AT 481 Project

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AT 48100-002 Project Draft Augustus Hickman, Caleb Probst, Johnny Gonsalez, Ella Blazek, and Graham Gardner November 7, 2023

1 Colgan Air Flight 3407, marketed as Continental Connection Flight 3407, was a Bombardier Q400 en route from Newark, NJ, to Buffalo, NY on February 12th, 2009. The aircraft entered an aerodynamic stall on approach to Buffalo, and crashed into a neighborhood, killing all 49 onboard. The official cause of the accident, according to the NTSB, was the pilot’s inappropriate response to stall warnings. In response to this accident, the victim’s families pushed Congress to enact stricter regulations for regional carriers and improve working conditions and scrutiny involving pilots. The flight was conducting an instrument approach, the ILS RNWY 13 into Buffalo. On this approach, the Q400 slowed to 145 KIAS, and the captain asked for 5º of flaps (first notch). Through transcripts from the cockpit voice recorder, as well as the flight data recorder, the captain successfully slowed the aircraft to its approach speed. However, instead of intercepting the localizer, the lateral guidance of the approach, and controlling his airspeed, he intercepted the localizer. He continued to slow the aircraft to a speed of 131 KIAS while asking for another notch of flaps (25º). At this airspeed, the aircraft’s stall identification system, the stick shaker, activated. In response to the stick shaker warning, the captain pitched up instinctively and increased his power. What he should have done, following proper stall recovery procedures, was lower his nose and increase his thrust. However, the captain continued to pitch up, and while he added full thrust, his first officer also raised the flaps, further inhibiting recovery. The aircraft’s FDR showed rapid and excessive movements of pitch and bank before it ultimately crashed, fatally killing all 49 occupants. The cause of the crash was the crew’s inability to properly monitor their aircraft’s instruments on the approach. The primary cause of this inattention was fatigue. Compounding upon this, the captain, although relatively experienced, was not quite comfortable in the aircraft,

2 and should have been grounded. Our research paper will analyze the specific events that led up to this accident, and how we could have prevented them. We will dissect the de-icing procedure at Newark, a non-standard system whose rehearsal may have distracted the flight crew, and prevented them from staying ahead of the aircraft during the flight. We will use new methods like the Pilot Records Database, and the FAA’s mandated fatigue period, to combat the catastrophic domino effect that resulted in this accident. It is clear that in response to the accident of Colgan Air Flight 3407 many different procedures need to be updated, especially pilot training and flight hour requirements, as pilot error was the main cause of the accident as reported by the National Transportation Safety Board. After such an accident it is crucial to put in place policies that would prevent this type of accident from happening in the future. Following the accident, Congress passed The Airline Safety and Federal Aviation Administration Extension Act of 2010 which details many of the procedures we would have implemented following the accident. However, we believe that there are ways to add and improve upon these policies to create a safer environment for air transportation. In the aftermath of the accident, it was discovered that there should have been red flags that should have prevented the captain from operating flight 3407 or required additional for the captain to operate safely. In records released following the incident, Colgan managers expressed concern with the captain’s ability to operate the Bombardier Dash-8 Q400, although the captain was still allowed to fly the aircraft. The captain had many issues while training including failing multiple check rides and struggling to upgrade to the aircraft he was flying; Colgate managers had every right to pull the captain from flying though they did not.

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3 It is hard for managers to stop flights or send pilots back for additional training when their jobs are focused on increasing profits. To prevent this situation from occurring in the future a digital database of pilot flights and other reports should be required and managed by the FAA. The FAA’s main focus is not profit, unlike the private air carrier companies that need to make a profit. When a red flag comes up in pilot training or any other pilot discrepancy appears the FAA can take action by requiring that pilot to attend additional training. A program such as this has been implemented by the FAA in the previous few years called the Pilot Records Database. This program has made it easier for air carriers to verify pilot history. With constantly updating technology in the future the FAA should plan to use this system as a real-time system to prevent accidents. The FAA should create an algorithm to sort through pilot records and flight data to flag potential issues that need to be reviewed by human safety professionals. This would be a radical policy change, as the FAA would begin to have more of an every-moment role in preventing accidents, instead of having incidents reported to them and then responding. I believe that this change in safety policy could prevent a large number of accidents before they occur. The major policy change required to enact this would be requiring all air carriers, operating in the United States, to share real-time flight data with the FAA to be used in the database for detecting possible situations for accidents. Pilot training needed to be updated in response to the accident of flight 3407. The Captain of flight 3407 had amassed only 618 flight hours before being hired by Colgan Air. Following the accident, the FAA mandated that 1,500 flight hours would be required to become an Air Transport Pilot. The new mandate certainly made air transportation safer, though many critics saw the requirement as overkill and hurt many safe pilots’ abilities to become air transport pilots.

