Image: Crash of Continental 3407
Dave Sherman  /  AP file
Continental Flight 3407 crashed into a suburban Buffalo home on Feb. 12, 2009. Safety investigators said that, faced with a stall, the pilot took action that was opposite to that which would have saved the aircraft.
updated 2/2/2010 8:15:23 PM ET 2010-02-03T01:15:23

Pilot error was the probable cause of an airline crash into a house near Buffalo, N.Y., last year, but the accident's root problems extend far beyond a single event, a federal safety panel said Tuesday.

The head of the National Transportation Safety Board, Deborah Hersman, said the accident casts doubt on whether regional airlines are held to the same level of safety as are major airlines, and she promised the board will pursue the issue. She also criticized the Federal Aviation Administration for taking too long to address safety problems raised by the crash, saying the same issues have turned up before.

"Today is Groundhog Day, and I feel like we are in that movie," Hersman said, referring to the 1993 Bill Murray movie about a Pittsburgh weatherman who repeatedly lives through the same day. "We have made recommendations time after time after time. They haven't been heeded by the FAA."

New fatigue rules proposed
The FAA said in a statement that it has driven significant improvements in pilot professionalism, training and background checks in the past year. The agency said it will soon propose new rules to prevent pilot fatigue, further improve training and increase the qualifications required to be an airline pilot.

The three-member board agreed unanimously that an "inappropriate response" by the captain of Continental Connection Flight 3407 to a key piece of safety equipment caused the crash. The board also said an incorrect airspeed entered into the plane's computers by the flight's first officer and the air carrier's inadequate procedures and training for entering airspeeds for freezing weather were contributing factors.

The board discussed issuing more than 20 safety recommendations as a result of the accident.

Hersman praised FAA Administrator Randy Babbitt for initiating regulation changes in response to the crash on Feb. 12, 2009, when a plane dove into a house, killing all 49 people aboard and one man in the house. But Hersman said Babbitt has been unable so far to push reforms "across the finish line" and that congressional action may be needed.

Flight 3407, operated for Continental Airlines by Colgan Air Inc., was approaching Buffalo-Niagara International Airport when the twin-engine turboprop experienced an aerodynamic stall and went into a dive. The board said Capt. Marvin Renslow should have been able to recover from the stall but that he did the opposite of what he should have done.

'Wasn't a split-second thing'
In the final seconds of the flight, two pieces of safety equipment activated — a stick shaker to alert the crew their plane was nearing a stall and a stick pusher that points a plane's nose down so it can recover speed, investigators said. The correct response to both situations would have been to push forward on the control column to increase speed, they said.

But Renslow pulled back on the stick shaker, investigators said. When the plane stalled and the pusher activated, Renslow again pulled back three times.

"It wasn't a split-second thing," NTSB safety investigator Roger Cox said. "I think there was time to evaluate the situation and initiate a recovery, but I can't give you a number of seconds."

Seventy-five percent of pilots who had experienced the stick-pusher activation in training also responded by pulling back instead of pushing forward, even though they knew ahead of time to expect a stall, investigators said.

The first officer, Rebecca Shaw, 24, should have stepped in to push the plane's nose down herself when Renslow, 47, responded improperly, but she may not have because she was a relatively inexperienced pilot, investigators said.

Shaw commuted across the country overnight to Newark, N.J., to make Flight 3407. It's not clear how much sleep either pilot received the night before the flight, but investigators said both pilots likely were suffering from fatigue. Hersman wanted to list fatigue as a contributing factors to the crash. The board's other two members declined, saying it couldn't conclusively be determined if fatigue had impaired the pilots' performance.

Airspeed error
Shaw erred at the beginning of the flight by programming an ordinary airspeed into the plane's computer, rather than the higher airspeed needed for freezing weather, investigators said. The plane didn't accumulate enough ice on the wings to stall, but the mix-up on speeds caused the stick shaker to warn of a stall even though one wasn't actually imminent.

Renslow's pull-back response, however, created a stall, the board said.

Both pilots violated rules against nonessential conversation during flight below 10,000 feet, which likely distracted them at a key moment, the board said.

Colgan's pilot training program was also criticized for not giving Renslow remedial attention despite his failures on several tests of piloting skill and for not emphasizing procedures for recovering from a full stall, including how to respond to the stick pusher.

Colgan said in a statement that the pilots were properly trained in how to recover from a stall.

"We have taken a number of important and specific steps to further enhance all of our training and hiring programs," the statement said.

Waiting on reforms
Federal regulators and lawmakers promised swift action after the Feb. 12, 2009 accident, but nearly a year later, key safety reforms haven't been implemented.

