<p>Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN.</p>


Contributor - Safety

Stuart “Kipp” Lau

<p>On Feb. 12, 2009, Colgan Air Flight 3407, a Bombardier Dash 8 Q400 turboprop aircraft, crashed about 5 nm from the Buffalo-Niagara International Airport in Buffalo, New York. Impact forces and a post-crash fire destroyed the aircraft, killing all 45 passengers, two pilots, two flight attendants, and one person on the ground.</p>
<p>The crash sequence began as the flight crew was slowing and configuring the aircraft for the approach before landing. Both pilots overlooked low airspeed cues and indications on the primary flight displays. As the airspeed continued to decay, the captain improperly responded to an impending aerodynamic stall by overriding the stick shaker, pulling aft on the control column, which led to a complete loss of control of the aircraft.</p>
<p>The entire sequence of events leading to the crash, from stick shaker activation to impacting a residential structure on the ground, took only 25 seconds. However, in the years that followed, this accident’s impact on commercial aviation safety and regulations would be enduring, significant, and sometimes controversial. It also coalesced the families of the victims in a way not seen before, and to this day, those families remain actively involved in aviation safety matters with the hopes of warding off future disasters.</p>
<p>Almost one year after the crash, on Feb. 2, 2010, the NTSB published its final aircraft accident report. Safety issues identified in the report were plentiful. The report focused on flight crew monitoring failures, pilot professionalism/sterile cockpit rules, fatigue, remedial training, pilot training records, airspeed selection procedures, stall training, FAA oversight, voluntary safety programs, and the use of personal portable electronic devices in the flight deck. The NTSB addressed many of these concerns in its final report by making formal recommendations to the FAA.</p>
<h2>NTSB Probable Cause</h2>
<p>In its report, the NTSB determined 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. Contributing to the accident were (1) the flight crew’s failure to monitor the airspeed in relation to the rising position of the low-speed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.</p>
<p>Fatigue was not considered a contributing factor to the accident by the NTSB. The entire Safety Board concurred with the findings, probable cause, and recommendations contained in the final report but debated whether fatigue was a contributing factor.</p>
<p>All board members acknowledged that the pilots were fatigued based on numerous “yawns” recorded on the cockpit voice recorder and mismanaged rest opportunities before the flight by the pilots. However, it could not be determined if fatigue adversely affected their performance during the flight. As an example, the captain—the pilot flying during the accident—had a history of FAA and company check ride failures due to his shortcomings in aircraft handling, judgment, and other procedures. Thus, the majority (two out of three) of the board members decided that fatigue was not a contributing factor.</p>
<h2>Outcomes</h2>
<p>Outcomes from the Colgan Air crash included sweeping regulatory changes that were codified in the Airline Safety and FAA Extension Act of 2010 (Public Law 111-216). President Barack Obama signed this act into law on Aug. 1, 2010. Before the crash, NTSB had been continuously pressing Congress to pass legislation that would improve airline safety standards; without this accident and the organized lobbying efforts of the crash victims’ friends and families, this bill may have never been passed.</p>
<p>Former NTSB chair Robert Sumwalt recently shared his thoughts on the passage of the Airline Safety and FAA Extension Act of 2010, saying, “The crash of Colgan 3407 resulted in the most widespread and profound changes in my lifetime, which at this point spans nearly seven decades.”</p>
<p>Sumwalt, now the executive director of the Boeing Center for Aviation and Aerospace Safety at Embry-Riddle Aeronautical University, added, “Congress mandated changes in the way airline pilots are selected, trained, and scheduled. Most people would tell you that this accident was the result of icing and/or fatigue. Surprisingly, the NTSB, which I was a board member of at the time, found that icing did not affect the aerodynamic characteristics of the airplane. Further, there is no NTSB finding that fatigue was the cause of the crash. Nevertheless, not letting facts get in the way, Congress mandated that FAA create an entirely new set of regulations regarding flight and duty times.”</p>
<p>In addition to new flight and duty time limitations, PL 111-216 specified several additional provisions to improve airline safety such as crew member screening and qualifications, crew member training that includes stall and upset recognition and recovery training, pilot records database, pilot professional development and mentoring, regional air carrier ticket disclosure, and safety management systems.</p>
<h2>ATP/R-ATP Requirement</h2>
<p>One of the most impactful and controversial provisions of the new regulations was changes to the required qualifications and flight experience levels of Part 121 airline pilots. Before the new rules, a first officer of a regional airliner could get hired with a commercial pilot certificate and as little as 250 hours of flight time. The new rule, enacted in July 2013, specified that the minimum requirements for a new hire at a Part 121 airline be required to hold an airline transport pilot (ATP) or restricted airline transport pilot (R-ATP) certificate. An ATP requires 1,500 hours of total time and a minimum age of 23 years old, whereas an R-ATP can be obtained with a minimum of 750 hours at age 21. The R-ATP is issued to qualified candidates trained, typically, through a four-year college flight program, the military, or a Part 141 flight academy.</p>
