Pilot Errors and the Crash of Continental Connection Flight 3407: Considerations for Team Readiness

Published on August 7, 2012 in "Top Ten" Lists | No Comments


“On February 12, 2009, 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.

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 National Transportation Safety Board determines that the probable cause of this accident was 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.”

                -NTSB Accident Report Executive Summary

”Essentially the airplane entered an aerodynamic stall from which it did not recover. It pitched over and hit the ground. The recovery procedure is fairly simple and straight forward. It requires pushing forward on the controls and adding full power. At any point in time had the captain pushed forward on those flight controls, he had a reasonably good chance of recovering quickly. Had the first officer simply called out, “you’re stalled,” advanced the power, pushed the nose over, the airplane would have been able to recover.

It wasn’t a split-second thing. I think there was time to evaluate the situation and initiate a recovery…“

           – Roger Cox, NTSB’s aviation safety operations group chairman

“From everything we’ve gained, that stall was recoverable, on a repeated number of levels, on a repeated basis. There was no reason for that plane to go down.”

           – John Kausner, Father of a 3407 passenger, aviation safety activist

The NTSB does a thorough job of investigating accidents and writing detailed reports of their findings and recommendations. Invariably, these accidents are the result of people issues, equipment issues, or environmental issues (or some combination there of) that are common to all teams, in all organizations. If anything good can come out of a horrific tragedy, it is that we learn from their experience.

Examining the NTSB’s report uncovers lessons learned and how they may apply to the people, equipment, or environmental issues that challenge our own teams. They call to our attention situations that can lead to serious problems, and how those problems may be avoided. Each of us has a responsibility to “sift through the wreckage” of flight 3407 to see how their experience applies to our own unique situation. How similar behavior, problems, and circumstances could be at work within our teams; affecting our own level of readiness. Below are some of our observations.


National Transportation Safety Board (NTSB) Findings
Excerpts from:
NTSB Report Flight 3407
Excerpts from:
Loss of Control on Approach
Colgan Air, Inc.
Operating as Continental Connection Flight 3407
Bombardier DHC-8-400, N200WQ
Clarence Center, New York
February 12, 2009
Accident Report

# Readiness Issue NTSB Findings Considerations for Team Readiness
1. Failure to take proper action

“The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall.”

  • Somewhere, someone on your team is likely to do something highly inappropriate, even experienced team members in leadership positions.

  • Whatever he or she does, may have serious, tragic consequences.

  • 2. Failure to understand the obvious

    “Explicit cues associated with the impending stick shaker onset, including the decreasing margin between indicated airspeed and the low-speed cue, the airspeed trend vector pointing downward into the low-speed cue, the changing color of the numbers on the airplane’s indicated airspeed display, and the airplane’s excessive nose-up pitch attitude, were presented on the flight instruments with adequate time for the pilots to initiate corrective action, but neither pilot responded to the presence of these cues.”

  • Never take for granted that every team member knows what is going on or will be able to solve even the most simple of problems.

  • Under the right conditions, people can become confused, prone to making the most obvious mistakes.

  • 3. Sloppy workmanship

    “The reason the captain did not recognize the impending onset of the stick shaker could not be determined from the available evidence, but the first officer’s tasks at the time the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management.”

    “The monitoring errors made by the accident flight crew demonstrate the continuing need for specific pilot training on active monitoring skills.”

  • Some team members may be doing sloppy work or engaging in sloppy behavior without realizing it or believing that it is inconsequential.

  • Sloppy work or conduct can cause big trouble.

  • 4. Startled & confused

    “The captain’s response to stick shaker activation should have been automatic, but his improper flight control inputs were inconsistent with his training and were instead consistent with startle and confusion.”

  • Most jobs have the potential for incidents to arise that will completely catch a team member by surprise.

  • Surprises force team members to react, and often work outside their comfort zone.

  • A team member caught completely by surprise, may be so startled & confused that he or she will not think or react logically.

  • The potential for confusion is not only present in emergency situations. Confusion can occur in ordinary circumstances, such as when a team member is distracted, under pressure, performing tasks that are done infrequently, or while tired/fatigued.

  • To mitigate the risks of mistakes, especially during times of confusion, its helpful to have documented procedures and good training programs that give team members the certainty and confidence to perform their duties safely and correctly.

  • 5. Making it worse

    “The captain did not recognize the stick pusher’s action to decrease angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation.”

