USAir Flight 405

For other flights numbered 405, see Flight 405 (disambiguation).

USAir Flight 405

The wreckage of USAir flight 405 lies partially inverted in Flushing Bay, New York
Accident
Date	March 22, 1992
Summary	Icing, improper deicing procedures, pilot error, unforeseen delays
Site	LaGuardia Airport, United States 40°46′15.56″N 73°51′17.47″W
Aircraft
Aircraft type	Fokker F28
Operator	USAir
Registration	N485USdisaster
Flight origin	LaGuardia Airport
Destination	Cleveland Hopkins International Airport
Passengers	47
Crew	4
Fatalities	27 (25 passengers + 2 crew)
Injuries	21
Survivors	24 (22 passengers + 2 crew)

USAir Flight 405 was a routine domestic passenger flight between LaGuardia Airport, New York City and Cleveland, Ohio. On March 22, 1992 a USAir Fokker F28, registration N485US, flying the route crashed in poor weather in a partially inverted position in Flushing Bay, New York upon liftoff from LaGuardia after the jet failed to gain lift and take off. 27 of the 51 people onboard, including the captain and one of the cabin crew members, were killed.

The subsequent investigation revealed that due to pilot error, inadequate deicing procedures at LaGuardia and several lengthy delays, a large amount of ice had accumulated on the wings and airframe, disrupting airflow, increasing drag and reducing lift, which prevented the jet from lifting off the runway. The NTSB concluded that the flight crew were unaware of the amount of ice that had built up, after the jet was delayed by heavy traffic taxiing to runway 13.

Investigators also found that the deicing procedures at LaGuardia were substandard, and the deicing fluid being used at the airport, and across the United States by the majority of commercial airlines was only effective for fifteen minutes, whilst the jet encountered a delay of up to 35 minutes. The crash led to a number of studies into the effect that ice has on aircraft, and several recommendations into prevention techniques.

Flight history

The jet involved in the accident was a Fokker F28 Series 4000 aeroplane manufactured in the Netherlands. The Fokker 28 is a two-engine, medium-range jet designed for transporting up to 95 passengers. The jet involved in the accident was registered in the United States as N458US. It was first delivered to Piedmont Airlines in August 1986, and was acquired by USAir three years later in August 1989 when Piedmont and USAir merged. The aircraft had amassed a total of 12,462 flying hours at the time of the accident.

The 44-year old captain was Captain Wallace J. Majure II, who was fully qualified to pilot the F28 and four other commercial aircraft, and had accumulated approximately 9,820 total flying hours, of which 2,200 hours were in the F28. He was hired as an F28 first officer by Piedmont Airlines in 1985. After serving as a first officer and then a captain on a Boeing 737, he was reassigned during company cutbacks to an F28 pilot.

The first officer, John J. Rachuba, age 30, was hired by Piedmont Airlines in 1989. At the time of the accident, company records indicate that he had accumulated an approximate total of 4,507 flying hours, of which 29 hours were in the F28. He held a flight engineer certificate with ratings for turbojet-powered aircraft and an expired instructor certificate issued on August 16, 1987. He also held an FAA license for non-federal control towers. Previously, he had served as a second officer on Boeing 737s and Boeing 727s.

Accident

An NTSB diagram of Flight 405's attempted takeoff, showing it veer off the left of the runway and hit a water pump

The aircraft took off from Jacksonville International Airport, Florida several hours before the accident, although the departure from Jacksonville was delayed by poor weather over LaGuardia and the removal of the baggage of a passenger who decided not to board the jet. When the plane reached LaGuardia, the landing was uneventful and the jet was not significantly delayed whilst in the air waiting to land, however congestion on the taxiways at LaGuardia delayed the arrival of the aircraft at the gate.

Upon arrival at Gate 1, the pilot advised a ground mechanic that the jet was "good to go." The flight crew then disembarked the jet to use facilities in the terminal. The poor weather did not improve as the jet was deiced with Type I fluid, a heated 50/50 water/glycol mixture. Following the completion of this process, one of the two deicing trucks delayed the pushback of the jet by around 20 minutes when it experienced mechanical problems in such a position that it prevented the aircraft from taxiing to the runway following the flight crew's return. After the deicing truck was repaired, the pilot requested a second deicing, though the flight crew did not perform a walkaround of their aeroplane, as USAir procedures did not require them to do so.

