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Colgan Air, Inc. Operating as Continental Connection Flight 3407. Bombardier DHC-8-400, N200WQ. Clarence Center, New York. February 12, 2009.
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National Transportation Safety Board. 2010. 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. Washington, DC.
Abstract: 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.
The National Transportation Safety Board (NTSB) is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.
Recent publications are available in their entirety on the Internet at http://www.ntsb.gov. Other information about available publications also may be obtained from the website or by contacting:
National Transportation Safety Board Records Management Division, CIO- 490 L’Enfant Plaza, SW Washington, DC 20594 (800) 877-6799 or (202) 314-
NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2010-910401 from:
National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-
The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.
Figures.............................................................................................................................................v
Tables ..............................................................................................................................................v
Abbreviations ............................................................................................................................... vi
Federal Aviation Administration Certificate Disapprovals and Colgan Air
Interview with Colgan Air Flight Crew of Burlington, Vermont
vi
AAIB Air Accidents Investigation Branch of the United Kingdom
AC advisory circular
ACARS aircraft communications addressing and reporting system
AFM airplane flight manual
agl above ground level
AIM Aeronautical Information Manual
AIRMET Airmen’s Meteorological Information
ALB Albany International Airport
ALPA Air Line Pilots Association
AOA angle-of-attack
AOM airplane operating manual
APM aircrew program manager
ASAP aviation safety action program
ASIAS aviation safety information analysis and sharing
ASOS automated surface observing system
ASRS Aviation Safety Reporting System
ATC air traffic control
ATCT air traffic control tower
ATIS automatic terminal information service
ATOS air transportation oversight system
BTV Burlington International Airport
BUF Buffalo-Niagara International Airport
vii
CFM company flight manual
CFR Code of Federal Regulations
CRM crew resource management
CVR cockpit voice recorder
CWA Center Weather Advisory
DOD Department of Defense
eice en route ice accumulation
EWR Newark Liberty International Airport
FAA Federal Aviation Administration
FDR flight data recorder
FOQA flight operational quality assurance
FRMS fatigue risk management system
FSDO flight standards district office
GIA Gulfstream International Airlines
Hg mercury
IAH George Bush Intercontinental Airport
IAS indicated airspeed
IATA International Air Transport Association
ICAO International Civil Aviation Organization
IEP internal evaluation program
IFR instrument flight rules
ILS instrument landing system
InFO information for operators
IOE initial operating experience
ix
SAFO safety alert for operators
SEA Seattle-Tacoma International Airport
SIC second-in-command
SIGMET Significant Meteorological Information
SMS safety management system
TSB Transportation Safety Board of Canada
Vfri flap retract speed
Vga go-around speed
Vref reference landing speed
VSR reference stall speed
VMC visual meteorological conditions
VOR very high frequency omnidirectional radio range
VVM verbalize, verify, and monitor
YYZ Toronto Pearson International Airport
x
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.
1945.^6 According to the cockpit voice recorder (CVR) recording, the EWR ground controller provided taxi instructions for the flight at 2030:28,^7 which the first officer acknowledged.
About 2041:35, the first officer stated, “I’m ready to be in the hotel room,” to which the captain replied, “I feel bad for you.” She continued, “this is one of those times that if I felt like this when I was at home there’s no way I would have come all the way out here.”^8 She then stated, “if I call in sick now I’ve got to put myself in a hotel until I feel better … we’ll see how … it feels flying. If the pressure’s just too much … I could always call in tomorrow at least I’m in a hotel on the company’s buck but we’ll see. I’m pretty tough.” The captain responded by stating that the first officer could try an over-the-counter herbal supplement, drink orange juice, or take vitamin C.
The CVR recorded the tower controller clearing the airplane for takeoff about 2118:23. The first officer acknowledged the clearance, and the captain stated, “alright cleared for takeoff it’s mine.” According to the dispatch release, the intended cruise altitude for the flight was 16,000 feet mean sea level (msl).^9 The flight data recorder (FDR) showed that, during the climb to altitude, the propeller deice and airframe deice equipment were turned on (the pitot static deicing equipment had been turned on before takeoff) and the autopilot was engaged.
