DCA09MA027

NTSB accident investigation · Bombardier DHC-8-402 · Clarence Center, NY · February 13, 2009

Accident · FatalClass 1 · MajorFinal report
Date
February 12, 2009, 20:17 local (Feb 13, 2009, 01:17 UTC)
Place
Clarence Center, NY
Injuries
50 fatal; on the ground: 1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N200WQBombardier DHC-8-402
Defining event
Approach-IFR initial approach: Loss of control in flight
Weather
Visual (VMC) · Night
Status
Completed · report March 28, 2010
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
TSB - Canada, AAIB, NATCA, ALPA, Colgan, FAA, Steelworkers Union - flight attendants union
Safety recommendations
Yes
FAA report
20090212001969A
Case key
73351

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

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 airspeed in relation to the rising position of the low-speed cue, (2) the flight crew 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.

Findings · 14

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Navigation system: stall warning systemAircraft › Aircraft systems · Incorrect use/operationBombardier DHC-8-402: 1 caseAll aircraft: 4 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · PilotBombardier DHC-8-402: 1 caseAll aircraft: 397 casesProbable cause
Communication (personnel): cRM/MRM techniquesPersonnel issues › Task performance · Flight crewBombardier DHC-8-402: 1 caseAll aircraft: 26 casesProbable cause
Workload managementPersonnel issues › Task performance · PilotBombardier DHC-8-402: 1 caseAll aircraft: 14 casesProbable cause
Policy/procedure: adequacy of policy/procOrganizational issues › Management · OperatorBombardier DHC-8-402: 1 caseAll aircraft: 106 casesProbable cause
Temp/humidity/pressure: conducive to structural icingEnvironmental issues › Conditions/weather/phenomena · Not specifiedBombardier DHC-8-402: 1 caseAll aircraft: 103 casesProbable cause
Alertness/FatiguePersonnel issues › Physical · Unknown/Not determinedBombardier DHC-8-402: 1 caseAll aircraft: 48 cases
Documentation/record keeping: personnel recordsOrganizational issues › Support/oversight/monitoring · OperatorBombardier DHC-8-402: 1 caseAll aircraft: 6 cases
Training: recurrent trainingOrganizational issues › Support/oversight/monitoring · OperatorBombardier DHC-8-402: 1 caseAll aircraft: 6 cases
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBombardier DHC-8-402: 1 caseAll aircraft: 61 cases
Safety programsOrganizational issues › Support/oversight/monitoring · OperatorBombardier DHC-8-402: 1 caseAll aircraft: 7 cases
Environmental issuesEnvironmental issues › Conditions/weather/phenomena · Availability of related infoBombardier DHC-8-402: 1 caseAll aircraft: 57 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-10/01. On February 12, 2009, about 2217 eastern standard time, 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. 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 flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at the time of the accident.

Factual narrative

The Safety Board’s full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-10/01. On February 12, 2009, about 2217 eastern standard time, 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. 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 flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at the time of the accident.

Aircraft

Registration
N200WQ
Reported as
Bombardier DHC-8-402
Category
Airplane
Serial number
4200
Airframe hours
1,819
Engines
P&W Canada PW150A, 5,071 horsepower, turbo propP&W Canada PW150A, 5,071 horsepower, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Operator
Colgan Air Inc, doing business as Continental Connection
Registered owner
Colgan Air Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · February 12, 2010
Departed
EWR · Newark, NJ
Destination
BUF · Buffalo, NY
Flight plan
IFR
Airport
BUF · Buffalo-Niagara International

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
47
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
December 3, 2008
Seat
Left
Toxicology
Performed
Flight hours
3,263 total · 110 in this make and model · 1,205 as pilot in command · 110 in the last 90 days · 51 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
24
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 16, 2008
Seat
Right
Toxicology
Performed
Flight hours
2,238 total · 768 in this make and model · 1,350 as pilot in command · 174 in the last 90 days · 51 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
250° at 15 knots
Visibility
3 statute miles
Lowest ceiling
2,100 ft broken
Observed at
BUF, 5 nm away

Docket · 136

The files NTSB released with the investigation on May 12, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 184 MB in all.

