USAir Flight 405
| USAir Flight 405 | |
|---|---|
 A Fokker F28 from the USAir, similar to the accident machine |
|
| Accident summary | |
| Accident type | Stopped flow at takeoff due to icing |
| place |
Flushing Bay at LaGuardia Airport , New York City , New York , United States
|
| date | March 22, 1992 |
| Fatalities | 27 |
| Survivors | 24 |
| Injured | 24 |
| Aircraft | |
| Aircraft type |
 Fokker F28-4000
|
| operator |
USAir
|
| Mark |
N485US
|
| Departure airport |
LaGuardia Airport , New York City , New York , United States
|
| Destination airport |
Cleveland Hopkins International Airport , Cleveland , Ohio , United States
|
| Passengers | 47 |
| crew | 4th |
| Lists of aviation accidents | |
USAir flight 405 (flight number: US405 ) was a scheduled domestic flight of the airline USAir from LaGuardia Airport to Cleveland Hopkins International Airport , on which a Fokker F28 crashed into Flushing Bay on March 22, 1992 after taking off from LaGuardia Airport in wintry conditions. 27 people were killed and 24 survived in the accident.
plane
The machine was a Fokker F28-4000 , which was initially delivered to Piedmont Airlines after its maiden flight on April 1, 1986 and was taken over by USAir three years later after the airlines merged. Since then, the machine had completed 12,462 flight hours and 16,280 take-offs and landings. The Fokker had the serial number 11235 and the aircraft registration N485US .
crew
Captain of the machine was the 44-year-old Wallace J. Majure II, the type rating for the Fokker F28 and four other types of aircraft owned. He had around 9,820 hours of flight experience, including 2,200 on the F28. Majure was first hired by Piedmont Airlines as the first officer of an F28. He was later assigned to the Fokker F28 as first mate and then as captain , but then captain of the F28 due to job cuts at the company.
First mate was 30-year-old John Rachuba, who was hired by Piedmont Airlines in 1989. At the time of the accident, he had 4,507 hours of flight experience, including 29 on the Fokker F28. Rachuba also had a flight engineer qualification for jet-propelled machines and an expired test captain qualification which had been issued on August 16, 1987. Previously, he had flown as a flight engineer on flights with Boeing 727 and Boeing 737 machines .
In addition, there were two flight attendants on board.
Before departure
On the day of the incident, the machine had already made a flight from Jacksonville International Airport in Florida to LaGuardia Airport . Many take-offs and landings there were delayed due to the adverse conditions. The machine rolled to Gate B1 66 minutes before take-off, where it was subsequently de-iced. Then a technical defect occurred on a de-icing vehicle when resetting. After a repair, the vehicle could only be started again 20 minutes later. Since the Fokker had been parked in the meantime due to the defect, the crew could not taxi to take off. The master requested a second de-icing. After this de-icing, the pilots did not conduct a tour to inspect the machine, nor was this required by the airline.
After the second de-icing, the Fokker received take-off clearance for runway 13. While taxiing, the pilots activated the engine de-icing and went through the take-off checklist. The master made an announcement that the buoyancy aids would be in the extended position during taxiing and that this need not worry the passengers. As a reminder, the captain put an empty coffee mug over the lever for the buoyancy aid.
According to weather reports, all runways, although cleared and treated with urea , were covered with a thin layer of wet snow. The first officer described the snowfall in the later investigation as "not strong" and "without large flakes". He said there was a watery layer on the aircraft's nose and that the snow had slipped down the sides of the aircraft. He testified that he had checked the wings "maybe ten, but certainly three times". Neither he nor the captain could have seen traces of icing on the wings and had therefore decided against a third de-icing.
While taxiing, the pilots looked back at the wings and the first officer said that everything looked fine and ice-free to him. The pilots then talked about de-icing processes. The first officer pointed to the aircraft in front of them and replied, "He could keep our wings (ice) free". The captain replied: "He could also cause us to freeze again ... I don't want to stay too close to him". The first officer later said, “Look at this, what's that?” To which the captain replied, “Sand, I guess. Urea sand. "
The wintry weather had caused traffic delays at LaGuardia Airport. Queues of machines waiting for clearance to start had formed. As a result, the departure of the plane, which was already hours late, was delayed even further.
the accident
After the Fokker, as investigators later estimated, had taken 25 to 45 minutes to travel from the gate to the start, it was finally given the go-ahead. The master accelerated the engine while the first officer announced the speeds. About 2.2 seconds after the take-off speed was reached, the captain pulled up the nose of the machine. The first officer later stated in interrogations that the aircraft appeared to behave normally during take-off and that he could not detect any shaking, loss of speed or any other signs of impending stall. Several passengers, however, stated that the machine was noticeably slow when taking off.
