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.