Accident Investigation and Incident Reporting

Colgan Air was operating a Flight 3407 on February 12, 2009, crashed in a residential neighborhood near its destination in Buffalo New York. The crashed cost 50 individuals their lives including various crew members; pilots, 2 flight assistants as well as one person on the ground, and all the 45 travelers. The aircraft was not also spared as it was destroyed due to the impact, and the post-crash fire. At the same time, one house, as well as two cars that were positioned at the driveway, were also wrecked. The captain of the airplane was 47 years old and had in the preceding year received a FAA first-class medical certificate, however, he was required to wear corrective lenses whenever he was in control of the aircraft. The first officer, on the other hand, was 24 years old, and also had a FAA first-class medical certificate that had not limitations. After the crash, wintry conditions, icing on the wings, and winds were used to explain the crash. Nevertheless, as the inquiries advanced it was established that a response to an imminent stall that went divergent to pilot training triggered the accidents. It is not the aim of this paper to document the events of what transpired, but to classify the accident, determine the accuracy of evidence, the role of fatigue, analyze CVR data, and to analyze the overall safety recommendations.
Accident Classification
Colgan Air, Inc., Operating a Flight 3407, Bombardier DHC 8 400, N200WQ accident can be categorized in the loss of control that led to the break down during the Flight (LOC-I).

This is due to the statistic that the NTSB established the likely reason of the calamity as the captain’s unsuitable reaction to the initiation of the sticker that headed to an aerodynamic stall that the aircraft did recuperate. Additionally, the report highlights that there were also other aspects that added to the accident which includes the crew’s ignorance to regulate airspeed about the rising level of the low-speed cue. Further, it is highlighted that the flight team’s blunder to observe to sterile field processes also added to the fate. Ultimately, the captain’s inadequacy in controlling the flight efficiently as well as Colgan’s Air insufficient measures for air spread selection and control throughout the methods in icing conditions also contributed to the accident.
According to Fielding, Lo and Yang (14), the direct causes of transportation accidents are commonly technical at first glance, for instance, birds striking an airplane’s engine, rare winds as well as icing conditions. Despite such causes, it is essential to pay attention to the fact that invention, as well as the adoption of major technologies, is solely human undertakings. Therefore, in many cases, including the Colgan Air accident, human factors are claimed to be the root cause of accidents. According to the NTSB (80) report on Colgan Air, the accident series including the negligible effect of icing on the plane’s performance are highlighted. Moreover, the crew’s inadequacy to regulate and monitor airspeed in connection with the increasing position of the low-speed cue as well as the leader’s inaccurate engagements in reply to the stall notice among other facts are discussed. Considering the gathered evidence on the Colgan Air accident, it is evident that the accident was mainly due to limitations in individual skills of the crew, which may be understandable considering the complications of modern transportation systems as well as the level of coordination that is required. Notably, the report asserts that even though the captain completed all entry, training, as well as operating levels without failure, he often encountered difficulties when it came to aircraft control. Ultimately, the general analysis underscores the fact that all the pilots were properly certificated as well as qualified, in agreement with applicable Federal laws. Moreover, there were no signs of any hitches with the aircraft’s ice protection system. Notably, the accident investigation also revealed chronic shortcomings in the operations; this may be as a result of unintentional mismanagement or intentional shortcuts. The Colgan Air, the accident also entailed code sharing, which can be described as a marketing arrangement in which regional airlines operate flights from the major airlines.
Flight Operations Quality Assurance
Today, the main objective of the air safety industry is to be predictive as well as proactive in obtaining the anticipated levels of safety. Therefore, it is vital for every organization in the industry to work together including the regulatory authorities as well as the operators. Additionally, it is important for the FAA to encourage the implementation of FOQA programs for all airline operators. Notably, the FAA employs de-identified data from all the operators to illustrate the common trends while encouraging mutual sharing of information across all its operating units (Ferguson, Michael D and Sean M Nelson 220). Notably, it is important to judge safety performance with regard to worldwide data on where some of the best practices as well as deficiencies can be observed.
It is worthwhile to note that although Colgan Air had already been offered the FAA consent, for the FOQA application as well as operations strategy, in the previous year, the FOQA package was never completely implemented; therefore, it was not offering significant data at the time of the mishap. Fitzgerald (212), assert that regardless of the circumstance that operator did not own a working FOQA package when the calamity took place, the company may have profited from different air transporters data regarding the Q400, this information also included stall warnings.
