NTSB Scrutinizes Pilot Actions in Q400 Crash Probe

 - May 12, 2009, 8:12 AM

The pilots of the Colgan Air Bombardier Q400 involved in the February 12 crash near Buffalo, N.Y., that killed 50 people did not observe the so-called sterile cockpit rule and the captain appears to have violated Colgan Air’s policy prohibiting the use of the crew room to sleep overnight, according to testimony read this morning during the NTSB’s public hearing on the crash.

NTSB hearing officer Lorenda Ward reported that the crew engaged in non-essential conversation while flying below 10,000 feet in violation of FAA rules, including, for example, a three-minute discussion on the crew’s experience in icing conditions and training. “This conversation occurred just a few minutes before the stick shaker activated and while the crew was executing the approach checklist,” said Ward.

Operating as Continental Connection Flight 3407 from Newark, N.J., to Buffalo Niagara International Airport, the 74-seat turboprop carried 45 passengers and four on-duty crewmembers when, after the airplane descended to about 2,300 feet, ATC lost contact with the pilots. FDR data shows that the Q400 pitched up at an angle of 31 degrees, then down to 45 degrees, followed by a 46-degree roll to the left, then a 105-degree roll to the right. The airplane fell the last 800 feet in five seconds, before crashing virtually onto a single house in the suburban town of Clarence Center, N.Y., killing one of the residents.

Although the pilots reported ice accretion on the airplane’s windshield, airplane performance modeling and simulation conducted by the NTSB show that icing had “minimal effect” on the stall speed of the airplane. Information from the airplane’s FDR indicates that the stick shaker activated at 130 knots, a speed consistent with an engaged de-icing system. FDR data further indicates that when the stick shaker activated, the control column experienced a 25-pound pull force, followed by an up elevator deflection and increase in pitch, angle of attack and g forces.

The NTSB has turned much of its attention to fatigue as a possible contributor to the crash. Records indicate that on the day of the accident, the captain logged into the company’s crew scheduling computer system at 3a.m. and 7:30 a.m., and that the first officer commuted to Newark on an overnight flight to Newark and had sent and received text messages on the day of the accident.

Colgan had scheduled the crew to report at 1:30 p.m. on the day of the accident, but high winds at the airport forced the cancellation of the first two flights of the day. Schedules called for Flight 3407 to take off at 7:45 p.m. and arrive in Buffalo at 10:21 p.m. Although ground crew pushed back the airplane from the gate at 7:45 p.m., the crew did not receive taxi instructions until 8:30 p.m. and the tower cleared the flight for takeoff at 9:18 p.m.

During the flight’s climb to 16,000 feet, the crew activated the de-icing systems and left them on throughout the flight.  About 40 minutes into the flight the crew began their descent and at 10:10 p.m. they discussed the build-up of ice on the windshield. At 10:12, the flight received clearance to descend to 2,300 feet and reached that altitude at 10:14. At 10:16 the crew lowered the landing gear and about 20 seconds later the first officer moved the flaps from 5 to 10 degrees. The stick shaker activated and the autopilot disengaged shortly thereafter. The crew added power to about 75 percent torque and the control column moved aft. That accompanied a pitch-up motion, a left roll, followed by a right roll, during which time the pusher activated and the flaps retracted. The airspeed then decreased and after further pitch and roll excursions the airplane pitched down and entered a steep descent from which it did not recover.

This morning’s testimony indicated that Colgan had put in place a fatigue policy before the accident occurred and that it covered the policy during indoctrination training. However, according to the testimony, by the date of the accident Colgan did not provide specific guidance to its pilots in fatigue management. On April 29 this year Colgan issued an operations bulletin that reiterates its fatigue management policy.

The hearings also revealed that the captain had accumulated four FAA certificate disapprovals, three of which occurred before his hiring at Colgan in 2005 and included disapprovals for his pilot instrument, commercial pilot initial and his commercial multi-engine rating. He also failed his first evaluation at Colgan for his ATP certificate. The first officer had received one FAA disapproval for her initial flight instructor certificate before she was hired by Colgan in January last year.

Both pilots were based in Newark. The captain commuted from the Tampa, Fla., area, and arrived in Newark on February 9 at 8 p.m. On February 10 the captain began the first day of a two-day trip at 5:45 a.m.

The first officer, who previously lived and was based in the Norfolk, Va. area, recently moved to Seattle and had changed her base to Newark. On February 11 she awoke between 9  and 10a.m. PST, and took a jump seat from Seattle to Memphis, Tenn., on a FedEx flight that departed just before 8 p.m. PST. The flight arrived at about 2:30 a.m. EST on February 12; at about 4:20 a.m. the first officer rode a jump seat from Memphis to Newark and arrived at about 6:30 a.m.

Colgan’s pilot handbook states only that the company expects the pilot to report for duty in a timely manner. Although a previous edition of the handbook said that flight crewmembers should not attempt to commute to their base on the same day they are scheduled to work, that statement does not appear in the current edition, according to today’s testimony.

Colgan requires its Newark-based crewmembers to provide their own sleeping accommodations, and “sleeping in operations or any crew room in Newark is strictly prohibited and will have severe disciplinary consequences up to and including termination,” according to a memo issued May 24 last year by Colgan’s Newark chief pilot.   

Even though company records indicate that both the captain and first officer acknowledged receipt of the memo, according to today’s testimony, no evidence exists that either crewmember had arranged for accommodations in Newark “and the captain had been reported to stay overnight in the crew room.”