NTSB: crew failings led to Colgan crash

Aviation International News » March 2010
February 23, 2010, 9:01 AM

The NTSB laid the primary blame on the pilots of Colgan Air Flight 3407 for the crash on February 12 last year that killed 50 people and perhaps more unflattering comparisons between the respective safety standards that prevail at regional airlines and their mainline counterparts. In a report adopted on February 2, the Safety Board determined that the captain of the Colgan Air Bombardier Q400 inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.

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 onto a single house in the suburban town of Clarence Center, N.Y., killing one of the residents.

According to the NTSB, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded by pushing forward on the control column. Instead, he pulled aft on the control column, placing the airplane into an accelerated stall.

According to the report, the crewmembers’ failure to recognize the indication of the low-speed cue on their flight displays and their failure to adhere to sterile-cockpit procedures contributed to the crash, as did 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.

No ‘Sterile Cockpit’

CVR transcripts offer clear evidence that the flight’s captain, Marvin Renslow, and first officer, Rebecca Shaw, violated the so-called “sterile cockpit” rules as they began their descent into Buffalo during an otherwise routine flight from Newark International Airport on February 12. The CVR recorded talk about prospects for upgrades and employment at other airlines, Renslow’s recollections of a Houston-based controller nicknamed “Mister Happy” and Shaw’s apprehension about flying in icing conditions. Extended transcripts released by the NTSB last July revealed that Shaw had complained to Renslow about feeling ill before the two received clearance to take off from Newark. However, the NTSB determined that the first officer’s illness likely did not affect her performance during the flight.

The Safety Board did express doubts about Renslow’s flying skills, however, noting that he did not “establish a good foundation of attitude instrument flying skills early in his career, and his continued weakness in basic aircraft control and instrument flying were not identified and addressed.” It also noted that while remedial training and additional oversight for pilots with training deficiencies would help ensure that pilots master the needed skills for safe flight, Colgan’s electronic pilot training records did not contain enough detail for the company or its principal operations inspector to properly analyze the captain’s trend of unsatisfactory performance.

The Board also noted that Colgan’s training at the time of the accident did not require flight crews to cross-check the approach speed bug settings in relation to the reference speeds switch position; “such awareness is important because a mismatch between the bugs and the switch could lead to an early stall warning,” it said, adding that current air carrier approach-to-stall training did not fully prepare the crew for a stall in the Q400 and did not address actions needed to recover from a fully developed stall.

“The circumstances of this and other accidents in which pilots have responded incorrectly to the stick pusher demonstrate the continuing need to train pilots on the actions of the stick pusher and the airplane’s initial response to the pusher,” said the Board in its synopsis of its final report, revisions to which it continued to make last month.

The hearings in May revealed that the captain had accumulated four FAA certificate disapprovals, three of them before his hiring at the airline in 2005, including 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 joined Colgan in January 2008.

The captain did not mention two of his failed tests on his employment application, according to testimony given last year by Colgan vice president of administration Mary Finnigan, who added that if the company knew that he had withheld the information, “he would have been dismissed immediately. That would have been falsifying documentation and it’s not tolerated.”

Finnigan explained that the company follows the FAA’s Pilot Records Improvement Act, which in 1996 set standards for airlines’ background checks of applicants, including a prohibition against tracking records dating back more than five years. Nevertheless, the NTSB concluded that Colgan did not use all available sources of information on the flight crew’s qualification and previous performance to determine its suitability for work at the company.

Fatigue Guidance

Critically, although the NTSB said fatigue “likely” impaired the pilots’ performance, it would not venture a judgment on the extent of the impairment and the degree to which fatigue contributed to the deficiencies exhibited during the flight. It did, however, fault the pilots for failing to manage their off-duty time and effectively use available rest periods and appropriate facilities before reporting to work. It also faulted Colgan Air for failing to “proactively address” pilot fatigue hazards associated with operations at a predominantly commuter base.

