The investigation found Captain Marvin Renslow, who was new to flying this type of plane, squandered critical time and attention while talking almost continuously to his co-pilot, Rebecca Shaw.
"It was as if the flight was a means for the captain to conduct conversation with the young first officer," NTSB investigator Robert Sumwalt said.
It's that inattention that the NTSB says may have led Captain Renslow to make a fatal mistake upon approach to Buffalo when an alarm alerted him to a pending stall. He pulled up on the controls of the plane, when he should have pushed the nose down to gain speed.
"That's very unusual behavior and, quite frankly, I can't explain it," Tom Haueter of the NTSB said.
In the final seconds of the flight, two pieces of safety equipment activated - a stick shaker to alert the crew their plane was nearing a stall and a stick pusher that points a plane's nose down so it can recover speed, investigators said. The correct response to both situations would have been to push forward on the control column to increase speed, they said.
But Renslow pulled back on the stick shaker, investigators said. When the plane stalled and the pusher activated, Renslow again pulled back three times.
"It wasn't a split-second thing," NTSB safety investigator Roger Cox said. "I think there was time to evaluate the situation and initiate a recovery, but I can't give you a number of seconds."
Seventy-five percent of pilots who had experienced the stick-pusher activation in training also responded by pulling back instead of pushing forward, even though they knew ahead of time to expect a stall, investigators said.
Attorneys representing passengers killed on flight 3407 say the pilots made errors because the airlines they flew for Continental and Colgan failed to adequately train them.
"If you're going to put your name behind a passenger ticket, you should be putting your training and experience there also," aviation attorney Noah Kushefsky said.
New training regulations promised after the crash have yet to be implemented by Congress or the FAA. Regional pilots still make near-poverty wages and commute long distances to work.
"Government must step in to enforce higher standards uniformly. You cannot leave to airlines to monitor their own performance effectively enough if they are so concerned with saving a dollar wherever they can save it," attorney Marc Moller said.
Shaw, 24, had earned less than $16,000 the previous year, which may have been why she lived with her parents near Seattle and commuted across the country overnight to Newark, N.J., to make Flight 3407. She felt sick but didn't want to pull out of the trip because she had already traveled so far, according to a cockpit voice recorder transcript.
It's not clear how much sleep either pilot received the night before the flight.
Shaw also erred at the beginning of the flight by programming an ordinary airspeed into the plane's computer, rather than the higher airspeed needed for freezing weather, investigators said. The plane didn't accumulate enough ice on the wings to stall, but the mix-up on speeds caused the stick shaker to warn of a stall even though one wasn't actually imminent.
Renslow's pull-back response, however, created a stall.
Shaw also violated FAA guidance by sending a text message about five minutes before takeoff from Newark's Liberty International Airport, and both pilots violated rules against nonessential conversation during flight below 10,000 feet.
Colgan's pilot training program was also criticized.
Since the accident, Babbitt has persuaded regional airlines to make a series of voluntary safety improvements. FAA has also increased inspections of its pilot training programs. But the agency is still drafting regulations to address the most critical safety issues raised by the accident. Final action is months or perhaps years away.
The last six deadly domestic airline accidents involved regional carriers. The NTSB has cited pilot performance as a factor in three of those accidents.
Regional airlines account for about half of all domestic departures and about one-quarter of the passengers. They are the only scheduled service to about 440 communities.
Some information from The Associated Press