According to the first officer, shortly after take-off it looked as if the machine had lost its lift. It rang six warnings that to a stall pointed. While the captain tried to align the wings horizontally, the pilots extended the right elevator to lower the machine again to abort take-off. According to the later investigation report, the control commands of the two pilots were consistent with each other at that time, from which it can be concluded that both the master and the first officer were aware at this time that the machine would not fly.
Five seconds after the landing gear was lifted from the ground, the left wing tip brushed the runway and the stall warning system activated. The machine then leaned first to the left, then to the right, and finally broke out of the runway to the left. The Fokker brushed against two lamps of the glide path lights, came back on the ground and after another 30 meters rose into the air before it flew into a radio beacon and a pump house next to the runway, whereby the left wing broke off, the kerosene ignited explosively and the Machine fell headlong into Flushing Bay.
Rescue operation
The master was killed in the accident, the first officer survived. A total of 27 of the 51 occupants of the machine died. Many passengers who were trapped or disoriented were unable to loosen their seat belts or were unable to rescue themselves from the wreckage and drowned despite no other life-threatening injuries. The survivors were able to exit the machine through large holes in the fuselage. Some were able to climb out of the knee-deep water and climb over the dike towards the runway, while others had to be pulled out of the water by other survivors or rescue teams. Burning wreckage floated on the water and thick black smoke rose.
About 200 people were involved in the rescue operation. Police rescue divers searched the water after the accident, but could not find any other survivors in the wreckage of the machine or in the water. Firefighters were busy fighting the fire, which, according to the head of operations, could be extinguished after 10 minutes.
In the report of the NTSB, the procedure of the paramedics and emergency doctors was noted, but not criticized: The rescuers turned to the victims, who had suffered life-threatening injuries but were conscious. Victims who showed no vital signs and showed signs of drowning were initially not treated because it was assumed that they could not be resuscitated . Around 15 ambulances were used to transport the injured to the hospitals, 40 more were available but were not needed. The accident report assessed the rescue operation as effective and found that it had increased the chances of survival of the occupants of the machine. The inadequate coordination of the medical staff was criticized.
Regarding rescue operations, the NTSB noted that a basic principle of first aid is to treat victims with the most life-threatening injuries first, and to use available medical resources and limited medical staff to be as effective as possible will. The NTSB is also aware that in previous years a number of people who had drowned in cold water could be successfully resuscitated. They survived after lying in cold water, including sea water, for an hour or more without breathing. In light of these facts, the NTSB believes that all rescue organizations should revise their emergency plans to make room for cardiopulmonary resuscitation (CPR) measures that can be taken once enough trained personnel have arrived on site. These possibilities should be available even in rescue operations with many victims, regardless of whether vital signs are visible or not. This applies in particular to cases in which accident victims were submerged in cold water while their other physical condition shows no signs of fatal injuries.
Accident investigation
The NTSB sent a team of investigators to the scene of the accident. The investigators found that ice had formed on the wings, which impaired the airflow and reduced lift.
icing
Investigators considered a number of causes for the loss of buoyancy in the accident investigation. An examination of the control systems did not reveal any malfunction prior to impact. The findings made it possible to rule out causes such as an incorrect position of the lift aids , activation of the air brake or a defect in the flight system or the aircraft structure. According to the investigators, the take-off run of the machine was normal.
When they investigated the question of why the wings were iced up, the investigators found that the machine had been properly de-iced twice and had initially been free of ice after the de-icing procedures. However, the time span between the second de-icing and the take-off run was around 35 minutes. During this time, the machine was exposed to prolonged precipitation at temperatures below freezing point. The NTSB was unable to determine the exact amount of ice that had formed on the wings. However, investigators concluded that the wing icing was the main cause of the accident.
