USAir Flight 427
N513AU, the aircraft involved the accident, taxing at John Wayne Airport in 1989.
|Date||September 8, 1994|
|Summary||Loss of control due to rudder hardover|
Beaver County, Pennsylvania
|Aircraft type||Boeing 737-3B7|
|Flight origin||O'Hare International Airport|
|Stopover||Pittsburgh International Airport|
|Destination||West Palm Beach Int'l Airport|
USAir Flight 427 was a scheduled flight from Chicago's O'Hare International Airport to Pittsburgh International Airport, with a final destination of West Palm Beach, Florida. On Thursday, September 8, 1994, the Boeing 737 flying this route crashed while approaching runway 28R of Pittsburgh International Airport, located in Findlay Township, Allegheny County, Pennsylvania, which at the time was the largest hub for the airline.
After the longest investigation in the history of the National Transportation Safety Board (NTSB), it was determined that the probable cause was that the aircraft's rudder malfunctioned and went hard-over in a direction opposite to that commanded by the pilots, causing the plane to enter an aerodynamic stall from which the pilots were unable to recover. All 132 people on board the aircraft were killed.
The aircraft involved was a Boeing 737-3B7, registration N513AU, and previously registered as N382AU. The aircraft was delivered in 1987 and was powered by two CFM56-3B2 engines. The aircraft had recorded approximately 16,800 hours of flight time before the crash.:1:6
The flight crew consisted of Captain Peter Germano, 45, who was hired by USAir in February 1981. The First Officer was Charles B. "Chuck" Emmett III, 38, who was hired in February 1987 by Piedmont Airlines (which merged into USAir in 1989). Both pilots were regarded as excellent pilots. They were both very experienced: Captain Germano logged approximately 12,000 flight hours, while First Officer Emmett logged 9,000 flight hours. Flight attendants Stanley Canty and April Slater were hired in 1989 by Piedmont Airlines. Flight attendant Sarah Slocum-Hamley was hired in October 1988 by USAir.
During its arrival into Pittsburgh, Flight 427 was sequenced behind Delta Air Lines Flight 1083, a Boeing 727-200. At no time was Flight 427 closer than 4.1 miles to Delta 1083, according to radar data.:2 Flight 427 was on approach at 6000 feet altitude, at flaps 1 configuration, and at approximately 190 knots.
At 7:02:57 p.m., the aircraft entered the wake turbulence of the Delta 727 it was sequenced behind, and there were three sudden thumps, clicking sounds, and a louder thump, after which the 737 began to bank and roll to the left.:4 As the aircraft stalled, Germano exclaimed "Hold on" numerous times,:138 while Emmett, under physical exertion, said, "Oh shit.":143 Germano exclaimed, "What the hell is this?":6 As air traffic control noticed Flight 427 descending without permission, Germano keyed the mic and stated, "Four-twenty-seven, emergency!":6 The mic was keyed for the rest of the event, resulting in the following exclamations in the cockpit being heard in the tower at Pittsburgh. The aircraft continued to roll while pitched nose-down at the ground, at which point against sharply rising G-forces, Germano yelled "Pull" three consecutive times before screaming, during which Emmett stated "God, no" seconds before impact. In an 80-degree nose-down position, banked 60 degrees left and traveling at approximately 300 mph (480 km/h), the 737 slammed into the ground and exploded at 7:03:25 p.m. in Hopewell Township, Beaver County, near Aliquippa approximately 28 seconds after entering the wake turbulence.
The National Transportation Safety Board investigated the crash. All 127 passengers and five crew members were killed.:ix For the first time in NTSB history, investigators were required to wear full-body bio-hazard suits while inspecting the accident site. As a result of the severity of the crash impact, the bodies of the passengers and crew were severely fragmented, leading investigators to declare the site a bio-hazard, requiring 2,000 body bags for the 6,000 recovered human remains. USAir had difficulty determining Flight 427's passenger list, facing confusion regarding five or six passengers. Several employees of the U.S. Department of Energy had tickets to take later flights, but used them to fly on Flight 427. One young child was not ticketed. Among the victims of the crash was noted neuroethologist Walter Heiligenberg.
