Colgan Air Q400 crash – interesting NTSB update

The NTSB has just issued an update on the investigation of the Colgan Air Q400 loss at Buffalo. Full text below. Several interesting hints at where this is going. Basically it is looking rather more as if this investigation will be looking hard at some of the more nuanced factors like training, scheduling, as well as the specifics of how the crash finally occurred – important though that obviously is.

Here’s my take on some key pointers:

  • icing looking less pertinent
  • nothing wrong with the aircraft

  • Colgan training operation of interest
  • Colgan (and perhaps industry) scheduling practices of interest
  • experience levels of interest (Capt 3,379hr total with 109 on type, F/O 2,220 total with 772 on type)

  • sterile cockpit procedures may be pertinent
  • questions about Buffalo ILS system not looking relevant
  • previously unrevealed recent Colgan Q400 stick-shaker incident at Burlington, Vt being looked at

Feel free to comment if you disagree (or agree) with me after you’ve read the document below.




In its continuing investigation into the crash of Colgan Air flight 3407 in Clarence Center, New York, the National Transportation Safety Board has released the following factual information.

On February 12, 2009, about 10:17 p.m. Eastern Standard Time (EST), a Colgan Air Inc., Bombardier Dash 8-Q400, N200WQ, d.b.a. Continental Connection flight 3407, crashed during an instrument approach to runway 23 at the Buffalo-Niagara International Airport (BUF), Buffalo, New York.  The crash site was approximately 5 nautical miles northeast of the airport in Clarence Center, New York, and mostly confined to one residential house.  The 4 crew members and 45 passengers were fatally injured and the airplane was destroyed by impact forces and post crash fire.  There was one ground fatality.  Night visual meteorological conditions prevailed at the time of the accident. The flight was a Code of Federal Regulations (CFR) Part 121 scheduled passenger flight from Liberty International Airport (EWR), Newark, New Jersey to Buffalo.

The NTSB has voted to conduct a public hearing on this accident.  The hearing, which will be held May 12 – 14, 2009, at the NTSB’s Board Room and Conference Center in Washington, D.C., will cover a wide range of safety issues

including:  icing effect on the airplane’s performance, cold weather operations, sterile cockpit rules, crew experience, fatigue management, and stall recovery training.  The public hearing is part of the Safety Board’s efforts to develop all appropriate facts for the investigation.


 ”The tragedy of flight 3407 is the deadliest transportation accident in the United States in more than 7 years,” Acting Chairman Mark V. Rosenker, who will chair the hearing, said.

 ”The circumstances of the crash have raised several issues that go well beyond the widely discussed matter of airframe icing, and we will explore these issues in our investigative fact-finding hearing.”

The hearing will be held “en banc,” meaning that all Members of the NTSB will sit on the Board of Inquiry.  Parties that will participate in the hearing will be announced at a later time.

The aircraft wreckage has been moved from the accident site to a secure location for follow-on inspections as may be needed.


A preliminary examination of the airplane systems has revealed no indication of pre-impact system failures or anomalies.  Investigators will perform additional examinations on the dual distribution valves installed in the airplane’s de-ice system.  The de-ice system removes ice accumulation from the leading edges of the wings, horizontal tail, and vertical tail through the use of pneumatic boots.

 The dual distribution valves, which transfer air between the main bleed air distribution ducts and the pneumatic boots, were removed from the airplane for the examination.

The airplane maintenance records have been reviewed and no significant findings have been identified at this time.

The ATC group has completed a review of recordings of controller communications with the flight crew during the accident flight and conducted interviews with air traffic controllers on duty at the time of the accident.  The group has no further work planned at this time.

Further review of the weather conditions on the night of the accident revealed the presence of variable periods of snow and light to moderate icing during the accident airplane’s approach to the Buffalo airport.  