During the examination of the cockpit, the investigators found that the switch for the engine de-icing was not activated. In the course of the investigation, however, it was found that the switch jumped into this position even with the slightest pressure. The investigators then ruled out an inactive engine de-icing as an accident factor. After the accident, USAir published maintenance instructions, according to which the switches of the de-icing systems should be modified so that they lock into the selected position.
The aircraft accident investigators found that the design of the wings of the Fokker F28 made them particularly susceptible to icing. Because of the orientation of the wings, even small amounts of ice could have devastating consequences. When the NTSB, in cooperation with Fokker, investigated the consequences of icing, it was found that even ice particles of 1–2 mm with a density of one particle per square centimeter could impair lift by up to 20 percent. In a letter that was published before the accident, Fokker pointed out that even a small amount of ice on the wings could cause an "uncontrollable roll".
Cockpit crew error
The investigation found that none of the pilots had taken any action to check the wings for icing before departure, although it is clear from the recorder footage that both pilots were aware that icing could occur under the prevailing weather conditions. The machine was only inspected and de-iced by the ground crew. Investigators found that when the captain requested a second de-icing as a result of a de-icing vehicle failing, he was concerned about the consequences if the machine continued to be exposed to prolonged precipitation. His decision to request a second de-icing had been prudent and followed the airline's instructions. After the second de-icing, the crew was visibly relieved that the machine was free of ice build-up. At this point in time, the crew was not aware of how long the departure would be delayed afterwards, so that their decision to leave the gate was understandable. After taxiing, when it became apparent that the departure would be significantly delayed, the pilots had conversations that showed that they were aware and concerned about the consequences of re-icing.
The investigators also found that the instructions and training of the flight crews by USAir was sufficient and that the pilots should actually be sensitized to ice formation on the aircraft, although in this case they were not clear about the condition of the wings. USAir regulations stated that the captain was responsible for taking precautions against icing. If more than 20 minutes have passed before departure and after the last de-icing, the captain is advised to carefully check the wings for ice formation in order to ensure that a safe take-off is necessary in accordance with the safety regulations.
In the final report of the NTSB it was noted that the crew should have taken more steps to ensure that the wings were free of ice, for example by going through the cabin and taking a closer look at the wings. The investigators admitted that it might be difficult to detect even a small amount of icing even during a visual inspection, but emphasized that an inspection would have made it more likely that the pilots would discover icing and return to the gate.
In a television interview, an NTSB investigator stated that the captain was facing a problem: if he had requested a third de-icing, he would have to leave the queue of machines waiting to be cleared, taxi all the way to the de-icing location and wait for the de-icing vehicle again. This would have delayed the departure and possibly even led to the flight being canceled.
The NTSB investigated the extent to which the first officer could see the right wing of the machine from his seated position in the cockpit. Investigators found that with the sliding window open, 80 percent of the sash could be seen, including the black stripe on which ice formation would have been easier to see in contrast to the otherwise white sash. With the window closed, as in the case of the crashed machine, details on the sash would have been difficult to make out and the view of the black stripe through the glass would have been distorted. Investigators found that the lighting would have only marginally improved the first officer's view of the wing in this case.
The investigators asked Fokker to conduct a study on the relationship between wing freezing on type F28 machines and control commands from pilots. The investigators evaluated the data obtained and found that the captain pulled the aircraft's nose up too early, namely at a speed of 119 knots (approx. 220 km / h), while the recommended rotation speed under the prevailing atmospheric conditions was 125 knots (approx . 232 km / h). During the evaluation of the voice recorder it was found that the first officer had announced the speed of rotation even earlier, namely at 113 knots (approx. 209 km / h) and that the master only raised his nose afterwards with a delay. It could never be determined why the rotation was announced and completed prematurely.
De-icing practices at LaGuardia Airport
Investigators also turned to de-icing practices at LaGuardia Airport. They found that the de-icing squads only used type I de-icing fluid, but not type II. Type I fluid is used to simply de-ice a machine, type II also prevents new icing. At the time of the accident, the use of Type II de-icing fluid was prohibited as tests showed that the dripping fluid impaired grip on the runways. Investigators learned that these regulations were made for LaGuardia Airport because of the short runways and the location on the water, which is why an aircraft overshooting the runway could result in a fall into the water.
