Research Proposal on "Colgan Air Flight 3407 Accident"

Research Proposal 12 pages (3090 words) Sources: 3 Style: APA

[EXCERPT] . . . .

Colgan Air Flight 3407 Accident

"These people knew what they were supposed to do, and they did it"

Kathryn O'Leary Higgins (as cited in Buffington, 2009, p. 351).

The Accident

On the night of February 12, 2009, Colgan Air Flight 3407, a 14 Code of Federal Regulations (CFR) Part 121 scheduled passenger flight, flying from Newark, New Jersey to Buffalo-Niagara International Airport, Buffalo, New York, crashed into a house in Clarence Center, New York. Reports confirm that at the time of the accident, night visual meteorological conditions existed. In addition, according to Mike Mitchell (2010), writer, in the Web article, "NTSB Colgan Air Flight 3407 Actions Led to Crash of Flight," the report states "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. & #8230;the captain inappropriately pulled & #8230;back on the control column" (Mitchell, 2010, "NTSB Colgan Air…," ¶ 3). This action placed the airplane into an accelerated aerodynamic stall.

During this paper, the researcher "investigates" the crash of Flight 3407; focusing on human factors that contributed to this accident; with particular focus on the two pilots.

The researcher addresses one pertinent research question: In consideration of the human factors that reportedly contributed to the Colgan Air Flight 3407 accident, what counter practices may pilots implement to help avoid this type tragedy?

In addition to the pilot, Martin D. Renslow and co-pilot Rebecca L .Shaw, who were flying Flight 3407, two flight attendants, and 45 passengers aboard the plane were killed during the crash. One individual on the ground was also killed. The number of individuals who lost their lives due to this one "accident" that day totaled - 50. In another Web article, "NTSB Report on Colgan Air Crash Highlights CAPA's Safety Concerns," Mike Mitchell (2010), reports that impact forces and a post-crash fire obliterate the airplane:

…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. (Mitchell, 2010, "NTSB Report…," ¶ 2).

Kathryn O'Leary Higgins complementary quote introducing this paper refers to the actions of Captain Chesley B. "Sully" Sullenberger III, the pilot flying Flight 1549, and his crew, who landed 155 individuals safely in the Hudson River, also during 2009. Comments regarding Renslow, the pilot of Flight 3407, and his crew, on the other hand, indicate that they did not do what they were supposed to do. Figure 1 and Figure 2 show part of the end result of that particular human error.

Figure 1: Remains of House and Flight 3407 (Williams, 2010).

Figure 2: Flight 3407 "Accident" Site (Mitchell, 2010, "NTSB Colgan Air…").

The National Transportation Board released the following excerpts from Flight 3407's Cockpit Voice Recorder (CVR). These passages represent the last communications between Renslow and flight control:

Excerpts from Cockpit Voice Recorder (CVR) transcript:

22:15:06.3 HOT-1 flaps five.

22:15:08.1 HOT-2 what?

22:15:08.8 HOT-1 flaps five please.

22:15:13.5 APP Colgan thirty four zero seven three miles from KLUMP turn left heading two six zero maintain two thousand three hundred until established localizer. cleared ILS approach runway two three.

22:15:22.2 RDO-2 left two sixty two thousand three hundred 'til established and cleared ILS two three approach Colgan thirty four zero seven.

22:15:31.7 HOT-1 alright approach is armed.

22:15:32.8 HOT-2 roger.

22:16:04.1 HOT-1 gear down…loc's alive.

22:16:06.4 APP Colgan thirty four zero seven contact tower one two zero point five. have a good night.

22:16:11.5 RDO-2 over to tower you do the same thirty four zero seven.

22:16:21.2 HOT-2 gear's down.

22:16:23.5 HOT-1 flaps fifteen before landing checklist.

22:16:26.6 HOT-2 uhhh.

22:16:37.1 HOT-2 I put the flaps up.

22:16:42.2 HOT-1 [grunt]

22:16:45.8 HOT-2 should the gear up?

22:16:46.8 HOT-1 gear up.

22:16:50.1 CAM [increase in ambient noise]

22:16:51.9 CAM [thump] (Flightpath, 2009, Excerpts from CVR

transcript Section)

Causes Contributing to the "Accident"

In the book, Squawk 7700: A Pilot's Adventure, Peter M. Buffington (2009) asserts that one primary cause contributing to the crash of Flight 3407 evolved from Renslow and Shaw permitting flight 3407 to slow to a precariously low speed. Renslow's reaction proved to be the exact opposite of the "he should have [reacted] once a stall warning sounded, meaning he couldn't regain control of the plane" (Buffington, p. 351). Other causes contributing to the accident included Renslow and Shaw failing to recognize the low-speed cue's position of the on the airplane's flight displays when it indicated the stick shaker would soon activate.