Colgan had instituted a fatigue policy before the accident occurred and it covered the policy during indoctrination training. However, according to testimony during last spring’s three-day NTSB hearing into the crash, by the date of the accident the airline did not provide specific guidance to its pilots in fatigue management. On April 29 last year Colgan issued an operations bulletin that reiterates its fatigue management policy.

Records indicate that on the day of the accident, the flight’s captain logged into the company’s crew scheduling computer system at 3:10 a.m., and that the first officer commuted to Newark on an overnight flight 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. Although ground crew pushed the airplane back from the gate at 7:45, the crew did not receive taxi clearance until 8:30 p.m., and the tower cleared the flight for takeoff at 9:18 p.m.

During the February 2 Board meeting, NTSB human performance investigator Dr. Evan Byrne noted that although Renslow stayed overnight in the crew room at Newark and the accident occurred during his normal bedtime, just after 10:17 p.m., neither he nor first officer Shaw showed degraded performance throughout the flight, and that the errors they did commit didn’t necessarily point to fatigue. Byrne concluded that although the pilots likely did experience some fatigue, this particular case didn’t warrant any indictment on current flight- and duty-time rules, nor did it invalidate the practice of commuting per se. In fact, most of Colgan’s pilots who fly from EWR commute.

However, noted Byrne, the airline did not discourage same-day commuting and did not enforce its policy against sleeping in crew rooms. In one of the NTSB’s 25 recommendations stemming from the investigation, the Safety Board called
for a requirement that all Part 121, 135 and 91K operators “address fatigue risks associated with commuting, including identifying pilots who commute, establishing policies and guidance to mitigate fatigue risks for commuting pilots, using scheduling practices to minimize opportunities for fatigue in commuting pilots and developing or identifying rest facilities for commuting pilots.”

The Safety Board has also recommended that the FAA implement strategies related to flight crew monitoring failures, pilot professionalism, remedial training, pilot records, stall training and airspeed selection procedures. Further recommendations address the FAA’s oversight and use of safety alerts for operators to transmit safety-critical information, flight operational quality assurance (FOQA) programs, use of personal portable electronic devices on the flight deck and weather information provided to pilots.

The FAA has responded with an advance notice of proposed rulemaking (ANPRM) that poses a series of questions, including:
1A. Should the FAA require all pilot crewmembers engaged in Part 121 air carrier operations to hold an ATP certificate? Why or why not?
1B. If a Part 121 air carrier pilot does not hold an ATP certificate, should he or she nevertheless be required to meet the ATP certificate aeronautical knowledge and experience requirements of FAA Part 61.159, even if he or she is serving as second-in-command? Why or why not?
The agency also asked for public comments on the question of whether it should consider crediting specific academic study in lieu of flight hour requirements and whether it should propose a new commercial pilot certificate endorsement for
Part 121 second-in-command privileges. “The FAA believes that an endorsement approach would target specific skill sets needed for Part 121 operations and establish the associated standards for content and quality of training,” according to the ANPRM, rather than rely strictly on a set number of flight hours.

The ANPRM also asks for comments on a proposal to require carrier-specific authorization–over and above the standard Part 121 requirements–to ensure that
each carrier has trained its pilots on, for example, the aircraft, routes and meteorological conditions unique to its operating environment.

Finally, the FAA seeks comments on whether it should change its existing monitoring, evaluation, information collection requirements and enforcement associated with current pilot performance.

Meanwhile the Safety Board said it will hold a public forum this spring to explore pilot and ATC standards. It noted that the accident was one of a series of incidents investigated by the Board in recent years–including a midair over the Hudson River–that raised questions of ATC vigilance. It also cited the incident last year in which a Northwest Airlines A320 overflew its destination airport in Minneapolis when the pilots allowed themselves to become distracted by non-flying activities. All the incidents in question involved air transportation professionals deviating from expected levels of performance, according to the NTSB.

The Board also plans to hold a forum on code-sharing in the fall that will address the practice of airlines marketing their services to the public while using other companies to actually perform the transportation. 

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