The US National Transportation Safety Board identified pilot error as the cause of the February 2009 Colgan Air Q400 crash that killed 50, stating in its report released late Tuesday, "When the stick-shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded correctly to the situation by pushing forward on the control column. However, the captain inappropriately pulled aft on the control column and placed the airplane into an accelerated aerodynamic stall."
Other factors cited by NTSB were the flight crew's failure to recognize the position of the low-speed cue on flight displays, failure to maintain a sterile cockpit and Colgan's "inadequate procedures" for airspeed selection and management during approaches in icing conditions (ATWOnline, Dec. 15, 2009).
The board said the issues encountered in the investigation will be "studied at greater length" later in the year and it delivered recommendations to FAA concerning strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot records, stall training and airspeed selection procedures. FAA said it would review the recommendations and "soon" propose rules to prevent pilot fatigue and improve training.
In a statement, Colgan said the pilots received thorough training in handling a stall situation and that it "cannot speculate on why they did not use their training" the night of the crash. The airline has "examined every aspect" of its operations since the accident and will "continually work to enhance all of our programs."
The Air Line Pilots Assn. commented that though the meeting "highlighted many longstanding aviation safety priorities. . .including identifying a clear need to improve pilot screening, training, and mentoring and modernize flight-time/duty-time regulations" for pilots, NTSB's final statement of probable cause ignored many of these factors. "The conclusion of simple pilot error ignores the multitude of contributing factors in every accident." ALPA President John Prater said.
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