4 We would propose to create a more robust system that can respond differently to each case and scenario. The digital database of pilot flight data could be used to determine if pilots are fit to fly with their current training. If a pilot is flawless through training they could receive their air transport pilot license more soon. Pilots that struggle could have training that fits their deficiencies better. In the case of flight 3407, the pilots responded incorrectly to a stall, which could have been prevented with additional training. If a pilot is struggling with stall procedures the pilot database could suggest specific stall training that the pilot can do with the oversight of an instructor, so that the pilot can become proficient with stall procedures. Some pilots may be able to receive their ATP license after 500 flight hours while it may take another pilot 2500 flight hours, to have complete proficiency among all pilots. This policy to use a robust approach, aided by development in technology, could revolutionize the way pilots are trained. With more and more data in the database, the training could improve with time. These new policies are a good addition to the policies used by the FAA. In particular, the policy to make the FAA an increasingly active participant in the day-to-day safety procedure of air carrier flights. These new policies we would enact would mitigate an accident such as Colgate Air Flight 3407. A policy this system would have trouble correcting is pilot fatigue. Following the accident, the FAA increased the minimum rest time for pilots and required pilots to report their “fitness for duty.” To aid in fatigue management we would require all pilots of commercial flights to report their fatigue levels to the FAA system, as a new qualitative data point for the newly in-placed real-time system. This new self-reporting requirement would allow pilots to state their fatigue without fear of punishment from their companies; This would give the FAA increased oversight over airlines’ fatigue management

5 systems. The FAA could protect pilots who are not constant offenders from punishment from their companies who are trying to influence, possibly without even knowing, pilots from flying on flights that they are not fit to be flying. When investigators researched and looked into why Colgan Air Flight 3407, there seemed to be no reason why this accident happened. The pilots were adequately certified, there was no detected fault by Air Traffic Control, and components recovered from the crash showed no sign of damage. Everything seemed to work perfectly. Pilot training failures and fatigue seem to be the leading causes of this tragic event. However, from a safety assurance perspective, how can we improve our current safety program and ensure employees are confident and comfortable with these changes? A new policy being implemented is a digital database for pilots that the FAA can monitor. This aims to monitor pilot performance and alert safety officials of any concerning practices so that pilots can be informed of their mistakes, or sent to be retrained. Since this is an algorithm, data collection will be easy. Red Flag safety events that occur can be collected and monitored to look for repetitive errors that need to be addressed. Likewise, if these mistakes are being made by the same pilot repetitively, corrective actions can be taken to find out the root cause of these issues. Some of these mistakes will occur as a result of human error, which can be corrected through processes such as retraining or discussions about what went wrong and how these errors can be fixed. At other times, however, mistakes will occur due to mechanical issues. In this case, the digital database will still come in handy. By monitoring pilot performance, safety officials can properly assess how pilots react to emergencies and if there needs to be more retraining on specific emergencies to prevent and address them. Once this system has been implemented for a long period, surveys will be sent out to pilots to see if they prefer this system or not. It is

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6 expected that pilots will not be pleased with being monitored constantly and changes can be made if this new system is disliked. With this digital database also comes records for pilots. This database will include flight times, what aircraft pilots have previously flown, timeslots that pilots usually fly, amounts of time pilots are currently receiving for rest periods, etc. The measurable outcome that can be monitored is whether or not the digital database can flag pilots if they do not possess enough experience to perform specific duties or fly certain aircraft. Another desirable outcome is that when pilots are assigned to certain aircraft, employees assigning pilots can use the algorithm to see an extensive list of those who have piloted a certain aircraft, and those who have not flown the certain aircraft. Then management can group these pilots so that the pilots can build experience instead of having to go back to restudy airplane specifications, or never fly a certain airplane for the rest of their career. This presents a safety risk of having only one pilot possessing knowledge about certain aircraft, but this is a better alternative than having no experience for either pilot. Plus, this would be a more accepted outcome amongst pilots, as compared to constantly sending inexperienced pilots to training. Once again, once this system has been implemented for a long period, surveys will be sent out to pilots to see if they enjoy this system or not. Another factor present in this new digital database is fatigue reporting. Fatigue is something that the FAA has been trying to mitigate for a while, with the FAA passing the Flightcre Member Duty and Rest Requirements, requiring flight crews to be given 30 consecutive hours free from all duty. However, since the Colgan Air Flight 3407 incident occurred in 2009, this was not a requirement and the captain was awake for fifteen hours, with the first officer being awake for over nine. With the new digital database, pilots will be

