Investigation Summary
The investigation revealed significant human factors issues, including the flight crew's failure to monitor airspeed as it decayed toward the stall cue. The captain's reaction to the stick shaker was the opposite of standard stall recovery procedures; he pulled back with 37 pounds of force, causing the nose to pitch up and the aircraft to enter a deep stall. The crew was also found to have violated 'sterile cockpit' rules by engaging in non-pertinent conversation during a critical phase of flight. Furthermore, the investigation highlighted concerns regarding pilot fatigue, as both pilots had commuted long distances and likely slept in crew lounges or on planes prior to the flight.
Final Conclusions
The NTSB determined the probable cause was the captain's inappropriate response to the stick shaker, leading to an aerodynamic stall. Contributing factors included the crew's failure to monitor airspeed, failure to adhere to sterile cockpit procedures, the captain's poor flight management, and Colgan Air's inadequate procedures for airspeed selection in icing conditions.
Video Analysis
The Tragic Crash of Colgan Air Flight 3407 — A detailed look at the 2009 crash in Buffalo, NY, exploring the pilot errors, fatigue, and training failures that led to the disaster.
Watch on YouTube ↗If playback is blocked, the owner has disabled embedding — use the link above.
Systems & Failure Modes
Stick Shaker
A mechanical device that rapidly vibrates the control yoke to warn the pilot of an imminent stall.
Stick Pusher
An automated system that pushes the control column forward to lower the nose and prevent a stall when the pilot fails to act.
De-icing System
Pneumatic boots on the wings used to shed ice; the crew had these activated during the approach.
Interesting Facts
- 01The captain had failed five previous flight checks during his career.
- 02The first officer had commuted from Seattle to Newark overnight before the flight.
- 03The aircraft was equipped with a 'Ref Speeds' switch set to 'INCR' for icing conditions, which increased the stall warning speed.
- 04The crash resulted in the landmark Airline Safety and Federal Aviation Administration Extension Act of 2010.
- 05One person was killed on the ground when the aircraft struck a house in Clarence Center.
Safety Actions & Advisories
1,500-Hour Rule
The FAA increased the minimum flight hours required for first officers at Part 121 airlines from 250 to 1,500 hours.
Pilot Fatigue Regulations
New rules (Part 117) were implemented to ensure pilots receive adequate rest and to limit duty periods based on start times.
Stall Recovery Training
Airlines were required to update training to emphasize nose-down pitch recovery rather than maintaining altitude during a stall.