PSA CRJ2 near Atlanta on Feb 7th 2013, upset causes loss of engine power

Last Update: June 10, 2020 / 14:12:38 GMT/Zulu time

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Incident Facts

Date of incident
Feb 7, 2013

Classification
Accident

Airline
PSA Airlines

Flight number
US-2382

Departure
Charlotte, United States

Destination
Fort Walton Beach, United States

Aircraft Registration
N261PS

Aircraft Type
Canadair Corporate Jetliner

ICAO Type Designator
CRJ2

A PSA Airlines Canadair CRJ-200 on behalf of US Airways, registration N261PS performing flight US-2382 from Charlotte,NC to Fort Walton Beach,FL (USA) with 37 passengers and 3 crew, was enroute at FL340 about 80nm northeast of Atlanta,GA when the aircraft encountered an inflight pitch upset, the left hand engine suffered a complete loss of power, the only flight attendant on board received minor injuries as result of he upset. The crew decided to divert to Atlanta where the aircraft landed safely about 30 minutes later.

The NTSB released their brief preliminary report on Feb 6th 2014, a year after the occurrence.

On Jun 10th 2020 the NTSB released their final report concluding the probable cause of the accident was:

he captain's inappropriate climb speed, his failure to monitor airspeed during the level off, and his inappropriate response to multiple stall warnings.

The NTSB described the sequence of events:

The captain (59, ATPL, about 25,000 hours total, 6,728 hours on type) was the pilot flying and the first officer (FO) (52, ATPL, 9,197 hours total, 6,012 hours on type) was the pilot monitoring.

After a normal takeoff, the flight was cleared to climb to flight level (FL) 340. The captain stated that he set the autopilot vertical speed (VS) command to 1000 feet per minute (FPM) during the climb. He stated it was common for him to see airspeed of 200 knots indicated airspeed (KIAS) during climb to high altitude and he believed it was company policy to fly at the minimum speed for climb out. He stated he did this because he thought air traffic control demanded that flights climb at 1000 fpm. Passing FL330 the captain state that he began setting up landing data in the flight management system (FMS). At that time, he observed the airspeed to be 200 KIAS and the low airspeed awareness cue, the "green line," to be at 180 KIAS.

After leveling off at their cruise altitude of FL340 the captain indicated that the airspeed bled off and it was 160 to 165 KIAS when he looked up. He immediately realized they were too slow and was about to use the autopilot vertical speed pitch wheel to lower the nose when the stick shaker activated, followed by the stick pusher, and the airplane began pitch excursions. According to the chief pilot, who had interviewed the captain immediately after the incident, the captain stated he pulled back on the yoke in an effort to maintain altitude, which caused the pusher to fire.

The captain stated he initially thought they were experiencing a false stick shaker because he had experienced a false stall warning two or three weeks earlier. He stated the airplane went through several ups and downs and it was "a heck of a ride." According to the flight attendant, they experienced a series of violent altitude changes which caused her to become airborne multiple times.

According to the captain, both pilots had their hands on the controls, but he could not recall what pitch inputs he made. He stated his first concern was the illumination of two engine low oil pressure lights and a flight spoilers Engine indication and crew alerting system message. The captain stated the FO called out "we have to get airspeed." The captain stated he responded to the FO's callout and put the nose down to increase airspeed and began a descent. The captain thought they had experienced a dual engine failure and he turned on the continuous ignition and one hydraulic pump. As they descended, the captain observed that the left engine had failed and he declared an emergency. He did not attempt a restart of the engine, which appeared to be damaged because the N1 (low pressure turbine speed) was zero and the interturbine temperature was above redline.

The airplane descended to FL310 and the captain called for and ran the engine failure in flight checklist. ATC cleared them to descend to FL240 and asked them if they would like to divert to ATL, to which they accepted. The flight subsequently landed without further incident.

The NTSB performed a study and reported:

An NTSB airplane performance investigator examined the recorded flight data from the incident flight. The data show that when the airplane was climbing through about 34,000 feet, it was slowing through 167 knots when the stick shaker activated, followed by the stick pusher at a recorded angle of attack of about 8 degrees. The airplane pitched down, and the crew responded by pulling back on the column, which again activated the pusher and resulted in a seven cycle stick pusher dynamic event with the column being pulling back after each pusher activation. A maximum recorded angle of attack of 14.8 degrees was reached on the fourth column pull.

The NTSB summarized the interviews of the incident captain as well as the operator's chief pilot:

The chief pilot stated in an interview that the company had trained all pilots in high altitude stall recovery. He said SPOT training on the subject was a focus of training for an entire year after the Pinnacle 3701 accident (2004) and the training was currently incorporated in new hire and upgrade training. He was not able to determine from company records when the event pilots had first taken high altitude training because they used the "crewqual" system, which only recorded if an event was satisfactory or unsatisfactory.

The chief pilot stated that climbing at 200 knots was not in accordance with company policy, and that either 250 knots or the ACARS climb index (CI) speed was the appropriate speed. The CI in use for the last year produced a climb speed of 262 knots.

The company director of training stated in an interview that the company taught pilots in the simulator to climb at 250 knots until crossing over to Mach range. He stated they put emphasis on stall and pusher training in 2009 following the Colgan 3407 accident (2008).He said after the Colgan accident they changed stall training to reduce angle of attack until you get the aircraft flying again and accept some altitude loss. Pilots experienced the pusher in recurrent training and they taught pilots not to fight the pusher.

The incident captain stated in an interview that he believed it was company policy to fly at the minimum speed for climb out, which was 200 knots. He stated there was no company policy regarding use of the vertical speed mode in climb and he had not been trained in how to recover from high altitude stalls. He recalled the Pinnacle accident but did not recall doing training related to that accident.

When asked to explain the company's stall recovery procedure, the captain said, "set vertical speed to prepare for the stall, then retract flight spoilers, apply full thrust and maintain 5 degrees of pitch." He said you should level off and once the airplane was at 200 knots the maneuver was complete. He repeated "they said 5 degrees."