Figure 3: Renslow's Fatal Mistake (Williams, 2010).

Renslow and Shaw also failed as a team. Reports indicate that neither Renslow nor Shaw adhered "to sterile cockpit procedures" (Mitchell, 2010, "NTSB Colgan Air…,"¶ 4). Renslow failed to perform his duties as the plane's captain, as he did not "effectively manage the flight and Colgan Air's inadequate procedures for airspeed selection and management during approaches in icing conditions" (Ibid.).

Brian Willams (2010) news anchor for NBC Nightly News, reported details regarding the final NTSB report regarding the Colgan Air Flight 3407 accident. According to the report, Renslow and Shaw were discussing personal matters during the flight. While in the plane's cockpit, Shaw had been texting; only moments before takeoff; a practice against NTSB rules. The NTSB stated "the crew was not up to the job." (NTSB, as cited in Williams, 2010). Furthermore, the report asserts that the crew lacked experience, professionalism, maturity and training; factors that contributed to the crash.

The final NTSB report indicates that Colgan Air, Associated with Continental Airlines, hires pilots with as little as 250 hours of flight experience. Currently, the NTSB is pushing for requirements for pilots to obtain 1500 hours of flight experience. Figures 4; 5; 6 depicts three reasons for stronger safety strategies.

Figure 4: Renslow and Shaw (Williams, 2010).

Figure 5: Rebecca Shaw, Co-Pilot (Williams, 2010).

Figure 6: Kevin Johnston, Passenger Killed in Crash (Williams, 2010).

"Discovery" of Human Factors

Some answers to the myriad of questions that the crash of Flight 3407 stimulated may never be known. A number of answers, however, surfaced and became known after the legal "Discovery" processes. According to Henry C. Black (1990) in Black's Law Dictionary: "Discovery is the ascertainment of that which was previously unknown; a disclosure or coming to light of what was previously hidden; the acquisition of notice of knowledge of certain acts of facts…" (p. 466). Basically, through the discovery process, facts become known.

In the article, "Pilot Error; Poor Training Blamed in Colgan Air Flight 3407 Crash," Brett Emison (2010), an attorney relates some of the facts brought to light during the discovery process following the Flight 3407 accident. Emison explains that the NTSB blamed pilot error and poor training for the horrific crash. The NTSB noted that Renslow "had not established a good foundation of attitude instrument flying skills early in his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed" (Emison, ¶ 3). During his 20-year career as a pilot, Renslow failed five performance checks. In 2005, when Colgan Air hired Renslow, however, the company was not aware of two of his performance failures. Spokesman for the airline reported that if the company had known, they would have refused to hire Renslow.

Williams (2010) reported that commuter plane companies, such as Colgan Air, experience more accidents than the larger air carriers. Since 2001, commuter carriers have been involved in every fatal airline crash. Reasons the NTSB attribute to aircraft accidents such as that of Flight 3407 and others include, but are not limited to the three factors Figure 5 spells out.

Figure 5: Human Factors in Airline Accidents (Williams, 2010).

Following the investigation of the Flight 3407, the Safety Board made a number of recommendations to the Federal Aviation Administration (FAA). Strategies to prevent flight crew monitoring failures, the Safety Board insists, must be strengthened. Areas needing to be addressed and monitored regularly include the components depicted in Figure 6.

Figure 6: Areas to Monitor (adapted from Mitchell, 2010, "NTSB Colgan Air…,"¶ 5).

The Safety Board made the following additional recommendations to address FAA's oversight, which include:

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 (Mitchell, 2010, "NTSB Colgan Air…," ¶ 5).

One sport pilot student and flight enthusiast, Harold Bay, reports he has flown a number of private aircrafts such as the Cessna 150, 152, 172 and the new Sky Arrow turbo prop from airports in Tennessee and suburban Maryland. Bay reports that he learned that each plane, like each motor vehicle, has its own particular, unique characteristics and idiosyncrasies. Some planes reportedly have extremely delicate and sensitive controls, while others may be quite forgiving and permit the pilot to experience a slight… READ MORE

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