WASHINGTON — An inept pilot and a young first officer who would not challenge him

flew Continental Connection Flight 3407 into the ground, accidentally killing themselves and

48 others in Clarence Center last February, federal safety investigators revealed in their

long-awaited report Tuesday.

"What this investigation reveals is a picture of complacency resulting in catastrophe,"

said Deborah A.P. Hersman, chairwoman of the National Transportation Safety Board, which

approved the report's findings after a 9-hour meeting that disclosed extraordinary

details about the crash and its ramifications.

Capt. Marvin D. Renslow's actions "led to an aerodynamic stall," a safety board

investigator said, spelling out the accident's probable cause.

What's more, Renslow responded to a stall warning not by following his training, but with a

response that indicated he was startled and confused, the safety board concluded.

Investigators said he did exactly the opposite of what he should have done.

Safety board members made it clear, though, that Renslow's actions were emblematic of

larger problems in the aviation industry — and not just the product of two poorly

performing pilots.

Renslow not only failed three flight tests in his career, but also showed repeatedly during

his training at Colgan Air that he tended to overreact in using a plane's controls. In

addition, he never received remedial training to address his weaknesses as an aviator.

"Everybody has a bad day now and again, ... but I think this pilot needed a good day to

pass the test," said Hersman, who wondered aloud how the system should better weed out pilots

with questionable aviation skills.

Another safety board member, Robert L. Sumwalt, marveled that Colgan — the

Continental subcontractor that managed the flight — hired Renslow without knowing about

all his failed flight tests.

"I want to know who's flying my airplane," said Sumwalt, a former pilot and airline

manager.

However, the safety board report did not single out Renslow.

Renslow and co-pilot Rebecca L. Shaw failed to monitor the plane's air speed, letting it

get so slow that a stall warning sounded. In addition, the random and irrelevant chatter

between the pilot and co-pilot, and the captain's failure to properly manage the flight were

contributing factors to the accident, the report said.

The report also said Colgan had inadequate procedures for pilots to use in setting

airspeeds on approach to landing during icing conditions.

Hersman proposed adding pilot fatigue as a contributing factor to the crash, given that the

pilot spent the night before the flight in the crew lounge while the co-pilot spent it

commuting to Newark, N.J., on red-eye flights from her home in Seattle.

But the other two board members disagreed, saying there was not enough evidence to prove

the crew's fatigue contributed to the crash.

The report revealed that problems began almost as soon as Renslow and Shaw boarded the

plane.

Shaw sent two text messages from the cockpit in violation of company and Federal Aviation

Administration policy.

And she sat mostly quiet as Renslow began and dominated long and irrelevant conversations

both at takeoff and on approach to Buffalo, when FAA rules ban pilot conversation about

anything except the flight at hand.

"It was as if the flight was just a means for the captain to conduct a conversation with

this young first officer," Sumwalt said.

Renslow was 47, and Shaw was 24.

Why did it matter? Sumwalt said the safety board draft report of the crash found that the

pilots "squandered their time" with chit-chat instead of "managing the plane."



And somewhere along the way, Shaw incorrectly entered speed settings into the plane's

controls, investigators said.

Then, "as the airspeed continued to slow, neither pilot remarked or took action," said Evan

Byrne, the safety board's performance group chairman.



The plane got so slow that the "stick shaker" — a device that helps to prevent stalls

— activated. But Renslow mistakenly pulled back on the plane's controls at that point,

which is exactly the opposite of what he should have done.

In total, Renslow pulled back on the controls three times in response to the stick shaker

and "stick pusher," forcing the nose upward. That caused and then exacerbated the stall, said

Lorenda Ward, the safety board investigator in charge.

Discussing Renslow's repeated attempts to right the plane using the wrong procedure, Tom

Haueter, director of the safety board's Office of Aviation Safety, said he had never seen a

pilot react to a stall as Renslow did.

"Quite frankly, I can't explain it," he said.

Making matters worse, once the plane lost control, Shaw set the flaps in the wrong

position.

And throughout the flight, she never tried to stop Renslow when he let the conversation

stray into irrelevant matters or made other mistakes, investigators said.

"They did not trap their errors. They did not challenge each other," said Byrne, the agency

investigator.

Ward said the investigation revealed no systems failures or engine problems. She said that

the weather was "typical" for a Buffalo night in February and that icing on the wing "did not

affect" the crew's ability to fly the craft.

The safety board's Dr. Kevin Renze said the plane had "performance capabilities to return

to a safe flight."



He noted "multiple recovery scenarios were possible for this aircraft."



With more than 60 people who lost loved ones sitting up front in the conference room,

safety board officials showed a video simulation of the final minutes of the flight. The

family members sat silently, a few wiping away tears.

While the board did not find fatigue to be a contributing factor to the crash, Mike Loftus

— a former Continental pilot who lost his daughter, Maddie, in the crash — said he

could understand why.

"This guy [Renslow] had so many other problems," Loftus said, "it was hard to say if it was

a training issue or a fatigue issue."