The airplane reached its cruising altitude of 16,000 feet about 2134:44. The cruise portion of flight was routine and uneventful. The CVR recorded the captain and the first officer engaged in an almost continuous conversation throughout that portion of the flight, but these conversations did not conflict with the sterile cockpit rule, which prohibits nonessential conversations within the cockpit during critical phases of flight.^10 About 2149:18, the CVR recorded the captain making a sound similar to a yawn. About 1 minute later, the captain interrupted his own conversation to point out, to the first officer, traffic that was crossing left to right. About 2150:42, the first officer reported the winds to be from 250° at 15 knots gusting to 23 knots; afterward, the captain stated that runway 23 would be used for the landing.
About 2153:40, the first officer briefed the airspeeds for landing with the flaps at 15° (flaps 15) as 118 knots (reference landing speed [Vref]) and 114 knots (go-around speed [Vga]), and the captain acknowledged this information. About 2156:26, the first officer stated, “might be easier on my ears if we start going down sooner.” About 2156:36, the captain instructed the first officer to “get discretion to twelve [thousand feet].” Less than 1 minute later, a controller from Cleveland Center cleared the flight to descend to 11,000 feet, and the first officer acknowledged the clearance.
(^6) ACARS enables pilots to communicate with company personnel on the ground. ACARS is used to exchange
routine flight status messages and weather information. Some of these messages, such as the time that a flight leaves the gate, takes off, and touches down, are sent and received automatically. (^7) About 7 minutes earlier, the captain had made an announcement over the public address system, indicating
that the taxi delay was the result of the weather conditions at the time. (^8) The CVR recorded the first officer sneezing and sniffling. (^9) All altitudes in this report are expressed as msl unless otherwise noted. (^10) The sterile cockpit rule refers to 14 CFR 121.542, “Flight Crewmember Duties,” which is discussed in
section 1.17.3.
About 2203:38, the Cleveland Center controller instructed the flight crew to contact BUF approach control, and the first officer acknowledged this instruction. The first officer made initial contact with BUF approach control about 2203:53, stating that the flight was descending from 12,000 to 11,000 feet with automatic terminal information service (ATIS) information “romeo,”^11 and the approach controller provided the airport altimeter setting and told the crew to plan an instrument landing system (ILS) approach to runway 23.
About 2204:16, the captain began the approach briefing. About 2205:01, the approach controller cleared the flight crew to descend and maintain 6,000 feet, and the first officer acknowledged the clearance. About 30 seconds later, the captain continued the approach briefing, during which he repeated the airspeeds for a flaps 15 landing. FDR data showed that the airplane descended through 10,000 feet about 2206:37. From that point on, the flight crew was required to observe the sterile cockpit rule.
About 2207:14, the CVR recorded the first officer making a sound similar to a yawn. About 2208:41 and 2209:12, the approach controller cleared the flight crew to descend and maintain 5,000 and 4,000 feet, respectively, and the first officer acknowledged the clearances. Afterward, the captain asked the first officer about her ears, and she indicated that they were stuffy and popping.
About 2210:23, the first officer asked whether ice had been accumulating on the windshield, and the captain replied that ice was present on his side of the windshield and asked whether ice was present on her windshield side. The first officer responded, “lots of ice.” The captain then stated, “that’s the most I’ve seen—most ice I’ve seen on the leading edges in a long time. In a while anyway I should say.” About 10 seconds later, the captain and the first officer began a conversation that was unrelated to their flying duties. During that conversation, the first officer indicated that she had accumulated more actual flight time in icing conditions on her first day of initial operating experience (IOE) with Colgan than she had before her employment with the company.^12 She also stated that, when other company first officers were “complaining” about not yet having upgraded to captain, she was thinking that she “wouldn’t mind going through a winter in the northeast before [upgrading] to captain.” The first officer explained that, before IOE, she had “never seen icing conditions … never deiced … never experienced any of that.”