7 encouraged to report their fatigue levels to indicate whether or not they are capable of performing their duties. The measurable outcome that can be monitored is to see how many pilots are willing to record their fatigue levels, how much time beforehand are they reporting fatigue, and if or if not the database can flag pilots that are reporting high levels of fatigue. This database will hopefully encourage management to seek new pilots to replace the fatigued ones and encourage management to give pilots ample resting periods before scheduling them for flights. Another outcome that must be monitored is management's response to fatigue reports, as there may be no pilots on standby and certain levels of fatigue may become acceptable to upper management to maintain profit. The misuse of this system may also cause pilots to report fatigue even when they are not fatigued and simply want to get out of work and should also be monitored and measured. Overall, employee cooperation and enjoyment of this new program is expected, since this is a new third-party system that can provide comfort for pilots knowing that there will be no consequences for reporting fatigue. However, once this system has been implemented for a long period, surveys will be sent out to pilots to see if they enjoy this system or not. Pilot fatigue is a longstanding concern in aviation. Fatigued pilots can exhibit reduced vigilance, slower reaction times, and impaired decision-making abilities. In Colgan Air Flight 3407, the captain had been awake for more than 15 hours and the first officer for over 9 hours at the time of the accident. Their early morning report times and commuting from far-off places contributed significantly to their fatigue. To mitigate this risk, the FAA took significant steps to enhance fatigue management. In 2011, they published the "Flightcrew Member Duty and Rest Requirements" to set limits on flight and duty periods while ensuring rest periods are adequate for recuperation. Airlines were also required to implement Fatigue Risk Management Systems.

8 Abnormal operations training is essential for pilots to be adept at handling unusual or emergency situations that diverge from standard operating procedures. The pilots of Flight 3407 did not respond correctly to the stick shaker and stick pusher activations, indicating an impending tail stall. The captain inappropriately pulled the yoke back, further inducing the stall rather than pushing forward to regain a safe flight attitude. To mitigate this risk the FAA took initiatives to emphasize the importance of recognizing and recovering from aerodynamic stalls in flight training. They proposed enhanced training methods with an emphasis on hands-on experience and realistic simulators. These measures were directed at ensuring pilots respond intuitively and correctly under stress. These procedures; however, will be specific to the company, so for each company it is important to have clear communication on what to do if a pilot finds themselves in an unsafe attitude. Environmental and external factors can pose serious risks to the safe operation of aircraft. Upon first glance, it seems ice accumulation on the plane’s wings was a contributing factor. While the Bombardier Q400 was equipped for flight into known icing conditions, and the pilots activated the deicing systems, the conditions were challenging. Moreover, the pilots discussed non-essential topics during a critical phase of the flight, a violation of the "sterile cockpit" rule, which could have contributed to their delayed response. In the wake of the crash, emphasis was placed on stricter adherence to the "sterile cockpit" rule, and further training was encouraged for operations in icing conditions. Awareness campaigns and training programs highlighted the risks associated with icing and the importance of focused attention during critical phases of flight. The tragedy of Colgan Air Flight 3407 exposed significant safety gaps in the regional airline industry. However, the subsequent rigorous investigations and analyses led to important reforms in fatigue management, training protocols, and operational safety. Such unfortunate

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9 incidents underscore the critical importance of continuous safety evaluations and updates in the aviation sector. Lessons drawn from Flight 3407 have certainly contributed to making air travel safer for all. In terms of Safety Risk Management, the FAA’s response allowed the aviation industry to appropriately learn from the mistakes that occurred during Colgan Air Flight 3407. Just preventing one hole in the Swiss Cheese model could prevent the accident itself; therefore, bringing these unsafe factors to light works to ensure crews are knowledgeable and do not make the same errors. Following the Colgan Air Flight 3407, Some procedures in place before the incident, known as SOPs, are standard procedures for their pilots to follow during the approach phase. The first procedure highlighted was the correct approach airspeed; this indicates that for average airspeed, all operators begin with Vref speed. In this case, with the bad weather that was also an essential variable in this situation, the pilots needed to add ten knots to that designated Vref speed but instead added seven, and that caused them to stall and not have enough speed to take off. Another procedure in place before the aircraft takeoff was the Sterile Cockpit Rule. This rule, in simpler terms, is the rule that they need to be engaged on their job, and no outside conversation or any personal conversation or any engagement of cell phone or other instruments that do not pertain to the flight must be aside while pre-flighting. Nevertheless, with the cockpit voice recorder, it was revealed that the first officer was on her cell phone during the taxi to send a text. The pilots were engaged in conversation about personal matters, and ultimately, the investigators believed these were the main reasons why the checklist completion took too long. They should have used specific techniques for deicing and also failed to realize the aircraft was flowing down and reaching a point of stall.

