Flight 3407 Case Study

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Fatigue has been linked to well over two hundred and fifty fatalities reported by major air carriers, not including general or experimental aviation according to the FAA. There is no doubt that fatigue played a major role in the crash of Bombardier DHC-8-400 operated by Colgan Air, Inc. the NTSB started aircraft accident report 10-01 in early February 2009. Bombardier DHC-8-400 tail number N200WQ flight 3407 was approaching Buffalo-Niagara International Airport. During the instrument approach, flight 3407 experienced ice buildup on the leading edges. Icey conditions coupled with poor monitoring of the airspeed lead flight 3407 to enter into an aerodynamic stall. Unable to recover, flight 3407 crashed into a residual home killing all forty-nine …show more content…
The demeanor of the captain displays his laissez-faire style of leadership especially in the cockpit, where the flight crew ignored both company and FAA‘s sterile cockpit rule. They carried on with a conversation below ten thousand feet that was not related to their duties. The flight crew also began to notice an excessive amount of ice buildup on the leading edges, instead of immediately employing di-icing boots they shifted their conversation to earlier training in icy conditions or lack thereof. At 2216 the first warning came of an impending aerodynamic stall. This happened in two ways, first the stick shaker was activated and started to shake. Second there were both audio and visual cues. The air crew was never able to get the aircraft back completely under control. They also failed to notice their air speed slowing down. Because of the lateness of the flight and being at the end of the day both pilot and copilot were very fatigued. Fatigue also greatly impacted their ability to multitask linking their inability to cope with icing conditions, stick shaker and losing air speed. The NTSB investigators came up with forty-six finding leading up to the fatal crash of flight …show more content…
(p 152)
The air crew’s fatigue likely reduced their performance, although it is unknown how significant the fatigue caused their performance deficiencies. NTSB investigators concluded that operators have the responsibility to assess and mitigate all risks associated with commuting pilots. It is left to the pilots who commute to manage their off-duty time effectively. Colgan Air poorly addressed fatigue issues even though it had a large number of commuters. The captain had a history of showing a weakness in basic aircraft controls and instrument flying, this notwithstanding he was not readily identified. Remedial training is a must for pilots with deficiencies.
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.

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