Order of hearing_1AItem 1 · PDF · 1 page · 41 KBNotice of designation of chairman of board of inquiry_1BItem 2 · PDF · 1 page · 51 KBDesignation of hearing officer_1CItem 3 · PDF · 1 page · 51 KBDesignation of parties to the hearing_1DItem 4 · PDF · 1 page · 42 KBNotice of hearing_1EItem 5 · PDF · 1 page · 42 KBExhibit list_1FItem 6 · PDF · 3 pages · 16 KBWitness list_1GItem 7 · PDF · 6 pages · 25 KBOperations 2A-factual report of group chairmanItem 8 · PDF · 44 pages · 909 KBOperations 2B-interviews in buffaloItem 9 · PDF · 52 pages · 473 KBOperations 2C-interviews-Vermont crewItem 10 · PDF · 11 pages · 146 KBOperations 2D-interview former apmItem 11 · PDF · 6 pages · 93 KBOperations 2E-interview dir flt stds barrettItem 12 · PDF · 44 pages · 292 KBOperations 2F-interview mgr flt stds baxterItem 13 · PDF · 64 pages · 354 KBOperations 2G-interview check airman campbellItem 14 · PDF · 41 pages · 298 KBOperations 2H-interview vp admin finniganItem 15 · PDF · 62 pages · 338 KBOperations 2I-interview chief pilot honanItem 16 · PDF · 84 pages · 512 KBOperations 2J-interview FAA apm jessieItem 17 · PDF · 88 pages · 450 KBOperations 2K-interview check airman kramerItem 18 · PDF · 89 pages · 499 KBOperations 2L-interview director of safety laclairItem 19 · PDF · 52 pages · 323 KBOperations 2M-interview FAA poi lundgrenItem 20 · PDF · 57 pages · 276 KBOperations 2N-interview dir crew training mitchellItem 21 · PDF · 49 pages · 323 KBOperations 2O-interview check airman moberleyItem 22 · PDF · 87 pages · 601 KBOperations 2P-interview ground instructor nagleItem 23 · PDF · 60 pages · 359 KBOperations 2Q-interview check airman nitsosItem 24 · PDF · 36 pages · 280 KBOperations 2R-interview check airman omairItem 25 · PDF · 83 pages · 483 KBOperations 2S-interview mgr flt safety trueItem 26 · PDF · 42 pages · 299 KBOperations 2T-interview Q400 fleet manager westonItem 27 · PDF · 44 pages · 289 KBOperations 2U-interview mgr crew training yaridItem 28 · PDF · 68 pages · 405 KBOperations 2V-acars reportItem 29 · PDF · 4 pages · 127 KBOperations 2W-aerodata reportItem 30 · PDF · 3 pages · 1.1 MBOperations 2X-colgan air loadItem 31 · PDF · 2 pages · 188 KBOperations 2Y-normal checklistItem 32 · PDF · 3 pages · 350 KBOperations 2Z-Q400 normal landing profileItem 33 · PDF · 3 pages · 176 KBOperations 2AA-Q400 stall profilesItem 34 · PDF · 4 pages · 132 KBOperations 2BB-capt and fo training recordsItem 35 · PDF · 4 pages · 224 KBOperations 2CC-colgan 24 hour ice protection checkItem 36 · PDF · 3 pages · 3.9 MBOperations 2DD-flight operations organization chartItem 37 · PDF · 2 pages · 152 KBOperations 2EE-recommendation report for A-05-002Item 38 · PDF · 4 pages · 54 KBOperations 2FF-renslow FAA certificatesItem 39 · PDF · 9 pages · 568 KBOperations 2GG-pilot training form 2003Item 40 · PDF · 3 pages · 275 KBOperations 2HH-sabre flight control crew managementItem 41 · PDF · 13 pages · 632 KBOperations 2II-colgan cfm section 1 introductionItem 42 · PDF · 5 pages · 229 KBOperations 2JJ-Q400 qrh-flight in icing conditionsItem 43 · PDF · 3 pages · 140 KBOperations 2KK-Q400 afm-ice protection proceduresItem 44 · PDF · 5 pages · 245 KBOperations 2LL-colgan cfm ops bulletin 09-001Item 45 · PDF · 7 pages · 384 KBOperations 2MM-colgan cfm ops bulletin 09-003Item 46 · PDF · 9 pages · 297 KBOperations 2NN-colgan cfm ops bulletin 09-004Item 47 · PDF · 7 pages · 373 KBOperations 2OO-FAA response to recommendation A-05-01Item 48 · PDF · 4 pages · 280 KBOperations 2PP-pilot records improvement actItem 49 · PDF · 5 pages · 280 KBOperations 2QQ-NTSB letter to FAA January 23 2007Item 50 · PDF · 19 pages · 1.5 MBOperations 2RR-FAA response to NTSB recommendation A-07-01 to A-07-11Item 51 · PDF · 6 pages · 405 KBOperations 2SS-Q400 aom abnormal and emgency procedures page 34-24Item 52 · PDF · 2 pages · 61 KBOperations 2-addendum 1Item 53 · PDF · 22 pages · 95 KBOperations 2-addendum 2Item 54 · PDF · 4 pages · 165 KBOperations 2-addendum 3Item 55 · PDF · 62 pages · 4.4 MBOperations 2-errata 1Item 56 · PDF · 2 pages · 72 KBATC 3-factual report of group chairmanItem 57 · PDF · 17 pages · 2.3 MBATC 3-exhibit 3-B FAA aircraft accident packageItem 58 · PDF · 112 pages · 13.3 MBMeteorology 5-factual report of group chairmanItem 59 · PDF · 56 pages · 4.0 MBMeteorology 5-errata 1Item 60 · PDF · 1 page · 157 KB
All 136 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.