Notably, the program is a volunteer protection strategy that the carrier collects, identifies and analyzes actual flight information contained in a QAR as well as an FDR to establish possible working risks as well as implement corrective action. Conferring to the FAA, as of the last day of October the same year, 19 of the 82 Part 121 credential owners had FAA ascertained programs. Therefore, it is imperative to acknowledge that though Colgan Air had already received FAA approval for its FOQA application and processes strategy in 2008. As noted earlier, the program was not entirely applied this may be understandable considering the circumstance that the FAA manager proposed that the implementation would take close to one year besides Colgan’s struggles were made difficult due to unexpected matters touching the fitting of the program’s hardware.
Fitzgerald (211), underscore that Colgan’s voluntary reporting structures such as the ASAP did not comprise any reports regarding stall warnings. Furthermore, it can also be argued that it is the stall caution from an incongruity among the ref speeds shift and the airspeed bugs were a more often occurrence considering the conditions of the incident and the BTV occasion. Further, the frequency, as well as circumstances of the stall cautions, could be analyzed as part of FOQA platform due to the point that while generating FOQA series, operatives determine the documented flight limits are evaluated, and one accessible limit is the flight instigation of the cautionary stall system. Therefore, any data acquired from the examination of the program records may have resulted to reviewed company processes; checklists, as well as training and they, could be shared with FAA and the aviation industry at large.
It is vital to note that not all the airplanes have the capability of supporting an FOQA data recording. The aircraft that are accomplished by supporting such recordings are often prepared with an information bus which permits information to be conveyed in an alphanumeric arrangement from numerous information radars to QARs. Moreover, the FAA may not have carried out a review of the part 121 air transporter convoy to establish how many planes that they have the ability to hold a quick access recorder (Gorton and Slade 110). Nevertheless, operatives of such airplanes that are capable of integrating the quick access recorder details may require an additional kind of documentation for a quick access recorder retrofit which proves not only to be costly but also time-consuming. Some new airplanes have quick access recorder proficiency previously installed so the procedure to implement the FOQA package would be significantly streamlined for the operators of these aircraft.
Fatigue
In aviation, fatigue has been acknowledged as a problem by many air crews. Caldwell and Lynn (23), assert that the effect of insufficient pilot alertness on safety historically has often been underappreciated. Such was the trend till 1993 when pilot fatigue was formal, ruled as a causative factor to an aviation accident. According to the NTSB report on Colgan Air Flight 3407, fatigue is blamed at least in part for the crash that left fifty people dead.
Firstly, the Captain’s normal sleep time was from 2200 to 0900 as stated by his wife. The Captain was not with a crash pad near EWR. Moreover, he frequently used the Colgan crew area for napping. According to the previous schedule, the captain had some chronic sleep loss, and he could not recover well. Further, the lady pilot’s partner recounted that she slept between 9 to 10 hours. The other pilot had flown into EWR over Seattle and had dozed through the trip. It is vital to acknowledge that Colgan Air did have not yet established a prescribed fatigue management structure when the tragedy happened. Consequently, the captain disregarded the determined stall recovery procedures for ignoring the stick shaker warnings and subsequently overriding the activated stick pusher in a desperate effort to maintain a nose-up attitude despite the dangerous deterioration in airspeed on approach. Therefore, it is evident that fatigue can be partly attributed to the Colgan Air accident.
According to Fitzgerald (160), for fatigue to be deliberated as a factor in the crew’s routine, deficiencies need to be easily discernable as well as reliable with the common impacts of fatigue, as well as any evidence backing alternative clarifications for such deficiencies ought to be considered. Various researchers have contended that there is negative impact of fatigue on human beings including reduced alertness as well as degraded mental as well as physical performance.