Following the second deicing, the aeroplane was granted permission to taxi to runway 13. The flight crew completed the pre-flight checklist during the taxi. Engine anti-ice was turned on for both of the two engines during taxi. The captain announced that the flaps would remain up during taxi, and he placed an empty coffee cup on the flap handle as a reminder, a procedure used by many flight crews. The captain announced they would use standard US Air contaminated runway procedures that included the use of 18 degrees flaps, and also decided that they would take off with a reduced V₁ speed of 110 knots.

Weather reports for LaGuardia stated that on the night of the accident, all taxiways were coated with a thin covering of snow. Runway 13 was also covered with a thin layer of wet snow, although it had been treated with urea and it had been sanded. The first officer described the snowfall as "not heavy, no large flakes." He told authorities that snow was sliding off the jet and the nose of the aeroplane was coated in a watery layer. He used a light positioned on the wing of his jet to check for signs of ice several times before they attempted to take off. Nor he or the pilot saw any evidence of contamination on the wing or on the black strip and therefore decided against a third deicing. He told investigators that he checked the wings "maybe 10 times, but at least 3." He said that he did not consider the snowfall heavy, and he did not recall any wind blowing the snow. The first officer stated that as they taxiied, they looked back at the wings several times. Near the time of the takeoff, he said "looks good to me, black strip is clear."

The flight crew spent the time taxiing discussing deicing procedures. The first officer suggested to the pilot that they "this [aircraft], he might keep our wings clear for us." The pilot replied that "it can cause us to re-freeze too ... I don't want to be very close to him." Later, the first officer remarked "look at all that stuff. What is that?" to which the pilot replied "sand I guess, urea sand."

The pilot of a jet taxiing behind flight 405, Northwest Airlines flight 517, a Boeing 757, stated that he had a good view of the top of flight 405's wing, and that there was just enough snow on the fuselage to "fuzzy" the USAir printing but that the wings appeared to be clear. He believed that the snow had "all but stopped" and was more concerned about the amount of vehicular traffic, such as sweepers and ploughs, than he was about the snowfall. Trump Shuttle flight 1541, a Boeing 727 which had landed around the time flight 405 was taxiing had "picked up a lot of snow quickly during my post-landing walkaround, but by the finish it seemed to be more rain," the second officer said. He described flight 405 as a "fairly clean aeroplane." He said that he could not comment on clear ice, but that the wings and fuselage were clear of snow.

Flushing Bay, New York, where the aircraft came to rest, partially inverted

The jet, already several hours behind schedule, then suffered further delays taxiing to the runway. The weather had created heavy traffic at LaGuardia, and it was reported that there were queues of aircraft waiting for permission for takeoff. Investigators estimated that the plane took between twenty five and forty five minutes to taxi from the gate to the runway.

Following permission for liftoff from controllers, the flight crew initiated the takeoff procedure and the first officer made a callout of 80 knots, and, several seconds later, a V₁ callout, followed by a V_R callout. Approximately 2.2 seconds after the V_R callout, the nose landing gear left the ground. The first officer described the takeoff as normal through the rotation. He stated that no problem was evident with vibration, rate of acceleration, ambient noise, and directional control.

Just under five seconds later, the stick shaker activated and the crew received six stall warnings, before the jet began banking to the left, leaving the runway. The aircraft struck two visual approach slope indicator posts, an ILS beacon and a water pump house. The first officer said it was "just like we lost lift." As the captain attempted to level the wings, the crew used right rudder to manoeuvre the aircraft back toward the ground and avoid the water below. The first officer said that the flight crew seemed to agree the jet wasn't going to fly. They continued to try to hold the nose up to impact in a flat attitude, although he stated that there were no "heavy control inputs." The flight crew did not alter the power levers.

The left engine then separated from the fuselage, before the jet impacted with the edge of Flushing Bay and came to rest partially inverted. Parts of the fuselage and cockpit were submerged in water. Minutes after the crash, several small fires broke out on the water and on the wreckage debris. Passengers who sustained minor injuries and injuries that were not life threatening most likely drowned as a result of confusion, disorientation or entrapment.

