Colgan Air Flight 3407


Colgan Air Flight 3407
Colgan Air Flight 3407

A Dash-8 Q400 similar to the aircraft involved.
Accident summary
Date February 12, 2009 (2009-02-12)
Type Stall caused by pilot error
Site Clarence Center, New York, USA
Passengers 45
Crew 4
Injuries 4 (all on the ground)
Fatalities 50 (1 on ground)
Survivors 0
Aircraft type Bombardier DHC8-402 Q400
Operator Colgan Air (as Continental Connection)
Tail number N200WQ
Flight origin Newark Liberty International Airport
Destination Buffalo Niagara International Airport

Colgan Air Flight 3407, marketed as Continental Connection under a codeshare agreement with Continental Airlines, was a daily U.S. regional airline commuter flight from Newark Liberty International Airport in New Jersey to Buffalo Niagara International Airport in New York State.

A Bombardier DHC8-402 Q400 operating as Flight 3407 departed late from Newark on February 12, 2009, at 9:20 p.m. EST. Shortly after the last communication by the flight crew with approach control at 10:17 p.m. (03:17, February 13 UTC), the plane stalled less than a mile northeast of the locator outer marker while on an ILS approach to Runway 23[1] and crashed into a house in the northeast Buffalo suburb of Clarence Center, about 9.3 kilometres (5.0 nmi) short of the runway threshold.

A total of 50 people were killed including the two pilots, two flight attendants, 45 passengers (including one off-duty pilot), and one person in the house into which the plane crashed. It was the first fatal crash of a commercial airliner in the United States since the crash of Comair Flight 191 in August 2006 which killed 49. The National Transportation Safety Board concluded that cause of the crash was pilot error.

Contents

Flight details

Colgan Air Flight 3407 (9L/CJC 3407) was marketed as Continental Connection Flight 3407. The flight made a delayed departure at 9:20 p.m. EST,[2] en route from Newark Liberty International Airport to Buffalo Niagara International Airport. The flight was one of seven Continental flights bound for Buffalo Niagara that day, out of a total of 110 incoming and departing flights across all carriers at Buffalo.[3]

The aircraft was a 74-seat Bombardier Dash 8 Q400, registered N200WQ. The two-engine turboprop was owned and operated by Colgan Air. N200WQ was registered with the Federal Aviation Administration in April 2008[4] and entered service later that month.[5]

The Q400 model has been involved in 13 incidents, but the crash of Flight 3407 was the first resulting in fatalities.[5] This crash was also the first fatality on a Colgan Air passenger flight since the company was founded in 1991; there was a previous fatal accident (not involving passengers) in August 2003 when a repositioning flight crashed offshore of Massachusetts, killing both crew members. The only prior aviation incident on 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.[6]

The crew of four was led by Captain Marvin Renslow, age 47, of Lutz, Florida, who was hired by Colgan in 2005 and had flown 3,379 hours. 261 of these hours were on the Dash-8 Q400 (including 109 as a captain).[7][8] He had previously worked stacking shelves in Tampa, Florida prior to joining Colgan[9], and in 2007, he became a pilot in command. First Officer Rebecca Lynne Shaw, age 24, of Maple Valley, Washington,[10][11][12] was hired by Colgan in January 2008, and had flown 2,200 hours, 772 of them on the Q400.[8] Flight Attendants Matilda Quintero and Donna Prisco both joined Colgan in May 2008. Captain Joseph Zuffoletto, an off-duty crew member aboard Flight 3407, was hired by Colgan in September 2005.[13][14]

Crash

Planform view of a Q400 showing the high aspect ratio (long, narrow) wings
FAA ILS/LOC approach plate to Runway 23 at Buffalo Niagara International Airport (KBUF). The flight crashed (marked in red) near the locator outer marker (LOM) (identifier: "KLUMP") about five nautical miles from the threshold of Rwy 23.

