This paper investigates the February 12, 2009, crash of Colgan Air Flight 3407 near Buffalo, New York, which killed all 49 people aboard and one person on the ground. Drawing on NTSB findings, CVR transcripts, and expert commentary, the paper examines the human factors that contributed to the accident — including Captain Martin Renslow's improper stall response, the crew's failure to maintain sterile cockpit procedures, inadequate training, and the systemic problem of pilot fatigue. The paper also considers the role of alcohol impairment in aviation safety and concludes with recommendations for counter-practices pilots and airlines can implement to prevent similar tragedies.
The paper demonstrates effective use of multi-source triangulation: it combines regulatory documents (FAR 91.17), official investigation findings (NTSB reports), journalistic accounts, expert commentary, and a personal communication to build a converging case. This technique strengthens arguments by showing that multiple independent sources point to the same conclusions about pilot error and systemic failures.
The paper opens with the accident narrative and a framing research question, then moves through immediate causes, legal discovery findings, systemic issues (fatigue, alcohol), and ends with a prescriptive conclusion. Each section layers additional causal depth onto the central human-factors thesis, creating a funnel structure that proceeds from specific incident details to broad safety recommendations.
"These people knew what they were supposed to do, and they did it."
— Kathryn O'Leary Higgins (as cited in Buffington, 2009, p. 351)
On the night of February 12, 2009, Colgan Air Flight 3407, a 14 Code of Federal Regulations (CFR) Part 121 scheduled passenger flight traveling from Newark, New Jersey to Buffalo-Niagara International Airport in Buffalo, New York, crashed into a house in Clarence Center, New York. Reports confirm that at the time of the accident, night visual meteorological conditions existed. According to Mike Mitchell (2010), writing in the web article "NTSB Colgan Air Flight 3407 Actions Led to Crash of Flight," the report states that "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. …the captain inappropriately pulled …back on the control column" (Mitchell, 2010, "NTSB Colgan Air…," ¶ 3). This action placed the airplane into an accelerated aerodynamic stall.
This paper investigates the crash of Flight 3407, focusing on the human factors that contributed to the accident — with particular attention to the two pilots. One pertinent research question is addressed: In consideration of the human factors that reportedly contributed to the Colgan Air Flight 3407 accident, what counter-practices may pilots implement to help avoid this type of tragedy?
In addition to pilot Martin D. Renslow and co-pilot Rebecca L. Shaw, two flight attendants and 45 passengers aboard the plane were killed in the crash. One individual on the ground was also killed. The total number of individuals who lost their lives that day was 50. In another web article, "NTSB Report on Colgan Air Crash Highlights CAPA's Safety Concerns," Mitchell (2010) reports that impact forces and a post-crash fire obliterated the airplane:
…a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection Flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. (Mitchell, 2010, "NTSB Report…," ¶ 2)
The opening quote from Kathryn O'Leary Higgins refers to the actions of Captain Chesley B. "Sully" Sullenberger III, the pilot of Flight 1549, and his crew, who safely landed 155 individuals in the Hudson River, also in 2009. Comments regarding Renslow, the pilot of Flight 3407, indicate that he and his crew did not do what they were supposed to do.
The National Transportation Safety Board (NTSB) released the following excerpts from Flight 3407's Cockpit Voice Recorder (CVR). These passages represent the last communications between Renslow and flight control:
Excerpts from Cockpit Voice Recorder (CVR) transcript:
22:15:06.3 HOT-1 flaps five.
22:15:08.1 HOT-2 what?
22:15:08.8 HOT-1 flaps five please.
22:15:13.5 APP Colgan thirty four zero seven three miles from KLUMP turn left heading two six zero maintain two thousand three hundred until established localizer. cleared ILS approach runway two three.
22:15:22.2 RDO-2 left two sixty two thousand three hundred 'til established and cleared ILS two three approach Colgan thirty four zero seven.
22:15:31.7 HOT-1 alright approach is armed.
22:15:32.8 HOT-2 roger.
22:16:04.1 HOT-1 gear down…loc's alive.
22:16:06.4 APP Colgan thirty four zero seven contact tower one two zero point five. have a good night.
22:16:11.5 RDO-2 over to tower you do the same thirty four zero seven.
22:16:21.2 HOT-2 gear's down.
22:16:23.5 HOT-1 flaps fifteen before landing checklist.
22:16:26.6 HOT-2 uhhh.
22:16:37.1 HOT-2 I put the flaps up.
22:16:42.2 HOT-1 [grunt]
22:16:45.8 HOT-2 should the gear up?
22:16:46.8 HOT-1 gear up.
22:16:50.1 CAM [increase in ambient noise]
22:16:51.9 CAM [thump] (Flightpath, 2009, Excerpts from CVR transcript section)
In the book Squawk 7700: A Pilot's Adventure, Peter M. Buffington (2009) asserts that one primary cause contributing to the crash of Flight 3407 evolved from Renslow and Shaw permitting the aircraft to slow to a precariously low speed. Renslow's reaction proved to be the exact opposite of what he should have done once a stall warning sounded, meaning he could not regain control of the plane (Buffington, p. 351). Other contributing causes included Renslow and Shaw failing to recognize the low-speed cue's position on the airplane's flight displays when it indicated the stick shaker would soon activate.