Since then, Federal Aviation Administration Administrator Randy Babbitt has persuaded regional airlines to make a series of voluntary safety improvements. FAA has also increased inspections of their pilot training programs. But the agency is still drafting regulations to address the most critical safety issues raised by the accident. Final action is at least months away, and perhaps even years.

Hersman said the NTSB board will follow up with a forum this spring on pilot and air traffic controller professionalism and with another forum on partnerships between major airlines and regional carriers, which increasingly handle the airlines' short haul-flights.

Karen Eckert of Williamsville, N.Y., whose sister Beverly Eckert was killed in the crash, said the victims' families are frustrated by the slow pace of the federal response to the crash. She noted, for example, that an earlier version of the crew-training proposal gave airlines five years from the proposal's effective date to comply.

"That's a very long time when there are lives that can be lost," she said.

'Nothing has changed'
On Capitol Hill, the House passed legislation aimed at forcing FAA to strengthen regulations. There's no disagreement over the need for legislation, but action has been slowed by unrelated Senate disputes. It remains unclear when a bill might be enacted.

"Here we are, almost a year later, and fundamentally nothing has changed in terms of the conditions that caused that accident," said former NTSB board member Kitty Higgins. "The only thing that has changed is public awareness."

The last six fatal domestic airline accidents involved regional carriers. The NTSB has cited pilot performance as a factor in three of those accidents.

More on: Flight 3407

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Video: Buffalo crash inquiry points to pilot errors

  1. Transcript of: Buffalo crash inquiry points to pilot errors

    WILLIAMS: Good evening.

    Newscast: Safety record of commuter airlines

    BRIAN WILLIAMS, anchor: If you fly a lot these days, that means you're likely flying on commuter airlines more of the time. They fly under the brand name of the big name carriers a lot of the time, but they're not. Their pilots look the same passing through the airport but often they are not. And the stats are not on their side. Every fatal airline crash since 2001 has involved a commuter airline . Most recently the loss of 50 lives near Buffalo , New York . Today the final report on that crash came out and the inescapable conclusion appears to be it didn't have to happen. It's where we begin tonight with NBC 's Tom Costello in our Washington newsroom. Tom , good evening.

    TOM COSTELLO reporting: Hi , Brian . The NTSB 's report coming out in record time . Regional airline Colgan Air was flying Flight 3407 for Continental but flying Continental 's logo. Today the NTSB heard evidence that this crew simply wasn't up to the job and it's time for some changes. The NTSB 's investigation into what caused Flight 3407 to crash outside of Buffalo points to a complete breakdown in cockpit discipline and basic piloting. First Officer Rebecca Shaw was texting from the cockpit just five minutes before takeoff, a violation of FAA rules. And during much of the hour-long flight from Newark , Shaw and Captain Marvin Renslow were talking about personal matters, not the flight.

    Mr. ROBERT SUMWALT (NTSB Board Member): It was as if the flight was just a means for the captain to conduct a conversation with this young first officer.

    COSTELLO: As the plane approached Buffalo , the crew failed to notice their air speed had dropped. When cockpit warnings went off, Captain Renslow , who'd failed multiple FAA tests and check rides, did exactly the wrong thing and pulled the nose up, causing the plane to stall and crash. At NTSB headquarters today, family and friends wore red in remembrance of the 50 people who died, among them Kevin Johnston 's family.

    Ms. KATHY JOHNSTON (Crash Victim's Wife): The more I learn, there is a lot of anger and frustration that this has gone on, that they were so incompetent up there.

    COSTELLO: Among the NTSB 's findings, crew fatigue, a lack of training, lack of professionalism and maturity, a lack of experience and basic skills all contributed to the crash.

    Ms. DEBORAH HERSMAN (National Transportation Safety Board Chairman): And unfortunately it's taken 50 more lives for us to focus additional attention on these issues that have not been addressed.

    COSTELLO: Today, Colgan Air insisted the crew was trained properly but, quote, "We cannot speculate on why they didn't use their training." But with regional airlines involved in the last six fatal accidents, a former NTSB chairman says new pilot hires should be required to have far more cockpit time.

    Mr. MARK ROSENKER (Former National Transportation Safety Board Chairman): You can get a job in the regionals with something like 250 to 300 hours. And maybe that's not good enough.

    COSTELLO: There's a big push for new pilots to have 1500 hours of cockpit time and much more training, more monitoring. Meanwhile, the NTSB is now planning new hearings into the relationship between the big airlines and the small, regional airlines that fly those code-sharing routes. Brian :

    WILLIAMS: What a haunting story for the families of those 50 souls. Tom Costello starting us off in Washington tonight. Tom , thanks.

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