NTSB Blames Crew in February 2009 Buffalo Crash

During a public meeting on February 2, 2010, the NTSB adopted a report on the February 12, 2009 crash of Continental Connection flight 3407 that determined that the captain inappropriately responded to the activation of the stick shaker, which led to a stall from which the airplane did not recover.

The aircraft was a Bombardier Dash 8 (N200WQ), and was flying as a Continental Connection aircraft, though it was operated by Colgan Air. On the night of February 12, 2009, it was on a scheduled flight from Newark, NJ to Buffalo, NY and crashed in a residential area about five miles (8km) from the airport. One house on the ground was destroyed. All 45 passengers and four crew members were killed, along with one person on the ground.

Their report stated that during approach, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded to the warning 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 from which the crew could not recover. The NTSB also identified as probable causes the flight crew's communications procedures, the captain's ineffective management, and the airline's procedures for airspeed selection during approaches in icing conditions.

This investigation has generated substantial public interest over the past year in part because of issues, that may have contributed indirectly to this accident, including crew fatigue and the related issue of pilot pay. The captain commuted hundreds of miles and the first officer commuted from the other side of the country prior to reporting for duty, and the NTSB concluded that both pilots used an inappropriate facility during their last rest period before the accident flight. The NTSB also concluded that the pilots’ performance was likely impaired because of fatigue.

The synopsis of the accident investigation report is currently available, and the full report will be available in a few months. In the meantime, the public can review a wide variety of information, including the public docket, which contains testimony, exhibits, and other information used by the NTSB during the investigation.

AirSafe.com's Initial Report on this Accident
Audio: MP3 | Video: iPod/MP4 | WMV | Google Video | YouTube

NTSB Accident Animation
The following NTSB animation of the last few minutes of the flight shows excerpts from the flight data recorder (FDR), the cockpit voice recorder (CVR) transcript, recorded radar data, and aircraft performance data. The audio portion of the video is from air traffic control communications, and does not include audio from the cockpit.

Resources
Additional information about this event
Synopsis of NTSB accident investigation
NTSB press release on the accident report
NTSB public docket on the investigation
Colgan Air input to the NTSB investigation
Previous Continental crashes
Other Dash 8 events
Continental Airlines Wikipedia page
Continental Express Wikipedia page
Continental Connection Wikipedia page
Continental fleet
Continental Express fleet
Colgan Air fleet

AirSafe.com YouTube channel

Airlines Fined for Stranding Passengers Plus The Best Passenger Safety Briefing Ever

Three Airlines Fined for Stranding Passengers Overnight
Earlier this year on August 8th, Continental Express Flight 2816, which was en route from Houston to Minneapolis and carrying 47 passengers, was diverted to Rochester, Minnesota because of thunderstorms where it landed about 12:30 am. The passengers and crew ended up stranded on the aircraft for over seven hours because the terminal had already closed for the night, and the employees who could have opened the terminal refused to do so.

This event attracted national attention at the time, and the US Department of Transportation (DOT) announced yesterday that it would impose $175,000 in fines on the three airlines involved. Continental Airlines and its regional airline partner ExpressJet, which operated the flight for Continental, were each fined $50,000. Mesaba Airlines, which was responsible for operating the terminal at Rochester, Minnesota, was fined $75,000.

This was the first time that the DOT has fined airlines for stranding passengers on the tarmac, but by no means was this the first time that passengers have been stuck on the tarmac for long periods of time. Earlier this month, AirSafeNews.com had an article about the delay statistics made available by the DOT's Bureau of Transportation Statistics.

The Best Passenger Safety Briefing Ever
When it comes to preflight passenger safety briefings, most passengers have sat through many of them, and most of them are not the least bit entertaining or memorable. The FAA does not dictate what information airlines should provide passengers during the preflight safety briefing. However, the FAA provides general guidance in Advisory Circular 121-24C, where one of the suggestions is that "The pretakeoff oral briefing should be given so that each passenger can clearly hear it and easily see required demonstrations. Flight attendants giving these briefings should speak slowly and distinctly."

Flight attendant David Holmes of Southwest Airlines created a preflight passenger briefing that ignored the advice about speaking slowly, and was both entertaining and memorable.

National Geographic Traveler published an extensive interview with David Holmes where he talked about his in-flight rapping. The following question and answer is the highlight of that interview.

National Geographic Traveler - The Federal Aviation Administration has some pretty strict requirements about in-flight safety announcements. How did you ensure that you met those, while still maintaining your artistic integrity?

David Holmes - Everything we have to say is carefully scripted for us -- all the safety information. As you know, one challenge is getting people to listen -- the other is making sure they have all the info. Why shouldn't it be fun?

Why not indeed.

Loose and Missing Screws on a Continental Airlines 737 Flying from Newark to Austin in September 2009

Back in August, the AirSafe News had a story about a Jat Airways 737 flying with numerous loose screws. One of this site's readers claims to have been an eyewitness to another loose screw event, this time involving a Continental Airlines 737. The first photo shows the right engine and strut, and in the second closeup picture, one screw appears to be completely missing and another appears to be loose.

