RFT 547: Colgan Air 3407
From Wikipedia:
Colgan Air Flight 3407 (9L/CJC 3407) was marketed as Continental Connection Flight 3407. It was delayed two hours, departing at 9:18 pm Eastern Standard Time (02:18 UTC), en route from Newark Liberty International Airport to Buffalo Niagara International Airport.
The twin-engine turboprop Bombardier Q400, FAA registry N200WQ, was manufactured in 2008 for delivery to Colgan. It was delivered to Colgan on April 16, 2008.
This was the first fatal accident for a Colgan Air passenger flight since the company was founded in 1991. One previous repositioning flight, with no passengers, crashed offshore of Cape Cod, Massachusetts, in August 2003, killing both of the crew on board. The only prior accident involving a Colgan Air passenger flight occurred at LaGuardia Airport, when another plane collided with the Colgan aircraft while taxiing, resulting in minor injuries to a flight attendant.
Captain Marvin Renslow, 47, of Lutz, Florida, was the pilot in command, and Rebecca Lynne Shaw, 24, of Maple Valley, Washington, served as the first officer. The cabin crew consisted of two flight attendants. Captain Renslow was hired in September 2005 and had accumulated 3,379 total flight hours, with 111 hours as captain on the Q400. First Officer Shaw was hired in January 2008, and had 2,244 hours, 774 of them in turbine aircraft, including the Q400.
Two Canadian passengers, one Chinese passenger, and one Israeli passenger were on board. The remaining 41 passengers, as well as the crew members, were American.
Shortly after the flight was cleared for an instrument landing system approach to runway 23 at Buffalo Niagara International Airport, it disappeared from radar. The weather consisted of light snow and fog with wind of 15 knots (28 km/h; 17 mph). The deicing system had been turned on 11 minutes after takeoff. Shortly before the crash, the pilots discussed significant ice buildup on the aircraft's wings and windshield. Two other aircraft reported icing conditions around the time of the crash.
The last radio transmission from the flight occurred when the first officer acknowledged a routine instruction to change to tower radio frequency. The plane was 3.0 mi (4.8 km) northeast of the radio beacon KLUMP (see diagram) at that time. The crash occurred 41 seconds after that last transmission. Since ATC approach control was unable to get any further response from the flight, the assistance of Delta Air Lines Flight 1998 and US Airways Flight 1452 was requested. Neither was able to spot the missing plane.
Following the clearance for final approach, landing gear and flaps (5°) were extended. The flight data recorder (FDR) indicated the airspeed had slowed to 145 knots (269 km/h; 167 mph). The captain then called for the flaps to be increased to 15°. The airspeed continued to slow to 135 knots (250 km/h; 155 mph). Six seconds later, the aircraft's stick shaker activated, warning of an impending stall, as the speed continued to slow to 131 knots (243 km/h; 151 mph). The captain responded by abruptly pulling back on the control column, followed by increasing thrust to 75% power, instead of lowering the nose and applying full power, which was the proper stall-recovery technique. That improper action pitched the nose up even further, increasing both the g-load and the stall speed. The stick pusher activated (The Q400 stick pusher applies an airplane-nose-down control column input to decrease the wing's angle of attack (AOA) after an aerodynamic stall), but the captain overrode the stick pusher and continued pulling back on the control column. The first officer retracted the flaps without consulting the captain, making recovery even more difficult.
In its final moments, the aircraft pitched up 31°, then pitched down 25°, then rolled left 46° and snapped back to the right at 105°. Occupants aboard experienced g-forces estimated at nearly 2 G. The crew made no emergency declaration, as they rapidly lost altitude and crashed into a private home at 6038 Long Street, about 5 mi (8.0 km) from the end of the runway, with the nose pointed away from the airport. The aircraft burst into flames, as the fuel tanks ruptured on impact, destroying the house of Douglas and Karen Wielinski, and most of the plane. Douglas was killed; his wife Karen and their daughter Jill managed to escape with minor injuries. Very little damage occurred to surrounding homes, though the lots in that area are only 60 ft (18.3 m) wide. The home was close to the Clarence Center Fire Company, so emergency personnel were able to respond quickly. Two firefighters were injured; 12 nearby houses were evacuated.
The autopilot was in control until it automatically disconnected when the stall-warning stick shaker activated. The NTSB found no evidence of severe icing conditions, which would have required the pilots to fly manually. Colgan recommended its pilots to fly manually in icing conditions, and required them to do so in severe icing conditions. In December 2008, the NTSB issued a safety bulletin about the danger of keeping the autopilot engaged during icing conditions. Flying the plane manually was essential to ensure pilots would be able to detect changes in the handling characteristics of the airplane, which are warning signs of ice accumulation.
After the captain reacted inappropriately to the stick shaker, the stick pusher activated. As designed, it pushed the nose down when it sensed a stall was imminent, but the captain again reacted improperly and overrode that additional safety device by pulling back again on the control column, causing the plane to stall and crash. Bill Voss, president of Flight Safety Foundation, told USA Today that it sounded like the plane was in "a deep stall situation".
