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)
Summary	Stalled during landing approach; crashed into a house
Site	Clarence Center, New York, United States
Passengers	45
Crew	4
Injuries (non-fatal)	4 (on the ground)
Fatalities	50 (one on the ground)
Aircraft type	Bombardier DHC8-402 Q400
Operator	Colgan Air as Continental Connection
Registration	N200WQ
Flight origin	Newark Liberty International Airport, Newark, New Jersey
Destination	Buffalo Niagara International Airport, Buffalo, New York

Colgan Air Flight 3407, marketed as Continental Connection under a codeshare agreement with Continental Airlines, was a scheduled passenger flight from Newark, New Jersey, to Buffalo, New York, which crashed on February 12, 2009. The aircraft, a Bombardier Dash-8 Q400, entered an aerodynamic stall from which it did not recover and crashed into a house in Clarence Center, New York at 10:17 p.m. EST (03:17 UTC), killing all 49 passengers and crew on board, as well as one person inside the house.

The accident triggered a wave of inquiries about the operations of regional airlines in the United States. It was the first fatal airline accident in the U.S. since the crash of Comair Flight 5191 in August 2006, with 49 fatalities.

The National Transportation Safety Board conducted the accident investigation and published a final report on February 2, 2010, which found the probable cause to be the pilots' inappropriate response to the stall warnings.

Families of the accident victims lobbied the U.S. Congress to enact more stringent regulations for regional carriers, and to improve the scrutiny of safe operating procedures and the working conditions of pilots. The Airline Safety and Federal Aviation Administrative Extension Act of 2010 required some of these regulation changes.

Flight details

Colgan Air Flight 3407 (9L/CJC 3407) was marketed as Continental Connection Flight 3407. It was delayed two hours, departing at 9:18 p.m. Eastern Standard Time (EST; 02:18 UTC), en route from Newark Liberty International Airport to Buffalo Niagara International Airport.

The twin-engine turboprop Bombardier Dash 8 Q400, FAA registry N200WQ, was manufactured in 2008 for Colgan.

This was the first fatal accident for a Colgan Air passenger flight since the company was founded in 1991. One previous ferry flight (no passengers) crashed offshore of Massachusetts in August 2003, killing both of the crew on board. The only prior accident involving 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.

Captain Marvin Renslow, 47, of Lutz, Florida, was the pilot in command, and Rebecca Lynne Shaw, 24, of Maple Valley, Washington, served as the first officer. There were two flight attendants: Matilda Quintero and Donna Prisco.

Captain Renslow was hired in September 2005 and had accumulated 3,379 total flight hours, with 111 hours as captain on the Q400. First officer Shaw was hired in January 2008, and had 2,244 hours, 774 of them in turbine aircraft including the Q400.

There were 2 Canadians, 1 Chinese, 1 Israeli and the remaining 46, including the crew members, were American.

Crash

A Q400 showing the high aspect ratio 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 flight had been cleared for the instrument landing system approach to Buffalo Niagara International Airport runway 23 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). The de-icing system was turned on 11 minutes into the flight by the crew, who discussed significant ice buildup on the aircraft's wings and windscreen shortly before the crash. Two other aircraft reported icing conditions around the time of the crash. The last radio transmission from the flight occurred when the plane was northeast of the airport radio beacon known as KLUMP (see diagram), when the first officer acknowledged a routine instruction to change to tower frequency. The aircraft crashed 41 seconds after the last transmission. After several attempts to hail the crew, controllers requested the assistance of Delta Air Lines Flight 1998 from Atlanta, Georgia and US Airways Flight 1452 from Charlotte, North Carolina to make visual contact with the missing airplane; the Delta crew members responded that they did not see the plane.

