Issues NTSB can do little about remain in play


That the Colgan 3407 accident was caused by pilot error comes as no surprise, given the string of failures identified at this week's National Transportation Safety Board meeting. Indeed, so much of the board meeting seemed to be marked by failure which hung like a cloud over the proceedings. While the crew and the airline may have failed, it was not that shadowing the board’s report. It was inactivity on the biggest issues raised by the accident – codesharing, professionalism, commuting and training.

Absolutely nothing has changed in the year since that Bombardier Q400 crashed killing 50, simply because not enough is known about any of these issues to know what changes would be effective. But whatever they are, they will increase costs. Indeed, as the board went through its paces and in reading the FAA’s Call to Action report, highly criticized by the board, the additional cost profile mounted.


One of the most disturbing aspects of Tuesday’s hearings is the fact that the board did not buy the Federal Aviation Administration accomplishments outlined in its Call to Action report. Issued a week earlier, so close to the board meeting, staff didn’t have a chance to study it. In fact, the board expressed impatience on this point.

The discussion on the widespread adoption of Flight Operations Quality Assurance programs at regionals made it sound as though the FAA's data was misleading and far less than 94% of the industry aircraft are actually covered. Even the FAA press release said 94% of the aircraft are operated by carriers who either have or plan to have both Aviation Safety Action Plans (ASAP) or FOQA, but there was no indication of how many are covered right now.

It definitely does not look as good, since only 22 of the 80 responding carriers in question have both ASAP and FOQA programs, with another 28 having only ASAP but intending to adopt FOQA. Nineteen said they had neither program, but intended to implement them. Ten have ASAP but did not state their intentions on FOQA, while another three had neither and no intention to start them. Eighteen carriers did not respond at all.

And, as NTSB Chair Deborah Hersman, frustrated at the time this is taking and the fact that there is no time limit as to when FOQA would cover all commercial aircraft, said, “The road to hell is paved with good intentions.” Staff wasn’t able to get an acceptable response from the FAA on just how much actual progress has been made.

Eighteen months ago, Board Member Robert Sumwalt praised the regional industry for its widespread adoption of ASAP but criticized it for not going further and adopting FOQA. So, the board’s question remains a very good one.

Requiring FOQA not so easy

FAA told NTSB that it not only does not have the authority to require FOQA, it has no way to seek it. That was not good enough for the NTSB, who recommended that not only should they get the authority (are you listening Congress?) but find some way to shield FOQA information from the public in order to ensure it remains a valuable program.

The hang up on requiring FOQA was there was no way to shield the reports from Freedom of Information Act requests which could chill the desire to share important safety information, a compelling argument. However, Ms Hersman did not buy it. Clearly indicating she was fed up waiting for the industry to voluntarily adopt FOQA, said it should now be required.

Aviation’s four horsemen

It is codesharing, professionalism, commuting and training that seem to scream for urgent action from the entire industry – unions, the federal government and the major airlines, not just the regionals. It is these issues that NTSB cannot address alone. Instead, the board is organising day-long meetings on both codesharing and professionalism for pilots and air traffic controllers, which, hopefully, would include commuting.

Pilot commuting

In the meantime, Ms Hersman chastised the industry, FAA and unions for failing to address the elephant in the room – commuting long distances to duty – during its call to action. It was completely ignored in the flight-and-duty-time deliberations before the Aviation Rulemaking Advisory Committee, despite major concerns in Congress.

However, in its Call-to-Action report, FAA said the Flight/Duty/Rest Aviation Rulemaking Advisory Committee (FRD ARAC) is addressing it as part of a Flight Risk Management Systems advisory circulars on commuting and rest to be issued for comment as part of the coming flight and duty time Notice of Proposed Rulemaking. A second AC would discuss identifying risks that can be managed by risk management programs such as low-time flight crews, crews flying together for the first time or crews with systemic performance problems. FAA chooses the advisory circulars or safety advisory route because actual rulemaking takes so long as evidenced by the flight and duty time rulemaking.

Pilot internet boards and comment forms have outlined the issues on commuting – base closures, numerous reassignments to various bases over a career and cost of living have all been mentioned – and make for compelling arguments.