On May 11, 2009, information was released about Captain Renslow's training record. According to an article in The Wall Street Journal, before joining Colgan, he had failed three "check rides", including some at Gulfstream International's training program, and "people close to the investigation" suggested that he might not have been adequately trained to respond to the emergency that led to the airplane's fatal descent. Investigators examined possible crew fatigue. The captain appeared to have been at Newark airport overnight, prior to the day of the 9:18 pm departure of the accident flight. The first officer commuted from Seattle to Newark on an overnight flight. These findings during the investigation led the FAA to issue a "Call to Action" for improvements in the practices of regional carriers.
Another press report said that the pilot had failed five prior tests, and also alleged "flirtatious" conversation in the cockpit between the pilot and the much younger first officer.
On February 2, 2010, the NTSB issued its final report, describing the details of its investigation that led to 46 specific conclusions.
One conclusion determined that both the captain and the first officer were fatigued at the time of the accident, but the NTSB could not determine how much it degraded their performance.
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.
Among those conclusions were the fact that both the captain and the first officer responded to the stall warning in a manner contrary to their training. The NTSB could not explain why the first officer retracted the flaps and suggested that the landing gear should also be retracted, though it did find that the current approach-stall training was not adequate:
The current air carrier approach-to-stall training did not fully prepare the flight crew for an unexpected stall in the Q400 and did not address the actions that are needed to recover from a fully developed stall.
Those findings were immediately followed by the board's "Probable Cause" statement:
The captain's inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew's failure to monitor airspeed in relation to the rising position of the low-speed cue, (2) the flight crew's failure to adhere to sterile cockpit procedures, (3) the captain's failure to effectively manage the flight, and (4) Colgan Air's inadequate procedures for airspeed selection and management during approaches in icing conditions.
NTSB Chairman Deborah Hersman, while concurring, made it clear that she considered fatigue to be a contributing factor. She compared the 20 years that fatigue had remained on the NTSB's Most Wanted List of transportation safety improvements, during which no meaningful action was taken by regulators in response, to the changes in tolerance for alcohol over the same period, noting that the impact on performance from fatigue and alcohol were similar.
However, Vice Chairman Christopher A. Hart and Board Member Robert L. Sumwalt III dissented on the inclusion of fatigue as a contributing factor, on the grounds that evidence was insufficient to support such a conclusion. Notably, the same kind of pilot errors and standard operating procedure violations had been found in other accidents where fatigue was not a factor.
The FAA has proposed or implemented several rule changes as a result of the Flight 3407 accident, in areas ranging from pilot fatigue to Airline Transport Pilot (ATP) certificate qualifications of up to 1,500 hours of flight experience for both pilot and copilot. One of the most significant changes has already taken effect, changing the way examiners grade checkrides in flight simulators during stalls.
From WGRZ:
A new rule from the Federal Aviation Administration will make it easy for airlines to share information regarding their pilots with each other.
It's the latest step to improve air safety as a result of the crash of Colgan Air Flight 3407 in Clarence Center 12 years ago.
The Pilot Records Database will be maintained by the F.A.A., and will require the airlines to report their pilots' employment history, training and qualifications.
The information can now be shared between air carriers, which will also be required to review records in the database before hiring pilots.
The database will include the following information:
- FAA pilot certificate information, such as certificates and ratings
- FAA summaries of unsatisfactory pilot applications for new certificates or ratings
- FAA records of accidents, incidents, and enforcement actions
- Records from employers on pilot training, qualification, and proficiency
- Pilot drug and alcohol records
- Employers’ final disciplinary action records
- Pilot records concerning separation of employment
- Verification of pilot motor vehicle driving record.
This measure was part of the push made by the families of the 49 passengers and crew who died, along with another person on the ground, when the crash occurred in February of 2009.
"I've said this before that in New York State, if you want to drive a school bus, they check their records all the way to when you got your driver's license," said John Kausner, who along with his wife Marilyn, lost their 24 year old daughter in the crash later blamed on pilot error.
"He was not qualified to fly that plane... he had failed five check rides prior to that and the airline didn't know it," John Kausner said. "And they testified at the NTSB hearing that had they known it, they wouldn't have hired him."
But while it's taken 12 years to get to this point airlines will have more than three years more to fully comply with the new rules.
"Welcome to the federal government," John Kausner said. "Yes, they have to come into compliance in 36 months. I think they have all the data collected, so why it can't be next month is beyond me but that's where we're at."
Flight 3407 families are heralding the news, however, as an important and final piece of a puzzle toward safer skies, which follows their previously successful efforts to lobby for increased and more rigorous pilot training and for mandatory rest periods between flights for air crews.
"It's a proud moment for us and we believe that the greatest legacy to our loved ones are all the lives that have been saved because they inspired us and we feel like we finished the race," Marilyn Kausner said.
Added her husband, "A lot of people don't realize that we haven't had an airline crash in the United States in 12 years. In the 20 years preceding that there was more than one crash per year on average in the United States. That was the record before the 3407 crash, and in the 12 years since there have been zero. And that's not just due to our efforts, but also due to the efforts of our congressional delegation and media which has kept these issues in the public eye."
Information on the Pilot Records Improvement Act