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Running head: COURSE CASE STUDY ASSIGNMENT

Continental Flight 3407 Accident

by Jim Warnick

Case Study Assignment

Submitted to the Worldwide Campus

In Partial Fulfillment of the Requirements

For SFTY 320 Human Factors in Aviation Safety Course

Embry-Riddle Aeronautical University

October 2017
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Introduction

The aviation community has committed themselves to ensuring that safety is a top

priority. They want to reduce and or eliminate any future accidents and ensure that they do not

have any repeat accidents

The National Transportation Safety Board (NTSB) organization mainly focuses on what the

cause was of an accident. They also make recommendations to the Federal Aviation

Administration (FAA) and aircraft manufacturers as to what changes they need to implement to

their programs and procedures in order to reduce the reoccurrence of future accidents. It is very

unfortunate that airline accidents usually have a large amount of live lost. The cost that is

acquired to better understand and develop newer and better programs, policies and procedures

for the aircrews and maintainers is invaluable. The more that they can learn and utilized to

prevent future accidents cannot have a price associated to it.

On the night of February 12, 2009, Continental flight 3407 took off from Liberty

International Airport, Newark, New Jersey. It was due to land at its final destination at Buffalo-

Niagara International Airport, Buffalo, New York. As the aircraft began its final approach just

five nautical miles from the airport it crashed killing all 45 passengers, two pilots, two flight

attendants and one person on the ground according to the (National Transportation Safety

Board, 2009). The aircraft accident is a prime example of how human factors and human error or

so closely related and have caused such a great concern within the aviation community

Cause of the Accident

As reported by the FAA (2009) Aircraft Accident Report, “The NTSB determined that

the probable cause of the 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” (pg.
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155). The human factors that were observed and discovered during the investigation should that

the procedures that the aircrew failed to follow and recognize were the reasons that lead the

aircrew to make their poor decisions. Their improper procedure that they went through when

they were reacting to an emergency situation during icing conditions, caused the flight crew to

react in a manner causing the aircraft to stall as they were making preparations for final approach

into Buffalo International Airport.

Some of the investigators findings showed that the captain was forced to decrease the

aircraft’s air speed quickly in order for him to make the correct approach, although he had lost

his positional awareness during a critical phase of the flight. The report also showed that the

captain and the first officer had been distracted as they had been talking about things that were

unrelated to their flight duties during most of the flight. It is believed that due to this distraction

it caused them to react to the final approach checklist to late into the approach preparation

sequence.

Human Factors Determined

Fatigue was just one of the major human factors that was discovered in the flight crew’s

poor decision making. Fatigue is a characteristic that is somewhat normal for most humans.

Most of the time an individual can easily recover from the state of fatigue by simply taking a nap

and getting some rest. They can also make the right decision to stop what they are doing and rest

until they are capable of making correct and cohesive decisions once again. Even though it is

thought that fatigue is very common and normal it has also been determined that it is extremely

difficult to determine how it effects every person individually. Humans react to fatigue in many

ways as it can be caused by repetitive efforts, boredom and different levels of physical exertion.
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No matter what level of fatigue a human in the aviation community is functioning, if it is not

properly recognized and controlled it can have dangerous consequences.

The FAA (2009) report mentions that playback of the cockpit voice recorder (CVR) the

first officer had made comments that he had been feeling tired even before the aircraft took off

from New Jersey. The CVR also had recorded both the captain and the first officer making

sounds which sounded like yawning during the flight. The report by the FAA (2009) also states

that “The captain had experienced chronic sleep loss, and both he and the first officer

experienced interrupted and poor-quality sleep during the 24 hours before the accident” (pg.

106). The investigation also revealed that the captain was talking about how he was having

difficulty due to his long commutes from his home in Florida to work. He was speaking of not

having a place to rest and get sleep that was closer to work when he was there. It was also

determined that the first officer had earlier flown aboard a on a cargo airplane from Memphis

Tennessee to Newark, New Jersey. The investigation reported that she had caught the flight

around 4:00 am and that she was seen sleeping during the two hour flight to New Jersey. It was

also mentioned that she was sleeping in the crew room at home base prior to the flight to

Buffalo.

Contributing Factors of the Accident

It is very common for the investigation to show that there are normally other important

factors that have taken place prior to the actual factor that causes the aircraft to crash.

The Continental Flight 3407 Accident was no different as it revealed the several levels of safety

prevention had failed as identified by the safety models such as the Human Factors Analysis and

Classification System (Wiegmann & Shappell, 2003). The aircraft accident report showed that

the Regional Chief Pilot did not have any type of record that showed Newark Liberty
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International Airport (EWR) exactly how many of their pilots had been commuting over long

distance each day. The reasons that were discover for why the aircrews had been making the

long commutes was due to the company’s low wages and the high cost of living in the Newark

area. It was for this reasoning why most of the pilots commuted from different states around the

country to work at Newark, New Jersey. Another reason was the company’s inability to properly

manage its fatigue policy and believed to be a contributing factor according to the (National

Transportation Safety Board, 2009). The policy that was in place allowed the company’s pilots

to self-report when they were feeling fatigued. There were also identified the procedures in place

in order for the proper notifications to be provided to the chief pilot or duty officer.

