Boeing Analyzes the Numbers Game

NTSB PRESS RELEASE

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: February 2, 2010
SB-10-02

CAPTAIN’S INAPPROPRIATE ACTIONS LED TO CRASH OF FLIGHT 3407 IN CLARENCE CENTER, NEW YORK, NTSB SAYS

The National Transportation Safety Board 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.
In a report adopted today in a public Board meeting in
Washington, additional flight crew failures were noted as
causal to the accident.

On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8-
400, N200WQ, operating as Continental Connection flight
3407, was on an instrument approach to Buffalo-Niagara
International Airport, Buffalo, New York, when it crashed
into a residence in Clarence Center, New York, about 5
nautical miles northeast of the airport. The 2 pilots, 2
flight attendants, and 45 passengers aboard the airplane
were killed, one person on the ground was killed, and the
airplane was destroyed by impact forces and a postcrash
fire. The flight was a 14 Code of Federal Regulations (CFR)
Part 121 scheduled passenger flight from Newark, New Jersey.
Night visual meteorological conditions prevailed at the
time of the accident.

The report 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 and
placed the airplane into an accelerated aerodynamic stall.

Contributing to the cause of 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 contributing
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 investigation, the Safety Board
issued 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 recommendations
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.

At today’s meeting, the Board 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 high standards. This
accident was one in a series of incidents investigated by
the Board 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 last
year where the airliner overflew its destination airport in
Minneapolis because the pilots were distracted by non-flying
activities – that have involved air transportation
professionals deviating from expected levels of performance.
In addition, this Fall the 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. For example, this
accident occurred on a Continental Connection flight,
although the transportation was provided by Colgan Air.

A summary of the findings of the Board’s report are
available on the NTSB’s website at:
http://www.ntsb.gov/Publictn/2010/AAR1001.htm
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