Board member Robert Sumwalt recounted his professionalism when he flew commercially. He would leave the afternoon before an early flight, get a hotel, have a relaxing dinner and show up fully rested for the flight, a luxury for regional pilots who are ill-paid, thanks in large part to their unions who trade on them in favour of their major carrier counterparts. The board recommended airlines provide some sort of rest accommodations.

Mr Sumwalt’s action is commendable, and repeated by hundreds of pilots every day, who consider it the cost of doing business, if they want to live where they live. Still, it is a practice worthy of more study in terms of fatigue and certainly leads to the actions of the Colgan copilot who commuted from the West Coast while counting on catching some sleep in noisy crew lounges.

Sumwalt’s actions on flying in the day before a flight really amounts to subsidising the airlines, one that was worth it when pay scales were a lot higher. From the airline perspective, becoming a hotelier is out of the question, as Sumwalt pointed out when he heard the recommendation and wanted an answer on this issue before he received a deluge of emails from industry.

But the point is that, with the restructuring of the industry, pilots and other employees have lost much, including their high salaries - and are likely unable to afford to take on these extra costs. Indeed, it is this restructuring that has brought on many of the problems facing the industry and it is in this context that a broader discussion on safety is warranted. This restructuring not only impacts commuting, but training and a host of other safety issues.

As for the Colgan accident, the board seemed to indicate that little would have made a difference in this accident because the actions of these pilots were so far beyond the pale. They even deliberated, and finally recommended, that air speed indicators be made more foolproof. Noting the Bombardier EFIS did not have a cautionary amber strip on the air speed indicator or aural alert to warn the pilots of deteriorating airspeed, the board wants all EFISs to include such features. But, given the fact that  these issues are not new, legislating and regulating against stupidity should not be the role of Congress.

Flight & duty regulations

Meanwhile new flight and duty time regs are moving at their usual glacial pace. FAA Administrator Randy Babbitt put ARC on a short fuse, calling for an NPRM by Sep-2009. That was pushed back until Jan-2010 and Hersman criticized the agency for its continual delays, noting it will be spring before we see it. That could put it almost a year from the start of Babbitt’s call to action.

Professionalism is still not apparent

Much has been said over the last year about professionalism, but little has changed. The Air Line Pilots Association said it has long had a professional code of ethics and conduct policies and other unions are developing them, according to FAA. ALPA also recently published a white paper on professionalism. In addition, the agency will be calling together pilots for a professionalism and cockpit discipline conference later this year.

Professionalism, often cited in regional airline accidents, seemed to be a concern only among the regionals until the Northwest crew decided to surf on their laptops in order to answer a question on new crew scheduling procedures. The board even cited the Continental accident in Denver in Dec-2008.

While industry-wide professionalism is a concern, the fact that so many regional pilots were cited for lack of professionalism in so many accidents, means the spotlight on that industry is just a little brighter, especially since this is an issue the industry ignored for so long.

Both Hersman and Sumwalt began talking about this issue long before Colgan, by two years, in fact. Sumwalt took his message on the road to numerous safety meetings in the two years before Colgan and received vast coverage on his concerns about the regional airline industry, it was ignored. The Regional Airline Association preferred to consider it a question about which the board needed to be educated.

Complaining pilots - not sacred cows

What can be expected from NTSB’s professionalism meeting is a recitation of all the changes in the industry, especially restructuring through bankruptcy and later concessions, and what that has done to the pilot. Fair enough, pilots have taken it hard, along with all other airline employee groups. But the pilots seem to insist on (at least judging from the testimony of Captains Sully Sullenberger and Jeff Skiles of the legendary mid-Hudson water landing) complaining about it and the fact they are making so little progress in regaining what they have lost.

The conclusion, according to Sullenberger and Skiles: pilots have let safety and professionalism slip, along with morale. They’re human, it is understandable, but it is not over yet. Judging from the language coming from last week's United Airlines analyst call, we have only seen the beginning of the structural changes in the US legacy airline industry and, according to United executives, pilots and regionals are prime targets in capturing greater cost efficiency. That means that rather than regaining their former remuneration, there are more cuts to come. “There are no sacred cows,” said United CEO Glen Tilton. “The industry has made expedient decisions, when it was seemingly affordable or comfortable to do so, and regretted them thereafter.”

