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  • Essay / The Colgan Air Flight 3407 Accident Case - 541

    Colgan Air Flight 3407 was a very interesting case to review. On February 12, 2009, at 10:17 p.m., Flight 3407 crashed into a house in New York after the pilots stalled. Flight 3407 was scheduled to fly from Newark, New Jersey to Buffalo, New York. The NTSB reported that the cockpit voice recorder (CVR) revealed some discrepancies experienced by the two pilots. The co-pilot had no experience with icing conditions, but icing was one of the reasons the aircraft entered a stall. However, the captain had some experience flying in icing conditions. The captain was experiencing fatigue, which effectively made him unfit to recover from a stall. With this in mind, the Human Factors Analysis Classification System (HFACS) will provide insight into some of the errors made by both pilots. According to “A Human Error Approach to Aircraft Accident Analysis…”, both authors stated that HFACS was developed based on the Swiss system. Cheese model to provide a tool to assist the investigative process to identify the probable human cause (Wiegmann and Shapell, 2003). Additionally, the HFACS is divided into four categories to identify the failure. In other words, before adverse events occur, HFACS will identify the type of error that is occurring. The first HFACS concerns dangerous acts. Unsafe acts begin at level one and are divided into two categories: errors and violations. While errors are based on errors of skill, decision, and perception, violation focuses on common and exceptional violations. Regarding Colgan Air Flight 3407, the elements of unsafe action that both pilots acted on were errors of skill and decision. Skill-based errors occurred when the crew was not paying attention to their speed and the captain was also not attempting to recover from a stall. For the decision error, the co-pilot had discovered icing on the wings but had not mentioned the seriousness of this error. The next level is the prerequisite for dangerous acts. The prerequisite starts at level two and is divided into environmental factors, operator condition and personal factors. Regarding Flight 3407, the environmental factors would be weather conditions. Icing was a factor when it occurred on the wings. Both pilots experienced fatigue during their flight. They pushed their bodies to the limits while their reaction times were not fully functional. Additionally, due to fatigue and insufficient situational awareness, the crew did not do their best on the job..