The aircraft had been cleared for the ILS Runway 23 approach to the nearby Buffalo Niagara International Airport when it disappeared from radar. Weather conditions were a wintry mix in the area, with light snow, fog, and winds at 17 miles per hour (15 knots). Two other aircraft reported icing conditions around the time of the crash. The last radio transmission from the flight occurred when the plane was 4.8 kilometres (3.0 mi) northeast of the airport radio beacon known as KLUMP (see diagram), when First Officer Shaw acknowledged a routine instruction to change to tower frequency. After several attempts to hail the crew, controllers requested the assistance of Delta Air Lines Flight 1998 from Atlanta, GA and US Airways Flight 1452 from Charlotte, NC to make visual contact with the missing airplane; the Delta crew members responded that they did not see the plane.[14][15][16][17][18][19][20][21][22]

During the flight and continuing through the plane's landing approach, the crew had been flying on autopilot. The de-icing system was turned on 11 minutes into the flight by the crew, who had discussed significant ice buildup on the aircraft's wings and windscreen shortly before the crash. Following this, the pilots extended the aircraft's flaps and landing gear for landing. According to the NTSB's official report, after the landing gear and flaps had been extended, the flight data recorder (FDR) indicated that the airspeed had decayed to 145 knots (269 km/h).[23] The captain, who was the pilot flying, then called for the flaps to be set at the 15 degree position. As the flaps transitioned past the 10 degree mark, the FDR indicated that the airspeed had further slowed to 135 knots (250 km/h). Six seconds later, the aircraft's stick shaker, a device intended to provide aural and tactile awareness of a low speed condition, sounded. At this time the cockpit voice recorder (CVR) recorded the autopilot disengaging. The FDR now indicated that the aircraft's speed was a dangerously slow 131 knots (243 km/h). Unfortunately, instead of following the established stall recovery procedure of adding full power and lowering the nose to prevent the stall, the captain only added about 75% power and continued applying nose-up inputs. As the aircraft came even closer to stalling the stick pusher activated ("The Q400 stick pusher applies an airplane-nose-down control column input to decrease the wing angle-of-attack [AOA] after an aerodynamic stall").[23] The captain overrode the pusher and continued pulling on the control yoke resulting in the upset and subsequent loss of control.[24] The plane pitched up at an angle of 31 degrees in its final moments, before pitching down at 45 degrees. It then rolled to the left at 46 degrees and snapped back to the right at 105 degrees. Occupants aboard experienced forces estimated at nearly twice that of gravity. Witnesses on the ground claimed to have heard the engines sputter just before the crash.[25]

The plane struggled for about 25 seconds, during which time the crew made no emergency declaration. It rapidly lost altitude and then crashed into a private home at 6038 Long Street, about 8 kilometres (5.0 mi) from the end of the runway, and nearly directly under its intended approach path, with the nose pointed away from the destination airport. The ensuing fire destroyed the house and most of the plane, with the tail of the plane broken off and nearly intact. The house was the home of Douglas and Karen Wielinski along with their daughter Jill. Douglas was killed; his wife and daughter escaped with minor injuries and were treated at the Millard Fillmore Suburban hospital. The lots in the area are only 18.3 metres (60 ft) wide; the plane hit the house squarely, destroying it in the ensuing fire with little damage to surrounding homes.[26] The home was close to the Clarence Center Fire Company, so emergency personnel were able to respond quickly. While fighting the blaze, two firefighters were injured. The crash and intense fire caused the evacuation of 12 nearby houses.[3][20][22][27][28][29][30]

Victims

The total number of fatalities was 50, including all four crew members and one off duty crew-member, all 45 passengers, and one resident of the house that was struck. One woman on the plane was pregnant. There were four injuries on the ground, including two other people inside the home at the time of the crash. Among the dead were:

President of the United States Barack Obama shaking hands with Beverly Eckert six days before the accident
Nationality Passengers Crew Ground Total[31]
United States American 41 4 1 46
Canada Canadian 2 0 0 2
China Chinese 1 0 0 1
Israel Israeli 1 0 0 1
Total 45 4 1 50

Reactions

  • During the afternoon, the U.S. House of Representatives held a moment of silence for the victims and their families.[39]
  • The University at Buffalo (UB), which lost 11 passengers who were former employees, faculty or alumni, and 12 who were family members of faculty, employees, students or alumni in the crash, also held a remembrance service on February 17, 2009.[41][42] A black band with the flight number was worn on UB players' uniforms for the remainder of the basketball season.
  • Buffalo State College's 11th President Muriel Howard released a statement regarding the six alumni lost on Flight 3407. Beverly Eckert was a 1975 graduate from Buffalo State.[43]
  • On March 4, 2009, New York Governor David Paterson proposed the creation of a scholarship fund to benefit children and financial dependents of the 50 crash victims. The Flight 3407 Memorial Scholarship would cover costs for up to four years of undergraduate study at a SUNY or CUNY school, or a private college or university in New York State.[44]
  • The accident was the basis for a PBS Frontline episode on the regional airline industry. Discussed in the episode were issues relating to regional airline regulation, safety, and working conditions. Also discussed were the operating principles of regional airlines and the agreements between regional airlines and major airlines.[45]

