NTSB says pilot error caused crash of Colgan Air Flight 3407

February 5, 2010

The U.S. National Transportation Safety Board (NTSB) has determined that the captain of Colgan Air Flight 3407, which crashed nearly a year ago outside Buffalo, New York during its approach to Buffalo Niagara International Airport, "inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the aeroplane did not recover," according to a statement issued by the NTSB.

The flight, operating as a codeshare with Continental Airlines under their Continental Connection brand, crashed last year on February 12, 2009 in Clarence Center, New York. The Bombardier Dash 8 Q400, crashed into a residence killing everyone on board as well as one on the ground.

The NTSB has blamed pilot error and poor training for the crash, noting that the plane's captain, Marvin Renslow, "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." Renslow's career spanned two decades and had failed five performance checks during that time. Colgan Air was only aware of three. Colgan said had they known about the other two, they would not have hired Renslow in 2005.

Colgan Air responded to the NTSB report in a letter: "They [the pilots] 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."

The Board added that Renslow's response to the "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 24-year-old first officer, Rebecca Lynne Shaw, was noted for her young age and lack of experience.

The Board also concluded that "the pilots' performance was likely impaired because of fatigue." Renslow and Shaw had spent the night at the crew lounge at Newark Liberty International Airport in violation of Colgan Air's company policies. However, the board voted down making fatigue a contributing factor. Shaw, the first officer, had flown the previous night on two separate planes from the Pacific Northwest where she lived with her parents. Shaw also appeared to be suffering from a bad cold.

However, the report also criticized Colgan saying that the airline, "did not pro-actively address the pilot fatigue hazards associated with operations at a predominantly commuter base." Adding that, "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."

Another factor brought up the by the NTSB was the violation of the Federal Aviation Administration's (FAA) sterile cockpit rule. It was noted that first officer Shaw had sent two text messages before take-off at Newark. The second message was sent two minutes before take-off.

Prior to landing, the cockpit voice recorder recorded that the pilots were holding a conservation that potentially distracted the captain from operating the plane. Robert Sumwalt, a member of the NTSB board said, "It was continuous and one-sided, with the captain doing most of the talking." He added, "It was as if the flight was just a means for the captain to conduct a conversation with this young first officer." The chairwoman of the NTSB, Deborah Hersman, has noted that electronic devices are becoming a hazard to transportation. Hersman said, "Recent NTSB investigations have identified personal wireless technology use on the job. This phenomenon is becoming more widespread, and these phone calls, texts and other distractions have deadly consequences and must be addressed with all due haste by the transportation industry."

The agency noted that distractions from electronics have played a part in many recent accidents and incidents, such as the August 2009 mid-air collision between a small private Piper aeroplane and a tour helicopter over the Hudson River in New York City killing all involved. The NTSB noted that one of the air traffic controllers was making a phone call and failed to warn the aircraft of the conflict that existed between each other in their airspace. However, this was disputed by the National Air Traffic Controllers Association which represents air traffic controllers nationwide. The NTSB later retracted some of its statements.

The other notable incident was that of Northwest Airlines Flight 188 in October, that overshot its destination of Minneapolis-Saint Paul International Airport by 150 miles (241 km) before the pilots noticed. The pilots claimed they were checking schedules on their laptop computers in violation of basic piloting rules, the sterile cockpit rule and the policy of Delta Air Lines, who had recently acquired Northwest.

The NTSB's last board meeting which was held two weeks ago, about the 2008 train collision between a Metrolink commuter rail train and a Union Pacific freight train in Chatsworth, California also pertained to distractions by electronic devices. In the statement released by the NTSB for that meeting, the board stated that "according to records from the wireless provider, on the day of the accident, while on duty, both the Metrolink engineer and the Union Pacific conductor used wireless devices to send and receive text messages." The NTSB has recommended that audio and video recorders be installed in locomotive and control cabs because of the collision.