Report into Buffalo air crash blames accident on basic error by captain

From Times Online February 3, 2010   Airlines in the United States have been told to review their flying standards after the crash of a commuter jet was officially blamed on elementary error by the captain.   The crash of the Colgan Air turbo-prop, which killed 50 people at Buffalo, New York, a year ago, was caused by Captain Marvin Renslow pulling the control column the wrong way, the National Transportation Safety Board (NTSB) said in its report on the accident.   The warning over poor performance on the flight deck echoed a view among experts in the US and Europe that some pilots lack old-fashioned skills in the automated cockpits of modern airliners.   On the Colgan Bombardier airliner, an automatic “stick shaker” vibrated the columns to alert the pilots that the aircraft was flying too slowly as it approached to land at Buffalo. Mr Renslow, 47, pulled back, raising the aircraft’s nose. This triggered an aerodynamic stall, sending the Bombardier airliner into an uncontrolled dive to the ground. All 49 onboard died as well as a man on the ground.   All pilots, from their first lesson, are taught never to raise the nose of an aircraft that is close to stalling. Lowering the nose — which is counter to instinct — increases the speed of the air over the wings, ensuring that lift is maintained.   The NTSB said: “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.”   Neither the captain or Rebecca Shaw, the 24-year-old first officer, appeared to have recognised that the aircraft was approaching a stall, it said.   The NTSB also noted a series of failures by the crew on the airliner, which was operating as a Continental Connection flight. Ms Shaw sent text messages from her mobile telephone while preparing for take-off from Newark, New Jersey. There was a misunderstanding between captain and co-pilot on the setting of a minimum speed alert. Before take-off the captain set it at a higher than standard speed to allow for possible icing but the co-pilot was unaware of this. Neither noticed ample visual warnings that speed was dropping to the minimum. There was unnecessary chatter between the crew. Ms Shaw was also tired from flying cross-country overnight to start her shift and she was suffering from a heavy cold.   The NTSB called on airlines to improve their crew training and procedures. That echoed an internal report in Air France last year, which raised the alarm over complacency and told its pilots that they needed to brush up on their technique as aviators. They should spend time hand-flying small aircraft, it told them.   The NTSB report also warned against the dangers of using mobile telephones and other appliances while in the pilot’s seat. “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,” it said. Similar advice came after the incident last autumn when a Northwest Airlines aircraft overflew its destination airport in Minneapolis because the pilots’ attention was focused on a discussion that involved using their laptop computers.   The NTSB noted other factors related to the Colgan crash, on a snowy night on February 12, 2009. Captain Renslow had failed five performance checks over the course of his flying career, although his employer knew of only three. The crew had failed to follow standard procedures for communicating between themselves and cross-checking their actions.   Contrary to earlier assumptions on the accident, the aircraft was not suffering from iced wings when it slowed to land. When the stick-shaker began, the aircraft was not yet in a stalled state. The smooth air-flow over the wings and tail was only disrupted when he pulled back on the column, over-riding the stick-pusher that comes into action automatically as a last resort on the edge of a stall.   Deborah Hersman, head of the NTSB, said that the accident casts doubt on the safety standards at regional US airlines compared with the major carriers.