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NTSB Hearings into the cause of CO3407 crash
On Tuesday, the opening day of the hearings, the Board released the transcript of the aircraft's cockpit voice recorder. The substance of the transcript is alarming with respect to the extent of non-essential conversation that occurred between Captain Renslow and First Officer Shaw. In direct violation of the FAA's sterile cockpit rules, the Captain and first officer engaged in almost non-stop chatter, discussing among other topics, their unease flying in icing conditions and First Officer Shaw's almost complete lack of experience flying under the cold weather conditions that eventually contributed to the crash. The cavalier attitude of the crew as demonstrated by the lack of attention to their responsibilities is particularly disturbing to family members whose loved ones died as a result of their carelessness.
Tuesday's testimony confirmed that neither Captain Renslow nor First Officer Shaw were trained to use the stick pusher anti-stall system on the Q400. This may explain why, when the aircraft approached an aerodynamic stall and the automatic anti-stall system drove the yoke of the aircraft forward, sending the nose downward to increase airspeed and allow for recovery, Captain Renslow yanked backward on the yoke, pulling the nose up and manually overriding this emergency protection and in effect sending the aircraft into its fatal stall.
The testimony elicited Tuesday also revealed that Bomardier made the conscious decision not to install an additional anti-stall system on the Q400, a low air speed alert that would have warned the crew that the speed of the aircraft was dangerously low before the stick shaker was activated, despite installing similar systems in its other aircraft. This additional warning system may have given Captain Renslow the opportunity to increase the plane's airspeed and prevent the aerodynamic stall. The Board also revealed inconsistencies in the flight manuals created by Bombardier relating to the Q400 that may have led to confusion in stall recovery training.
Testimony by Colgan witnesses on Wednesday indicated that Captain Renslow failed to disclose all failed check rides on his employment applications. Colgan did nothing to verify the veracity of the information provided on pilots' applications dating back beyond the 5 year minimum period mandated by the FAA. Colgan neglected to ask the pilots to allow Colgan access to their records prior to that period. Colgan representatives testified that had they learned that Renslow lied on his application, he would have been terminated prior to the crash.
Substantial testimony was elicited on the issue of pilot fatigue. Colgan representatives confirmed that a third of all Colgan pilots based in Newark were commuting from distances of more than 400 miles, majority of those commuting more than 1,000 miles. Commuting hours are not included in duty time payable by the airline. First Officer Shaw, based in Newark and residing near Seattle, WA, had flown the red eye from Seattle to Newark the morning of Flight 3407. She complained of fatigue and feeling under the weather, though she was permitted to report for duty. The Board made note of the First Officer's $16,000 base salary and suggested to the Colgan witnesses that the pilots may be set up for fatigue problems by the need to commute from lower cost of living areas to a base such as Newark because of their low wages.
Colgan's VP of Safety described a "very, very good" safety culture at Colgan, despite pervasive fatigue management problems and sterile cockpit violations, violations which, he noted, pilots don't report to the airline under Colgan's Aviation Safety Action Program, a voluntary program that allows pilots to report safety violations to management.
Thursday's testimony again focused on the issues of pilot fatigue, sterile cockpit violations and the stall warning system on the Q400. The Board again questioned not only the pilots' wrong response to the stall warnings they received in the form of the activated stick shaker and stick pusher, but also whether an additional visual or aural low air speed warning in advance of the stick shaker activation would have been more effective in alerting the crew to urgency of their situation and prompted an appropriate response.
The Board again questioned why, in so many recent crash investigations, they have seen unbridled violation of the sterile cockpit rule and expressed doubt at witness suggestions that these violations are the exception and not the rule. There was also more questioning regarding the problems relating to low paid pilots commuting great distances to work in high cost of living areas.
Members of the Board noted that there is little standardization of safety practices among even code share partners and encouraged better rulemaking across the board to maximize passenger safety.
Ken Nolan and Gerry Lear attended the NTSB hearings on behalf of our firm's clients. Overall they were pleased with the Board's inquiry, but look forward to the information that will be uncovered during the course of pre-trial discovery on behalf of our clients. They may be reached at kpn@speiserkrause.com and grl@speiserkrause.com.

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