Wresting control of the deteriorating safety situation that belies the US accident statistics is the hallenge. The Board is seeing underlying trends which need to be addressed not only in the context of an accident but also in the context of industry changes since 2000. A more pertinent question is whether all the meetings being planned and those between regional and major partners will result in action.

Codesharing's impact on behaviour

This will likely be the most interesting of the discussions. Congress, as does the public, definitely feels that the major carriers are responsible for the safety of their regional partners. They contend that majors want all the benefits of codesharing, but, as soon as there is a problem, they want to shove the issue on to the regionals.

Indeed, they have done a good job of this in the past, which can be seen in the cancellation rate of regional flights compared to mainline flights. Of course, it makes perfect business sense since, as with the air traffic control system, they are biased toward accommodating maximum throughput.

Regionals have complained that, while they dutifully cancel flights at the request of the major, they are then punished for it in one way or another. At least that is what Mesa contends, but Mesa cannot be alone. It was for that reason, regionals began reporting their operational performance by measuring controllable performance, not just overall performance.

Now, if only the Department of Transportation would hop on board, since it does not delve into the reasons a flight might be chronically late or cancelled. However, if one drills down into the statistics, the regional performance is not nearly as bad as that depicted in the general DOT report.

Contract review

The FAA and DOT are trying to develop the authority and processes to review codesharing contracts. In the meantime, they are calling on carriers to “develop specific and concrete ways to ensure smaller airline partners adopt and implement the larger company’s most effective practices.”

And apparently they are doing it, according to the FAA Call-to-Action report. Unfortunately, it looks as if it has more to do with attending meetings than anything else. The Air Transport Association has invited both National Air Carriers Association and the Regional Airline Association to attend its Safety Council meetings. FAA also reported that all the major carriers have taken steps to ensure their partners implement their best practices but it also calls for regular meetings. Those meetings would analyze ASAP and FOQA data to identify common risk areas and address specific issues such as winter ops…once all regionals develop FOQA programs.

Frontline: "Flying Cheap"

Next week, three days before Colgan 3407’s first anniversary, Frontline will air Flying Cheap. The title alone tells you everything you need to know about its conclusion – major carriers are short changing safety in order to contract with the lowest cost provider. That is also very much on the minds of Congress, when it states reasons for why the major should be responsible for everything that happens on a flight.

The theory is widely accepted. “The Colgan Air crash highlights a major dilemma facing regional airlines,” reported ABC News’ Lisa Stark. “While they are subjected to the same rules and regulations as large carriers, who they often codeshare with, their earnings are lower and hence they pay their pilots less, have a less thorough evaluation process and often make their staff work the maximum number of hours allowed.”

"One of the reasons why we've got such a growth in regional carriers, which have done a tremendous job overall in improving over the last 20 years,” intoned safety expert John Nance. “But the problem here is that they are always running on the edge of economic disaster because they are the ones that the big carriers turn to try and save money.” But, John, it is the regional carriers which consistently are profitable, even as their major partners are awash in red ink.

While these sound bites may make good copy and dramatic headlines, they clearly show a lack of understanding of the regional airline industry and do a disservice to the carriers and the pilots.

Yes, using a regional airline is less expensive than having higher paid pilots and higher cost jets serve small- and medium-sized communities, but it is far from cheap, nor it is it good business. One has only to look at the major carrier balance sheets to see how much is spent on regional programs. Last year, it was approximately USD10.5 billion compared to revenues of approximately USD15.2 billion.

As much as they’d like to see it otherwise, the pilots, who perpetuate this impression, are hardly the best judge of business decisions. Not to mention the fact that, in criticising their regional members, they are really throwing them under a bus rather than helping the situation. Mainline pilot salaries come right out of the pockets of regional pilots.

While this suggests that there is plenty of money available to improve regional safety, the major carriers lost money as regional revenues were overwhelmed by the majors’ other expenses. So, these numbers cannot be seen in isolation from the major industry losses. The regional airlines, which almost always are profitable when their major counterparts are not, will likely post profits this year although they will be down from last year.

