Critical human-factors safety issues laid bare during the NTSB’s probe of a regional airline crash near Buffalo, N.Y., are mobilizing the aviation community to overhaul the way pilots qualify and train for a seat on the flight deck.

At the final hearing last week on Continental Connection/Colgan Air Flight 3407, the NTSB said pilot error—specifically, the captain’s improper response to stickshaker activation—was the probable cause of the Feb. 12, 2009, accident that killed 50 people.

The board cited both pilots’ failure to monitor airspeed and adhere to the “sterile-cockpit” rule as contributing factors, as well as the captain’s failure to effectively manage the flight and Colgan Air’s inadequate procedures for airspeed selection and management for approaches in icing conditions.

The NTSB issued more than 25 Colgan Air-related safety recommendations. They include requiring training in monitoring skills, professionalism and fatigue management, as well as the installation of redundant airspeed cues on flight instruments (see box below).

In addition, the NTSB is urging that flight operational quality assurance (FOQA) programs be established at all carriers and that operators provide pilots with realistic upset-recovery training in simulators. (For a complete list, go to: http://www.ntsb.gov )

The accident sequence supports NTSB Chairman Debbie Hersman’s description of Flight 3407’s cockpit —“a picture of complacency and confusion that resulted in catastrophe.”

With light snow and light-to-moderate icing expected on the night approach to Buffalo-Niagara International Airport, the captain appropriately set the reference speed switch to “increase” position. This lowered the angle of attack (AOA) reference for stickshaker (stall warning) activation and raised the position of the low-speed cue on the airspeed indicator, explains Investigator-in-Charge Lorenda Ward. The procedure ensures that the Bombardier Dash 8-Q400 would have the same or greater stall-speed margins in icing conditions as long as the landing airspeeds remain above the stall-warning threshold.

However, the first officer obtained the landing airspeeds for non-icing conditions and did not indicate in an electronic message that the aircraft would be in icing conditions. This resulted in setting a landing speed of 118 kt., which was 13 kt below the 131-kt. stickshaker activation speed.

The cockpit voice recorder (CVR) reveals that the two pilots were engaged in non-flight-related conversations from pushback at Newark (N.J.) Liberty International Airport —a violation of the sterile-cockpit rule. This created a flight-deck environment that prevented the crew from quickly detecting errors. “It was as if the flight was just a means for the captain to conduct a conversation with the first officer,” NTSB Member Robert Sumwalt noted.

When the crew noticed ice accumulating on the windshield, the first officer said she had never seen aircraft icing, an indication that she had not received training for winter operations specific to the route.