Un Dash 8 Q400 s'écrase dans l'état de New York

Critical human-factors safety issues laid bare during the NTSB’s probe of a regional airline crash near Buffalo, N.Y., are mobilizing the aviation community to overhaul the way pilots qualify and train for a seat on the flight deck.

At the final hearing last week on Continental Connection/Colgan Air Flight 3407, the NTSB said pilot error—specifically, the captain’s improper response to stickshaker activation—was the probable cause of the Feb. 12, 2009, accident that killed 50 people.

The board cited both pilots’ failure to monitor airspeed and adhere to the “sterile-cockpit” rule as contributing factors, as well as the captain’s failure to effectively manage the flight and Colgan Air’s inadequate procedures for airspeed selection and management for approaches in icing conditions.

The NTSB issued more than 25 Colgan Air-related safety recommendations. They include requiring training in monitoring skills, professionalism and fatigue management, as well as the installation of redundant airspeed cues on flight instruments (see box below).

In addition, the NTSB is urging that flight operational quality assurance (FOQA) programs be established at all carriers and that operators provide pilots with realistic upset-recovery training in simulators. (For a complete list, go to: http://www.ntsb.gov )

The accident sequence supports NTSB Chairman Debbie Hersman’s description of Flight 3407’s cockpit —“a picture of complacency and confusion that resulted in catastrophe.”

With light snow and light-to-moderate icing expected on the night approach to Buffalo-Niagara International Airport, the captain appropriately set the reference speed switch to “increase” position. This lowered the angle of attack (AOA) reference for stickshaker (stall warning) activation and raised the position of the low-speed cue on the airspeed indicator, explains Investigator-in-Charge Lorenda Ward. The procedure ensures that the Bombardier Dash 8-Q400 would have the same or greater stall-speed margins in icing conditions as long as the landing airspeeds remain above the stall-warning threshold.

However, the first officer obtained the landing airspeeds for non-icing conditions and did not indicate in an electronic message that the aircraft would be in icing conditions. This resulted in setting a landing speed of 118 kt., which was 13 kt below the 131-kt. stickshaker activation speed.

The cockpit voice recorder (CVR) reveals that the two pilots were engaged in non-flight-related conversations from pushback at Newark (N.J.) Liberty International Airport —a violation of the sterile-cockpit rule. This created a flight-deck environment that prevented the crew from quickly detecting errors. “It was as if the flight was just a means for the captain to conduct a conversation with the first officer,” NTSB Member Robert Sumwalt noted.

When the crew noticed ice accumulating on the windshield, the first officer said she had never seen aircraft icing, an indication that she had not received training for winter operations specific to the route.

When the Q400 reached 131 kt. , the stickshaker activated and the autopilot disengaged. The pilot reacted by pulling back on the control column with a 25-lb. force. (Proper recovery from a wing stall requires pushing the column down to lower the nose and gain airspeed.)

His move resulted in increasing the AOA, pitch-up and load factor—and led to an accelerated wing stall. In this sequence, the stickpusher activated three times, a signal to decrease the AOA; however, for reasons undetermined by investigators, each time, the captain pulled back on the column, a response that was inconsistent with training but consistent with a “startle and confusion” reaction, according to the NTSB. And the first officer’s move to raise the flaps and her suggestion to raise the gear were inconsistent with proper recovery procedures.

Meanwhile, the Q400’s airspeed kept decreasing as pitch and roll excursions continued during the aircraft’s final descent.

Ward says performance data indicated that initially the Q400 was not close to an actual stall, since there was only a minimum ice accretion that did not affect the ability of the crew to fly and control the aircraft.

However, the pilots’ “missing [the low-airspeed] cues reflects a breakdown in monitoring and workload management,” according to the NTSB. Investigators determined that the flight instruments provided “explicit” airspeed cues, and the pilots had adequate time to take corrective action. It was the captain’s (pilot flying) primary responsibility to monitor instruments and the first officer’s (pilot monitoring) job to provide backup and corrective input.