Rescue

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Location of crash site

The tower cab coordinator on duty at the time of the accident stated that he saw flames and a fireball emanating from the crash site following the accident, and he sounded an alarm, alerting the Port Authority of New York and New Jersey Police, who responded. An investigation revealed that there were technical problems with an emergency telephone at LaGuardia, however it was found that these issues did not hinder the emergency response.

The Port Authority of New York and New Jersey Police initially sent four vehicles, and the personnel in these vehicles reported that snow and fog hampered their visibility whilst heading to the crash site, and they could not see the destroyed aircraft. However, one member of the fire crew observed people standing on top of a dike near the crash site. Police divers also entered the water following the crash, although they found no-one alive inside the jet or in the water.

The fire-fighters continued spraying the fire, and the incident commander estimated that they had the fire under control ten minutes after their arrival at the scene. The New York Times reported that:

"the accident sent thick black smoke billowing above the airport as more than 200 emergency workers ... had to contend not only with blustery snow but the powerful icy current in Flushing Bay ... the tense drama of the rescue continued into the early hours, with fire-fighters and police officers in water up to their shoulders and helicopters shining spotlights on the wreckage and an ice-covered mound of earth at the end of the runway so slick the rescue workers needed metal ladders to walk across it."

The final report noted, but did not criticise the medical operation at the scene, where paramedics attended to those who were conscious with life threatening injuries, but did not make any attempts to resuscitate victims who appeared drowned or lacked vital signs because they believed that they could not be revived because they had succumbed to the cold salt water. It was estimated by the authorities who attended the scene of the crash that 15 ambulances responded to the accident site, all of which were used to transport the injured to hospitals, and that 40 additional ambulances were available near the site of the crash, but were not needed.

The NTSB investigation described the emergency response as "effective and contributed to the survivability of the aeroplane's occupants. However, the response by the emergency medical services personnel was inadequately coordinated, and the ambulance response times to the hospitals were excessive."

Investigation

The National Transportation Safety Board sent a team to the crash site to investigate the accident. They concluded that, unknown to the crew, ice had collected on the wings, disrupting airflow and reducing lift. The inquiry lasted just under one year.

They suggested multiple reasons why the jet was unable to gain lift, but the accident report states there was no evidence to suggest corrosion on the wings, and the speed brakes were not deployed. The aeroplane's flight control systems was also examined and revealed no failure prior to impact. The report reads that "the evidence did not support improper wing configuration, airframe or system defects, or deployment of the speed brakes as reasons for the loss of aerodynamic efficiency. The investigators also stated that the takeoff roll of the jet was not abnormal. The board came to the conclusion that ice had built up on the wings, and this had contributed largely to the accident.

Buildup of ice

With frost roughness present on the wing upper surface the characteristic of slow stall progression towards the wing tip is lost and uncontrollable roll may develop at angle of incidence as low as 10 degrees ... The drag of the clean wing is such that the aircraft is capable of climbing away at the required climb angle at V2 with one engine inoperative. In the case of a contaminated wing the drag may, however, be doubled due to a wing stall which occurs at an angle of incidence (attack) only slightly greater than that for stick shaker operation. Consequently, acceleration is lost even with all engines operating at T.O. power.

From a document written by Fokker detailing the effect
of ice on the wing of an F28

When attempting to find out why ice was present on the wings of the jet, the board determined that the aeroplane had been properly cleared of ice and snow during the two deicing procedures at the gate. However, approximately 35 minutes elapsed between the second time that the aircraft was deiced and the initiation of takeoff during which the aeroplane was exposed to continuing precipitation in below freezing temperatures. The NTSB were unable to determine how much ice had built up on the wings following the second deicing. However, investigators thought it was highly likely that "some contamination occurred in the 35 minutes following the second deicing and that this accumulation led to this accident."

"The Safety Board views the evidence as conclusive that the primary factor in this accident was the reduced performance of the wing due to ice contamination. Therefore, the Safety Board evaluated the extent to which the decisions of, and procedures used by the flight crew could have contributed to the accident," read the final report.

When the NTSB, in collaboration with Fokker, investigated the effect ice can have on an aircraft, they found that ice particles as small as one millimetre to two millimetres can cause a loss of lift of 22 percent in ground effect and 33 percent out of ground effect.

