Conclusion:

15. Although the reasons the first officer retracted the flaps and suggested raising the gear could
not be determined from the available information, these actions were inconsistent with
company stall recovery procedures and training.

37. Pilots could have a better understanding of an airplane’s flight characteristics during the
post-stall flight regime if realistic, fully developed stall models were incorporated into
simulators that are approved for such training.

38. The inclusion of the National Aeronautics and Space Administration icing video in Colgan
Air’s winter operations training may lead pilots to assume that a tailplane stall might be
possible in the Q400, resulting in negative training.

About the same time, the captain called for the
flaps to be set to 15° and for the before landing checklist. The CVR then recorded a sound
similar to flap handle movement, and FDR data showed that the flaps had been selected to 10°.16
FDR data also showed that the airspeed at the time was about 135 knots.

At 2216:27.4, the CVR recorded a sound similar to the stick shaker. (The stick shaker
warns a pilot of an impending wing aerodynamic stall17 through vibrations on the control
column, providing tactile and aural cues.) The CVR also recorded a sound similar to the
autopilot disconnect horn, which repeated until the end of the recording. FDR data showed that,
when the autopilot disengaged, the airplane was at an airspeed of 131 knots. FDR data showed
that the control columns moved aft at 2216:27.8 and that the engine power levers were advanced
to about 70° (rating detent was 80°) 1 second later.18 The CVR then recorded a sound similar to
increased engine power, and FDR data showed that engine power had increased to about 75
percent torque.

FDR data also showed that, while engine power was increasing, the airplane pitched up;
rolled to the left, reaching a roll angle of 45° left wing down; and then rolled to the right. As the
airplane rolled to the right through wings level, the stick pusher activated (about 2216:34), and
flaps 0 was selected. (The Q400 stick pusher applies an airplane-nose-down control column
input to decrease the wing angle-of-attack [AOA] after an aerodynamic stall.) About 2216:37,
the first officer told the captain that she had put the flaps up. FDR data confirmed that the flaps
had begun to retract by 2216:38; at that time, the airplane’s airspeed was about 100 knots. FDR
data also showed that the roll angle reached 105° right wing down before the airplane began to
roll back to the left and the stick pusher activated a second time (about 2216:40). At the time, the
airplane’s pitch angle was -1°.