<p>Complaining that this rule is exacerbating a potential pilot shortage and provides an entry barrier, particularly for the regional carriers, airline lobbyists have urged alternatives such as more simulator credit in lieu of actual flying hours. They argue that, as is, pilots are forced to build hours in operations dissimilar to airliners. This became a focal point in the debate surrounding the most recent FAA reauthorization bill. However, proponents of the measure point to an unprecedented safe period since the law was passed and key backers on Capitol Hill suggested requiring additional simulator time rather than in place of flight time. The Air Line Pilots Association disputes discussions around the pilot shortage and thus the need for changes.</p>
<p>This measure was adopted even though the captain had 3,379 flight hours and the first officer 2,244. However, the first officer was a commercial pilot—not an ATP.</p>
<h2>Fatigue Rules</h2>
<p>Another major change resulted in an entirely new set of flight and duty time regulations for all Part 121 passenger airlines (cargo carriers are exempt). FAR Part 117 was developed to implement science-based flight, duty, and rest requirements for flight crewmembers. These regulations were implemented in January 2014 and account for the effects of circadian rhythm on the human body, the number of takeoffs and landings in a duty period, and the number of time zones crossed, as an example. Past flight and duty limits simply provided a limit on the maximum duty period allowed or flight time during a 24-hour period—regardless of the report time.</p>
<p>In addition to establishing FAR Part 117 for all scheduled passenger airlines, all Part 121 airlines were required to submit a comprehensive fatigue risk management plan to the FAA for approval. These plans must include current flight time and duty period limitations and a strategy to identify and mitigate fatigue in its operations. In addition, annual training is required to increase the awareness of fatigue and its effects and to review fatigue countermeasure strategies.</p>
<p>However, the rule exempted cargo carriers—to the dismay of pilots’ unions.</p>
<h2>Upset Prevention and Recovery Training</h2>
<p>During its investigation, the NTSB determined that the captain of the accident flight inappropriately responded to an impending aerodynamic stall by overriding the stick shaker and pulling aft on the control column. This led to a stall and loss of control of the aircraft. Additionally, actions by the first officer, such as retracting the flaps during the stall, were also contrary to industry-recognized aerodynamic stall recovery procedures.</p>
<p>As a result, the FAA mandated that airlines provide additional training to all pilots that focuses on upset prevention and recovery strategies. This new training emphasized reducing the angle of attack of the aircraft versus the old method of maintaining altitude during a stall recovery. These new simulator-based training requirements included upset recovery maneuvers, recoveries from full stalls with stick pusher activation, bounced landings, slow flight, and unreliable airspeed scenarios. In addition, pilots must manually fly instrument departures and arrivals and takeoffs and landings in gusty crosswind conditions to improve manual handling skills.</p>
<p>The deadline to begin this training was March 2019; many airlines and training providers had to modify the aerodynamic models of their full-flight simulators to enable this extended envelope training (EET). This new regulation also required new ATP candidates to complete UPRT as part of their training.</p>
<h2>Pilot Records Database</h2>
<p>One of the most complex aspects of the Airline Safety and FAA Extension Act of 2010 was to establish a centralized/national electronic database of pilot records to be used for employment verification purposes. NTSB investigators examining the training records of the Colgan Air Flight 3407 flight crew found many inconsistencies and deficiencies in recordkeeping at the airline.</p>
<p>Known as the Pilot Records Database (PRD), each air carrier, before allowing an individual to begin service, must access and evaluate information pertaining to the pilot. The PRD serves as a clearinghouse of information from the FAA (airman and medical certificate information, practical test failures, and any legal actions), air carriers (training records, disciplinary actions, terminations, et cetera), and the national driver registry records (violations such as a DUI). The PRD replaces previous records required by the Pilot Records Improvement Act (PRIA); the new records are much more detailed and include the training, qualifications, and professional competencies of the pilot to include comments by designated check airman recorded during training and checking events.</p>
<p>The applicant pilot must provide written consent for an airline to access the PRD. Likewise, under the provisions of the law, pilots can access their own records and correct any inaccuracies. Access to the PRD, by air carriers, is limited to using the records only to assess the qualifications of an individual for employment considerations; the pilot is afforded privacy protections.</p>