Investigation

The National Transportation Safety Board (NTSB) announced that they would send a team to the crash site on February 13 to begin the investigation.[16][17] NTSB spokesman Steve Chealander said that 14 investigators were assigned to the crash of Continental Connection Flight 3407.[46] Both the Flight data recorder (FDR) and the Cockpit voice recorder (CVR) were retrieved and analyzed in Washington, D.C.[22][47]

After initial FDR and CVR analysis, it was determined that the aircraft went through severe pitch and roll oscillations after positioning its flaps and landing gear for landing. Until that time, the Dash 8 had been maneuvering normally. The de-icing system was reported to be turned on. During descent, the crew reported about 3 miles (4.8 km) of visibility with snow and mist. Preceding the crash, the aircraft's stall-protection systems had activated. Instead of the aircraft's diving straight into the house as was initially thought, it was found that the aircraft fell 800 feet (240 m) before crashing pointing northeast, away from the destination airport. The passengers were given no warning of any trouble by the pilots. Occupants aboard the Dash 8 experienced an estimated force two times that of gravity just before impact. Chealander said information from the aircraft's flight data recorder indicates that the plane pitched up at an angle of 31 degrees, then down at 45 degrees. The Dash 8 rolled to the left at 46 degrees, then snapped back to the right at 105 degrees, before crashing into the house.[20][22][22][29][48][49]

At the crash scene, an area 2 square miles (5.2 km2) in size was cordoned off, despite the small footprint of the actual damage. Investigators stated it would take three or four days to remove all human remains and a few weeks to positively identify them. As the recovery efforts proceeded, Chealander remarked that freezing temperatures as well as difficulty accessing debris were slowing the investigation. Portable heaters had to be brought to the site to thaw ice left in the wake of the firefighting efforts. Initial analysis of the aircraft's remains revealed the cockpit had sustained the greatest impact force, while the main cabin was mostly destroyed by the ensuing fireball. Towards the rear of the aircraft, passengers were found still strapped in their seats.[29][48][50]

On February 15, more information on the crash was released by the NTSB saying it appeared the plane had been on autopilot when it went down. The investigators did not find evidence of the severe icing conditions that would have required the pilots to fly manually.[51] Colgan Air recommends pilots fly manually in icing conditions, and requires they do so in severe icing conditions. The NTSB had issued a safety alert about the use of autopilot in icing conditions in December 2008. Without flying manually, pilots may be unable to feel changes in the handling characteristics of the airplane, which is a warning sign of ice buildup. The NTSB also revealed that the plane crashed a mere 26 seconds after trouble was first registered on the flight data recorder.[52][53][54]

More details emerged on February 18. It was reported that a re-creation of events leading up to the crash indicated that the stick pusher had activated, which pushes the nose down when it determines a stall is imminent in order to maintain airspeed so the wings continue to generate lift and keep the aircraft aloft. The crew, concerned about a nose-down attitude so close to the ground, may have responded by pulling the nose upward and increasing power, but over-corrected, causing a stall or even a spin.[55] Bill Voss, president of Flight Safety Foundation, told USA Today that it sounded like the plane was in "a deep stall situation".[56]

On March 25, 2009, NTSB investigators said that icing probably did not contribute greatly to the accident.[57] On May 11, 2009, new information came out that Captain Renslow had failed three "check rides" - the flying equivalent of driver proficiency tests[58] , and it was suggested that he may not have been adequately trained to respond to the emergency that led to the airplane's fatal descent.[59] Crew fatigue was also suspected, as both pilots appear to have been at Newark airport overnight and all day prior to the 9:18 pm departure.[60] In response to questioning from National Transportation Safety Board members, Colgan Air officials acknowledged that both pilots apparently were not paying close attention to the aircraft's instruments and failed to follow the airline's procedures for handling an impending stall in the final minutes of the flight. 'I believe Capt. Renslow did have intentions of landing safely at Buffalo, as well as first officer Shaw, but obviously in those last few moments ... the flight instruments were not being monitored, and that's an indication of a lack of situational awareness,' said John Barrett, Colgan's director of flight standards. The official transcript of the crew's communication, obtained from the cockpit voice recorder, as well as an animated depiction of the crash, constructed using data from the flight data recorder were made available to the public on May 12, 2009, the first day of the public hearing. Some of the crew's communication violated federal rules banning nonessential conversation.[61]

On June 3, 2009, the New York Times published an article[62] detailing complaints about Colgan's operations from an FAA inspector who observed test flights in January 2008. As in a previous FAA incident handling other inspectors' complaints,[62] the Colgan inspector's complaints were deferred and the inspector was demoted. The incident is under investigation by the Office of Special Counsel, the agency responsible for U.S. Government federal whistle-blower complaints.