Both the CVR and FDR were recovered and used for the investigation. Due to the limited parameters recorded by the FDR, investigators did not have access to the position of the flight-control surfaces (rudder, ailerons, elevator, etc.) for the accident. However, two parameters recorded by the FDR were crucial, one being the aircraft's heading, the other being the pitch control yoke position. During the approach, Flight 427 encountered wake turbulence from Delta 1083; the FAA, however, determined "the wake vortex encounter alone would not have caused the continued heading change that occurred after 1903:00.":245 The abrupt heading change shortly before the dive pointed investigators immediately to the rudder. Due to the absence of rudder pedal positions from the data, investigators had to determine whether the rudder moved hard-over by a malfunction or by pilot command. This in turn led to the CVR being more heavily scrutinized than most other recordings as statements and breathing from the pilots could potentially tell investigators if they were fighting for control over a rudder malfunction or inadvertently stomped on the wrong rudder pedal in excitement from the wake-turbulence. Boeing felt the latter more likely, while USAir and the Pilot's Union felt the former was more likely.
Reading the control yoke data from the FDR revealed that the pilots made a crucial error by pulling back on the control yoke throughout the dive with the stick-shaker audible on the CVR from the onset of the dive. This raised the aircraft's angle of attack, removed all aileron authority, prevented recovery from the roll induced by the rudder, and caused an aerodynamic stall. Because the aircraft had entered a slip, pulling back on the yoke only aggravated the bank angle further. Boeing's test pilots reenacted the fatal dive in both a simulator, as well as a test 737-300 by flying the same parameters on the accident FDR, and found that recovery from a fully deflected rudder at level flight, while at 190 knot crossover speed, was accomplished by turning the wheel to the opposite direction of the roll, and not pulling back on the yoke to regain aileron authority.:153 The NTSB remarked that no airline had ever trained a pilot on the proper recovery technique for the situation experienced by the pilots and that the pilots had just 10 seconds from the onset of the roll to troubleshoot before recovery of the aircraft was impossible.:153 The FDR revealed that after the aircraft stalled, it along with the crew and passengers were subjected up to a 4g load throughout the dive until impact with the ground in an 80 degree nose-down attitude traveling at approximately 300 mph under significant sideslip.
Investigators later discovered that the recovered accident rudder PCU was much more sensitive to bench-tests than other new PCU's. The exact mechanism of the failure involved the servo valve, which remains dormant and cold for much of the flight at high altitude, seizing after being injected with hot hydraulic fluid that has been in continuous action throughout the plane. This specific condition occurred in fewer than 1% of the lab tests, but explained the rudder malfunction that caused Flight 427 to crash. The jam left no trace of evidence after it occurred and a Boeing engineer later found that a jam under this controlled condition could also lead to the slide moving in the opposite direction than that commanded. In light of this, Boeing felt that the test results were not real-world and not applicable due to the extremes under which the valve was tested. Boeing stated that the rudder reversal was more likely psychological, likening it to examples when a human panics and intends to step on the brake during an automotive accident, but accidentally presses on the gas pedal instead while under duress. The FAA's official position was that there was not enough evidence for probable cause of rudder system failure.
After the longest accident investigation in NTSB history — lasting more than four and a half years — the NTSB released its final report on March 24, 1999. The NTSB concluded that the accident was due to mechanical failure:
The National Transportation Safety Board determines that the probable cause of the USAir Flight 427 accident was a loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.:ix
The NTSB concluded that similar rudder problems had caused the previously mysterious March 3, 1991 crash of United Airlines Flight 585 and the June 9, 1996 incident involving Eastwind Airlines Flight 517, both Boeing 737s.:292–295
At the time of the crash, Flight 427 was the second-deadliest accident involving a Boeing 737 (all series); as of 2012, it was the sixth deadliest. It was also the seventh-deadliest aviation disaster in the history of the United States, and the deadliest in the US involving a 737; as of 2012, it ranks eleventh. The accident marked USAir's fifth crash in the period from 1989 to 1994. The state of Pennsylvania spent approximately $500,000 in recover and cleanup for the accident site.
USAir submitted to the NTSB that pilots should receive training with regard to a plane's crossover speed and recovery from full rudder deflection. As a result, pilots were warned of and trained how to deal with insufficient aileron authority at an airspeed at or less than 190 knots (352 km/h), formerly the usual approach speed for a Boeing 737. Boeing maintained that the most likely cause of the crash was that the co-pilot inadvertently deflected the rudder hard-over in the wrong direction while in a panic and for unknown reasons maintained this input until impact with the ground.:96–100 According to aviation law firm Katzman, Lampert, and McClune, which represented families and victims of both US Air 427 and United 585, Boeing did not contest in open court that its 737's rudder was prone to an uncommanded rudder issue while in flight. Nonetheless, Boeing agreed to redesign the rudder control system with a redundant backup and paid for the retrofit of the entire worldwide 737 fleet. As one of the NTSB's main recommendations, airlines were required to add four additional channels of information — pilot rudder pedal commands — into flight data recorders, to which the FAA gave airlines until August 2001 to comply. In 2016, former investigator John Cox stated that time so far has proven the NTSB correct in their findings due to the absence of a rudder reversal incident since Boeing's redesign.