Should the majors and regionals spend more on safety? It isn’t clear that this is strictly a money problem as suggested by Congress, reporters and pilots. Indeed, the board seemed to indicate as much on Tuesday which brings us to our next point.

Training: quality is needed

While the Colgan pilots may be convenient scapegoats, it is not clear that they represent the vast majority of regional pilots. Even so, the regional accidents that have occurred do cause concern as so rightly pointed out by the board.

"Since the accident, we have examined every aspect of our operations to make sure that everything that could be done is being done," Colgan Air's parent company, Pinnacle Airlines Corp., said in a statement. "As a result, we have taken more than 20 important and specific steps to further enhance our operations."

After its acquisition of Colgan Air in 2007, Pinnacle immediately began to invest millions of dollars in upgrades to crew training, operations, leadership and equipment, according to Tuesday’s statement after the board meeting.

Even so, the board’s discussion depicted a training program that left pilots confused on one of the most basic of aircraft capabilities – whether or not it was subject to a tail stall. It is not. Early on it was thought the captain’s actions were done to address a tail stall but the board indicated that had he not panicked, there was time to correctly diagnose the onset of a wing stall. Indeed, he over-rode the aircraft stick pusher which was trying to put them nose down while he was pulling back on the yoke. Exacerbating this was the fact that the co-pilot did nothing to challenge the captain’s actions, the violations of the sterile cockpit rule and the programming a normal speed rather than the higher speed required for freezing weather when the crew was taking off from Newark.

Pinnacle also said that prior to the accident, it had also “proactively begun to adopt a full range of voluntary safety initiatives recommended by the NTSB and the Federal Aviation Administration (FAA) and did so before any calls were made for such programs to be mandatory. With these investments, we have established the same or better capabilities as every other major carrier in the United States.”

Training studies

The General Accountability Office last summer accepted an assignment from Congress to conduct a comprehensive review of all commercial airline pilot training and certification programs. In addition, the House passed HR 3371 The Airline Safety and Pilot Training Improvement Act of 2009 which includes measures to combat pilot fatigue, improve training practices and establish an electronic pilot’s records database.

The bill has been sitting there for some months awaiting Senate action. It would increase training requirements for commercial experience – to 1500 hours from the current 250. But, regionals have recruiting standards that are even higher than 1500 hours

Airlines have accepted suggestions of going beyond obtaining pilot records from previous employers by asking for voluntary permission to look at a pilot’s entire flight history, said the FAA. This would have revealed the many failures the pilot had before being hired by Colgan.

Indeed, this is a troubling issue. The board indicated there is no policy establishing how many times a pilot, whether student or already hired by a commercial airline, can fail before he is banned from flying. If there were ever a candidate, the Colgan pilot was it. Hersman said he had flunked so many times that he had to have a rare good day to pass.

A broader question

But, focusing on only regional airline pilots misses the point. Years ago we entered a new world, one that could no longer rely on the military to provide the training for commercial airline pilots.

It is no secret that pilots don’t see commercial aviation as a great career any longer. Just listen to the Sullenberger testimony last year and you get the picture. Many are opting for corporate pilot positions. Military pilots face two questions, continue to help save the world in a military that has made staying in far more attractive, or leave for the right seat of a regional jet. No contest.

While the NTSB has targeted two of the four problems for symposia, it should also call for a training symposium because this has gone on far too long as an issue. The descriptions of training academies and hours required for a commercial license must have been bone chilling and frustrating for the families sitting through Tuesday’s meeting. They sound ridiculous even to seasoned ears.

The FAA reported that it needed a supplemental or revised NPRM on training given the discussions during the 12 safety forums held last year. That NPRM, too, is scheduled for early 2010.

Mentoring programs between major and regional pilots has also been mentioned but FAA reported few actionable ideas emerged from the 15-June meeting. The FAA, consequently delayed the issue since the subsequent safety forums identified challenges including the fact that a personal commitment is required of pilots in any such program. “It is difficult to develop a program that assures this,” said FAA, who added that it was also difficult to set goals and metrics.