In the final report of the NTSB, it was criticized that at that time a large number of airport operators were relying on type I deicing fluid and not using type II at all. The NTSB emphasized that tests had shown that the de-icing fluids of both types I and II did not drip off in relevant amounts during take-off runs, contrary to popular opinion.
conclusion
In their final report, the accident investigators attributed the accident to the inability of the aviation industry and the air traffic control authority to formulate procedures and criteria by which flight crews can act when flight delays occur under wintry conditions. Another cause of the accident was the decision by the Fokker crew to start the take-off run without first making sure that the wings were free of ice, even though the aircraft had been exposed to steady precipitation for 35 minutes since the last de-icing. The icing caused a stall and loss of control after taking off. Inappropriate measures by the crew as well as inadequate coordination between the pilots, which had led to rotation below the prescribed speed, contributed to the accident.
recommendations
The NTSB recommended that the Air Traffic Control Authority improve the training of aircraft crews and ground personnel who are responsible for inspecting aircraft surfaces before take-off. It was recommended, as part of regular training, to demonstrate visually what the icing of a wing looks and feels like and what amounts of ice can be seen under different lighting conditions. Investigators also instructed airlines to put in place procedures to train flight crews on variants and mixtures of common de-icing fluids, their half-lives, and moisture build-up rates.
With regard to the obstacles that the machine collided with during the accident, the NTSB recommended that all pump houses along runway 13/31 be positioned so that they no longer pose any obstacles for aircraft.
Cinematic processing
The accident was the subject of the sixth episode of the ninth season of the Canadian television series Mayday - Alarm im Cockpit . The program focused on another aircraft accident that was related to USAir flight 405.
Relation to Air Ontario Flight 1363
After the accident, experts referred to an incident that had occurred three years earlier with a Fokker F28 and a similar accident sequence in Dryden , Canada . It was objected that in the course of investigating the accident on Flight 1363, it had been recommended that pilots should inspect the wings from the cockpit in wintry conditions and that the aircraft should be de-iced near the runways and not at the gate, at that time to save. Canadian investigators also recommended the use of Type II deicing fluid instead of Type I at airports. Dryden's report attributed the cause of the accident to increasing competitive pressures as a result of deregulation of the aviation market. It argued that this would undermine safety standards and that the succinct practices and questionable procedures put aircrews in difficult situations.
Judge Virgil P. Mohansky, who was involved in the investigation into the Dryden aircraft accident and who wrote the investigation report, claimed on the TV show Mayday - Alarm in the Cockpit that the accident on USAir Flight 405 could have been avoided if the Recommendations from the accident report would have been implemented in the meantime.
Film bug
In the broadcast, the crash of the Fokker on Flight 405 is reconstructed on film, but the sequences contain several errors. For example, you can see the machine rolling over the runway forwards and falling into the water without causing a fire. In fact, the machine had swerved to the left and collided with a pump house before falling on fire into Flushing Bay at the end of the runway. The wreck of a USAir machine is also shown in a film sequence, but it is not the Fokker, but a Boeing 737-400 of the USAir, which is also at LaGuardia Airport on USAir flight 5050 on the same runway crashed in the opposite direction.
See also
- Air Ontario Flight 1363
- Turkish Airlines Flight 301
- Air France flight 7775
- Continental Airlines Flight 1713
- Air Florida Flight 90
- Arrow Air Flight 1285
Individual evidence
- ↑ a b c d e Accident report F28-4000 N485US , Aviation Safety Network (English), accessed on March 6, 2019.
- ↑ F28-4000 Operational History , N485US Jetphotos.com, accessed March 30, 2019.
- ↑ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad Aircraft Accident Report, Takeoff Stall in Icing Conditions, USAir Flight 405, Fokker F-28, N485US, LaGuardia Airport, Flushing, New York, March 22, 1992. (PDF) In: National Transportation Safety Board . February 17, 1993, Retrieved March 30, 2019 (NTSB / AAR-93/02).
Coordinates: 40 ° 46 ′ 15.6 ″ N , 73 ° 51 ′ 17.5 ″ W.