10 Furthermore, on the procedures, the CVR also picked up yawns from both the captain and the first officer. In addition, the first officer told the captain that she did not feel well before the flight. Within these indications, many incorrect procedures were taken to overcome certain aspects and bring in this idea of unwanted attitudes in the workplace, meaning having a macho attitude. Throughout all these procedures that were associated with the accident, they failed to keep operations for pilots in check. To begin with, the very first procedure that is presented is the correct approach speed, which is also connected to the sterile cockpit rule that the FAA has installed for every pilot in operation. The reason why it failed was because there was no leadership from the captain. Reflecting on what the first officer had said, she told the captain that she was not feeling well. However, the captain continued normal operations without taking the correct action needed for this particular situation. As a captain for any flight or airline, leadership is still a heavy skill for this type of work. In this case, if the captain knew how to take the right course of action, the outcome could have been different, but instead, it was not taken. Also, this goes back to the prior history between the captain and his career; as stated in the report by Aerotime Hub, The captain for this flight had failed three tests beforehand, and it was stated that NTSB suggested this captain was not adequately trained to handle such scenarios of stolen which was also a factor in this incident. However, the improper amount of training amongst the pilots and these scenarios affect the lives of the pilots and those on board because it was taken. In this line of work, any shortcut taken could cost the lives of everyone on board. As stated in the report, they failed to check flight instruments and respond to those instruments before coming to a stall. With the steps taken throughout the operation of this flight, we can reflect on where these mistakes start to present themselves and how they failed in the overall operation of this flight.

11 Overall, what we would improve to better situate any other Pilots who were to go through a situation like this would be more on the hiring side and making sure we are hiring qualified people who have experience in these situations and have a certain amount of hours that is required. This shows that we have experienced pilots, and in any given scenario, they know what to do and what correct course of action needs to be taken. Another idea we would improve is self-evaluating amongst pilots and making sure that they are feeling well before their flight, and if not feeling well, to let their pilot know and take the correct course of action. Furthermore, another thing that would have helped in this scenario is better leadership skills among the pilots; if airlines were to hire a pilot, they could display or at least show leadership from previous work experiences. With all this being said, we as humans make mistakes, but we can always reflect on those mistakes made by others to continuously improve in an area that is constantly busy 24 hours a day and seven days a week with no stopping any time of the day. Doing things by the book, not taking shortcuts, and having proper training and qualifications could create a healthy work culture and a successful safety management system. The Tragedy of the Colgan Air Flight 3407 serves as a reminder to rethink some of our embedded safety protocols, through pilot training and targeted fatigue risk management for the aviation sector. In the aftermath of this accident, improved on-site pilot training systems were implemented, including prudent mandatory rest periods, and emphasized focus on training during critical stages of flight. Implementing our real-time self-evaluation solution acts as a preventative means to combat pilot fatigue. Pilots shouldn’t be incentivized to fly in conditions that they do not feel comfortable with. The incorporation of fatigue reporting mechanisms within this system can enable proactive management of pilot fatigue, ensuring that pilots are adequately rested and capable of performing their duties at an optimal level. The enhancement of training

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12 scenarios during critical stages of flight, as well as a mandated sterile cockpit policy, can help combat some of the distractions encountered by Flight 3407 pilots. Furthermore, emphasized training on aerodynamic stalls and adherence to strict recovery procedures will ensure that pilots are prepared for any condition within these critical stages of flight. In conclusion, the tragic events of Colgan Air Flight 3407 allow us as future members of the sector to implement fatigue management and targeted training procedures to avoid these catastrophes in the future.

13 Citations Fatigue in aviation brochure - Federal Aviation Administration. (n.d.-a). https://www.faa.gov/pilots/safety/pilotsafetybrochures/media/Fatigue_Aviation.pdf Jeff PetersonJeff Peterson serves on the faculty of the Minnesota State University, & Peterson, J. (2023, June 5). How not to lose control: What we can learn from Colgan 3407 . Air Facts Journal. https://airfactsjournal.com/2023/06/how-not-to-lose-control-what-we-can-learn-from-colga n-3407/ Loss of control on approach Colgan Air, Inc.. operating as continental ... (n.d.-b). https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1001.pdf Mickeviciute, byRosita, & Mickeviciute, R. (2023, June 9). How flight 3407 completely changed aviation safety . AeroTime. https://www.aerotime.aero/articles/23034-flight-completely-changed-aviation-safety Public Broadcasting Service. (n.d.). Internal emails reveal doubts about flight 3407 pilot . PBS. https://www.pbs.org/wgbh/frontline/article/internal-emails-reveal-doubts-about-flight-3407 -pilot/