Industry has suggested that Joint Strategic Committees be established within a “family of mainline and regional partners in order to develop both pilot and corporate mentoring programs. Other suggestions called for periodic safety conferences led by employee association’s professional standards committees as well as mentor programs with aviation universities. So far, little has happened.

Déjà vu and complacency

Finally, Hersman noted that the lessons learned from Colgan had all be learned before which made her conclude only one thing – complacency was a contributing factor to the Colgan crash.

"Today is Groundhog Day, and I feel like we are in that movie," Hersman said, referring to the movie about a Pittsburgh weatherman reliving ground hog day over and over again. "We have made recommendations time after time after time. They haven't been heeded by the FAA." She said since FAA has yet to push reformed “across the finish line,” Congressional action will likely be needed.

STOP PRESS - Pilot fatigue ANPRM due next week

Saying experience is not measured by flight time alone, Federal Aviation Administrator Randy Babbitt called for recommendations on how to improve pilot qualification and training requirements in the wake of the Colgan Flight 3407 crash. Accompanying the announcement was an Advanced Notice of Proposed Rule Making on pilot certification with a 60-day comment period.

The call comes two days after the National Transportation Safety Board cited pilot training and qualification as major issues that go far beyond the crash of a single aircraft. The board also wants to standards set on how many times a pilot candidate can fail before being banned for commercial flight operations. The board indicated that the industry is well into a new era in which it can no longer rely of military trained pilots since the military has made it attractive to remain in and since the fate of airline pilots has diminished since 2000.

“Pilots need to have quality training and experience appropriate to the mission to be ready to handle any situation they encounter,” said Babbitt.

The public will have 60 days to comment on basic pilot certification in four key areas:

  • Should all pilots who transport passengers be required to hold an Air Transport Pilot (ATP) certificate with the appropriate aircraft category, class and type ratings, which would raise the required flight hours for these pilots to 1,500 hours?
  • Should the FAA permit academic credit in lieu of required flight hours or experience?
  • Should the FAA establish a new commercial pilot certificate endorsement that would address concerns about the operational experience of newly hired commercial pilots, require additional flight hours and possibly credit academic training?
  • Would an air carrier-specific authorization on an existing pilot certificate improve safety?

Its proposed rule on enhancing airline pilot training received more than 3,000 pages of public comments forcing, the agency to develop a supplemental proposal due out this spring along with the long-awaited and long-overdue flight and duty-time regs.


Colgan conclusions

  1. The flight crew was properly certificated and qualified in accordance with applicable Federal regulations.
  2. The airplane was properly certified, equipped, and maintained in accordance with Federal regulations.
  3. The recovered components showed no evidence of any preimpact structural, engine, or system failures, including no indications of any problems with the airplane’s ice protection system.
  4. The air traffic controllers who were responsible for the flight during its approach to Buffalo-Niagara International Airport performed their duties properly and responded immediately and appropriately to the loss of radio and radar contact with the flight.
  5. This accident was not survivable.
  6. The captain’s inappropriate aft control column inputs in response to the stick shaker caused the airplane’s wing to stall.
  7. The minimal aircraft performance degradation resulting from ice accumulation did not affect the flight crew’s ability to fly and control the airplane.
  8. 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.
  9. 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.
  10. The flight crew did not consider the position of the reference speeds switch when the stick shaker activated.
  11. 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.
  12. 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.
  13. It is unlikely that the captain was deliberately attempting to perform a tailplane stall recovery.
  14. No evidence indicated that the Q400 was susceptible to a tailplane stall.
  15. 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.
  16. 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, that would have facilitated the flight crew’s detection of the developing low-speed situation.
  17. 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.
  18. 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.
  19. The monitoring errors made by the accident flight crew demonstrate the continuing need for specific pilot training on active monitoring skills.
  20. Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior.
  21. 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.
  22. 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.
  23. 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.
  24. 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 determined.
  25. 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.
  26. Colgan Air did not proactively address the pilot fatigue hazards associated with operations at a predominantly commuter base.
  27. 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.
  28. The first officer’s illness symptoms did not likely affect her performance directly during the flight.
  29. 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.
  30. 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.
  31. 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.
  32. 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.
  33. 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.
  34. 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.
  35. 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.
  36. 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.
  37. 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.
  38. 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.
  39. 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.
  40. Mandatory flight operational quality assurance programs would enhance flight safety because all operators would have readily available data to identify operational risks and use in developing corrective actions.
  41. 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 required to share the data with the Federal Aviation Administration.
  42. 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.
  43. 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.
  44. 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.
  45. Weather documents missing key weather products 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.
  46. 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.

