2009 — Feb 12, Colgan Air/Continental 3407 Crash, Clarence Center, NY — 50
— 50 Aircraft Crashes Record Office (Geneva, Switzerland). New York.
— 50 CNN. “50 Killed in Crash as Plane Hits Buffalo House.” February 13, 2009.
— 50 Lacagnina, Mark. “Startled and Confused.” AeroSafety World, March 2010, pp. 20-25.
— 50 NTSB. Loss of Control on Approach, Colgan Air, Inc…Clarence Center, NY… 2-2-2010.
— 50 NTSB. “Update on NTSB Investigation into Crash of Colgan Air Dash-8 Near Buffalo.”
— 50 Werfelman, Linda. “Shape Up.” AeroSafety World, June 2011.
CNN: “On February 12, 2009, about 10:17 p.m. Eastern Standard Time (EST), a Colgan Air Inc., Bombardier Dash 8-Q400, N200WQ, d.b.a. Continental Connection flight 3407, crashed during an instrument approach to runway 23 at the Buffalo-Niagara International Airport (BUF), Buffalo, New York. The crash site was approximately 5 nautical miles northeast of the airport in Clarence Center, New York, and mostly confined to one residential house. The 4 crew members and 45 passengers were fatally injured and the airplane was destroyed by impact forces and post crash fire. There was one ground fatality. Night visual meteorological conditions prevailed at the time of the accident. The flight was a Code of Federal Regulations (CFR) Part 121 scheduled passenger flight from Liberty International Airport (EWR), Newark, New Jersey to Buffalo.” (NTSB Press Release, March 25, 2009)
“CLARENCE CENTER, New York (CNN) — A Continental Airlines plane crashed into a house near Buffalo, New York, late Thursday, killing all 49 people aboard and a person in the home, authorities said.
“Continental Connection Flight 3407, a Bombardier Dash 8 Q400 74-seat turboprop, was en route from Newark, New Jersey, to Buffalo when it went down at around 10:20 p.m. ET, about seven miles from Buffalo Niagara International Airport.
“Dave Bissonette, Clarence Center’s natural disaster services coordinator, said it was “clearly a direct hit” on the house.
“Four people were injured at the crash site, including a mother and daughter inside the house that was hit. They suffered minor injuries and were treated and released from a Williamsville hospital, a spokeswoman said.
“CNN has listened to a tape of communications between air traffic control and the flight crew. The first officer was calm. The plane was cleared for approach. About two minutes later, the air traffic controller came back, his voice full of stress. Radar contact was lost.
“The question goes out: Can other planes see anything? No one responds. The controller says they might have a plane down. The pilot’s last comment was “Colgan Flight 3407.” There were no sounds of distress.” (CNN. “50 Killed in Crash as Plane Hits Buffalo House.” Feb 13, 2009.)
Lacagnina: “The captain’s inappropriate response to a stick shaker activation was the probable cause of an unrecoverable stall and the crash of a Colgan Air Bombardier Q400 on approach to Buffalo Niagara (New York, U.S.) International Airport the night of Feb 12, 2009, according to the U.S. National Transportation Safety Board (NTSB).
“All 45 passengers and four crewmembers in the airplane, plus one person on the ground, were killed, and the airplane was destroyed when it struck a house in Clarence enter, New York, about 5 nm (9km) northeast of the airport.
“In its final report on the accident, NTSB said that the captain caused the airplane to stall by pulling on his control column when the stick shaker activated at an artificially high airspeed – a reaction that was consistent with ‘startle and confusion’ rather than with his training.
“The Report said that factors contributing to the accident were ‘the flight crew’s failure to monitor airspeed in relation to the rising position of the low-sped cue…the flight crew’s failure to adhere to sterile cockpit procedures, 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.’ Fatigue also was a likely factor, but investigators could not determine conclusively the extent to which the pilots were impaired by fatigue or how it might have contributed to their ‘performance deficiencies’ during the flight, the report said.”
(Lacagnina, Mark. “Startled and Confused.” AeroSafety World, March 2010, pp. 20-25.)
NTSB: “This report discusses the accident involving a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, which experienced a loss of control on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, and crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The safety issues discussed in this report focus on strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot training records, airspeed selection procedures, stall training, Federal Aviation Administration (FAA) oversight, flight operational quality assurance programs, use of personal portable electronic devices on the flight deck, the FAA’s use of safety alerts for operators to transmit safety-critical information, and weather information provided to pilots. Safety recommendations concerning these issues are addressed to the FAA.” (Abstract) ….
“Executive Summary:
“On February 12, 2009, about 2217 eastern standard time, 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 operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at the time of the accident.
“The National Transportation Safety Board determines that the probable cause of this accident was 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.
“The safety issues discussed in this report focus on strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot training records, airspeed selection procedures, stall training, Federal Aviation Administration (FAA) oversight, flight operational quality assurance programs, use of personal portable electronic devices on the flight deck, the FAA’s use of safety alerts for operators to transmit safety-critical information, and weather information provided to pilots. Safety recommendations concerning these issues are addressed to the FAA.
“Probable Cause. The National Transportation Safety Board determines that the probable cause of this accident was 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. Loss of Control on Approach, Colgan Air, Inc… 2010, p. x.)
NYT: “Amherst, N.Y. — The crew of the plane that crashed on approach to Buffalo Niagara International Airport on Thursday night, killing 50, reported “significant ice buildup” on the wings and windshield minutes before hitting a house and exploding into an intense fire, a federal transportation official said Friday.