The NTSB concluded that both pilots were likely fatigued, due in part to inadequate sleep— a result of long commutes to their Newark base. However, investigators were unable to determine how extensively fatigue affected the pilots’ performance.

What happened in the 26 sec. that elapsed from stickshaker activation until the CVR ended at aircraft impact with the ground raised serious questions about the effectiveness and oversight of pilot training, notes the NTSB.

As the board launched its aggressive probe of Flight 3407 focused on human performance and operational factors, the FAA also responded. Administrator Randy Babbitt launched a “Call to Action on Airline Safety and Pilot Training” initiative, which aims to set one level of safety for regionals and majors, and speed a revision of flight-/duty-time guidelines. A proposed rulemaking is scheduled for publication in the spring instead of December 2009 as initially planned. The agency this week will issue an Advance Notice of Proposed Rulemaking that seeks industry input on whether current eligibility, training and qualification requirements for commercial pilot certification are adequate or need improvement.

The accident also led to congressional hearings and the introduction of the Airline Safety and Pilot Training Improvement Act. At a House Aviation subcommittee hearing last week on the progress of the FAA’s plan, Rep. Jerry Costello (D-Ill.) noted that the legislation was introduced out of concern that improvements would take too long to implement in the FAA’s rulemaking process. Among the bill’s many provisions is one specifying that all pilots seeking a Part 121 job—captains as well as first officers—hold an Airline Transport Pilot license to qualify for employment. The ATP requires a minimum of 1,500 hr. of flight time. First officers currently are required to hold a Commercial license, which requires a minimum of 250 hr. (The bill, approved by the House in late 2009, is now before the Senate.)

Hersman addressed concerns about the often glacial pace of rulemaking . While commending Babbitt for “taking a fresh look at the issues,” she said the FAA “has not yet pushed across the finish line,” and urged the agency’s swift acceptance of the recommendations.


Further ahead, the NTSB intends to examine two safety issues that are “bigger than this accident” and that have far-reaching implications for the aviation industry, says Hersman.

In late spring, the NTSB plans a safety forum to explore professional standards for pilots and air traffic controllers. Another forum in late fall will “dig deeper” into the implications of code-sharing partnerships, including whether regionals have the same level of safety as their major partners.

Hersman is not adverse to congressional legislation mandating pilot training improvements. The NTSB would welcome any help it can get to implement its proposals, she adds. “And if it takes Congress to say, ‘Enough talk, and a little more action,’ then that’s what we need.”

Photo Credit: BOMBARDIER

Sampling of NTSB Safety Recommendations to FAA based on Colgan Air Flight 3407 investigation


• Pilot monitoring techniques. Require Part 121, 135 and 91K operators to review and verify that their standard operating procedures are consistent with flight-crew monitoring techniques described in FAA Advisory Circular AC 120-71A.

• Airspeed warning instrumentation. Require operators of aircraft engaged in commercial operations under Parts 121, 135 and 91K to install low-airspeed alert systems that would provide pilots with backup aural and visual warnings of impending, hazardous low airspeeds.

• Airspeed cues. Require that airspeed indicator displays on all aircraft with electronic flight instrument systems and certified under Part 25 depict a yellow/amber cautionary band above the low-speed cue—or that the indicator digits change from white to amber/yellow as airspeed approaches the low-speed cue.

• Pilot leadership, professionalism. Issue an advisory circular providing guidance on leadership training for upgrading captains. Develop and distribute to all pilots multimedia guidance materials about professionalism in aircraft operations. Standards of performance as well as best practices for maintaining the sterile-cockpit rule are among the many topics to be covered in the materials.

• Fatigue-commuting. Require that Part 121, 135 and 91K operators address fatigue risks linked with pilot commutes to base of operations. This would include establishing policy and guidance to mitigate fatigue risks, changing scheduling to minimize the hazard, and developing or identifying rest facilities for commuting pilots.


Source: U.S. National Transportation Safety Board