Safety issues examined during the accident investigation process, included pilot training, hiring, and fatigue problems, leading the FAA to issue a "Call to Action" for improvements in the practices of regional carriers.[63]

On February 2, 2010, the NTSB adopted its final report into the accident. This was the first time in 15 years that a report had been adopted by the NTSB in less than a year from the date of the accident. It concluded that the cause of the accident was pilot error.

The captain failed to react in the proper manner, by decreasing the angle-of-attack, when the stick shaker activated. Instead, following the activation of both the stick shaker and the stick pusher, he countermanded by pulling back on the stick, which greatly exacerbated the situation. "...his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion. It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery."[23]

The NTSB was unable to determine why the first officer retracted the flaps and also suggested that the landing gear should be retracted. Her actions were also inconsistent with company stall recovery procedures and training. The actions of both pilots led to the aircraft entering an accelerated stall.[23]

The method by which civil aircraft pilots can obtain their licenses was also criticized by the NTSB. The report was published on February 25, 2010.[64]

The NTSB Probable Cause finding:

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 lowspeed 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.[23]

The Board further found that: "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." Chairman Hersman, while concurring, was clear in considering that fatigue was a contributing factor. She compared the twenty years that fatigue has remained on the NTSB's Most Wanted List of Transportation Safety Improvements (without getting substantial action on the matter from regulators) to the changes in tolerance for alcohol over the same time period, noting that the performance impacts of fatigue and alcohol were similar.[23]"

In October 2011, more than a year after the NTSB's report was published, new questions were raised about Captain Renslow's qualifications in flying the Q400. Several internal Colgan Air e-mails were released, showing that staff members at the airline had expressed doubts about Renslow's ability to fly the aircraft. In one e-mail, Bill Honan, Colgan Air's chief pilot, claimed that Renslow "had a problem upgrading" from the smaller Saab 340, and that he was "already off the list" of promotions to the Q400. However, Colgan Air promoted Renslow to fly Q400s about a month after the e-mails were exchanged. These e-mails were released as part of a wrongful death lawsuit against Colgan Air and its parent company, Pinnacle Airlines, by families of the victims; Hugh Russ III, an attorney for the plaintiffs, accused Colgan and Pinnacle of ignoring Renslow's lack of qualifications in order to pursue profits.[65]

Legacy

The FAA has proposed or implemented several rule changes as a result, in areas ranging from fatigue to Airline Transport Pilot Certificate (ATP) qualifications. One of the most significant has already taken effect, changing the way examiners grade checkrides in flight simulators during stalls.[66]

Renslow's decision to pull back on the elevators when the stick began to shake, raising the nose, baffled investigators initially, since that was the exact opposite of what pilots are trained to do in that situation. Since it caused the stall, it was the reason his error was blamed for the crash. Investigators were still not sure why he had pulled when he should have pushed, as he had at least 2,000 feet (610 m) to recover with.[66]

One eventually looked at the Practical Test Standards (PTS) for ATP certification, which allowed for an elevation loss of no more than 100 feet (30 m) in a simulated stall. The NTSB theorized that due to this low tolerance, pilots may have come to fear loss of altitude in a stall and so acted more to prevent that even to the detriment of recovering from the stall itself. New standards subsequently issued by the FAA eliminate any specific amount, calling instead for "minimal loss of elevation" in a stall. One examiner has told an aviation magazine that he is not allowed to fail any applicant for losing altitude in a simulated stall so long as the pilot is able to regain the original altitude.[66]

Dramatization

The story of the disaster was featured on the tenth season of Canadian National Geographic Channel show Mayday (known as Air Emergency in the US, Mayday in Ireland and France, and Air Crash Investigation in the UK and the rest of world).

See also

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References

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External links

Coordinates: 43°00′42″N 78°38′21″W / 43.011602°N 78.63904°W / 43.011602; -78.63904


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