The National Transportation Safety Board (NTSB) determined that the captain of Colgan Air Flight 3407 inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. The Safety Board’s probable cause determination also said additional flight crew failures contributed to the accident.
On February 12, 2009, a Colgan Air Bombardier DHC-8- 400 (N200WQ) operating as Continental Connection Flight 3407 was on an instrument approach to Buffalo-Niagara International, Buffalo, NY, when it crashed into a residence about five nautical miles northeast of the airport.
The two pilots, two flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground also died. The flight had originated in Newark, NJ, the flight deck crew’s base station.
At the controls of the Dash 8 turboprop that day were Capt. Marvin Renslow, 47, who lived near Tampa, FL and First Officer Rebecca Shaw, 24, who had commuted across the country overnight from Seattle, WA, where she lived with her parents. Pilot fatigue is suspected to have contributed to the fatal accident.
Early in the NTSB probe, there was immediate suspicion that severe icing may have played a critical role in the fatal accident. Some aviation safety experts suspect that a tailplane (horizontal stabilizer) stall prompted the crash of the Colgan Air Bombardier Dash 8 Q400. Experts say it is difficult to tell the difference between a tailplane stall and a wing stall. And the recovery from each is completely different. For a wing stall, you push the control yoke forward and increase airspeed. For a tailplane stall you do the opposite: pull the yoke back, reduce flaps and on some aircraft, ease off on power.
Renslow began flying the Dash 8 Q400 in December 2009, accumulating 110 hours. But he had 3,379 flying hours, with much of that in the Saab 340, where tailplane stalls can be more of a problem. There is reason to believe that Renslow, who was in control of the Dash 8 when the stick shaker activated, reacted as if he were still flying a Saab 340, and in suspecting a tailplane stall pulled back hard on the yoke. First Officer Shaw had 774 hours in the Dash 8 Q400, but a total of 2,244 hours at the controls.
The NTSB/s final report on the accident states that, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded correctly to the situation by pushing forward on the control column. However, the captain inappropriately pulled aft on the control column, stalling the aircraft.
Contributing to the accident were the crewmembers’ failure to: recognize the position of the low-speed cue on their flight displays, which indicated that the stick shaker was about to activate; and, their failure to adhere to sterile cockpit procedures. Other factors were the captain’s failure to effectively manage the flight; and, Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
As a result of this accident probe, the Safety Board issued numerous recommendations to the Federal Aviation Administration (FAA) regarding strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot records, stall training, and airspeed selection procedures.
Additional advisories from the NTSB address FAA’s oversight and use of safety alerts for operators to transmit safety-critical information, flight operational quality assurance (FOQA) programs, use of personal portable electronic devices on the flight deck, and weather information provided to pilots.
Colgan Air said in a statement that the pilots were properly trained in how to recover from a stall.
“We want to make clear again that our pilots are highly trained to handle all situations they may encounter. Like all Colgan pilots, Captain Renslow and First Officer Shaw had thorough initial and recurrent training on how to recognize an impending stall situation and recover from it.
“By all accounts, Captain Renslow and First Officer Shaw were fine people. But they knew what to do in the situation they faced that night a year ago, had repeatedly demonstrated they knew what to do, and yet did not do it. We cannot speculate on why they did not use their training in dealing with the situation they faced.
“Since the accident, we examined every aspect of our operations to make sure that everything that could be done was being done. As a result, and as we have already publicly said, we have taken a number of important and specific steps to further enhance all of our training and hiring programs,” said Colgan Air.
The FAA said in a statement that it has driven significant improvements in pilot professionalism, training and background checks in the past year. The agency said it will soon propose new rules to prevent pilot fatigue, further improve training and increase the qualifications required to be an airline pilot.
“Airline passengers deserve an expertly trained and well rested crew, whether they are flying on a major or a regional jet. Pilots must be trained for the mission they are flying and the FAA already is working to further improve their professional qualifications. The FAA will review and evaluate the NTSB recommendations to help determine what further actions may be needed,” the statement added.
Specific conclusions and recommendations made by the Safety Board include:
CONCLUSIONS
The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall.
The minimal aircraft performance degradation resulting from ice accumulation did not affect the flight crew’s ability to fly and control the airplane.
Explicit cues associated with the impending stick shaker onset, including the decreasing margin between indicated airspeed and the low-speed cue, the airspeed trend vector pointing downward into the low-speed cue, the changing color of the numbers on the airplane’s indicated airspeed display, and the airplane’s excessive nose-up pitch attitude, were presented on the flight instruments with adequate time for the pilots to initiate corrective action, but neither pilot responded to the presence of these cues.
The reason the captain did not recognize the impending onset of the stick shaker could not be determined from the available evidence, but the first officer’s tasks at the time the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management.
The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.
The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation.
It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery.
No evidence indicated that the Q400 was susceptible to a tailplane stall.
The captain’s failure to effectively manage the flight (1) enabled conversation that delayed checklist completion and conflicted with sterile cockpit procedures and (2) created an environment that impeded timely error detection.
Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior.
Specific leadership training for upgrading captains would help standardize and reinforce the critical command authority skills needed by a pilot-in-command during air carrier operations.
The flight crewmembers’ performance during the flight, including the captain’s deviations from standard operating procedures and the first officer’s failure to challenge these deviations, was not consistent with the crew resource management (CRM) training that they had received or the concepts in the Federal Aviation Administration’s CRM guidance.
The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined.
All pilots, including those who commute to their home base of operations, have a personal responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight.
Colgan Air did not proactively address the pilot fatigue hazards associated with operations at a predominantly commuter base.
Operators have a responsibility to identify risks associated with commuting, implement strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty.
The first officer’s illness symptoms did not likely affect her performance directly during the flight.
The captain had not established a good foundation of attitude instrument flying skills early in his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed.
Distractions caused by personal portable electronic devices affect flight safety because they can detract from a flight crew’s ability to monitor and cross-check instruments, detect hazards, and avoid errors.
RECOMMENDATIONS included:
Identify which airplanes operated under 14 Code of Federal Regulations Part 121, 135, and 91K are susceptible to tailplane stalls and then (1) require operators of those airplanes to provide an appropriate airplane-specific tailplane stall recovery procedure in their training manuals and company procedures and (2) direct operators of those airplanes that are not susceptible to tailplane stalls to ensure that training and company guidance for the airplanes explicitly state this lack of susceptibility and contain no references to tailplane stall recovery procedures. (A-10-XX)
The NTSB will have a lot more to say about the fatal crash. It announced that two issues that had been encountered in the Colgan Air investigation would be studied at greater length in proceedings later this year.
The Board will hold a public forum this Spring exploring pilot and air traffic control standards. It said the Colgan Air accident was only one in a series of incidents in recent years (including a mid-air collision over the Hudson River that raised questions of air traffic control vigilance and the Northwest Airlines incident where the crew over flew the destination because the pilots were distracted by non-flying activities) that have involved deviation from expected levels of performance.
In addition, this Fall the Safety Board will hold a public forum on code sharing, the practice of airlines marketing their services to the public while using other companies to actually perform the transportation.