https://fr.wikipedia.org/wiki/Vol_Colgan_Air_3407
Extrait
Executive Summary
On February 12, 2009, about 2217 eastern standard time, 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. The
2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the
ground was killed, and the airplane was destroyed by impact forces and a postcrash fire. The
flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night
visual meteorological conditions prevailed at the time of the accident.
The National Transportation Safety Board determines that the probable cause of this
accident was the captain’s inappropriate response to the activation of the stick shaker, which led
to an aerodynamic stall from which the airplane did not recover. Contributing to the accident
were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s
failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed
selection and management during approaches in icing conditions.
The safety issues discussed in this report focus on strategies to prevent flight crew
monitoring failures, pilot professionalism, fatigue, remedial training, pilot training records,
airspeed selection procedures, stall training, Federal Aviation Administration (FAA) oversight,
flight operational quality assurance programs, use of personal portable electronic devices on the
flight deck, the FAA’s use of safety alerts for operators to transmit safety-critical information,
and weather information provided to pilots. Safety recommendations concerning these issues are
addressed to the FAA