Errors by the flight crew

The report found that the flight crew were aware that the poor weather was likely to cause ice buildup, however neither of them took any action to check the condition of the wing leading edge and upper surface. The aircraft was evaluated by ground crew and was deiced. After the mechanical failure of the deicing truck, the investigators reported that, as the captain requested another deice, there was an indication he was:

concerned about the continuing exposure to precipitation, and the request was prudent and in accordance with USAir guidance. Following the second deicing, the flight crew was most likely satisfied that the aeroplane was free of adhering contamination. The flight crew was not aware of the exact delay that they would encounter before takeoff and their decision to leave the gate was reasonable. After taxiing, when it became evident that they would be delayed for a prolonged period, conversations between the crew showed that they were aware of and probably concerned about the risk of reaccumulating frozen contamination on the wing.

They also found that USAir guidance and flight crew training was sufficient and should have alerted the flight crew to the risk of attempting a takeoff whilst they were unaware of the condition of the wing.

The Safety Board believes that the flight crew of flight 405 should have taken more positive steps to assure a contamination-free wing, such as entering the cabin to look at the wing from a closer range. Although the Safety Board acknowledges that the detection of minimal amounts of contamination, sufficient to cause aerodynamic performance problems, is difficult and may not be possible without a tactile inspection, an observation from the cabin would have improved the chance of seeing some contamination and might have prompted the flight crew to return to the gate. The Safety Board believes that the flight crew’s failure to take such precautions and the decision to attempt takeoff while unsure of wing cleanliness led to this accident and is a cause of it.

In a television interview, one of the NTSB investigators suggested that "the captain was faced with quite a problem. If he wanted to be deiced a third time, he would have had to get out of the line [of jets waiting to take off] and taxi all the way back to the parking area and meet up with a deicing truck again. That would have put him very very late and it may have even caused the cancellation of the flight."

The NTSB carried out tests to discover why the first officer was unable to see the ice buildup on the wing of the jet. When the sliding window of the cockpit was fully open, the first officer would have been able to see the outer eighty percent of the wing, including the black strip used to contrast the white surface of the wing so the flight crew can search for a build up of ice. When the sliding window was shut, as it was in the accident, it would be difficult to make out any details of the wing, and the black strip would have been distorted by the glass. They also found that the ice light made little difference to how much the first officer would have been able to see.

The investigators also requested that Fokker conduct a study of the effects of ice contamination and pilot technique on the F-28 aircraft. The NTSB evaluated the data from the tests and found that the pilot initiated the rotation five knots earlier at 119 knots instead of the proper rotation speed of 124 knots. The data from Fokker was correlated with the cockpit voice recording and confirmed that the first officer called a rotation speed of 113 knots but the captain did not rotate until 119 knots. It was never established why the rotation was called and initiated earlier than was standard.

Deicing procedures at LaGuardia

Investigators also focused on deicing practices at LaGuardia. They found that the airport was using only Type I deicing fluid, not Type II. Type I fluids are used for the actual deicing of the jet, whilst Type II fluids are used for preventing buildup of ice. The accident report criticised the fact that the majority of the aeroplane operators in the United States rely only upon Type I fluids for protection, and they do not use Type II. Investigators observed maintenance staff at LaGuardia and found that Type II fluids were not available at the airport. The board stated that tests have shown that both Type I and Type II fluids do flow off the wings of a treated aeroplane in significant amounts during the initial takeoff ground run. The NTSB stated:

There are a number of views on the potential uses of Type I and II fluids. The use of Type I fluid raises concern because its holdover time is shorter than the holdover time for Type II fluid under certain conditions. Both fluids are under scrutiny for their environmental impacts, and it is uncertain if Type II fluid diminishes the runway coefficient of friction since the fluid rolls off the airplane during the takeoff roll. Also, the use of either type fluid may result in a temporary degradation in the airplane's aerodynamic performance, a reduced stall margin, and an increase in drag.

Safety card errors

An NTSB diagram of the deaths and injuries to the passengers aboard Flight 405

Whilst it was not named as a cause of the accident, investigators also found that the passenger safety briefing cards in the aeroplane showed two types of galley service doors. However, only one door is installed on a particular F28 model at any one time. The examination also showed that the safety card did not show how to operate either of the two types of galley service doors in the emergency mode if the normal opening mode failed. However, the final report stated that this "did not contribute to the fatalities in the accident."