Examination of the FDR data and preliminary evaluation of airplane performance models shows that some ice accumulation was likely present on the airplane prior to the initial upset event, but that the airplane continued to respond as expected to flight control inputs throughout the accident flight.  The FDR data also shows that the stall warning and protection system, which includes the stick shaker and stick pusher, activated at an airspeed and angle-of-attack (AOA) consistent with that expected for normal operations when the de-ice protection system is active.  The airplane’s stick shaker will normally activate several knots above the actual airplane stall speed in order to provide the flight crew with a sufficient safety margin and time to initiate stall recovery procedures.  As a result of ice accumulation on the airframe, an airplane’s stall airspeed increases.  To account for this potential increase in stall speed in icing conditions, the Dash 8-Q400′s stall warning system activates at a higher airspeed than normal when the de-ice system is active in-flight to provide the flight crew with adequate stall warning if ice accumulation is present.

Preliminary airplane performance modeling and simulation efforts indicate that icing had a minimal impact on the stall speed of the airplane.  The FDR data indicates that the stick shaker activated at 130 knots, which is consistent with the de-ice system being engaged.  FDR data further indicate that when the stick shaker activated, there was a 25-pound pull force on the control column, followed by an up elevator deflection and increase in pitch, angle of attack, and Gs.  The data indicate a likely separation of the airflow over the wing and ensuing roll two seconds after the stick shaker activated while the aircraft was slowing through 125 knots and while at a flight load of 1.42 Gs.  

The predicted stall speed at a load factor of 1 G would be about 105 knots.  Airplane performance work is continuing.

Since returning from on-scene, the Operations & Human Performance group has conducted additional interviews with flight crew members who had recently flown with and/or provided instruction to the accident crew, as well as personnel at Colgan Air responsible for providing training of flight crews and overseeing the management and safety operations at the airline.  The group also conducted interviews with FAA personnel responsible for oversight of the Colgan certificate, which included the Principal Operations Inspector (POI) and aircrew program manager for the Dash 8 Q-400.  The team has also continued its review of documentation, manuals, and other guidance pertaining to the operation of the Dash 8 Q-400 and training materials provided to the Colgan Air flight crews.

The Operations & Human Performance group continues to investigate and review documentation associated with the flight crew’s flight training history and professional development during their employment at Colgan as well as prior to joining the company.

Post-accident toxicological testing of the flight crew was performed by the FAA Civil Aerospace Medical Institute

(CAMI) toxicology lab.  Specimens taken from the first officer were negative for alcohol, illicit substances, and a wide range of prescription and over the counter medications.

 Specimens taken from the captain were negative for alcohol and illicit substances, and positive for diltiazem, a prescription blood pressure medication that had been reported to and approved for his use by the Federal Aviation Administration.

The Safety Board is also examining several other areas potentially related to the accident, including:

?    The circumstances of a recent event involving a Dash

8-Q400, operated by Colgan Air, in which the airplane’s stick shaker activated during approach to the Burlington International Airport (BTV) in Burlington, Vermont.  A preliminary review of the FDR data from that flight shows the momentary onset of the stick shaker during the approach phase of flight.  The airplane subsequently landed without incident.  NTSB investigators have conducted interviews with the pilots and check airman on board this flight and will continue to investigate the incident.

?    Reports of airplane deviations resulting from

distortion of the instrument landing system (ILS) signal for runway 23 at BUF.  There is an existing Notice to Airmen (NOTAM) related to this distortion condition. To date, investigation into these reports has not revealed any connection to the accident flight.

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7 Responses to Colgan Air Q400 crash – interesting NTSB update

  1. Flight Instructor March 25, 2009 at 6:12 pm #

    This is becoming a more convoluted case by the moment. It seems like the initial diagnosis was mostly incorrect. I hope they get to the bottom of this before the same mistake is repeated.

  2. starviego March 25, 2009 at 8:16 pm #

    “sterile cockpit procedures may be pertinent”

    What are you saying? That someone other than the flight crew may have entered the cockpit and distracted them?