  • Not all team members are fully qualified for all the jobs they may be asked to perform.

  • There may be a tendency to underestimate the consequences of poor performance or sloppy workmanship. Beyond just doing a bad job, there is the real possibility for loss of life, injury, damage to equipment, and damage to reputation.

  • 6. Doing your own thing

    “Although the reasons the first officer retracted the flaps and suggested raising the gear could not be determined from the available information, these actions were inconsistent with company stall recovery procedures and training.”

  • Some team members will try to do their own thing (especially if they panic), in direct violation of policy, management direction, training, and standard operating procedures.

  • Team members that go rogue, can cause major problems.

  • In a panic, people react based on impulse or instinct. Having good documentation of procedures and good training programs will help ingrain a natural reaction, an impulsive response for performing a procedure correctly.

  • 7. Instrumentation could be more helpful

    “The Q400 airspeed indicator lacked low-speed awareness features, such as an amber band above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, which would have facilitated the flight crew’s detection of the developing low-speed situation.”

  • Instruments can be confusing to read and understand, especially in stressful situations.

  • Often, simple markings or modifications can be added to instruments that facilitate reading and understanding.

  • In some cases, it may make sense to replace existing instruments with others that are easier to read and understand, especially if its clear that these instruments could be difficult to read in high stress situations.

  • 8. A series of alerts

    “An aural warning in advance of the stick shaker would have provided a redundant cue of the visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker.”

  • No one likes to be surprised by dangerous or serious situations.

  • Team members may not always be paying attention or even fully recognize what is going on when they receive a single warning.

  • Setting up a series of escalating warnings or having multiple mechanisms for alerting a team member (e.g., visual and audio cues) may be helpful in creating situational awareness that facilitates the appropriate action, but it is not always easy implement.

  • Adding easily accessed documented procedures, supplemented with training for what do when an alert happens may be the most immediate, most effective solution to address the problem.

  • 9. A little less conversation…

    “The captain’s failure to effectively manage the flight (1) enabled conversation that delayed checklist completion and conflicted with sterile cockpit procedures and (2) created an environment that impeded timely error detection.”

  • We are social beings.

  • In most work situations opportunities arise where team members will socialize when they should be working.

  • Socializing while on the job, engaging in inappropriate conversation at inappropriate times can have disastrous consequences.

  • Short, effective training videos, shown as part of a regularly viewed series of online training courses may help address these and many other issues affecting organizations.

  • 10. Procedures that did not go far enough

    “Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior.”

  • Procedures can be a tremendous help in mitigating risk and avoiding trouble.

  • Existing procedures can often be improved to make them more complete or user friendly.

  • The important thing is that procedures get documented and placed where they can be easily accessed.

  • Once documented, it is important that procedures are used and placed under a process of continuous feedback and improvement.

  • 11. Leaders aren’t born….

    “Specific leadership training for upgrading captains would help standardize and reinforce the critical command authority skills needed by a pilot-in-command during air carrier operations.”

  • Team members are often put into leadership positions for which they are unprepared.

  • Team members placed in leadership positions need training to help them develop the skills they need to succeed.

  • 12. Slacking – its a big problem

    “Because of the continuing number of accidents involving a breakdown of sterile cockpit discipline, collaborative action by the Federal Aviation Administration and the aviation industry to promptly address this issue is warranted.”

  • Many organizations and industries share the same types of people problems.

  • Benchmarking or collaborating with other organizations to address these issues can inspire or uncover “best practice” solutions.

  • Collaborating internally, among team members, can also yield solutions.

  • Training courses and procedures can be quickly updated with these solutions.

  • 13. All, like sheep, went astray.

    “The flight crewmembers’ performance during the flight, including the captain’s deviations from standard operating procedures and the first officer’s failure to challenge these deviations, was not consistent with the crew resource management (CRM) training that they had received or the concepts in the Federal Aviation Administration’s CRM guidance.”

  • In a panic situation, people tend to be reactive. Sound thinking, analysis, and team work gives way to impulse.

  • Often there will be a disconnect between how people perform in a training and how people will perform in an actual emergency.

  • A good training program attempts to make the appropriate response to a situation instinctive, so it becomes a natural reaction.

  • 14. Fatigue, its a problem.

    “The pilots’ performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determine

    “All pilots, including those who commute to their home base of operations, have a personal responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight.”