<p>The final PRD rule was published on June 10, 2021. Full implementation of the PRD by the FAA was completed in September 2024.</p>
<h2>Mentoring, Leadership, and Command</h2>
<p>NTSB noted the captain’s failure to effectively manage the flight and the crew’s lack of adherence to sterile cockpit rules as contributors to the accident of Colgan Air Flight 3407. Following the passage of PL 111-216, the FAA convened an aviation rulemaking committee (ARC) to develop procedures for Part 121 airlines that focused on mentoring, professional development, and leadership and command training for airline pilots.</p>
<p>Outcomes from these rulemaking activities now require newly hired pilots to observe flight operations, typically on the jumpseat of a scheduled line flight, to increase their familiarization with procedures before serving as a flight crewmember. Likewise, airlines are required to provide mentorship and leadership and command training to all pilots. FAA AC 121-42, published in March 2020, provides guidance to operators in establishing leadership and command training. &nbsp;</p>
<h2>Safety Management Systems</h2>
<p>Before the crash of Colgan Air Flight 3407, many operators had begun to voluntarily develop safety management systems (SMS) to help identify and mitigate risks in their operations. Most major airlines felt an SMS was a natural extension to other voluntary safety programs that were already implemented into their operations, such as flight operational quality assurance (FOQA), line operations safety audits (LOSA), advanced qualification programs (AQP), and aviation safety action programs (ASAP). At the time of the Buffalo crash, however, only a few regional airline operators had FAA-approved FOQA, ASAP, or AQP programs.</p>
<p>Following the Colgan Air Flight 3407 crash, the Airline Safety and FAA Extension Act (sections 213-215) emphasized the use and promoted the effectiveness of these voluntary safety programs including proposals to mandate ASAP and FOQA to all Part 121 airlines. The FAA established an ARC to explore widespread implementation of voluntary safety programs throughout the Part 121 community; in the end, following the NPRM responses, only SMS was mandated for Part 121 airlines; the final rule was published in January 2015 with a requirement for airlines to have a functional SMS by March 2018.</p>
<p>Today, code-sharing agreements between regional airlines and their mainline partners, or other auditing standards (such as IATA’s IOSA), have become the de facto regulator for smaller airlines to employ proactive safety programs such as ASAP and FOQA.</p>
<p>The FAA has since expanded on the SMS rule, which established a new Part 5, extending the requirements to charter operators, air tours, airports, and manufacturers.</p>
<h2>Ticket Disclosure—Code Share Partners</h2>
<p>Colgan Air Flight 3407 was marketed as a “Continental Connection” flight operating from Newark, New Jersey, to Buffalo, New York. At the time of the accident, there were no requirements to disclose the name of the airline operating code-sharing flights. Following the accident, it is now considered an “unfair or deceptive practice” to not disclose the name of the air carrier providing air transportation, and if there is more than one flight segment, the name of each air carrier must be disclosed. Likewise, if the ticket is sold online, the name of the airline must appear on the first page of the website.</p>
<h2>Results</h2>
<p>The crash of Colgan Flight 3407, as tragic as it was, may have been the tipping point for the industry since it was the last of four high-profile regional airline accidents in the U.S. over a five-year period (2004 to 2009). Other accidents during this time frame included Comair Flight 5191 (“Delta Connection”), Corporate Airlines Flight 5966 (“American Connection”), and Pinnacle Flight 3701 (Northwest Airlink). Combined, these accidents—including Colgan Air Flight 3407—resulted in 114 fatalities.</p>
<p>These investigations highlighted several safety issues in the “fee-for-departure” segment of the regional airline industry. Fee-for-departure is a common scheme where regional airlines are paid per segment by their code-sharing major airline partners.</p>
<p>NTSB made many recommendations to the FAA to improve airline safety following each of these accidents. The crash of Colgan Air Flight 3407 further highlighted many of these recommendations, and with strong lobbying efforts from the crash victim’s family and friends and support from Congress, these recommendations became law. These new regulations significantly impact the level of safety in commercial aviation. Since the Colgan Air accident 16 years ago, there have been only two fatalities on Part 121 passenger airline flights (Southwest Flight 380 in Pennsylvania and PenAir Flight 3296 in Alaska) in the U.S.</p>
<p>As for the families, they not only lobby in Washington but work to spread a safety message.&nbsp; At the most recent Air Charter Safety Foundation Safety Symposium, Scott and Terry Maurer, parents of Colgan Flight 3407 victim Lorin Maurer, highlighted issues facing families when accidents happen.</p>
<p>“This is a tough subject,” Scott Maurer said. “I want all of you to know we’ve done this many times, we want to do it for you, and it’s also a way of us honoring those loved ones we’ve lost…Put the families first, do not be defensive, do not impede the message, and I can’t say enough, communicate, communicate, communicate.”</p>


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