During the flight and continuing through the plane's landing approach, the crew had been flying on autopilot. During final approach, the pilots extended the aircraft's flaps and landing gear for landing. 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). 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 that 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). Instead of following the established stall recovery procedure of adding full power and lowering the nose to prevent the imminent low-altitude 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"). The captain overrode the stick pusher and continued pulling on the control yoke which caused the aircraft upset and later loss of control; in addition, the first officer retracted the flaps without consulting with the captain, making recovery more difficult. The aircraft went into a yaw and pitched up at an angle of 31 degrees in its final moments, before pitching down at 25 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.

The plane struggled for about 25 seconds, during which time the flight crew made no emergency declaration. The Q400 rapidly lost altitude and crashed into a private home at 6038 Long Street, about from the end of the runway, and nearly directly under its intended approach path, with the nose pointed away from the destination airport. The fuel tanks ruptured on impact and the aircraft burst into flames, destroying 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 Hospital. The lots in the area are only 60 feet (18.3 meters) wide; the plane hit the house squarely, destroying it in the ensuing fire with little damage to surrounding homes. The home was close to the Clarence Center Fire Company, so emergency personnel were able to respond quickly. Two of the firefighters were injured. The crash and intense fire caused the evacuation of 12 nearby houses.

Victims

A total of 50 people died, including the 49 passengers and crew on board when the aircraft was destroyed, and one resident of the house that was struck. There were four injuries on the ground, including two other people inside the home at the time of the crash. Among the dead were:

• Alison Des Forges, a human rights investigator and an expert on the Rwandan genocide.
• Beverly Eckert, who became co-chair of the 9/11 Family Steering Committee and a leader of Voices of September 11 after her husband Sean Rooney was killed in the September 11 attacks. She was en route to Buffalo to celebrate her husband's 58th birthday and award a scholarship in his memory at Canisius High School.
• Gerry Niewood and Coleman Mellett, jazz musicians who were en route to a concert with Chuck Mangione and the Buffalo Philharmonic Orchestra.
• Susan Wehle, the first American female Jewish Renewal cantor.

File:Obama and Beverly Eckert.jpg

U.S. President Barack Obama shaking hands with Beverly Eckert six days before the accident

Reactions

• Colgan Air set up a telephone number for families and friends of those affected to call on February 13, and a family assistance center was opened at the Cheektowaga Senior Center in Cheektowaga CDP, Town of Cheektowaga, New York. The American Red Cross also opened reception centers in Buffalo and Newark where family members could receive support from mental health and spiritual care workers.
• During the afternoon, the U.S. House of Representatives held a moment of silence for the victims and their families.
• Buffalo's professional ice hockey team, the Buffalo Sabres, held a moment of silence prior to their scheduled game the next night against the San Jose Sharks.
• 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. A 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.
• 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.
• 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, training requirements, safety, and working conditions. Also discussed were the operating principles of regional airlines and the agreements between regional airlines and major airlines.

Investigation

This 3-D animated reconstruction shows the last 2 minutes of the February 12, 2009, accident involving a Bombardier DHC-8-400, N200WQ, operated by Colgan Air, Inc., which crashed about 5 nautical miles northeast of Buffalo-Niagara International Airport, Buffalo, New York, while on an instrument landing system approach to runway 23.

The U.S. National Transportation Safety Board (NTSB) began their inquiry on February 13, with a team of 14 investigators. Both the flight data recorder (FDR) and the cockpit voice recorder (CVR) were recovered and analyzed in Washington, D.C.

After initial analysis of the recordings, 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 aircraft 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 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 aircraft rolled to the left at 46 degrees, then snapped back to the right at 105 degrees, before crashing into the house, and erupting in flames on impact.

At the crash scene, an area 2 square miles (5.2 km²) in size was cordoned off. 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 melt 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.

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. Colgan recommends pilots fly manually in icing conditions, and requires them to 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 26 seconds after trouble was first registered on the flight data recorder.

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. Bill Voss, president of Flight Safety Foundation, told USA Today that it sounded like the plane was in "a deep stall situation".

