|[[size smaller]] Video embedded from YouTube on 30 August 2012|
Colgan Air 3407 lost control during an instrument approach into Buffalo International Airport killing all on board. Ultimately the cause of the accident was determined to be the Captain’s inapt response to the stick shaker warning, which then led to an unrecoverable aerodynamic stall. Although pilot error resulted in the crash, poor management was the primary factor that created an environment for an accident. As demonstrated in Reason’s Swiss Cheese Model, four factors are identified as causing most failures. These are organizational influences, unsafe supervision, preconditions for unsafe acts, and unsafe acts themselves. According to the theory, the holes represent weakness in the system that is always changing. Failure happens when all the holes line up momentarily to create an environment for an accident.
Sequence of Events
The flight departed Liberty International Airport at 21:18 under the command of Capt. M Renslow assisted by F.O Shaw. The aircraft climbed to its cruising altitude of 16,000feet with no problems.
At 21:49 the cockpit voice recorder recorded the captain making a sound similar to a yawn.
At 21:56 Capt. Renslow instructed F.O Shaw to descend after she mentioned that it would be easier on her ears due to her being ill, she can be heard yawning, sneezing and sniffling.
At 22:16 now down to 2,300feet with flaps 10° set, an “ice detected” message appeared on the screen.
Seconds later the stick shaker warning can be heard on the CVR warning of an impending stall, the aircraft stalls, power was applied however there was no nose pitch down as is the norm in stall recovery, “stick, power, rudder”.
The aircraft rolled dangerously to the left then to the right repeating several times while losing altitude. The aircraft crashed nose first into a house.
The situational factors at the time in the cockpit was night time environment with two fatigued pilots one which was sick, it was a critical stage of the flight, the weather was conducive to icing conditions. All of these factors combined and lined up to cause the accident. These factors on their own most likely would not have led to the accident. However, it was the organizational and management factors that primarily caused the crash.
The official cause of the accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an irrecoverable aerodynamic stall, the flight crew’s failure to monitor airspeed, and the captain’s failure to effectively manage the flight however poor management both in the cockpit and the company was the main cause of the accident. Poor monitoring and workload management in the cockpit led to the pilot being unable to detect the decreasing airspeed and ice buildup. More importantly, the company’s scheduling system created an environment of fatigued pilots due to them having to commute to work then start their shift. Colleagues saw both pilots asleep in the crew lounge after long shifts and commutes.
Prevention of future occurrences
Prevention would include strict enforcement of no unnecessary chatter below 10,000feet during critical stages of flight by companies randomly checking cockpit recordings to see if the rule is be followed. Also the company needs to effectively organize its crew schedules in a manner that allows sufficient rest periods between flights and more importantly commutes. Pilots commuting for several hours before they start work in my opinion creates a pilot who is not at their peak as they are not fully rested. This in turn would produce a fatigued pilot who is not efficient. If pilots have no choice but to commute then there needs to be an appropriate rest area for pilots that is not a crew lounge, for example somewhere quiet and dark.
1. Ewing, R.L. (2003) Aviation medicine and other human factors for pilots. (5th ed). Christchurch: Old Sausage Publications.
2. Lloyd, S. & Parker, R. (Producers). (2010). Dead Tired [Television series episode]. In Air Crash Investigations. Canada: Cineflex.
3. National Transport Safety Board. (2010, February 02). Loss of Control on Approach, Colgan Air, Inc. Retrieved March 24, 2012, from Aviation Accident Reports: http://www.ntsb.gov/doclib/reports/2010/AAR1001.pdf
4. Reason, J.T. (1990). Human error. Cambridge, England: Cambridge University Press.
5. Wikipedia (2012). Colgan Air Flight 3407. Retrieved August 30, 2012 from http://en.wikipedia.org/wiki/Colgan_Air_Flight_3407
6. YouTube (2012). Air Crash Investigation-Colgan Air Flight 3407. Retrieved August 30, 2012 from http://www.youtube.com/watch?v=T82OYswahHY&feature=plcp
Want to know more?
http://en.wikipedia.org/wiki/Colgan_Air_Flight_3407 :More in depth analysis of Colgan Air Flight 3407