  • Its a fact that team members will, at times, show up for work tired, weary and not functioning at peak performance.

  • Policies that attempt to mitigate the occurrence of team members who come to work fatigued is a good thing, but the fact remains that fatigued team members are still going to be on the job, sometimes.

  • Documented procedures that are easy to access and easy to understand, along with specific training courses for those procedures, will help ensure that jobs get done correctly and safely, especially when a team member may be operating on little sleep or in a high stress environment.

  • 15. When somebody screws up, investigators blame the company

    “Colgan Air did not proactively address the pilot fatigue hazards associated with operations at a predominantly commuter base.”

    “Operators have a responsibility to identify risks associated with commuting, implement strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty.”

  • When a team member makes a mistake that results in an outside investigation (government, lawyers, insurance agents, etc.), the company will usually be found at fault.

  • Lawyers will typically look for two basic things related to the incident: Did the company have documented procedures and did the company offer training on those procedures?

  • Team members may make mistakes, no one is perfect. But when a company fails to provide procedures and training in those areas, it looks negligent to lawyers and juries.

  • 16. Weak performance not identified or addressed

    “The captain 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.”

    “Remedial training and additional oversight for pilots with training deficiencies and failures would help ensure that the pilots have mastered the necessary skills for safe flight.”

  • Keeping records of weak performance can be labor intensive and an administrative burden.

  • Using online tools like TeamReadiness’s TRM On Demand software, automates the process with email reminders to view documents, electronic agreements about reading and understanding content, course completion and testing results. Automating the process enables team leaders to easily look at a team members performance record and a plan corrective action.

  • Failure to identify a team member’s performance issues and to implement corrective action plans, gives lawyers a chance to cry negligence.

  • 17. Insufficient detail in training records

    “Colgan Air’s electronic pilot training records did not contain sufficient detail for the company or its principal operations inspector to properly analyze the captain’s trend of unsatisfactory performance.”

  • Training records, if they are to be valuable to the organization, must be customizable to contain the necessary information.

  • A good training software tool will enable customization for needed data inputs, perform analysis to “flag” issues, and automatically alert the appropriate people when a team member’s performance is unsatisfactory.

  • 18. People hide stuff about their past…

    “Notices of disapproval need to be considered along with other available information about pilot applicants so that air carriers can fully identify those pilots who have a history of unsatisfactory performance.”

  • A team member may not disclose or be upfront about past performance issues.

  • For each specific duty a team member performs, TeamReadiness makes possible effective and affordable training, testing, and certification programs along with reference documentation and collaboration tools to help ensure good levels of performance for all team members.

  • 19. Thorough background check

    “Colgan Air did not use all available sources of information on the flight crew’s qualifications and previous performance to determine the crew’s suitability for work at the company.”

  • Once an incident occurs, team members may be singled out as part of an outside investigation, where a detailed background check may be done.

  • Knowing “all” the sources to check for such things should be part of a well documented process.

  • The process should be enabled with software, like TRM On Demand, that provides access to a formal list of contact information that to ensure a thorough check can be made.

  • 20. Training that did not go far enough

    “Colgan Air’s procedures and training at the time of the accident did not specifically require flight crews to cross-check the approach speed bug settings in relation to the reference speeds switch position; such awareness is important because a mismatch between the bugs and the switch could lead to an early stall warning.”

    “The current air carrier approach-to-stall training did not fully prepare the flight crew for an unexpected stall in the Q400 and did not address the actions that are needed to recover from a fully developed stall.”

    “The circumstances of this and other accidents in which pilots have responded incorrectly to the stick pusher demonstrate the continuing need to train pilots on the actions of the stick pusher and the airplane’s initial response to the pusher.”

    “Pilots could have a better understanding of an airplane’s flight characteristics during the post-stall flight regime if realistic, fully developed stall models were incorporated into simulators that are approved for such training.”

    “Detailed icing definitions that include accretion rates and recommended pilot actions would help pilots more accurately determine the icing conditions to report in airframe icing pilot reports and more effectively respond to those conditions.”

  • Good training and testing programs, tailored for the specific tasks in questions, can be a tremendous help in mitigating risk and avoiding trouble.

  • Existing training programs should reviewed and updated regularly, as part of a continuous improvement process.

  • The important thing is that training is available for each job function, used by team members, and put under a process of continuous feedback and improvement.