According to Fink (734), fatigue remains to be a safety concern for most airline pilots since they often work prolonged schedules, night shifts as well as multiple time zones. Additionally, it has often been noted that airline accidents occur disproportionately when the pilots are on flight duty for 10 hours or longer. Notably, the fatigue approach may not always offer information about how the pilots were fatigued during the flight, but they weren’t involved in an accident. Additionally, even though fatigue is disputed as a probable cause of the Colgan Air accident, there is a probability that Fatigue may have played a significant role, but the NTSB report established that the role might not have been significant. Therefore, even though substantial attention was paid to the first officer’s travel a possible fatigue following the 2009 Colgan Air crash in Buffalo New York, the accident was clearly a culmination of a series of events as well as errors by the flight crew (Cramoisi 315). Therefore, just like the NTSB, fatigue could not be determined as either probable cause or a causative factor in the accident (NTSB 107). Regarding the evidence offered in the accident, it is clear that management of fatigue is still a learning procedure of the issued recommendations by the NTSB as well as the aviation industry initiatives that were generated.
It evident through various surveys conducted that a good number of pilots report for duty even when they are fatigued. This is due to many pilots and airlines have made it a tradition not to miss duty. Moreover, many of the pilots find it challenging to file a fatigue report. Therefore it is important for operators such as Colgan Air to not only obtain an official FRMS but also evaluate is effectiveness and functioning. Consequently, most operators would acknowledge the impacts of fatigue and work to eliminate fatigue related issues. According to the Colgan Air report, the recommendations forwarded to FAA are significant. The report discussed fatigue as well as commuting; consequently, the NTSB forwarded various recommendations.
Safety Recommendations
The NTSB reported various major findings regarding the Colgan Air accident, firstly, the crew did not acknowledge the impending onset stick shaker despite the crew having sufficient time to recover. Additionally, the Colgan air’s SOPs did not encourage real monitoring behavior. It did not need flight teams to make sure the method speed bugs, and the ref swiftness switch location, causative to a lesser situational cognizance. Notably, the safety recommendations that are addressed in the reported emphasis on the approaches to avert flight crew observing failures, pilot professionalism, fatigue, as well as remedial preparation. Moreover, pilot preparation registers, airspeed assortment procedures, stall teaching, FAA monitoring, flight working quality assurance programs, use of individual moveable automatic gadgets on the cockpit area, the Federal Aviation Administration’s utilization of protection warnings for operatives to transit safety critical data and weather the information offered to the team are also recommendations. Notably, the safety recommendations that are highlighted in the report are provided to the federation. According to Dillingham (18), FAA’s voluntary reporting programs such as ASAP, ASRS, FOQA as well as VDRP develop safety information that FAA does not identify through other means.
The recommendations are important because through such programs as ASAP, ASRS, and VDRP, airspace users including air carriers, airspace operators as well as employees, self-report events as well as violations of their operating certificates and company procedures. The recommendations are vital for the improvement of aviation safety. Additionally, according to the officials of ICAO, FAA, and other safety experts, voluntary reporting is perceived to be a cornerstone of SMS. This is in line with the fact that ICAO has noted that operational personnel in the best position to report the presence of safety hazards and to attest to what works and does not work during the everyday operations.
According to Stark, local carriers have enhanced into the preparation flyers in trainer airplane, this can be attributed to an effort by the local carriers group. However, finances remain the vital factor. Moreover, the FAA is moving forward with stronger safety standards that are founded on regulations to reduce pilot fatigue, however, such laws may take a long period to be implemented. Further, the FAA has also encouraged various airlines to advance remedial teaching for the crew members who may not be able to perform excellently in cockpit situations. The recommendations shall also encourage regulations that encourage their crew members to report risky situations without holding back. According to Colgan Air, it has completed 20 safety enhancements, including improving training, necessitating fresh crew members acquire more skills as well as expertise, refining the crew’s basic evaluation procedures as well as accumulating the regularity of evaluation trips by expert pilots.
Analysis of CVR Data and Probable Causes
The Colgan report also brings out the CVR data from the crash of the air. The report gives a detailed examination of the Cockpit Voice Recorder which serves to bring out the probable reasons for the crash. After takeoff, the CVR records the pilot, and the first officer was involved in a conversation, but this did not go against the sterile cockpit law. According to Dismukes et al. (50), the sterile cockpit rule is a conservative measure to reduce the distraction from cockpit duties. Conversations between tasks may seem harmless to pilots if the workload is low. Nevertheless, pilots may not realize that even light conversations make substantial cognitive demands, and even momentary diversions of attention may reduce chances of noticing important cues particularly the ones that are not salient. The rule was designed by the FAA after revising a series of mishaps that were caused by pilots who were unfocused to their flying duties. In essence, the CVR during takeoff and some parts of the flights of the flight does not capture the pilot of the first officer on the wrong.