Conclusion

The final report, published by the NTSB, cited the probable cause of the accident to be:

the failure of the airline industry and the Federal Aviation Administration to provide flight crews with procedures, requirements, and criteria compatible with departure delays in conditions conducive to airframe icing and the decision by the flight crew to take off without positive assurance that the aeroplane's wings were free of ice accumulation after 35 minutes of exposure to precipitation following de-icing. The ice contamination on the wings resulted in an aerodynamic stall and loss of control after lift-off. Contributing to the cause of the accident were the inappropriate procedures used by, and inadequate coordination between, the flight crew that led to a takeoff rotation at a lower than prescribed air speed.

Aftermath

NTSB recommendations

The NTSB made several recommendations to the FAA, including "flight crew members and appropriate ground personnel responsible for the inspection of transport-category aeroplanes for wing contamination receive specific periodic training that will illustrate what contamination looks like and feels like on a wing and the amount of contamination that is detectable under different light conditions."

"If gate holds are requited to limit deicing fluid holdover time, encourage air traffic control to initiate the gate holds as soon as a deicing operation begins, rather than after delays have exceeded 15 minutes" they recommended.

They also ordered a review of Fokker F28 passenger safety briefing cards "to ensure that they clearly and accurately depict the operation of the two types of forward cabin doors in both their normal and emergency modes and that they describe clearly and accurately how to remove the overwing emergency exit and cover."

Dryden report allegations

The crash featured on National Geographic Channel in an episode of Air Crash Investigation entitled Snowbound, where the accident was compared with Air Ontario Flight 1363, which crashed in Dryden, Ontario after the crew did not deice their jet. The programme opened by saying that Canadian investigators were "stunned" to hear of the accident, as it mirrored the Air Ontario flight which had occurred three years earlier.

The Honourable Virgil P. Moshansky, who investigated the crash in Dryden, appeared in the documentary, alleging that if the recommendations in his report, such as the use of Type II deicing fluid rather than Type I, deicing trucks near the runway rather than at the gate, and that the crew should inspect their wings not only from the cockpit, but also the cabin, had been followed at LaGuardia and other US airports, the accident on USAir flight 405 could have been prevented. His report concluded that competitive pressures caused by commercial deregulation cut into safety standards and that many of the industry’s sloppy practices and questionable procedures were placing pilots in difficult situations.

Moshansky told the documentary that his report "probably sat on someone's [at the FAA] desk." He said "when I first heard about it I thought, my God, it's Dryden all over again ... certainly if they had followed the recommendations in my report, the F28 crash at LaGuardia could have been averted."

Another investigator into the Air Ontario accident told the documentary that "after all of this work [investigating the Dryden crash], after all of the efforts, to see it happen again was extremely frustrating." The documentary focused largely on these allegations, whilst also reconstructing the Air Ontario flight and the USAir flight. However, it was reported that the FAA refute Moshansky's allegations, and they claim that they never received his report.

International Conference on Ground Deicing

These ice formations on the propeller and fuselage surfaces of a test unit installed in the Icing Research Tunnel at the Aircraft Engine Research Laboratory of the National Advisory Committee for Aeronautics, Cleveland, Ohio, show what may happen to an aircraft in flight under certain atmospheric conditions.

Following the crash of flight 405, along with American Eagle Flight 4184, an ATR 72 which suffered a catastrophic loss of control after the wings were contaminated with freezing rain in 1994, Air Florida Flight 90, when pilot error lead to ice buildup of the wings, causing the jet to crash into the Potomac river in 1982, and Air Ontario Flight 1363, the FAA began to research methods of improving deicing practices at airports to minimise the number of accidents caused by a buildup of ice.

A report on the conference by the FAA read:

the FAA initiated a 6-month effort to improve the safety of winter flight operations. This effort will result in safety improvements that will be implemented before next winter. A better understanding of aeroplane ground deicing and anti-icing issues is a crucial prerequisite to the implementation of feasible and effective safety improvements. To achieve this goal, the FAA sponsored a conference at which the international aviation community could exchange thoughts and offer recommendation on a variety of issues concerning safe winter operations. On May 28 and 29, 1992, the FAA held the International Conference on Aeroplane Ground Deicing to develop a better understanding of aeroplane deicing and anti-icing issues. More than 750 participants discussed the problems posed by aircraft deicing and examined possible solutions. The conference produced suggestions for corrective actions the should be taken before this winter and possible long-term improvements to existing systems. The focus of the conference was carrier operated turbine-powered aeroplanes with more than 30 passenger seats.