  • 21. Negative Training

    “The inclusion of the National Aeronautics and Space Administration icing video in Colgan Air’s winter operations training may lead pilots to assume that a tailplane stall might be possible in the Q400, resulting in negative training.”

  • When a training program attempts to leverage other resources that make less than perfect connections with a specific job function, it may do more harm than good.

  • Because of the affordability, speed, and relevance of the training and procedural materials created for specific tasks by TeamReadiness, there is no need to compromise training programs with content that has only marginal or high level relevance.

  • 22. Going above and beyond government regulations

    “The current Federal Aviation Administration surveillance standards for oversight at air carriers undergoing rapid growth and increased complexity of operations do not guarantee that any challenges encountered by the carriers as a result of these changes will be appropriately mitigated.”

  • There is the desire on the part of many people for more government regulations, especially were safety is a factor.

  • Often, these regulations are costly and burdensome.

  • Often these regulations are put in place after an incident.

  • Having affordable, high value training programs as well as documented procedures that are easy to understand and access, especially for task where safety is a factor, may mitigate the risk of tragic incidents and costly regulations.

  • 23. Investigators suggest mandatory electronic monitoring

    “Mandatory flight operational quality assurance programs [electronic monitoring equipment] would enhance flight safety because all operators would have readily available data to identify operational risks and use in developing corrective actions.”

    “The viability of flight operational quality assurance programs depends on the confidentiality of the data, which would currently not be guaranteed if operators were required to implement these programs and were required to share the data with the Federal Aviation Administration.”

    “The systematic monitoring of all available safety data, as part of a flight operational quality assurance program, could provide operators with objective information regarding the manner in which flights are conducted, and a periodic review of this information would enhance flight safety by assisting operators in detecting and correcting deviations from standard operating procedures.”

    “The current use of safety alerts for operators to transmit safety-critical information is not effective because oversight and documentation of an operator’s response are not required and critical safety issues may not be effectively addressed.”

  • There’s an old saying, “People do what’s INSPECTED, not what’s EXPECTED.”

  • To the extent that a task is being monitored, reviewed and critiqued by others, the person(s) responsible for the task are more likely to give that task a higher level of attention.

  • When problems arise, investigators often suggest corrective action in an effort to prevent similar problems from occurring in the future. Legislators may pass new laws as a result.

  • Often, these corrective actions and laws require team members to follow a new formal procedure.

  • Mitigate the risk and consequences of tragic accidents and problems. Documented procedures and training courses on those procedures provide team members with the knowledge, confidence, and awareness for doing a job correctly.

  • 24. Don’t text and fly

    “Distractions caused by personal portable electronic devices affect flight safety because they can detract from a flight crew’s ability to monitor and cross-check instruments, detect hazards, and avoid errors.”

  • Texting can be a huge distraction, especially when driving or operating equipment.

  • Documented procedures and training that warn against texting while completing specific tasks, help mitigate this dangerous behavior.

  • 25. Access to useful, up-to-date Information

    “Weather documents missing key weather products (e.g., weather reports, ground based radar images) or containing products that are no longer valid prevent flight crewmembers from having relevant, readily available weather-related safety information for preflight and in-flight decision-making.”

  • Having access to the internet or cellular communications enables access to information.

  • Having online tool such as TeamReadiness’ TRM On Demand software enables access to the useful, up-to-date documentation and information team members need to do their jobs successfully.

  • DMW by line3

    How Can TeamReadiness Help Your Team Achieve Readiness Capability?

    • 1. We document your plans, procedures, processes, policies, best practices, and training courses.

    • 2. TeamReadiness documentation is highly visual, easy-to-use, and easy-to-understand.

    • 3. TeamReadiness documentation provides powerful knowledge that team members, suppliers, and customers need.

    • 4. Our TRM On Demand™ software provides easy and secure online access to your documentation, training, and records.

    • 5. Easily create online tests and course completion certificates that reinforce learning and build esprit de corps.

    • 6. Easily communicate and collaborate with your team to optimize knowledge and learning.

    • 7. TeamReadiness gets people involved and engaged in ways that promote “buy-in,” sharing, collaboration, and cooperation.

    • 8. TeamReadiness documentation breaks learning down into small, quick, easily understood videos or other formats.

    Let TeamReadiness help. We can assist with the entire process to quickly and cost effectively help team members grow their capabilities and achieve team readiness!


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