Probable cause

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. 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’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.


As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

  1. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques described in Advisory Circular (AC) 120‑71A, “Standard Operating Procedures for Flight Deck Crewmembers”; if the procedures are found not to be consistent, revise the procedures according to the AC guidance to promote effective monitoring. (A‑10-XX)
  2. For all airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121, 135, and 91K, require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low-speed condition. (Supersedes Safety Recommendations A‑03-53 and ‑54)
  3. Require that airspeed indicator display systems on all aircraft certified under 14 Code of Federal Regulations Part 25 and equipped with electronic flight instrument systems depict a yellow/amber cautionary band above the low-speed cue or the digits on the airspeed indicator change from white to amber/yellow as the speed approaches the low-speed cue, consistent with Federal Aviation Administration Advisory Circular 25-11A.
  4. Issue an advisory circular with guidance on leadership training for upgrading captains at 14 Code of Federal Regulations Part 121, 135, and 91K operators, including methods and techniques for effective leadership; professional standards of conduct; strategies for briefing and debriefing; reinforcement and correction skills; and other knowledge, skills, and abilities that are critical for air carrier operations. (A-10-XX)
  5. Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide a specific course on leadership training to their upgrading captains that is consistent with the advisory circular requested in Safety Recommendation [2]. (A‑10‑XX)
  6. Develop, and distribute to all pilots, multimedia guidance materials on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile cockpit adherence; techniques for assessing and correcting pilot deviations; examples and scenarios; and a detailed review of accidents involving breakdowns in sterile cockpit and other procedures, including this accident. Obtain the input of operators and air carrier and general aviation pilot groups in the development and distribution of these guidance materials. (A-10-XX) (Supersedes Safety Recommendation A‑07-8)
  7. Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to address fatigue risks associated with commuting, including identifying pilots who commute, establishing policy and guidance to mitigate fatigue risks for commuting pilots, using scheduling practices to minimize opportunities for fatigue in commuting pilots, and developing or identifying rest facilities for commuting pilots. (A-10-XX)
  8. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to document and retain electronic and/or paper records of pilot training and checking events in sufficient detail so that the carrier and its principal operations inspector can fully assess a pilot’s entire training performance. (A‑10-XX)
  9. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to include the training records requested in Safety Recommendation [6] as part of the remedial training program requested in Safety Recommendation A-05-14.
  10. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to provide the training records requested in Safety Recommendation [6] to hiring employers to fulfill their requirement under Pilot Records Improvement Act.
  11. Develop a process for verifying, validating, auditing, and amending pilot training records at 14 Code of Federal Regulations Part 121, 135, and 91K operators to guarantee the accuracy and completeness of the records. (A‑10‑XX)
  12. Direct all 14 Code of Federal Regulations Part 121, 135, and 91K operators of airplanes equipped with a reference speeds switch or similar device to (1) develop procedures to establish that, during approach and landing, airspeed reference bugs are always matched to the position of the switch and (2) implement specific training to ensure that pilots demonstrate proficiency in this area. (A-10-XX)
  13. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators and 14 Code of Federal Regulations Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features, such as a reference speeds switch. (A-10-XX)
  14. Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators of stick pusher-equipped aircraft to provide their pilots with pusher familiarization simulator training. (A-10-XX) (Supersedes Safety Recommendation A-07-4)
  15. Define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required angle-of-attack and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded. (A-10-XX)
  16. Identify which airplanes operated under 14 Code of Federal Regulations Part 121, 135, and 91K are susceptible to tailplane stalls and then (1) require operators of those airplanes to provide an appropriate airplane-specific tailplane stall recovery procedure in their training manuals and company procedures and (2) direct operators of those airplanes that are not susceptible to tailplane stalls to ensure that training and company guidance for the airplanes explicitly state this lack of susceptibility and contain no references to tailplane stall recovery procedures. (A-10-XX)
  17. Develop more stringent standards for surveillance of 14 Code of Federal Regulations (CFR) Part 121, 135, and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents, or other changes that warrant increased oversight, including the following: (1) verify that inspector staffing is adequate to accomplish the enhanced surveillance that is promulgated by the new standards, (2) increase staffing for those certificates with insufficient staffing levels, and (3) augment the inspector staff with available and airplane-type-qualified inspectors from all Federal Aviation Administration regions and 14 CFR Part 142 training centers to provide quality assurance over the operators’ aircrew program designee workforce. (A-10-XX)
  18. Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators to (1) develop and implement flight operational quality assurance programs that collect objective flight data; (2) analyze these data and implement corrective actions to identified systems safety issues; and (3) share the deidentified aggregate data generated through these analyses with other interested parties in the aviation industry through appropriate means. (A‑10‑XX)
  19. Seek specific statutory and/or regulatory authority to protect data that operators share with the Federal Aviation Administration as part of any flight operational quality assurance program. (A‑10‑XX)
  20. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to (1) routinely download and analyze all available sources of safety information, as part of their flight operational quality assurance program, to identify deviations from established norms and procedures; (2) provide appropriate protections to ensure the confidentiality of the deidentified aggregate data; and (3) ensure that this information is used for safety-related and not punitive purposes. (A-10-XX)
  21. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate explicit guidance to pilots, including checklist reminders as appropriate, prohibiting the use of personal portable electronic devices on the flight deck. (A‑10‑XX)
  22. Implement a process to document that all 14 Code of Federal Regulations Part 121, 135, and 91K operators have taken appropriate action in response to safety-critical information transmitted through the safety alert for operators process or another method. (A-10-XX)
  23. Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to revise the methodology for programming their adverse weather phenomena reporting and forecasting subsystems so that the subsystem-generated weather document for each flight contains all pertinent weather information, including Airmen’s Meteorological Information, Significant Meteorological Information, and other National Weather Service in-flight weather advisories, and omits weather information that is no longer valid. (A‑10-XX)
  24. Require principal operations inspectors of 14 Code of Federal Regulations Part 121, 135, and 91K operators to periodically review the weather documents generated for their carriers to verify that those documents are consistent with the information requested in Safety Recommendation [21] (A‑10-XX)
  25. Update the definitions for reportable icing intensities in the Aeronautical Information Manual so that the definitions are consistent with the more detailed intensities defined in Advisory Circular 91‑74A, “Pilot Guide: Flight in Icing Conditions.” (A-10-XX)