Described by the FAA as a “sharply focused effort”, experts convened on May 28 and 29 1992 in Reston, Virginia for the International Conference on Ground Deicing. At the conference, industry methods were discussed and agreed on actions that should be taken in the long term and short term.

It was reported that discussions over different types of deicing fluid were discussed, along with different deicing equipment and techniques. They also found that the pilot in command was the ultimate authority for take off decisions but that all operators had to provide proper training and criteria to follow in order for the pilot in command to base a proper decision.

The conference concluded with an amendment to all carriers operating under FAA regulations. They stated that airlines should put in place FAA approved ground deicing or anti-icing procedures anytime weather conditions of ice, snow or frost prevailed. The new rules went into effect on November 1, 1992.

Developments in deicing

An American Airlines MD-80 aircraft being deiced at Syracuse Hancock International Airport

In the years that followed the accident, airlines started using Type IV deicing fluid, which is more effective than both Type I and Type II fluids. Type IV fluids stick to aircraft for up to two hours. Chicago O'Hare International Airport was the first to introduce deicing facilities at the runway, something which has now become commonplace.

Aircraft themselves now have more sophisticated deicing systems that can be used on the ground and in the air. Many modern civil fixed wing transport aircraft use anti-ice systems on the leading edge of wings, engine inlets and air data probes using warm air. This is bled from engines and is ducted into a cavity beneath the surface to be anti-iced. The warm air heats the surface up to a few degrees above zero, preventing ice from forming. The system may operate autonomously, switching on and off as the aircraft enters and leaves icing conditions.

Ground deicing technologies are also developing, and a newer technology is infrared deicing. This is the transmission of energy by means of electromagnetic waves or rays. Infrared is invisible and travels in straight lines from the heat source to surfaces and objects without significantly heating the space (air) it passes through. When infrared waves strike an object, they release their energy as heat. This heat is either absorbed or reflected by the cooler surface. Infrared energy is continually exchanged between "hot" and "cold" surfaces until all surfaces have reached the same temperature (equilibrium). The colder the surfaces, the more effective the infrared transfer from the emitter. This heat transfer mechanism is substantially faster than conventional heat transfer modes used by conventional deicing (convection and conduction) due to the cooling effect of the air on the deicing fluid spray.

Aircraft de-icing vehicles have also improved since the accident, usually consisting of a large tanker truck, containing the concentrated de-icing fluid, with a water feed to dilute the fluid according to the ambient temperature. The vehicle also normally has a cherry picker crane, allowing the operator to spray the entire aircraft in as little time as possible; an entire Boeing 737 can be treated in under 10 minutes by a single de-icing vehicle.

Airport runways are also de-iced by sprayers fitted with long spraying arms. These arms are wide enough to cross the entire runway, and allow de-icing of the entire airstrip to take place in a single pass, reducing the length of time that the runway is unavailable.

USAir

On November 12, 1996, the airline announced that it would change its name to US Airways and introduce a new corporate identity in early 1997. The new logo, a stylized version of the Flag of the United States, would be adopted. The new branding was to be applied to terminals and ticket jackets. The airline planned to paint aircraft in deep blue and medium gray with red and white accent lines.

Following the re-branding to US Airways, the airline placed an order for up to 400 Airbus A320-series narrow body aircraft, with 120 firm orders at the time of the order signing. At the time, the order was regarded as the largest bulk aircraft request in history. In 1998, the airline followed with an order for up to 30 Airbus A330-series wide-body aircraft, with an initial firm order for seven of the A330-300 airliners. These orders enabled US Airways to replace its older aircraft with newer, more efficient aircraft, and it helped with the re-branding and repositioning efforts of US Airways.

See also

• List of accidents and incidents involving commercial aircraft
• Air safety
• China Eastern Airlines Flight 5210
• Air Florida Flight 90
• American Eagle Flight 4184

External links

• Accident description at the Aviation Safety Network
• NTSB Report