The Colgan Air Flight 3407 Crash Case

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The Colgan Air Flight 3407 was a very interesting case to look at. On February 12, 2009, at 10:17 pm, flight 3407 crashed at a house in New York after the pilots experience a stall. Flight 3407 was scheduled to fly from Newark, New Jersey to Buffalo, New York. The NTSB reported the cockpit voice recorder (CVR) revealed some discrepancies both pilots were experience. The first officer did not have any experience with icing condition but icing was one of the reasons the plane went into a stall. On the other hand, the captain had some experience flying in icing condition. The captain was experiencing fatigue, which indeed, made him unfit to recover from a stall. With that in mind, the Human Factor Analysis Classification System (HFACS) will give insight of some errors both pilots made.

According to “A Human Error Approach to Aviation Accident Analysis…”, both authors stated that HFACS was developed based off from the Swiss Cheese model to provide a tool to assist in the investigation process to identify the probable human cause (Wiegmann and Shappell, 2003). Moreover, the HFACS is broken down into four categories to identify the failure occur. In other words, leading up to adverse events the HFACS will identify the type error occur.

The first HFACS is unsafe acts. Unsafe act begin at level one and it is divided into two catergories, errors and violation. While errors are based on skills, decision and perceptual errors the violation focuses on routine and exceptional violations. As to Colgan Air flight 3407, the unsafe act elements both pilots acted on were skill-based and decision errors. The skill-based errors were occurring when the crew failed to pay attention to their airspeed and the captain also failed to try recover from a stall. For the decision error, the co-pilot had discovered icing on the wings but failed to mention how serious it was.

The next level is Precondition for Unsafe Acts. Precondition begins at level two and it is dividing into environmental factors, condition of operator, and personnel factors. In regards to Flight 3407, the environmental factors would be the weather condition. Icing was a factor when occurred on the wings. Both pilots were experiencing fatigue during their flight. They have pushed their body to limits where as their reaction times were not fully functional. Furthermore, due to fatigues and not adequate situational awareness, the crew did not perform to their best optimal on the job.

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