In 2009, Colgan Flight 3407, flying a commuter segment for Continental Airlines, experienced a stall and crashed near Buffalo, New York. There were no survivors from this crash, so the National Transportation Safety Board could not gain any direct information from the crew or passengers. All the data came from indirect sources: the flight data recorder, communications with the tower, reconstructions of the crash process based on the debris, and information about the crew from people who talked with them before the flight. All of these sources were crucial in determining why 50 (45 passengers, 4 crew, and 1 person in the house) people died, and what steps should be taken to prevent similar tragedies from happening in the future (NTSB, 2009).
Judging from the basic facts of the plane’s attitude when the crash occurred, the messages from the pilot and copilot to the tower, and the flight data, it appeared that the crash was caused by an engine stall that was not properly handled by the flight crew. The airplane they were flying, the Bombardier Q400, was fitted with a stick shaker and a stick pusher, both of which were designed to encourage proper response to stalls. The stick shaker began to make noise as soon as the stall was beginning, based on a rapid decrease in engine speed. Normally, pilots are trained extensively in how to recognize and handle a stall event. Even if they don’t recognize the stall immediately, another device, the stick pusher, takes action to lower the plane’s nose in order to increase air speed and avoid a deep stall. However, the flight crew didn’t seem to understand what these two events meant. They were apparently alarmed when the stick pusher lowered the nose, and overrode it by rapidly raising the nose. This only made the stall worse, and the plane began to pitch and roll as it descended and finally slammed into a house in Buffalo, bursting into flames on impact (NTSB, 2010).
Although the stall was unresolved primarily due to pilot and copilot error, there were secondary factors that may have contributed to bringing the plane, the pilot, and the copilot to the state they were in right before the stall. The human factors included flight crew fatigue, failure to follow sterile cockpit procedure, lack of sufficient training in how to correct an imminent stall, and an overall lack of leadership by the pilot. Also, flight crew fatigue could have been related to long commutes (the copilot flew from Seattle to Newark in a cargo plane to get to this flight) (Brown & Whitehurst, 2012), illness (the copilot believed she might be getting “a cold”), schedules and pay levels that encouraged pilots to fly too often, even when they weren’t feeling 100% capable of another run (NTSB, 2009).
Besides the human factors, the National Transportation Safety Board (NTSB) examined the aircraft itself (its debris), focusing on performance data, maintenance records, the indicators for airspeed and other quantities, the ice detection and deicing systems, and the stall protection system. Meteorological records for the location and time when the crash occurred were also scrutinized, along with navigation aids, air traffic control tapes, and the cockpit voice recorder / flight data recorder.
The copilot commuted from Seattle to Newark, which required a fairly long flight to Newark and a three-hour time difference. A later report suggested that this situation was inappropriate and that Colgan should not have hired her for the Newark flights (Brown & Whitehurst, 2012). The pilot and copilot had other reasons to be fatigued, because they had been on recent flights and had slept in the Colgan crew room in Newark. Sleeping there was better than not sleeping at all, but they would not have had refreshing, unbroken sleep given the nature of such a room, where people go in and out, talking, eating, and engaging in activities. The NTSB determined that pilots are responsible for making sure they get rest in appropriate places (i.e. not in the crew rooms). Fatigue was likely to have increased the pilots’ confusion when the stall protection system activated, but if they had been through sufficient training, to the point that the reaction to the stick shaker was automatic, the fatigue would not have made as much difference. This is the reason a large amount of training is crucial. Operators of airlines (in this case, Colgan) have a responsibility to adequately train their pilots and to test them periodically to ensure the training has been retained. If it has not, the pilot should receive remedial training (NTSB, 2010).
The NTSB determined that the two pilots needed more general training as well in completing in-flight checklists and in monitoring devices in the cockpit. When a pilot is unfamiliar with the equipment or with a checklist it will take longer to complete, and there was evidence that this interfered with the copilot’s ability to check the pilot’s actions. Another factor was the lack of sterile cockpit protocols, which should have been enforced by the pilot. The cockpit voice recorder revealed that discussions were occurring that had no relation to the landing taking place. This is a serious breach of protocol because the pilots’ should have their entire focus on landing. NTSB suggested that the importance of sterile cockpit procedures should be emphasized for all flight crews and that additional oversight, such as occasionally listening to cockpit voice recorders, might be required.
There were no malfunctions found in the aircraft or in the monitoring systems in the cockpit. The plane’s deicing components appeared to be working properly, and the flight data recorder indicated that there were reports of ice at certain times during the flight. The NTSB also pointed out that the meteorological reports in that area did not include information that would be specific to the needs of prop planes like the Q400. Although this issue was not related to this crash, it needed to be identified proactively.
The crash of Colgan Flight 3407 was found to be due to human error — in fact, more than one error. The pilots did not react appropriately to the stall warning and protection systems. The pilot did not maintain leadership, allowing conversations that violated sterile cockpit protocol as well as the use of personal electronic devices. Finally, the pilots had not received sufficient training to respond to emergencies when they were fatigued.
- Brown, L., & Whitehurst, G. (2012, May). Effects of Commuting on Crewmember Fatigue. In Brown, L., Whitehurst, G.,(2011)“The Effects of commuting on Pilot Fatigue” International Symposium on Aviation Psychology Proceedings (Vol. 422, pp. 2-5).
- NTSB. (2009) Press Release. Retrieved from http://www.ntsb.gov/news/press-releases/Pages/Update_on_NTSB_Investigation_into_Crash_of_Colgan_Air_Dash-8_near_Buffalo_New_York;_Public_Hearing_Scheduled.aspx
- NTSB. (2010). Aircraft Accident Report. Retrieved from http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1001.pdf