BOMBARDIER INC DHC-8-402 near Clarence Center, NY — 2009-02-13

Probable cause

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 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.

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 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.

NTSB narrative

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-10/01. 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.

NTSB coding

• Loss of control in flight · Approach-IFR initial approach
• Attention / Monitoring

Evidence available

• CVR
• FDR / data
• Photos
• 138 docket documents

Docket documentsshowing 50 of 138

• ATC 3 - Exhibit 3-B FAA Aircraft Accident Packageatc
• ATC 3 - Factual Report of Group Chairmanatc
• Meteorology 5 - Attachment 2 Dispatch Release/Weather Documentatc
• Cockpit Voice Recorder 12 - Addendum 1cvr
• Cockpit Voice Recorder 12 - Factual Report of Group Chairmancvr
• Cockpit Voice Recorder 12 - Stick Shaker Sound Spectrum Data for Figures 4-7cvr
• Cockpit Voice Recorder 12 - Stick Shaker Spectrum Studycvr
• Human Performance 14P - Letter from VP Flight Ops to ALPA regarding FOQA-CVRcvr
• Flight Data Recorder 10 - Ancillary 1 Factual Report Attachment 1 (FDR tabular data)fdr
• Flight Data Recorder 10 - Ancillary 1 Specialist's Factual Reportfdr
• Flight Data Recorder 10 - Factual Report Attachment 1 (FDR tabular data. The csv file was zipped to reduce the size of the file.)fdr
• Flight Data Recorder 10 - Factual Report of Group Chairmanfdr
• Flight Data Recorder 10 Addendum 1- Specialist's Factual Reportfdr
• Flight Data Recorder 10 Addendum 1- Specialist's Factual Report Attachment 1 (GPWS Alert Warning tabular FDR data for Plot 1)fdr
• Aircraft Performance 13B - Aircraft Performance Group Chairman Studyform
• Aircraft Performance 13D - AC 20-73A: Aircraft Ice Protectionform
• Aircraft Performance 13E - AC 25-25: Performance and Handling Characteristics in the Icing Conditions Specified in Part 25, Appendix Cform
• Aircraft Performance 13G - NPA 25F-219 Issue 2 (1992): Flight in Icing Conditions - Acceptable Handling Characteristics and Performance Effectsform
• Aircraft Performance 13H - AMA 525/2: Flight in Icing Conditions - Performanceform
• Aircraft Performance 13I - AMA 525/5: Flight in Icing Conditions - Flight Characteristicsform
• Aircraft Performance 13K - Aircraft Performance Group Simulation Studyform
• Human Performance 14 - Addendum 1form
• Human Performance 14 - Addendum 2form
• Human Performance 14A - Factual Report of Group Chairmanform
• Human Performance 14B - Attachment 1: Interview and information summariesform
• Human Performance 14C - Attachment 2: Monthly flight standards newsletter informationform
• Human Performance 14D - Attachment 3: Quarterly flight standards newsletter informationform
• Human Performance 14E - Attachment 4: Read and sign memo informationform
• Human Performance 14F - Attachment 5: CrewTrac messagesform
• Human Performance 14G - Attachment 6: Sterile cockpit proceduresform
• Human Performance 14H - FAA SAFO 06004. Approach and landing accident reduction: sterile cockpit, fatigueform
• Human Performance 14I - FAA SAFO 06015. Remedial training for part 121 pilots.form
• Human Performance 14J - FAA Order 8000.87A Safety Alerts for Operatorsform
• Human Performance 14K - Advisory Circular AC 120-71Aform
• Human Performance 14L - Flight Safety Foundation Conference Monitoring Paperform
• Human Performance 14M - Flight Safety Digest 2003 Article on Upset Trainingform
• Human Performance 14N - Excerpts from Airplane Upset Recovery Training Aid Revision 2form
• Human Performance 14O - Colgan Operations Bulletin FOPPM #09-001 (Crewmember Fatigue)form
• Human Performance 14Q - Colgan Air Safety Initiativesform
• Human Performance 14R - FAA AC120-90 Line Operations Safety Auditsform
• Human Performance 14S - FAA Notice 8900.71form
• Operations 2D - Interview Former APMform
• Operations 2GG - Pilot Training Form 2003form
• Additional witness interview done by the FBI on August 31, 2009interview
• Operations 2B - Interviews in Buffalointerview
• Operations 2C - Interviews - Vermont Crewinterview
• Operations 2E - Interview Dir Flt Stds Barrettinterview
• Operations 2F - Interview Mgr Flt Stds Baxterinterview
• Operations 2G - Interview Check Airman Campbellinterview
• Operations 2H - Interview VP Admin Finniganinterview

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