Renslow and Shaw also failed as a team. Reports indicate that neither pilot adhered "to sterile cockpit procedures" (Mitchell, 2010, "NTSB Colgan Air…," ¶ 4). Renslow failed to perform his duties as captain, as he did not "effectively manage the flight and Colgan Air's inadequate procedures for airspeed selection and management during approaches in icing conditions" (Mitchell, 2010).
NBC Nightly News anchor Brian Williams (2010) reported details from the final NTSB report on the Flight 3407 accident. According to the report, Renslow and Shaw were discussing personal matters during the flight. While in the cockpit, Shaw had been texting only moments before takeoff — a practice against NTSB rules. The NTSB stated "the crew was not up to the job" (NTSB, as cited in Williams, 2010). Furthermore, the report asserts that the crew lacked experience, professionalism, maturity, and training — all factors that contributed to the crash.
The final NTSB report also indicates that Colgan Air, associated with Continental Airlines, hired pilots with as little as 250 hours of flight experience. At the time, the NTSB was pushing for requirements mandating pilots to obtain 1,500 hours of flight experience before serving as commercial crew members.
Some answers to the many questions raised by the crash of Flight 3407 may never be known. A number of answers, however, surfaced through the legal discovery process. According to Henry C. Black (1990) in Black's Law Dictionary: "Discovery is the ascertainment of that which was previously unknown; a disclosure or coming to light of what was previously hidden; the acquisition of notice of knowledge of certain acts or facts…" (p. 466). Through the discovery process, facts become known.
In the article "Pilot Error; Poor Training Blamed in Colgan Air Flight 3407 Crash," attorney Brett Emison (2010) relates some of the facts brought to light during discovery following the Flight 3407 accident. Emison explains that the NTSB blamed pilot error and poor training for the crash. The NTSB noted that Renslow "had not established a good foundation of attitude instrument flying skills early in his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed" (Emison, ¶ 3). During his 20-year career as a pilot, Renslow failed five performance checks. When Colgan Air hired Renslow in 2005, the company was not aware of two of those failures. A spokesman for the airline reported that had the company known, they would have refused to hire him.
Williams (2010) also reported that commuter plane companies, such as Colgan Air, experience more accidents than larger air carriers. Since 2001, commuter carriers had been involved in every fatal airline crash. Reasons the NTSB attributed to accidents such as Flight 3407 include pilot inexperience, inadequate training, and poor crew coordination.
Following the investigation, the Safety Board made a number of recommendations to the Federal Aviation Administration (FAA), insisting that strategies to prevent flight crew monitoring failures must be strengthened. The Safety Board also made recommendations to address FAA oversight, including:
Use of safety alerts for operators to transmit safety-critical information, flight operational quality assurance (FOQA) programs, the use of personal portable electronic devices on the flight deck, and weather information provided to pilots (Mitchell, 2010, "NTSB Colgan Air…," ¶ 5).
One sport pilot student and flight enthusiast, Harold Bay, reports having flown a number of private aircraft, including the Cessna 150, 152, 172, and the Sky Arrow turboprop, from airports in Tennessee and suburban Maryland. Bay notes that each plane, like each motor vehicle, has its own particular characteristics and idiosyncrasies. Some planes have extremely delicate and sensitive controls, while others may be quite forgiving and permit a slight margin of error. Still others may be slow to respond to the pilot's commands, complicating the piloting process — much like a sports car that understeers or a truck that oversteers (Personal Communication, 2010). Bay contends that training on more than one aircraft of a particular model would be a positive practice for airlines to implement.
Bay also asserts that the following questions needed to be answered regarding the cause of the Flight 3407 crash: How much training and experience did the pilots have with this particular aircraft? How many flight hours did they have in this specific type of aircraft? Did pilot fatigue play a part? Could alcohol have been a factor? Were there any known defects with the plane? Did any mechanical malfunction occur? On what date was the plane last inspected and/or serviced? (Personal Communication, 2010).
Prior to the crash, the CVR in the cockpit of Flight 3407 recorded that Renslow and Shaw engaged in a conversation that potentially distracted Renslow from effectively operating the plane. Robert Sumwalt, a member of the NTSB board, perceived the conversation as basically one-sided and continuous, with Renslow talking most of the time. Sumwalt added, "It was as if the flight was just a means for the captain to conduct a conversation with this young first officer" (Emison, 2010, ¶ 5).
Whatever the primary, ultimate cause of the crash may be, Buffington (2009) notes that the Clarence Center crash "spurred a cry for greater pilot training and other safety measures at regional airlines such as Colgan Air." Jeffry Skiles, Vice President of the Coalition of Airline Pilots Associations, contends that the fault extends beyond the crew alone: "The crew had not been fully trained in stall recovery" (Buffington, p. 351). The system, Buffington argues, positioned Renslow and Shaw to fail.
In the study "The Cockpit, the Cabin, and Social Psychology," Robert Baron (2005), PhD, explains that each airline pilot is required to receive crew resource management (CRM) training. This training "augments technical flight and ground training with human factors subjects. …Unfortunately, in real flight operations, …cognitive and physical factors …cause these disparate groups to work less than efficiently… particularly when a cohesive environment is critical, such as in an emergency" (Baron, Abstract).
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