    Intersting that they didn’t mention the unreleased cockpit voice recorder(CVR). One would think that the last communications from the crew would be relevant, but apparently not.

  3. Steve March 25, 2009 at 10:43 pm #

    The CVR transcript will not be entered into the public docket until the day the public hearing begins. It is generally understood to be far too personal and potentially controversial to be released ad hoc. It is released with the CVR group chairman’s factual report, so that its contents can be viewed in the correct context.

    Having studied the effects of icing for many years, I would be careful not to dismiss it as a contributor just yet. What the Board has said is that the stick shaker operated correctly with the ice protection systems selected on, which means that the icing bias applied to the shaker was adequate to trigger a warning prior to a contaminated wing stall. However, that says nothing about where the stall speed actually was between the predicted speed of 105 knots and the biased shaker activation at 130 knots. It also says nothing about changes in pitching moment or total drag. The airfoil component of total drag is strongly influenced by ice accretion, and is probably the most undertrained and overlooked aspect of the effects of ice on aircraft.

    To date, the NTSB has not released or clarified the most important technical detail: the position of the power levers. If the power levers were appropriately positioned for the configuration, then another reason for the speed bleed must exist. It is possible that ice induced drag played a role in this. On the other hand, if the power levers were overlooked by the crew and power was not appropriate, we have another story altogether.

    This ought to be a pretty simple DFDR parameter to read; I am very curious why it has not been released yet. I’d rather know this than the precise bank angle at impact, which seems to satisfy the mainstream media.

  4. Kieran Daly March 26, 2009 at 9:07 am #


    no I’m not saying that. There’s much more to the sterile cockpit concept than physical presence on the flightdeck (as you may be well aware). In particular, what a crew is discussing and paying attention to. I think it’s striking that the board is looking at sterile cockpit issues on an approach accident – in my experience it’s something more commonly associated with departure incidents when the potential for distraction and general extraneous activity is higher.

  5. Howard April 4, 2009 at 2:23 pm #

    FDR data further indicate that when the stick shaker activated, there was a 25-pound pull force on the control column, followed by an up elevator deflection and increase in pitch, angle of attack, and Gs. The data indicate a likely separation of the airflow over the wing and ensuing roll two seconds after the stick shaker activated while the aircraft was slowing through 125 knots and while at a flight load of 1.42 Gs.

    When the stick shaker activated, so does the stick pusher, the coloumn would have moved forward but the above statement shows the pilot pulled(25-pound pull force) against the pusher(fatal mistake in my opinion, need to see a flight manual to see what they should have done but i doubt pulling back on the column until a greater airspeed than stated would have been necessary) which stalled the airplane. Aircraft went into a flat spin. A friend of mine went through the synopsis in a sim the other day.

  6. tim edwards May 18, 2009 at 3:46 am #

    Having flown ATR for american Eagle after the roselawn accident, and after spending serveral years with the FAA as an inspector and accident investigator, several things stand out with this accident. For one there is no substitute for a well rested and well trained flight crew, no substitute for experience, These reginal airlines have a tough time hiring qualified and experienced people, 2 years ago many commuters were hiring folks with 250 hours total time and placing them in the right seat of jets. The low pay, poor working conditions lead to low moral and excess fatige. Somthing the FAA has turned a blind eye to for years. also absolutly steril cockpit below 10. crew was operating in icing conditions, about to begin an approach, operating in the north east, should have been nothing but buisness. absoluty no time for inatention. I think possible the captain may have thought he was experiencing a tail plane stall, as evidenced by him retracting the flaps, pulling back on the control colume and not increasing power, all would have been correct for ice induced tail plane stall The industry needs to clean up its act. we need to do away with reduced rest. we need adequate rest and liveable pay

  7. mutuelle santé October 6, 2010 at 10:56 am #

    I’m not surprised this happened to Colgan Air. Colgan Air is a money-pinching, fly-by-night, bottom-feeder airline living on the brink of closing that places inexperienced kids in the cockpit and trains them on the job.

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