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The NTSB has issued its findings about what caused Colgan Air Flight 3407 to crash a year ago outside Buffalo, New York. Several sources, including this one, have reported on the NTSB’s findings, which blamed pilot error and poor training for the crash that killed all on board.

The crash has raised eyebrows about how well (or how poorly) pilots are trained at smaller regional airlines and passenger confusion about who is really operating their flights.

The NTSB has blamed pilot error and poor training for the crash, noting that the plane’s captain, Marvin Renslow, "had not established a good foundation of attitude instrument flying skills early in his career, and his continued weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed." Renslow’s career spanned two decades and had failed five performance checks during that time. Colgan Air was only aware of three. Colgan said had they known about the other two, they would not have hired Renslow in 2005.

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[T]he report also criticized Colgan saying that the airline, "did not pro-actively address the pilot fatigue hazards associated with operations at a predominantly commuter base." Adding that, "Operators have a responsibility to identify risks associated with commuting, implement strategies to mitigate these risks, and ensure that their commuting pilots are fit for duty."

Another factor brought up the by the NTSB was the violation of the Federal Aviation Administration’s (FAA) sterile cockpit rule. It was noted that first officer Shaw had sent two text messages before take-off at Newark. The second message was sent two minutes before take-off.

Prior to landing, the cockpit voice recorder recorded that the pilots were holding a conservation that potentially distracted the captain from operating the plane. Robert Sumwalt, a member of the NTSB board said, "It was continuous and one-sided, with the captain doing most of the talking." He added, "It was as if the flight was just a means for the captain to conduct a conversation with this young first officer."

According to The Huffington Post, the Airline Pilots Association is furious about the probable cause issued by the NTSB.

In a statement later, ALPA president John Prater pointed out what should be obvious to the board because its a basic truth in accident investigations; there is no one cause.

"The Board has missed a valuable opportunity to highlight the many factors that combined to cause this tragedy," Mr. Prater said.

The full NTSB probable cause statement follows below, but in summary, the board cites four actions, lapses actually: 1) the crew’s failure to monitor airspeed, 2) its failure to observe discipline in the cockpit, 3) the captain’s failure to monitor the flight and 4) the airline’s operating procedures for flights in icing conditions.

As The Huffington Post asks: How was this pilot in the cockpit in the first place?

John Gadzinski, an airline pilot and fellow member of the International Society of Air Safety Investigators told me once – and I’m going to paraphrase here because truth be told, we were drinking at the time – that an airline’s commitment to safety can be easily determined by answering this simple question. Is there a gap between its policies and its practices?

Colgan repeatedly states that safety is a top concern and yet, here’s the gap. Colgan claimed to have a policy prohibiting pilots from overnighting in crew lounges, yet it was a well known fact that commuting pilots did just that. Colgan claimed use of personal electronic devices was prohibited, and yet, the 24-year-old first officer on the flight not only felt free to send text messages, but when she did so, the captain failed to say anything to her about it.

Sterile cockpit? We’ll that’s not just a Colgan "policy"; its an F.A.A. requirement. On the night of the crash, Flight 3407 had an hour-long taxi out at Newark Liberty Airport while waiting takeoff. Virtually the entire time was spent in conversation, but only sixteen minutes of talk was about the flight.

Its just not believable that this kind of cockpit behavior was unknown to Colgan. Getting to the heart of why that was the case is entirely relevant to determining why this plane crashed. Its bigger than Mr. Renslow and Ms. Shaw. Its bigger than Colgan too. There’s a crisis here, but you’d never know it by reading the probable cause statement.

I have previously highlighted the need for better training and more experienced pilots at these small regional airlines. The Buffalo News did an in-depth investigation that found small regional airlines were twice as likely as major airlines to have crashes caused by pilot error. Part of the reason is gross underpayment of regional airline pilots. When you pay your pilots only $20,000 per year, you tend to get what you pay for.

Airlines need to do more to ensure their pilots are properly trained and properly compensated. I don’t know about you, but I want to make sure the man or woman in charge of taking me safely from 30,000 feet down to the ground has the very best training and actually makes more money than the very nice flight attendant serving me a Coke in the back.

All airlines — regional, national, international — need to make sure that those charged with delivering hundreds of passengers from city to city receive the highest and best training possible. One little mistake can have disastrous consequences.

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