about fatigue, congestion from a cold and saying she should have called in sick.  One link in an intact chain of events.

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A Delta Pilot's Japan Earthquake Story

Diverted aircraft parked at Yokota Air Base

Disclosure:  I didn't write this story but offer thanks to the Delta Pilot who shared his experience.

I'm currently still in one piece, writing from my room in the Narita crew hotel.

It's 8am. This is my inaugural trans-pacific trip as a brand new, recently checked out, international 767 Captain and it has been interesting, to say the least, so far. I've crossed the Atlantic three times so far so the ocean crossing procedures were familiar.

Everything was going fine until 100 miles out from Tokyo and in the descent for arrival. The first indication of any trouble was that Japan air traffic control started putting everyone into holding patterns. At first we thought it was usual congestion on arrival. Then we got a company data link message advising about the earthquake, followed by another stating Narita airport was temporarily closed for inspection and expected to open shortly (the company is always so positive).

From our perspective things were obviously looking a little different. The Japanese controller's anxiety level seemed quite high and he said expect "indefinite" holding time. No one would commit to a time frame on that so I got my copilot and relief pilot busy looking at divert stations and our fuel situation, which, after an ocean crossing is typically low.

It wasn't long, maybe ten minutes, before the first pilots started requesting diversions to other airports. Air Canada, American, United, etc. all reporting minimal fuel situations. I still had enough fuel for 1.5 to 2.0 hours of holding. Needless to say, the diverts started complicating the situation.

Japan air traffic control then announced Narita was closed indefinitely due to damage. Planes immediately started requesting arrivals into Haneada, near Tokyo, a half dozen JAL and western planes got clearance in that direction but then ATC announced Haenada had just closed. Uh oh! Now instead of just holding, we all had to start looking at more distant alternatives like Osaka, or Nagoya.

One bad thing about a large airliner is that you can't just be-pop into any little airport. We generally need lots of runway. With more planes piling in from both east and west, all needing a place to land and several now fuel critical ATC was getting over-whelmed. In the scramble, and without waiting for my fuel to get critical, I got my flight a clearance to head for Nagoya, fuel situation still okay. So far so good. A few minutes into heading that way, I was "ordered" by ATC to reverse course. Nagoya was saturated with traffic and unable to handle more planes (read- airport full). Ditto for Osaka.

With that statement, my situation went instantly from fuel okay, to fuel minimal considering we might have to divert a much farther distance. Multiply my situation by a dozen other aircraft all in the same boat, all making requests, demands and threats to ATC for clearances somewhere. Air Canada and then someone else went to "emergency" fuel situation. Planes started to heading for air force bases. The nearest to Tokyo was Yokoda AFB. I threw my hat in the ring for that initially. The answer - Yokoda closed! No more space.

Sendai Airport Tsunami Damage

By now it was a three ring circus in the cockpit, my copilot on the radios, me flying and making decisions and the relief copilot buried in the air charts trying to figure out where to go that was within range while data link messages were flying back and forth between us and company dispatch in Atlanta. I picked Misawa AFB at the north end of Honshu Island. We could get there with minimal fuel remaining. ATC was happy to get rid of us so we cleared out of the maelstrom of the Tokyo region. We heard ATC try to send planes toward Sendai, a small regional airport on the coast which was later the one I think that got flooded by a tsunami.

Atlanta dispatch then sent us a message asking if we could continue to Chitose airport on the Island of Hokkaido, north of Honshu. Other Delta planes were heading that way. More scrambling in the cockpit - check weather, check charts, check fuel, okay. We could still make it and not be going into a fuel critical situation ... if we had no other fuel delays. As we approached Misawa we got clearance to continue to Chitose. Critical decision thought process. Let's see - trying to help company - plane overflies perfectly good divert airport for one farther away...wonder how that will look in the safety report, if anything goes wrong.

Suddenly ATC comes up and gives us a vector to a fix well short of Chitose and tells us to standby for holding instructions. Nightmare realized. Situation rapidly deteriorating. After initially holding near Tokyo, starting a divert to Nagoya, reversing course back to Tokyo then to re-diverting north toward Misawa, all that happy fuel reserve that I had was vaporizing fast. My subsequent conversation, paraphrased of course...., went something like this:

"Sapparo Control - Delta XX requesting immediate clearance direct to Chitose, minimum fuel, unable hold."

"Negative Ghost-Rider, the Pattern is full" (every aviation story needs a top gun quote)

"Sapparo Control - make that - Delta XX declaring emergency, low fuel, proceeding direct Chitose"

"Roger Delta XX, understood, you are cleared direct to Chitose, contact Chitose approach....etc...."

Enough was enough, I had decided to preempt actually running critically low on fuel while in another indefinite holding pattern, especially after bypassing Misawa

As it was - we landed Chitose, safe, with at least 30 minutes of fuel remaining before reaching a "true" fuel emergency situation. That's always a good feeling, being safe. They taxied us off to some remote parking area where we shut down and watched a half dozen or more other airplanes come streaming in. In the end, Delta had two 747s, my 767 and another 767 and a 777 all on the ramp at Chitose.  We saw two American airlines planes, a United and two Air Canada as well. Not to mention several extra Al Nippon and Japan Air Lines planes.