The witness, who goes by the name conscious_consumer, in the blog about this event, describes being on Continental Airlines Flight 350 (Newark, NJ to Austin, TX) and seeing loose and missing screws on part of the engine strut. While no date was given in the blog, the two photos have a date stamp of 28 September 2009.


Seeing something like this may make any passenger uncomfortable, as the following description of the event from conscious_consumer shows:

I was aboard Continental flight 350 EWR – AUS @ 7:15AM EST) and looked out of my window and realized that something about the mounting (I am sure it’s not the proper technical term but I hope I’ll get my point across using it) of the engine caught my eye. It looked like one of the screws was not all the way in, creating an odd looking shadow – which was catching my attention. When I took a closer glance, I noticed that, right below the odd looking screw, an entire screw appeared to be missing.

Key Questions
Given the potential seriousness of these loose and missing screws, the kinds of questions posed by the AirSafe.com News in its earlier story about Jat Airways should be asked again:

- Were the flight crew or maintenance crew aware of the loose and missing screws before the flight?

- Did the maintenance and flight crews follow procedures with respect to the missing and loose screws?

- Are the airline's procedures consistent with Boeing's recommended procedures for this model of the 737?

- Are the airline's procedures consistent with FAA regulations?

- How many flights did this aircraft make before the condition was corrected?

- Are missing screws a common occurrence with aircraft in the Continental fleet?

Comments and Feedback
The AirSafe.com News would like to ask its readers for feedback, especially from pilots, maintenance technicians, and airline safety professionals, about this particular event. Any information or evidence that would confirm that this event occurred would be especially welcome. Feel free to leave comments on this site, or to contact AirSafe.com at feedback.airsafe.org.

You can also file an official report with the following organizations:

FAA Aviation Safety Hotline - You can call the 24-hour hotline at 800.255.1111 or fill out the online form at http://www.faa.gov/contact/safety_hotline/ for issues related to improper maintenance activities, aircraft incidents, bogus parts, and violations of FAA regulations.

NASA Confidential Reports - Pilots, cabin crew, maintenance crew, and other aviation professions with direct knowledge of this issue can confidentially send a report to NASA's Aviation Safety Reporting System (ASRS).

At Least 14 Injured in Suspected Continental Turbulence Event

Continental Airlines Flight 128, a 767 en route from Rio de Janeiro to Houston, diverted to Miami after apparently experiencing a turbulence event. Unrestrained light attendants and passengers were thrown against the ceiling and into the overhead compartments. One woman reportedly hit a luggage bin so hard that her head stuck there. After landing, 14 people were taken to Miami-area hospitals and were treated for their injuries; four were in serious condition.

This is the fourth safety related event in the last 12 months for Continental. In December 2008, Continental Flight 1404 crashed in on takeoff in Denver and was destroyed by fire. None of the passengers or crew were seriously injured. In February 2009, Continental Connection Flight 3407 crashed near Buffalo during approach, killing all 49 passengers and crew members, as well as one person on the ground. In June of this year a Continental 777 captain died during a transatlantic flight en route from Brussels to Newark.

In its annual safety review released by the NTSB in March 2009 indicated that turbulence was associated with 22 percent of all U.S. airline accidents and 49 percent of serious injury accidents between 1996 and 2005.

While this is suspected to be a turbulence event, further investigation may reveal the ultimate cause of this event. For example, last year, a Qantas A330 was involved in what was first thought to be a turbulence event, but the Australian authorities found that it was not the case.

Plane Crashes and Significant Events for Continental
Plane Crashes and Significant Events for the 767
Fatal Turbulence Events Since 1980
Turbulence Resources for Passengers

Continental Airlines Captain Dies During Transatlantic Flight

The captain of Continental Airlines Flight 61, a 777 en route from Brussels to Newark, died while the aircraft was in flight over the Atlantic. The captain was replaced by a reserve first officer and the crew declared an emergency. The aircraft landed without further incident. There were 247 passengers on board, and there were no other injuries to passengers or crew.

Early reports indicate that the captain, who apparently died of natural causes, was removed from the cockpit and placed in the crew rest area. The airline stated that the crew of this flight included the captain and two first officers, this extra flight crew member is required by the FAA for longer flights such as this one.

The airline reported that the captain was 60 years old and had been with the airline for 32 years. Coincidentally the FAA changed the rules in December 2007 to raise the mandatory retirement age from 60 to 65 to fly large passenger aircraft. This rule change was consistent with a 2006 ICAO regulation change that also changed the mandatory retirement age to 65.

This is the third safety related event in the last 12 months for Continental. In December 2008, Continental Flight 1404 crashed in on takeoff in Denver and was destroyed by fire. None of the passengers or crew were seriously injured. In February 2009, Continental Connection Flight 3407 crashed near Buffalo during approach, killing all 49 passengers and crew members, as well as one person on the ground. The last significant safety event for the 777 was a January 2008 crash of British Airways Flight 38 in London. None of the 16 crew members or 136 passengers were killed.

