In February 2009, a Colgan Air DHC-8-400 crashed into a residence in Clarence Center, New York while on approach to Buffalo. Fifty people were killed.
The National Transportation Safety Board (NTSB) determined that the captain of Colgan Air flight 3407 inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. In a report adopted today additional flight crew failures were noted as causal to the accident.
The report states that, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded correctly to the situation by pushing forward on the control column. However, the captain inappropriately pulled aft on the control column and placed the airplane into an accelerated aerodynamic stall.
Contributing to the cause of the accident were the crewmembers’ failure to recognize the position of the low-speed cue on their flight displays, which indicated that the stick shaker was about to activate, and their failure to adhere to sterile cockpit procedures. Other contributing factors were 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.
As a result of this accident investigation, the Safety Board issued recommendations to the Federal Aviation Administration (FAA) regarding strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot records, stall training, and airspeed selection procedures. Additional recommendations address 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. (NTSB)