About 2212:18, the approach controller cleared the flight crew to descend and maintain 2,300 feet, and the first officer acknowledged the clearance. Afterward, the captain and the first officer performed flight-related duties but also continued the conversation that was unrelated to their flying duties. About 2212:44, the approach controller cleared the flight crew to turn left onto a heading of 330°. About 2213:25 and 2213:36, the captain called for the descent and approach checklists, respectively, which the first officer performed. About 2214:09, the approach controller cleared the flight crew to turn left onto a heading of 310°, and the autopilot’s
(^11) An ATIS broadcasts continuous weather observations and other advisory information to pilots operating on
or near an airport. ATIS broadcasts are updated hourly or more frequently if conditions change. ATIS information “romeo” relayed information from a BUF weather observation at 2154; see section 1.7 for information about the observation. (^12) According to the CVR, the first officer stated, about 2210:58, that she had accumulated 1,600 hours during
flights in the Phoenix, Arizona, area. Section 1.5.2 provides additional details about the first officer’s flying experience.
when the autopilot disengaged, the airplane was at an airspeed of 131 knots. FDR data showed that the control columns moved aft at 2216:27.8 and that the engine power levers were advanced to about 70° (rating detent was 80°) 1 second later.^18 The CVR then recorded a sound similar to increased engine power, and FDR data showed that engine power had increased to about 75 percent torque.
FDR data also showed that, while engine power was increasing, the airplane pitched up; rolled to the left, reaching a roll angle of 45° left wing down; and then rolled to the right. As the airplane rolled to the right through wings level, the stick pusher activated (about 2216:34), and flaps 0 was selected. (The Q400 stick pusher applies an airplane-nose-down control column input to decrease the wing angle-of-attack [AOA] after an aerodynamic stall.) About 2216:37, the first officer told the captain that she had put the flaps up. FDR data confirmed that the flaps had begun to retract by 2216:38; at that time, the airplane’s airspeed was about 100 knots. FDR data also showed that the roll angle reached 105° right wing down before the airplane began to roll back to the left and the stick pusher activated a second time (about 2216:40). At the time, the airplane’s pitch angle was -1°.
About 2216:42, the CVR recorded the captain making a grunting sound. FDR data showed that the roll angle had reached about 35° left wing down before the airplane began to roll again to the right. Afterward, the first officer asked whether she should put the landing gear up, and the captain stated “gear up” and an expletive. The airplane’s pitch and roll angles had reached about 25° airplane nose down and 100° right wing down, respectively, when the airplane entered a steep descent. The stick pusher activated a third time (about 2216:50). FDR data showed that the flaps were fully retracted about 2216:52. About the same time, the CVR recorded the captain stating, “we’re down,” and a sound of a thump. The airplane impacted a single-family home (where the ground fatality occurred), and a postcrash fire ensued.^19 The CVR recording ended about 2216:54.
(^18) The rating detent for the engine power levers (80° in this case) is a low-force, or soft, detent on the power
quadrant at which the engines’ fully rated power for takeoff, climb, and cruise is achieved. Power lever travel beyond the rating detent is possible but is available only for emergency use. (^19) The postcrash fire was also the result of a severed natural gas service pipeline at the home, as discussed in
section 1.15.2.
Table 1. Injury Chart
Injuries Flight Crew Cabin Crew Passengers Other Total Fatal^2 2 45 1 Serious^0 0 0 0 Minor^0 0 0 0 None^0 0 0 0 Total^2 2 45 1
The airplane was destroyed by impact forces and a postcrash fire.
One house and two cars in the driveway of the house were destroyed as a result of the airplane’s impact and the postcrash fire. The house’s detached garage remained intact, but an attached garage of an adjacent house was damaged from the impact of a section of the airplane’s outboard right wing.
1.5.1 The Captain
The captain, age 47, held an airline transport pilot certificate and a Federal Aviation Administration (FAA) first-class medical certificate dated August 22, 2008, with a limitation that required him to wear corrective lenses while exercising the privileges of this certificate. The captain received a type rating on the DHC-8 on November 18, 2008.
According to his application for employment with Colgan, from August 2004 to April 2005,^20 the captain attended the first officer program at Gulfstream Training Academy, Fort Lauderdale, Florida, where he was the second-in-command (SIC) on the Beech BE-1900D for Gulfstream International Airlines (GIA).^21 Between April and August 2005, the captain worked
(^20) FAA records indicated that the captain received his private pilot single-engine and instrument certificates in
June 1990 and October 1991, respectively. FAA records also indicated that the captain received his commercial pilot instrument and single-engine certificates in June 2002 and his multiengine certificate in April 2004. (^21) The CVR recorded the captain stating, about 2050:33, “I went through Gulfstream’s program ‘cause … it
was the best program for … the timeframe that I had. You know how fast I wanted to get into the one twenty one environment … so it really worked out well for me.” Information on the Gulfstream Training Academy is provided in section 1.18.5.