Altogether, the CVR documented the pilot and the first pilot yawning on several occasions which demonstrated fatigue. As these yawns continue, the pilot and the first officer are recorded by the CVR violating the sterile cockpit. When the aircraft descended to 10,000 feet, the pilot and the first officer were expected to observe the rule. However, the pilot and first officer are recorded having conversations that are unrelated to their flying duties hence this can be said to have partly contributed to the crash. Apart from the information the CVR recorded from the pilot and the first officer, information from other parts of the aircraft was also recorded. Firstly, the CVR recorded sounds comparable to that of landing gear positioning. Secondly, the sound of flap movement was also recorded by the CVR. The sound recorded by the CVR was the autopilot disconnects horn which was repeatedly recorded up to the end of the CVR recording (NTSB 18). In general, these sounds should have served as a warning sign to the pilot, and the first officer that the aircraft was not in good condition as they approached landing.
According to the NTSB report, the cause of the aircraft crash was the aviator’s unsuitable reaction to the stick shaker. The lacks of reaction to the stick shaker instigated the aerodynamic to stall leading to the accident. According to Williamson (127), the probable reason of the accident was the pilot’s error, and this was accurately captured in the NTSB report. The other probable causes of the aircraft the lack of monitoring the wind speed by the first officer. Additionally, the pilot and the first officer also failed to adhere to the sterile rule leading to the crash of the aircraft. The captain also failed to effectively manage the aircraft during the flight, and this further led to the fatal air crash. Nevertheless, the NTSB report neglects the fact that fatigue could have been a contributory factor to the accident. For example, the pilot and the first officer continually engaged in a conversation although, and this may be interpreted that they were trying to stay awake during the flight because they were tired. It is, therefore, essential to determine the effect that fatigue may have had during the Colgan accident.
Analysis of Safety Recommendations
Apart from the recommendations that have been forwarded by the NTSB report, there are also previous safety recommendations that are also accurate and can be applied to avoid such accidents in future. Firstly, sterile cockpit adherence has been advanced in more than one report as one of the most effective measures of preventing airline accidents. Pilots and other crew members should, therefore, ensure that they do not engage in activities that may distract them from their flying duties.
Pilot awareness and situational awareness is also the another safety measure that can be used to prevent such accidents in future. During flights, pilots should strive to maintain high levels of professionalisms so that they can fly the aircraft safely to its destination. However, some pilots decide to engage in unprofessional behavior which leads to accidents. Furthermore, flight companies should also monitor their pilot activities from time to time to ensure that they are respecting the regulations that govern their profession. The airline crew should also be accorded with enough time to avoid instances of fatigue that may lead to such accidents.
Conclusion
Colgan Flight 3407 was one of the most avoidable accidents in the airline’s industry if the pilot and the first officer had been careful during the flight the flight which cost 50 people their lives was because of loss of control of the aircraft by the pilot and the first officer. Moreover, it has been determined through the NTSB report that the evidence documented in the report is accurate given the manner in which it is presented. Further, the role of fatigue has also been brought out in the report, but one of the main eliminations is that it was not documented as a possible cause of the accident. An analysis of the CVR data underscores the fact that the pilot and the first officer were fatigued, and in some instances, they violated the sterile rule which was supposed to guide their conduct in the cockpit. Additionally, the report also made accurate safety recommendations, and this was supplemented by the previous one. In general, the Colgan Flight 3407 could have been prevented had it not been the negligence of the pilot and the first officer.

Works Cited
Caldwell, John A. Fatigue in Aviation. 1st ed., Taylor And Francis, 2016,.Cramoisi, George. Air Crash Investigations: Deadly Mistakes the Crash of Air China Flight 129. 1st ed., Lulu.Com, 2012,.Dillingham, Gerald L. Aviation Safety: Improved Data Quality And Analysis Capabilities Are Needed As FAA Plans A Risk-Based Approach To Safety Oversight. 1st ed., DIANE Publishing, 2010,.Dismukes, Key, Benjamin A. Berman, and Loukia D. Loukopoulos. The limits of expertise: Rethinking pilot error and the causes of airline accidents. Ashgate Publishing, Ltd., 2007.
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