Following the airline's response to the Flight 427 accident, the United States Congress required airlines to deal more sensitively with the families of crash victims. and US Airways ceased using Flight 427 as a valid flight number. Flight 427 was the second fatal USAir crash in just over two months, the other being Flight 1016 at Charlotte-Douglas Airport in July 1994. The crashes contributed to the financial crisis USAir was experiencing at the time.
In popular culture
The Discovery Channel Canada / National Geographic TV series Mayday (also called Air Crash Investigation or Air Disasters) dramatized the crash of Flight 427 and the NTSB's 737 rudder investigation in a 2007 episode titled Hidden Danger (broadcast in some countries as Mystery Crashes).
- Boeing 737 rudder issues
- United Airlines Flight 585
- Eastwind Airlines Flight 517
- American Airlines Flight 1
- Northwest Airlines Flight 85
- Aircraft Accident Report – Uncontrolled Descent and Collision With Terrain, USAir Flight 427, Boeing 737-300, N513AU, Near Aliquippa, Pennsylvania, September 8, 1994 (PDF). National Transportation Safety Board. March 24, 1999.
- "FAA Registry". Federal Aviation Administration.
- "28 Seconds of Horror," Pittsburgh Tribune-Review
- Bertorelli, Paul (1997-10-19). "USAir 427: US Airways' View of the Accident – AVweb Features Article". Avweb.com. Retrieved 2016-12-03.
- "28 Seconds: Roxie, Trixie and the fat guy 3". Sptimes.com. 1994-09-08. Retrieved 2016-12-03.
- Federal Aviation Administration (1994-09-08). "Lessons Learned". Lessonslearned.faa.gov. Retrieved 2016-12-03.
- "Hidden Danger". Mayday. Season 4. 2007. Discovery Channel Canada / National Geographic Channel.
- "28 Seconds: The Mystery of USAir Flight 427 Part One: Zulu." 4. Retrieved on December 31, 2012.
- "List of Crash Victims." Wilmington Morning Star. September 10, 1994. 4A. Google News (28 of 49). Retrieved on October 3, 2009.
- Adair, Bill (2002). The Mystery of Flight 427: Inside a Crash Investigation. ISBN 1-58834-005-8.
- "Business - Expert Panel May Have Key To Which 737S Are Most At Risk - Seattle Times Newspaper". community.seattletimes.nwsource.com.
- NTSB Office of Public Affairs (March 24, 1999). "NTSB Concludes Longest Investigation in History; Finds Rudder Reversal was Likely Cause of USAIR Flight 427, A Boeing 737, Near Pittsburgh in 1994" (Press release). National Transportation Safety Board. Retrieved July 18, 2016.
- Ranter, Harro. "ASN Aircraft accident Boeing 737-3B7 N513AU Aliquippa, PA". aviation-safety.net.
- October 29, 1996 (1996-10-29). "The Seattle Times: Safety at issue: the 737". Old.seattletimes.com. Retrieved 2016-12-03.
- Katzman Lampert & McClune "US Air 427 crash Near Pittsburgh, Pennsylvania."
- "Boeing: News Feature -- 737 Rudder Enhancements -- Enhanced Rudder System". January 12, 2008. Archived from the original on 2008-01-12.
- "NTSB Concludes Longest Investigation in History; Finds Rudder Reversal was Likely Cause of USAIR Flight 427, A Boeing 737, Near Pittsburgh in 1994". Ntsb.gov. 1999-03-24. Retrieved 2017-07-22.
- "Fatal Flaws". Why Planes Crash. Season 2. 2016. MSNBC.
- "Remarks from acting NTSB Chairman, 2002".
- Halvonik, Steve. "Disaster only one in a string of setbacks for troubled company." Pittsburgh Tribune-Review. Sunday September 5, 2004. Retrieved on January 1, 2012.
- NTSB Accident Report
- NTSB Accident Investigation Docket (Archive)
- CVR Transcript (Archive)
- FDR Transcript (Archive)
- Boeing's report to the NTSB (Archive)
- ALPA's report to the NTSB (Addendum) (Archive)
- Accident description at the Aviation Safety Network
- Photo of the accident aircraft from Airliners.net
- USAir Flight 427 Memorial at Find a Grave