On March 25, 2009, NTSB investigators said that icing probably did not contribute greatly to the accident. On May 11, 2009, new information came out that Captain Renslow had failed three "check rides", including some at Gulfstream International in its pay to fly program, 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. Investigators also suspected crew fatigue as both pilots appear to have been at Newark airport overnight and all day before the 9:18 pm departure. In response to questioning from the NTSB, Colgan Air officials acknowledged that both pilots apparently were not paying close attention to the aircraft's instruments and unable 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 which was led by the NTSB's chair Mark Rosenker. Some of the crew's communication violated federal rules banning nonessential conversation. From May 12 to 14, the NTSB interviewed 20 witnesses of the flight.

On June 3, 2009, the New York Times published an article 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, 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.

Final report

On February 2, 2010, the NTSB issued its final report, describing its investigation, findings, conclusions and recommendations. The report includes a "Conclusions" section that summarizes the known facts and lists a variety of contributing factors relating to the flight crew. According to the final report, the accident's 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 further added the following contributing factors:

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.

However, the NTSB was unable to determine why the first officer retracted the flaps and suggested that the landing gear should be retracted. The method by which civil aircraft pilots can obtain their licenses was also criticized by the NTSB. It also 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."

NTSB Chair Deborah Hersman, while concurring, made it clear she considered fatigue 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.

However, Vice‐Chairman Christopher A. Hart and Board member Robert L. Sumwalt, III, disagreed that fatigue should be included as a contributing factor, because there was not enough evidence to support such a conclusion. It was noted that the same kind of pilot errors and SOP violations had also been found in other accidents where fatigue was not a factor.

Legacy

The FAA has proposed or implemented several rule changes as a result of the Flight 3407 accident, in areas ranging from pilot fatigue to Airline Transport Pilot Certificate (ATP) qualifications of up to 1500 hours of flight experience prior to hiring. One of the most significant changes has already taken effect, changing the way examiners grade checkrides in flight simulators during stalls.

Investigators also scrutinized the Practical Test Standards (PTS) for ATP certification, which allowed for an altitude loss of no more than 100 feet (30 m) in a simulated stall. The NTSB theorized that due to this low tolerance in a tested simulation environment, pilots may have come to fear loss of altitude in a stall and thus focused primarily on preventing such a loss, even to the detriment of recovering from the stall itself. New standards subsequently issued by the FAA eliminate any specific altitude loss stipulation, 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.

The crash site is now a vacant lot as the remains of the building were removed.

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) episode entitled "Dead Tired".

See also

• Atlantic Coast Airlines Flight 6291
• China Airlines Flight 140 - a similar accident caused by aerodynamic stall
• Icing conditions in aviation

External links

• Cockpit Voice Recorder transcript and accident summary
• Flight 3407 Information - Colgan Air (Archive)
• Website created and maintained by family members and close friends of victims who perished onboard flight 3407
• NTSB Computer simulation of last 2 minutes of flight 3407, National Transportation Safety Board
• NTSB Public hearing, May 12-14, 2009. (Includes webcast of complete hearing and link to docket with all relevant documents, including Flight Data Recorder data and Cockpit Voice Recorder transcript)
• Flight path for CJC3407 in 3D/Google Earth at flightwise.com
• Flight track data for Continental Connection flight 3407 at flightwise.com
• Information Regarding Flight 3407 - Continental Airlines
• Flight tracker and Track log
• Flickr photo set of the crash
• A picture of the aircraft taken in late 2008.
• After Sept. 11, 'He Wanted Me To Live A Full Life' (about victim Beverly Eckert) from NPR radio
• Buffalo Crash Puts Focus On Regional Airlines from NPR radio
• Frontline (U.S. TV series) - Flying Cheap - February 9, 2010. One year after the deadly crash of Continental 3407, FRONTLINE investigate the safety issues associated with regional airlines.
• Track log for Continental Connection flight 3407 (CJC3407) at flightwise.com