Flight crew members dying or becoming incapacitated in flight are rare events. One recent incident of note was another transatlantic flight, this one a January 2008 Air Canada 767 flight from Toronto to London where the first officer had to be physically removed from the aircraft due to erratic behavior.

Note: An earlier version of this post mistakenly identified the incapacitated Air Canada flight crew member as the captain.

Plane Crashes and Significant Events for Continental
Plane Crashes and Significant Events for the 777

NTSB Hearings on the Buffalo Plane Crash

On May 12th, 2009, the NTSB began a three-day public hearing about its ongoing investigation into the fatal February 2009 crash of a Continental Connection airliner in Buffalo, NY. Among the issues that came up were the possible roles of crew fatigue and crew training in the accident. During the last day of the hearing, noted aviation consultant Mike Boyd and I sat down with host Dave Berns of the "State of Nevada" program on KNPR radio in Las Vegas.

KNPR Interview on 14 May 2009 (15:21)

Additional Information
NTSB Public Docket on the Investigation
Accident Details from AirSafe.com
Todd Curtis book Understanding Aviation Safety Data

Risk, Safety, and the Plane Crash in Buffalo

Yesterday, the NTSB began its public hearings into the 12 February 2009 crash of a Continental Connection Dash 8 near Buffalo, NY. One of the issues that is of interest to the media is the safety of feeder airlines like Colgan Air which operated the Continental Connection accident aircraft. While the aircraft had "Continental" painted on the side, and may have a similar paint scheme as Continental, the fact is that the aircraft was not operated by Continental Airlines.

One common question that AirSafe.com gets about this situation is whether the feeder airline is just as safe. When I was contacted by the Wall Street Journal on the day the hearing again, in my quote that appeared in an article the paper the next day, my point was that safety is a subjective concept, and different people can have different ideas on whether an activity is safe or unsafe. I gave the example of skydiving. While sky divers believe the activity is safe, most other people would think that it was an excessively risky activity.

This brings out a more important point, that safety and risk are not the same concept and and not substitutes for one another. As explained in some detail on AirSafe.com, risk, typically an unwanted outcome combined with the likelihood of that outcome, is something that can be defined explicitly and be measured objectively. Given the same definitions and data, different people should come to the same conclusion about how much risk exists in a situation.

By comparison, safety, like beauty, is in the eye of the beholder, and does not have to be associated with anything measurable. For example, the FAA requires that any US airline operating an airliner with the capacity for 10 or more passenger seats operate under the same set of regulations. However, an aircraft that is designed to seat 10 passengers will have FAA design requirements that are very different, and in some ways less strict, than the design requirements for an aircraft that can seat 300 passengers.

The different design requirements imply that different potential risks are dealt with in different ways depending on the size of the aircraft. These differences mean that the risks of flying on these two types of aircraft are not the same. However, the FAA allows both aircraft to operate under the same safety regulations.

Risk and safety questions can come up in other ways during an accident investigation. During the first day of the public hearings, it was revealed that shortly before the crash, a specific warning system was activated, but the crew apparently reacted to the warning in ways that made the situation worse and led to the aircraft departing from controlled flight.

Even more revealing were media reports that prior to the accident, Colgan pilots were no required by the airline to have hands-on simulator experience that would show them how to respond to this kind of warning. To the average passenger, allowing pilots to fly a plane without having adequate training in how to respond to critical warning systems is both unsafe and too risky. It will be months before the public finds out if the NTSB agrees.

Updates to Two Most Recent Continental Crashes

AirSafe.com just finished updating the status of the 20 December 2008 crash of a Continental Airlines 737-500 at Denver. The aircraft, which was on a scheduled flight to Houston's Intercontinental Airport, departed the runway during takeoff and skidded across a taxiway and a service road before coming to rest in a ravine several hundred yards from the runway. The aircraft sustained significant damage, including a post crash fire, separation of one engine and separated and collapsed landing gear. There were about 38 injuries among the 110 passengers and five crew members, including two passengers who were seriously injured. Because this did not involve the death of an airline passenger, this is a significant event as defined by AirSafe.com

Below are the audio and video versions of the podcast.

Continental Airlines Accident in Denver
Audio: MP3 | Video: iPod/MP4 | WMV | Google Video | YouTube

For more videos, visit the AirSafe.com YouTube channel at video.airsafe.org.

Additional Information on the Buffalo Accident
The site added a page with fatal and significant events involving the Dash 8 model airliner, the same model involved in the fatal 12 February 2009 crash in Buffalo, NY.

Additional information about both the Buffalo and Denver events is available at http://www.airsafe.com/events/airlines/cal.htm

Continental Connection Crash in Buffalo 12 February 2009

The aircraft, a scheduled flight from Newark, NJ and operated by Colgan Air, crashed in a residential area about five miles from the airport. At least one house on the ground was destroyed. All 44 passengers and four crew members were killed, along with one person on the ground.

AirSafe.com's Initial Report on this Accident
Audio: MP3 | Video: iPod/MP4 | WMV | Google Video | YouTube

Additional information about this event.
Plane crashes involving the Dash 8
Synopsis of NTSB accident investigation

For more videos, visit the AirSafe.com YouTube channel.