Final NTSB report on Colgan/CO 3407

[SteveC]

National Transportation Safety Board
Washington, DC 20594

January 29, 2010

NTSB TO MEET ON FINAL REPORT ON COLGAN AIR DASH-8 ACCIDENT
NEAR BUFFALO, NEW YORK

The National Transportation Safety Board will hold a Board
meeting on Tuesday, February 2, 2010, at 9:30 a.m. in its
Board Room and Conference Center, 429 L'Enfant Plaza, S.W.,
Washington, D.C. The Board will consider a final report on
the following investigation:

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.

A live and archived webcast of the proceedings will be
available on the Board's website at
http://www.ntsb.gov/events/Boardmeeting.htm. Technical
support details are available under "Board Meetings" on the
NTSB website. To report any problems, please call 703-993-
3100 and ask for Webcast Technical Support.

A summary of the Board's final report, which will include
findings, probable cause and safety recommendations, will
appear on the website shortly after the conclusion of the
meeting. The entire report will appear on the website
several weeks later.

 

[Qgar]

Hard to believe it's almost a year since that terrible night. There's not a day that goes by without me thinking about Matilda and Donna, the rest of the crew and the other victims.

 

[SpiceWeasel]

Had a passenger behind me in line last week while I was trying to get on the jumpseat. This guy asked me what "2-12-2009" meant on the sticker I had....

 

[Qgar]

Had a passenger behind me in line last week while I was trying to get on the jumpseat. This guy asked me what "2-12-2009" meant on the sticker I had....

where did you get that sticker, Rex? I'd love to have one.

 

[SpiceWeasel]

where did you get that sticker, Rex? I'd love to have one.

If you get a hold of Seggy he should be able to point you in the right direction. I got a bunch for the Atlanta crew base Pinnacle pilots. Should have gotten some more for myself since I may be switching flight cases soon.

 

[Qgar]

thanks!

 

[MOONWOLF]

Makes me sad again thinking about it. I was a class mate and friend of the f/o on 3407.

 

[Clocks]

Sort of reminds you that behind all the debate that the accident spurred there's 49 real human beings who were killed.

 

[v1valarob]

I have a stack of 500 black ribbon 3407 stickers paid for by ALPA CJC. PM me if you want a few. They ordered like 2000 for a pilot group of 450.

 

[pullup]

Sort of reminds you that behind all the debate that the accident spurred there's 49 real human beings who were killed.

50

 

[stuckingfk]

Sort of reminds you that behind all the debate that the accident spurred there's 49 real human beings who were killed.

That assumed they had competent pilots up front...

Sad

 

[Firebird2XC]

That assumed they had competent pilots up front...

Sad

Wow, just wow.

 

[Baronman]

Had a passenger behind me in line last week while I was trying to get on the jumpseat. This guy asked me what "2-12-2009" meant on the sticker I had....

I wouldn't have had any idea myself. Don't remember the date of TWA800 (summerish '96) or Lockerbee either.

 

[Cruise]

where did you get that sticker, Rex? I'd love to have one.

Hey P....send me your address and I will see to it you have one. I've got a bunch.

 

[Cruise]

That assumed they had competent pilots up front...

Sad

Wow, your post is Sad!

 

[SpiceWeasel]

I wouldn't have had any idea myself. Don't remember the date of TWA800 (summerish '96) or Lockerbee either.

I guess not. Little bit easier to remember the date when you knew someone on board...

 

[SteveC]

************************************************************
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

 

[sdfcvoh]

RIP to all. I hope we gain something from this terrible tragedy.... all of us.

 

[surreal1221]

That assumed they had competent pilots up front...

Sad

Stay Classy.

Not surprised though.

 

[HeyEng]

Not to take away from the loss of life, but I have a serious question about the ALPA response to the NTSB. In part, they said:

"Analysis of the flight crew’s performance reveals some errors, but neither 'pilot error' nor any one of the many other factors was 'the cause' of this accident."

In the report, ALPA's findings did not even hint at the fact that the pilot may have messed up. Why is this? I understand that ALPA is the original "Pilot Protection Association"...but some fault lies with the crew...why not acknowledge that?

Here is the ALPA submission: http://www.ntsb.gov/Dockets/Aviation/DCA09MA027/431209.pdf