Previously Issued Recommendations Reiterated in This Report

The NTSB reiterates the following recommendations to the Federal Aviation Administration:

Require all Part 121 and 135 air carriers to obtain any notices of disapproval for flight checks for certificates and ratings for all pilot applicants and evaluate this information before making a hiring decision. (A-05-1)

Require all 14 Code of Federal Regulations Part 121 air carrier operators to establish training programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures in the training environment that would require a review of their whole performance history at the company and administer additional oversight and training to ensure that performance deficiencies are addressed and corrected. (A-05-14)

Require that all pilot training programs be modified to contain modules that teach and emphasize monitoring skills and workload management and include opportunities to practice and demonstrate proficiency in these areas. (A-07-13)

Previously Issued Recommendations Reclassified in This Report

Safety Recommendation A-07-13 is reclassified “Open—Unacceptable Response” in section 2.3.1 of this report.

Safety Recommendations A-03-53 and -54 are reclassified “Closed—Unacceptable Action/Superseded” in section 2.3.3 of this report. The recommendations are superseded by Safety Recommendation [2].

Safety Recommendation A-07-8 is reclassified “Closed—Unacceptable Action/Superseded” in section 2.4.2 of this report. The recommendation is superseded by Safety Recommendation [4].

Safety Recommendation A-05-1 is reclassified “Open—Unacceptable Response” in section 2.7.3 of this report.

Safety Recommendation A-07-4 is reclassified “Closed—Unacceptable Action/Superseded” in section 2.9.1 of this report. The recommendation is superseded by Safety Recommendation [12].

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