“The crew, having earlier requested a descent to avoid haze, lowered the landing gear and then extended the flaps, the movable panels on the rear edge of the wings that allow a plane to maintain lift as it slows, according to the flight data recorder.
“But the plane immediately experienced “severe pitch-and-roll excursions,” meaning that the nose was moving up and down and the wings were wagging from side to side, said Steven Chealander of the National Transportation Safety Board.
“Within 40 seconds, the plane had crashed, at a steep angle, into a white-and-gray frame house in the hamlet of Clarence Center, N.Y., about six miles from the airport runway, killing the 61-year-old man who lived there and all 49 people on the aircraft.” (New York Times, “Crew Reported ‘Significant Ice Buildup’ Before Crash,” Feb 13, 2009.)
Werfelman: “Citing a “disturbing number” of events involving nonadherence with standard operating procedures by pilots and air traffic controllers, the U.S. National Transportation Safety Board (NTSB) is complaining of “an erosion of … professionalism” and urging action to improve on-the-job behavior. The NTSB added “pilot and air traffic controller professionalism” to its new “Most Wanted List” of the top 10 changes needed to prevent accidents in aviation and other forms of transportation….
“…the most recent accident cited in the board’s discussion of professionalism — the Feb. 12, 2009, crash of a Colgan Air Bombardier Q400 during approach to Buffalo Niagara (New York, U.S.) International Airport….[1] All 49 people in the airplane and one person on the ground were killed, and the airplane was destroyed in the accident. The NTSB said the probable cause was 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.”
The NTSB’s list of contributing factors included the flight crew’s failure to monitor airspeed and failure to adhere to sterile cockpit procedures, as well as the captain’s “failure to effectively manage the flight.”
“The board also cited the captain’s “several disapprovals” in seeking pilot ratings and certificates and “training problems throughout his flying career,” both before and after he was hired by Colgan. In a discussion of pilot professionalism contained in the safety recommendation letter, the NTSB said that, “on the basis of his actions during the flight, including the late performance of checklists and callouts because of an ongoing conversation, the captain showed inadequate leadership.”[2]
“The NTSB noted that, especially because the captain had held that position for more than two years, “his failure to establish the appropriate cockpit tone during the initial stages of the operation and show strong command authority during the flight is disconcerting.”
“The FAA does not require Part 121 operators to provide training to help new captains make the transition to pilot-in-command (PIC), but at the time of the accident captain’s 2007 upgrade, Colgan offered upgrading captains a one-day course on their new duties and responsibilities. However, the NTSB said that the course concentrated on a captain’s administrative duties and paid little attention to leadership skills, management oversight and command authority. “For many new captains, including the accident captain, the initial upgrade represents the first time in which they are held responsible for leading and managing multiple crewmembers during air carrier operations,” the NTSB said. “Because of the PIC’s critical role in establishing and maintaining safe operating conditions, upgrading captains would greatly benefit from specific training on command and leadership skills.”
“As a result, the NTSB recommended that the FAA issue an advisory circular to provide guidance to Part 121, Part 135 and Part 91K fractional ownership operators on leadership training for their upgrading captains, “including methods and techniques for effective leadership; professional standards of conduct; strategies for briefing and debriefing; reinforcement and correction skills; and other knowledge, skills and abilities that are critical for air carrier operations.”
“Also included among the 25 recommendations was a call for the FAA to require Part 121, Part 135 and Part 91K operators to provide specific leadership training for upgrading captains. Another recommendation said that the FAA should “develop, and distribute to all pilots, multimedia guidance materials on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile cockpit adherence; techniques for assessing and correcting pilot deviations; … and a detailed review of accidents involving breakdowns in sterile cockpit and other procedures.” (Werfelman, Linda. “Shape Up.” AeroSafety World, June 2011.)
Sources
Aircraft Crashes Record Office (Geneva, Switzerland). New York. Accessed 3-9-2009 at: http://www.baaa-acro.com/Pays/Etats-Unis/New%20York.htm
CNN. “50 Killed in Crash as Plane Hits Buffalo House.” February 13, 2009. Accessed at: http://www.cnn.com/2009/US/02/13/plane.crash.new.york/index.html
Lacagnina, Mark. “Startled and Confused.” AeroSafety World, March 2010, pp. 20-25. Accessed at: http://flightsafety.org/asw/mar10/asw_mar10_p20-25.pdf
National Transportation Safety Board. Aircraft Accident Report. Loss of Control on Approach, Colgan Air, Inc. Operating as Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ, Clarence Center, New York, February 12, 2009 (NTSB/AAR-10/01; PB2010-910401). Washington, DC: NTSB, adopted Feb 2, 2010, 299 pages. Accessed at: http://www.ntsb.gov/doclib/reports/2010/AAR1001.pdf
National Transportation Safety Board. NTSB Advisory. “Update on NTSB Investigation into Crash of Colgan Air Dash-8 Near Buffalo, New York; Public Hearing Scheduled.” March 25, 2009. Accessed at: http://www.ntsb.gov/pressrel/2009/090325.html
Werfelman, Linda. “Shape Up.” AeroSafety World, June 2011. Accessed at: http://flightsafety.org/aerosafety-world-magazine/june-2011/shape-up
[1] References: Mark Lacagnina, “Startled and Confused.” AeroSafety World, March 2010, pp. 20-25.
[2] Cites: NTSB. Safety Recommendations A-10-10 through A-10-34. Feb. 23, 2010.