The reporting investigators also determined that there were discrepancies based from the

interview conducted with the EWR regional chief pilot regarding the company’s policy relating

to pilot and aircrew fatigue. The FAA (2009) document showed the regional pilot stated:

“If a pilot had repeatedly called in for being fatigued, that he would speak with the pilot

to determine what was the reasoning behind the calls. A crew check airman mentioned

that he had called in fatigued a few times and that there was never any follow up

conducted afterward.” (pg. 49)

It was determined that the lack of effort and oversight from senior managers on existing policies,

had provided the pilots away to be able to deviate from the responsibility of self-reporting when

they felt they could not properly conduct their duties and responsibilities.

Another very important finding that contributed to the factors was that there was a

deficiency in the levels of experience on how to properly identify and utilize the aircraft’s de-

icing system. The deicing system as it was designed to provide an aircraft stall warning prior to

normal airspeed for a de-icing condition. All the factors determined by the investigation relating
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to the situation directly contributed to the incorrect decision to pulling back on the control which

slowed the aircraft instead of pushing forward to increase the aircraft’s air speed in order to

prevent the aerodynamic stall.

Recommendations from the NTSB

The investigations report findings of Continental Flight 3407 Accident specifically

recommended to the FAA, that their operators must review follow the standard operating

procedures to ensure they were consistent with monitoring techniques. The NTSB proposed to

make a change to the airspeed indicator display that provided warning lights so that the pilots

could quickly see when a critical condition existed. This also included a low airspeed alert

system which provided flight crews with visual and audible warnings of a hazardous low speed

condition. It was also reported by the NTSB (2009) a requirement for all operators under the 14

Code of Regulations Part 121, 135, and 91K to have to take a leadership course of training. This

training provided specific requirement for operators to brief commuting pilots of the dangers of

fatigue associated with commuting. In addition to ensuring the establishment of policies and

guidance to mitigate risks associated with fatigue for those pilots and aircrew who commuted to

have established place for rest near the home base for flight departures. The NTSB also made it

a requirement for all operators to conduct simulator training requirements to enable the pilots to

be able to recover an aircraft from an aerodynamic stall if the need arises.

The effort of the NTSB’s recommendations was to do its part in identifying the causes

and setting procedures in place to prevent similar accidents from recurring. They also wanted to

ensure that it was more than just the pilots and aircrew complying with its minimum

requirements and recommendation. A prime example of this was just a few months after the

Continental 3407 accident, when Air France Flight 447 crashed in the Atlantic Ocean in July
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2009. The cause of the crash was determined to have been once again pilot error, it was

discovered that when the aircrafts autopilot disengaged along with the combination of its flight

by wire system failure the aircraft became uncontrollable. The co-pilot reaction to mistakenly

pull back on the stick and causing the aircraft to take a rapid nose up direction was cause for him

to encounter a stall warning and placing the aircraft in an aerodynamic stall, which the aircrew

was not able to recover from and causing the aircraft to crash.

Aircraft system engineers and the manufacturers are consistently try to take full

advantage and implementation of newly designed technologies to make aircraft and flight safer.

The installation of, and reliance on newly automated systems has drawn cause for concern as

pilots have become more accustom to allowing the aircraft to fly itself. It is for these reasons

that it has been determined that pilots and aircrews have been less attentive on the duties and

responsibilities associated with actually flying the aircraft. This has provide aircrews with a

seemingly higher level of complacency and lacking the basic training and knowledge resulting in

poor judgement reactions when they are dealing with aircraft inflight emergencies.

Conclusion

It is understandable that aviation safety programs, procedures and policies have been

established to prevent and reduce aircraft accidents. They have also been established so that

when an accident does occur they can determine and provide training and guidance to prevent

another similar accident from happening. The use of safety strategies and models aids the

investigators in how to identify the causes behind the accidents. It is very unfortunate though that

even with all the safety locks in place there will always be aircraft accidents and new and betters

ways of discovering what the causes were will need to be implemented. But even with all this

there will always be the issue relating to human factors and what part they play in identifying the
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human conditions that directly affect the flight crews’ decision making efforts. It will still remain

difficult in identifying how the human performance traits are significantly degraded when placed

in emergency situations.

The Continental Flight 3407 accident was a direct example of the consequences of an

aircraft flight crew deviating from established policies related to human factors. As it had been

determined by the investigators final report that the fatal crash could have possibly been avoided

if the flight crew had followed the proper procedures of self-reporting the levels of fatigue they

were experiencing prior taking charge of the flight. It has also been determined that if fatigue

was not a factor in this accident, the flight crew could have reacted properly during the

emergency. However the compilation of factors such as; fatigue, lack of situational awareness,

and poor system knowledge made this a prime candidate for an accident to happen.
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References

National Transportation Safety Board. (2009). Loss of Control on Approach Colgan Air, Inc.

Operating as Continental Connection Flight 3407 (Accident Report No. NTSB/AAR-

10/01 PB2010-910401) (p. 299). Clarence Center, New York. Retrieved from

http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1001.pdf

Wiegmann, D., & Shappell, S. (2003). A Human Error Approach to Aviation Accident Analysis:

The Human Factors Analysis and Classification System. Ashgate.