Investigators concluded that the pilot, Marvin Renslow, 47, did exactly the opposite of what he should have done and what he was trained to do to avoid a stall in the air.
When an aircraft drops in speed sufficiently to risk a stall (which is diminished lift under the wings to keep the plane in the air), the correct response is to push the stick forward, or nose the plane down. The maneuver serves to increase airspeed sufficiently to increase lift beneath the wings, allowing the pilot greater control of the aircraft and avoiding a full-out stall.
Renslow, surprised and panicked, responded to the Bombardier Dash-8 twin turbo-prop's automatic stall warning system by pulling back on the stick to nose the plane up, serving only to exacerbate the stall, reduce airspeed even further and doom the Q400 aircraft.
And there were other revelations, according to a summary of the NTSB's findings in today's edition of the Buffalo News.
First Officer Rebecca Shaw, a junior pilot who was found to have breached the "sterile cockpit" rule by sending text messages from her cell phone before takeoff in Newark, incorrectly set speed settings into the plane's controls.
The agency's investigator said that neither pilot noticed the dropping airspeed until the stick shaker, an audible and physical system warning that the plane was about to go into a stall, screamed into action. Startled, Renslow pulled back on the yoke not once, but three times—forcing the nose up on the plane. Shaw also set the flaps and landing gear inappropriately once trouble ensued, the newspaper reported.
"What this investigation reveals is a picture of complacency resulting in catastrophe," said Deborah Hersman, the board's chairman.
Hersman proposed to add pilot fatigue to the list, given that Shaw had endured an all-night commute to Newark the day before, while Renslow had spent the previous night in the crew lounge. However the other two NTSB members eschewed that view, citing a lack of evidence.
The NTSB ruled out weather as a factor and concluded the investigation revealed neither system failure nor engine problems. Lorenda Ward, the NTSB lead investigator, said their inquisition revealed that icing on the wing "did not affect" the crew's ability to fly the aircraft, and the NTSB's Dr. Kevin Renze said the plane had "performance capabilities to return to a safe flight."
However, the NTSB did rule that Colgan Air, the regional airline that managed the flight for Continental, had inadequate procedures for pilots to use in setting air speeds on approach to landing during icing conditions.
The NTSB also approved more than 20 safety recommendations, including:
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—Bolstering leadership training for pilots being promoted to captain
—Forcing airlines to address risks associated with pilots commuting a long distance from their home to begin their work shift
—Increasing Federal Aviation Administration oversight of fast-growing airlines like Colgan
The final report, conclusions and recommendations came at the end of a daylong meeting exceeding nine hours, attended by numerous family members and relatives of those who died in the February 12 crash last year.
All passengers and crew aboard the plane died, together with one occupant of the house in the Buffalo suburb of Clarence Center, after the plane dropped like a rock from the sky and crashed onto the dwelling.