Post-script - 9 hours later, Japan air lines finally got around to getting a boarding ladder to the plane where we were able to get off and clear customs. - that however, is another interesting story.

By the way - while writing this - I have felt four additional tremors that shook the hotel slightly - all in 45 minutes.

Cheers,

J.D.

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Al Capone and Chicago O'Hare

Two stories, both true and worth reading…

STORY NUMBER ONE

Many years ago, Al Capone virtually owned Chicago.  Capone wasn't famous for anything heroic. He was notorious for enmeshing the windy city in everything from bootlegged booze and prostitution to murder. 

Capone had a lawyer nicknamed "Easy Eddie." He was Capone's lawyer for a good reason.   Eddie was very good!  In fact, Eddie's skill at legal maneuvering kept Big Al out of jail for a long time.

To show his appreciation, Capone paid him very well.   Not only was the money big, but Eddie got special dividends as well.  For instance, he and his family occupied a fenced-in mansion with live-in help and all of the conveniences of the day.  The estate was so large that it filled an entire city block in Chicago.

Eddie lived the high life of the Chicago mob and gave little consideration to the atrocity that went on around him. 

Eddie did have one soft spot, however. He had a son that he loved dearly.  Eddie saw to it that his young son had clothes, cars, and a good education. Nothing was withheld.  Money was no object.

And, despite his involvement with organized crime, Eddie even tried to teach his son right from wrong.  Eddie wanted his son to be a better man than he was.

Yet, with all his wealth and influence, there were two things he couldn't give his son; he couldn't pass on a good name or a good example.

One day, Easy Eddie reached a difficult decision.  Easy Eddie wanted to rectify wrongs he had done.  He decided he would go to the authorities and tell the truth about Al "Scarface" Capone, clean up his tarnished name, and offer his son some semblance of integrity.  To do this, he would have to testify against The Mob, and he knew that the cost would be great.  So, he testified.

Within the year, Easy Eddie's life ended in a blaze of gunfire on a lonely Chicago Street.  But in his eyes, he had given his son the greatest gift he had to offer, at the greatest price he could ever pay.  Police removed from his pockets a rosary, a crucifix, a religious medallion, and a poem clipped from a magazine.

      The poem read:

"The clock of life is wound but once, and no man has the power to tell just when the hands will stop, at late or early hour.  Now is the only time you own.  Live, love, toil with a will. Place no faith in time.  For the clock may soon be still."

        STORY NUMBER TWO

World War II produced many heroes. One such man was Lieutenant Commander Butch O'Hare.  He was a fighter pilot assigned to the aircraft carrier Lexington in the South Pacific.

One day his entire squadron was sent on a mission.  After he was airborne, he looked at his fuel gauge and realized that someone had forgotten to top off his fuel tank.  He would not have enough fuel to complete his mission and get back to his ship.  His flight leader told him to return to the carrier.  Reluctantly, he dropped out of formation and headed back to the fleet.

As he was returning to the mother ship, he saw something that turned his blood cold; a squadron of Japanese aircraft was speeding its way toward the American fleet.  The American fighters were gone on a sortie, and the fleet was all but defenseless.  He couldn't reach his squadron and bring them back in time to save the fleet.  Nor could he warn the fleet of the approaching danger.  There was only one thing to do.  He must somehow divert them from the fleet.

Laying aside all thoughts of personal safety, he dove into the formation of Japanese planes.  Wing-mounted 50 caliber's blazed as he charged in, attacking one surprised enemy plane and then another.   Butch wove in and out of the now broken formation and fired at as many planes as possible until all his ammunition was finally spent.  Undaunted, he continued the assault.  He dove at the planes, trying to clip a wing or tail in hopes of damaging as many enemy planes as possible, rendering them unfit to fly.

Finally, the exasperated Japanese squadron took off in another direction.  Deeply relieved, Butch O'Hare and his tattered fighter limped back to the carrier.  Upon arrival, he reported in and related the event surrounding his return.  The film from the gun-camera mounted on his plane told the tale.  It showed the extent of Butch's daring attempt to protect his fleet.   He had, in fact, destroyed five enemy aircraft. This took place on February 20, 1942, and for that action Butch became the Navy's first Ace of WWII, and the first Naval Aviator to win the Medal of Honor.

A year later Butch was killed in aerial combat at the age of 29.  His home town would not allow the memory of this WW II hero to fade, and today, O'Hare Airport in Chicago is named in tribute to the courage of this great man.     

So, the next time you find yourself at O'Hare International, give some thought to visiting Butch's memorial displaying his statue and his Medal of Honor.  It's located between Terminals 1 and 2.

Butch O'Hare was "Easy Eddie's" son.

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