Crash of a McDonnell Douglas MD-88 in LaGuardia

Date & Time: Mar 5, 2015 at 1102 LT
Type of aircraft:
Operator:
Registration:
N909DL
Survivors:
Yes
Schedule:
Atlanta – New York
MSN:
49540/1395
YOM:
1987
Flight number:
DL1086
Crew on board:
5
Crew fatalities:
Pax on board:
125
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15200
Captain / Total hours on type:
11000.00
Copilot / Total flying hours:
11000
Copilot / Total hours on type:
3000
Aircraft flight hours:
71196
Aircraft flight cycles:
54865
Circumstances:
The aircraft was landing on runway 13 at LaGuardia Airport (LGA), New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane’s nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Flight 1086 was a regularly scheduled passenger flight from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, operating under the provisions of 14 Code of Federal Regulations Part 121. An instrument flight rules flight plan had been filed. Instrument meteorological conditions prevailed at the time of the accident. The captain and the first officer were highly experienced MD-88 pilots. The captain had accumulated about 11,000 hours, and the first officer had accumulated about 3,000 hours, on the MD-88/-90. In addition, the captain was previously based at LGA and had made many landings there in winter weather conditions. The flight crew was concerned about the available landing distance on runway 13 and, while en route to LGA, spent considerable time analyzing the airplane’s stopping performance. The flight crew also requested braking action reports about 45 and 35 minutes before landing, but none were available at those times because of runway snow clearing operations. The unavailability of braking actions reports and the uncertainty about the runway’s condition created some situational stress for the captain, who was the pilot flying. After runway 13 became available for arriving airplanes, the flight crews of two preceding airplanes (which landed on the runway about 16 and 8 minutes before the accident landing) reported good braking action on the runway, so the flight crew expected to see at least some of the runway’s surface after the airplane broke out of the clouds. However, the flight crew saw that the runway was covered with snow, which was inconsistent with their expectations based on the braking action reports and the snow clearing operations that had concluded less than 30 minutes before the airplane landed. The snowier-than-expected runway, along with its relatively short length and the presence of Flushing Bay directly off the departure end of the runway, most likely increased the captain’s concerns about his ability to stop the airplane within the available runway distance, which exacerbated his situational stress. The captain made a relatively aggressive reverse thrust input almost immediately after touchdown. Reverse thrust is one of the methods that pilots use to decelerate the airplane during the landing roll. Reverse thrust settings are expressed as engine pressure ratio (EPR) values, which are measurements of engine power (the ratio of the pressure of the gases at the exhaust compared with the pressure of the air entering the inlet). Both pilots were aware that 1.3 EPR was the target setting for contaminated runways.As reverse thrust EPR was rapidly increasing, the captain’s attention was focused on other aspects of the landing, which included steering the airplane to counteract a slide to the left and ensuring that the spoilers had deployed (a necessary action for the autobrakes to engage). The maximum EPR values reached during the landing were 2.07 on the left engine and 1.91 on the right engine, which were much higher than the target setting of 1.3 EPR. These high EPR values likely resulted from a combination of the captain’s stress; his relatively aggressive reverse thrust input; and operational distractions, including the airplane’s continued slide to the left despite the captain’s efforts to steer it away from the snowbanks alongside the runway. All of these factors reduced the captain’s monitoring of EPR indications. The high EPR values caused rudder blanking (which occurs on MD-80 series airplanes when smooth airflow over the rudder is disrupted by high reverse thrust) and a subsequent loss of aerodynamic directional control. Although the captain stowed the thrust reversers and applied substantial right rudder, right nosewheel steering, and right manual braking, the airplane’s departure from the left side of the runway could not be avoided because directional control was regained too late to be effective.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inability to maintain directional control of the airplane due to his application of excessive reverse thrust, which degraded the effectiveness of the rudder in controlling the airplane’s heading. Contributing to the accident were the captain’s:
- situational stress resulting from his concern about stopping performance and
- attentional limitations due to the high workload during the landing, which prevented him from immediately recognizing the use of excessive reverse thrust.
Final Report:

Crash of a Boeing 737-7H4 in New York

Date & Time: Jul 22, 2013 at 1744 LT
Type of aircraft:
Operator:
Registration:
N753SW
Survivors:
Yes
Schedule:
Nashville – New York
MSN:
29848/400
YOM:
1999
Flight number:
WN345
Crew on board:
5
Crew fatalities:
Pax on board:
145
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
12522
Captain / Total hours on type:
7909.00
Copilot / Total flying hours:
5200
Copilot / Total hours on type:
1100
Aircraft flight hours:
49536
Circumstances:
As the airplane was on final approach, the captain, who was the pilot monitoring (PM), realized that the flaps were not configured as had been briefed, with a setting of 40 degrees for the landing. Data from the flight data recorder (FDR) indicate that the captain set the flaps to 40 degrees as the airplane was descending through about 500 ft altitude, which was about 51 seconds from touchdown. When the airplane was between 100 to 200 ft altitude, it was above the glideslope. Concerned that the airplane was too high, the captain exclaimed repeatedly "get down" to the first officer about 9 seconds from touchdown. About 3 seconds from touchdown when the airplane was about 27 ft altitude, the captain announced "I got it," indicating that she was taking control of the airplane, and the first officer replied, "ok, you got it." According to FDR data, after the captain took control, the control column was relaxed to a neutral position and the throttles were not advanced until about 1 second before touchdown. The airplane touched down at a descent rate of 960 ft per minute and a nose-down pitch attitude of -3.1 degrees, resulting in the nose gear contacting the runway first and a hard landing. The airplane came to a stop on the right side of the runway centerline about 2,500 ft from its initial touchdown. The operator's stabilized approach criteria require an immediate go-around if the airplane flaps or landing gear were not in the final landing configuration by 1,000 ft above the touchdown zone; in this case, the flaps were not correctly configured until the airplane was passing through 500 ft. Further, the airplane's deviation about the glideslope at 100 to 200 ft would have been another opportunity for the captain, as the PM at this point during the flight, to call for a go-around, as indicated in the Southwest Airlines Flight Operations Manual (FOM). Accident data suggest that pilots often fail to perform a go-around or missed approach when stabilized approach criteria are not met. A review of NTSB investigated accidents by human factors researchers found that about 75% of accidents were the result of plan continuation errors in which the crew continued an approach despite cues that suggested it should not be continued. Additionally, line operations safety audit data presented at the International Air Safety Summit in 2011 suggested that 97% of unstabilized approaches were continued to landing even though doing so was in violation of companies' standard operating procedures (SOPs). The Southwest FOM also states that the captain can take control of the airplane for safety reasons; however, the captain's decision to take control of the airplane at 27 ft above the ground did not allow her adequate time to correct the airplane's deteriorating energy state and prevent the nose landing gear from striking the runway. The late transfer of control resulted in neither pilot being able to effectively monitor the airplane's altitude and attitude. The first officer reported that, after the captain took control of the airplane, he scanned the altimeter and airspeed to gain situational awareness but that he became distracted by the runway "rushing" up to them and "there was no time to say anything." The captain should have called for a go-around when it was apparent that the approach was unstabilized well before the point that she attempted to salvage the landing by taking control of the airplane at a very low altitude. In addition, the captain did not follow SOPs at several points during the flight. As PM, she should have made the standard callout per the Southwest FOM when the airplane was above glideslope, stating "glideslope" and adding a descriptive word or words to the callout (for example, "one dot high"). Rather than make this callout, however, the captain repeatedly said "get down" to the first officer before stating "I got it." The way she handled the transfer of airplane control was also contrary to the FOM, which indicates that the PM should say "I have the aircraft." The flight crew's performance was indicative of poor crew resource management.
Probable cause:
The captain's attempt to recover from an unstabilized approach by transferring airplane control at low altitude instead of performing a go-around. Contributing to the accident was the captain's failure to comply with standard operating procedures.
Final Report:

Crash of an Airbus A320-214 in New York

Date & Time: Jan 15, 2009 at 1531 LT
Type of aircraft:
Operator:
Registration:
N106US
Flight Phase:
Survivors:
Yes
Schedule:
New York - Charlotte
MSN:
1044
YOM:
1999
Flight number:
US1549
Crew on board:
5
Crew fatalities:
Pax on board:
150
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19663
Captain / Total hours on type:
4765.00
Copilot / Total flying hours:
15643
Copilot / Total hours on type:
37
Aircraft flight hours:
25241
Aircraft flight cycles:
16299
Circumstances:
Aircraft experienced an almost complete loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from La Guardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport, Charlotte, North Carolina, and had departed LGA about 2 minutes before the in-flight event occurred. The 150 passengers, including a lap held child, and 5 crew members evacuated the airplane via the forward and overwing exits. One flight attendant and four passengers were seriously injured, and the airplane was substantially damaged.
Probable cause:
The ingestion of large birds into each engine, which resulted in an almost total loss of thrust in both engines and the subsequent ditching on the Hudson River. Contributing to the fuselage damage and resulting unavailability of the aft slide/rafts were:
-the Federal Aviation Administration’s approval of ditching certification without determining whether pilots could attain the ditching parameters without engine thrust,
-the lack of industry flight crew training and guidance on ditching techniques,
-the captain’s resulting difficulty maintaining his intended airspeed on final approach due to the task saturation resulting from the emergency situation.
Contributing to the survivability of the accident was:
-the decision-making of the flight crew members and their crew resource management during the accident sequence,
-the fortuitous use of an airplane that was equipped for an extended overwater flight, including the availability of the forward slide/rafts, even though it was not required to be so equipped
-the performance of the cabin crew members while expediting the evacuation of the airplane,
-the proximity of the emergency responders to the accident site and their immediate and appropriate response to the accident.
Final Report:

Crash of a Beechcraft 200 Super King Air in Fitchburg: 6 killed

Date & Time: Apr 4, 2003 at 0935 LT
Operator:
Registration:
N257CG
Flight Type:
Survivors:
Yes
Schedule:
New York-LaGuardia – Fitchburg
MSN:
BB-1739
YOM:
2000
Crew on board:
2
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
6100
Captain / Total hours on type:
1334.00
Copilot / Total flying hours:
1080
Copilot / Total hours on type:
4
Aircraft flight hours:
359
Circumstances:
While on approach to the airport, the airplane entered a left turn, which the surviving passenger described as "almost completely upside down." The airplane briefly leveled, then entered another left turn with a bank angle of the same severity. The airplane seemed to roll level, then entered a steep dive, until it impacted a building. The passenger reported that the engines were running normally throughout the entire flight, and the steep turns performed by the pilot did not concern her, as she had flown with him before and knew he "liked to make sharp turns." Examination of the airplane and engines revealed no pre-impact mechanical anomalies, and weather at the time of the accident included a broken cloud ceiling of 1,100 feet, with 3 miles visibility in mist. According to the FAA, Airplane Flying Handbook,"...[An] airplane will stall at a higher indicated airspeed when excessive maneuvering loads are imposed by steep turns, pull-ups, or other abrupt changes in its flightpath." A review of the "Stall Speeds - Power Idle" chart from the POH revealed that with approach flaps selected, at a bank angle of 60 degrees, the airplane would stall at about 123 knots. Radar data indicated the airplane descended along the approach course at an average speed of 120 knots. Toxicology testing performed on the pilot revealed imipramine and carbamazepine in the pilot's urine and blood, and morphine in the pilot's urine. According to the pilot's medical and pharmacy records, he suffered from a severe neurological disorder, possibly a seizure disorder, which resulted in frequent, unpredictable episodes of debilitating pain. Additionally, approximately three months prior to the accident, the pilot was diagnosed with viral meningitis, and a severe skin infection with multiple abscesses on his extremities. The pilot had been prescribed imipramine, an antidepressant that has detrimental effects on driving skills and other cognitive functions. He had also been prescribed carbamazepine, typically used to control seizures or treat certain chronically painful conditions. Carbamazepine has measurable impairment of performance on a variety of psychomotor tests. Morphine, a prescription opiate painkiller, is also a metabolite of heroin and many prescription medications, such as codeine, used to control moderate pain. No indication was observed in the pilot's medical records that he was recently prescribed any opiates. Neither the pilot's medical condition, nor the medication he was routinely taking was reported on his application for an airman medical certificate.
Probable cause:
The pilot's low altitude maneuver using an excessive bank angle, and his failure to maintain airspeed which resulted in an inadvertent stall and subsequent collision with a building. A factor was the pilot's impairment from prescription medications.
Final Report:

Crash of an Airbus A319 in New York

Date & Time: Jan 19, 2003 at 0715 LT
Type of aircraft:
Operator:
Registration:
N313NB
Flight Phase:
Survivors:
Yes
MSN:
1186
YOM:
2000
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Two maintenance technicians where on board Northwest Airlines' Airbus A319 N313NB which was taxied from a maintenance area to Gate 10. When they arrived in the vicinity of gate 10, the mechanic who was steering the plane, activated the parking brake and waited for ground personnel and a jetway operator to arrive. After the ground personnel arrived he released the parking brake. The airplane did not move and he advanced the throttles out of their idle detents "a couple of inches, about halfway." The airplane began to move at a "fairly decent speed," and he realized the throttles were still out of the idle detent position. He pulled the throttle back and applied brakes; however, the airplane did not slow and continued until it struck the concrete support column of the jetway, and the left wing contacted the right side of a Boeing 757-251 (N550NW, parked at gate 9). The nose gear sheared off the Airbus, and the right side of the Boeing sustained a 6-foot long, 2-foot wide gash, just aft of the R1 door. The mechanic estimated that the airplane was about halfway down the parking line when he pulled back the throttles. Initial review of the flight data recorder for the time period surrounding the accident revealed that about 10 seconds after the parking brake was released, the thrust lever angles for both engines were increased to about 17 degrees for about 8 seconds, before they were returned to the idle position. During that time, the engines N1 and N2 speeds increased to about 71, and 85 percent, respectively.
Probable cause:
Maintenance personnel failure to maintain aircraft control as a result of excessive throttle input.

Crash of a Learjet 35 in Schenectady

Date & Time: Jan 4, 2001 at 1547 LT
Type of aircraft:
Registration:
N435JL
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Schenectady – New York-LaGuardia
MSN:
35-018
YOM:
1975
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2570
Captain / Total hours on type:
1065.00
Copilot / Total flying hours:
1600
Copilot / Total hours on type:
497
Aircraft flight hours:
16302
Circumstances:
The captain stated that prior to departure the flight controls were tested, with no abnormalities noted, and the takeoff trim was set to the "middle of the takeoff range," without referring to any available pitch trim charts. During the takeoff roll, the pilot attempted to rotate the airplane twice, and then aborted the takeoff halfway down the 4,840 foot long runway, because the controls "didn't feel right." The airplane traveled off the departure end of the runway and through a fence, and came to rest near a road. The pilot reported no particular malfunction with the airplane. Examination of the airplane revealed that the horizontal stabilizer was positioned at -4.6 degrees, the maximum nose down limit within the takeoff range. The horizontal stabilizer trim and elevator controls were checked, and moved freely through their full ranges of travel. According to the AFM TAKEOFF TRIM C.G. FUNCTION chart, a horizontal stabilizer trim setting of -7.2 was appropriate with the calculated C.G. of 20% MAC. Additionally, Learjet certification testing data stated that the pull force required at a trim setting of -6.0 degrees, the "middle of the takeoff range", was 33 pounds. With the trim set at the full nose down position (-1.7 degrees), 132 pounds of force was required.
Probable cause:
The pilot's improper trim setting, which resulted in a runway overrun and impact with a fence.
Final Report:

Crash of a Gulfstream GII in New York

Date & Time: Mar 25, 1997 at 0510 LT
Type of aircraft:
Operator:
Registration:
N117FJ
Survivors:
Yes
Schedule:
Allentown - New York
MSN:
229
YOM:
1978
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9900
Captain / Total hours on type:
3860.00
Copilot / Total flying hours:
21000
Copilot / Total hours on type:
4000
Aircraft flight hours:
6743
Circumstances:
All positions at LaGuardia Tower were combined to the local control position from 0011 EST until after the accident. At about 0430 EST, ground personnel in 'Vehicle 1277' (communicating on ground control frequency), were cleared on runway 13/31 to perform 'lighting maintenance.' Later, during repair of centerline lights and while N117FJ was inbound to the airport, Vehicle 1277 stalled on runway 13/31. Personnel of Vehicle 1277 attempted to restart the vehicle, but were unable, so they shut off all vehicle lights to reduce electrical load, and again attempted to restart the vehicle, but to no avail. At 0507 (during darkness), N117FJ made initial call to the tower for landing. The controller acknowledged the call, scanned runway 13/31, did not see Vehicle 1277, and cleared N117FJ to land on runway 31. At 0510, personnel of Vehicle 1277 observed N117FJ in the approach/landing phase and radioed ground controller that they were stuck on the runway. The controller then radioed, 'go-around, aircraft on the runway go-around, aircraft on the runway go-around, seven fox juliet go-around.' Moments later, N117FJ impacted Vehicle 1277. The FAA ATC Handbook stated, 'Ensure that the runway to be used is clear of all known ground vehicles, equipment, and personnel before a departing aircraft starts takeoff or a landing aircraft crosses the runway threshold.'
Probable cause:
The tower controller's inadequate service by clearing the airplane to land on the same runway, where he had previously cleared a maintenance vehicle to perform maintenance to the runway centerline lights. Factors related to the accident were: darkness, partial failure of the runway centerline lights, the electric maintenance vehicle's loss of engine power, and a failure to have adequate emergency backup lighting.
Final Report:

Crash of a Fokker F28 Fellowship 4000 in New York: 27 killed

Date & Time: Mar 22, 1992 at 2135 LT
Type of aircraft:
Operator:
Registration:
N485US
Flight Phase:
Survivors:
Yes
Schedule:
Jacksonville – New York – Cleveland
MSN:
11235
YOM:
1986
Flight number:
US405
Crew on board:
4
Crew fatalities:
Pax on board:
47
Pax fatalities:
Other fatalities:
Total fatalities:
27
Captain / Total flying hours:
9820
Captain / Total hours on type:
2200.00
Copilot / Total flying hours:
4507
Copilot / Total hours on type:
29
Aircraft flight hours:
12462
Aircraft flight cycles:
16280
Circumstances:
USAir flight 405 was scheduled to depart Jacksonville, FL (JAX) at 16:35 but was given a ground delay because of poor weather in the New-York-LaGuardia (LGA) area and was further delayed in order to remove the baggage of a passenger who chose to deplane. The Fokker F-28 jet departed Jacksonville at 17:15 and was cleared into the LaGuardia area without significant additional delays. The first officer accomplished an ILS approach to LaGuardia's runway 04 to minimums and initiated braking on the landing roll. Ramp congestion delayed taxiing to the parking gate. The airplane was parked at Gate 1 at approximately 19:49, 1 hour and 6 minutes behind schedule. After the airplane was parked at Gate 1, the line mechanic who met the flight was advised by the captain that the aircraft was "good to go." The captain left the cockpit and the first officer prepared for the next leg to Cleveland , OH (CLE) that had originally been scheduled to depart at 19:20. Snow was falling as the F-28 was prepared for departure. The airplane was de-iced with Type I fluid with a 50/50 water/glycol mixture, using two trucks. After the de-icing, about 20:26, one of the trucks experienced mechanical problems and was immobilized behind the airplane, resulting in a pushback delay of about 20 minutes. The captain then requested a second de-icing of the airplane. The airplane was pushed away from the gate to facilitate de-icing by one de-icing truck. The second de-icing was completed at approximately 21:00. At 21:05:37, the first officer contacted the LaGuardia ground controller and requested taxi clearance. The airplane was cleared to taxi to runway 13. At 21:07:12, the flightcrew switched to the LaGuardia ground sequence controller, which they continued to monitor until changing to the tower frequency at 21:25:42. The before-takeoff checklist was completed during the taxi. Engine anti-ice was selected for both 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. The captain announced they would use US Air's contaminated runway procedures that included the use of 18 degrees flaps. They would use a reduced V1 speed of 110 knots. The first officer used the ice (wing) inspection light to examine the right wing a couple of times. He did not see any contamination on the wing or on the black strip and therefore did not consider a third de-icing. Flight 405 was cleared into the takeoff and hold position on runway 13 at 21:33:50. The airplane was cleared for takeoff at 21:34:51. The takeoff was initiated and the first officer made a callout of 80 knots, and, at 21:35:25, made a V1 callout. At 21:35:26, the first officer made a VR callout. Approximately 2.2 seconds after the VR callout, the nose landing gear left the ground. Approximately 4.8 seconds later, the sound of stick shaker began. Six stall warnings sounded. The airplane began rolling to the left. As the captain leveled the wings, they headed toward the blackness over the water. The crew used right rudder to maneuver the airplane back toward the ground and avoid the water. They continued to try to hold the nose up to impact in a flat attitude. The airplane came to rest partially inverted at the edge of Flushing Bay, and parts of the fuselage and cockpit were submerged in water. After the airplane came to rest, several small residual fires broke out on the water and on the wreckage debris.
Probable cause:
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 airplane'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.
Final Report:

Crash of a Boeing 737-401 in New York: 2 killed

Date & Time: Sep 20, 1989 at 2321 LT
Type of aircraft:
Operator:
Registration:
N416US
Flight Phase:
Survivors:
Yes
Schedule:
New York - Charlotte
MSN:
23884
YOM:
1988
Flight number:
US5050
Crew on board:
6
Crew fatalities:
Pax on board:
57
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
5525
Captain / Total hours on type:
140.00
Copilot / Total flying hours:
3287
Copilot / Total hours on type:
8
Aircraft flight hours:
2235
Aircraft flight cycles:
1730
Circumstances:
A USAir Boeing 737-401, registration N416US, was scheduled to depart from Baltimore/Washington (BWI) as flight 1846 at 15:10, but air traffic inbound to New York-LaGuardia (LGA) delayed the takeoff until 19:35. Holding on the taxiway at BWI for 1.5 hours required the flight to return to the terminal area for fuel. The Boeing 737-400 left BWI uneventfully and arrived at LGA's Gate 15 at 20:40. Weather and air traffic in the LGA terminal area had caused cancellations and delayed most flights for several hours. The USAir dispatcher decided to cancel the Norfolk leg of Flight 1846, unload the passengers, and send the flight to Charlotte (CLT) without passengers. Several minutes later, the dispatcher told the captain that his airplane would not be flown empty but would carry passengers to Charlotte as USAir flight 5050. This seemed to upset the captain. He expressed concern for the passengers because more delays would cause him and the first officer to exceed crew duty time limitations before the end of the trip. While passengers were boarding, the captain visited USAir's ground movement control tower to ask about how decisions were made about flights and passengers. The captain returned to the cockpit as the last of the passengers were boarding, and the entry door was closed. After the jetway was retracted, the passenger service representative told the captain through the open cockpit window that he wanted to open the door again to board more passengers. The captain refused, and flight 5050 left Gate 15 at 22:52. The 737 taxied out to runway 31. Two minutes after push-back, the ground controller told the crew to hold short of taxiway Golf Golf. However, the captain failed to hold short of that taxiway and received modified taxi instructions from the ground controller at 22:56. The captain then briefed takeoff speeds as V1: 125 knots, VR: 128 knots, and V2: 139 knots. The first officer was to be the flying pilot. He was conducting his first non supervised line takeoff in a Boeing 737. About 2 minutes later, the first officer announced "stabilizer and trim" as part of the before-takeoff checklist. The captain responded with "set" and then corrected himself by saying: "Stabilizer trim, I forgot the answer. Set for takeoff." Flight 5050 was cleared into position to hold at the end of the runway at 23:18:26 and received takeoff clearance at 23:20:05. The first officer pressed the autothrottle disengage and then pressed the TO/GA button, but noted no throttle movement. He then advanced the throttles manually to a "rough" takeoff-power setting. The captain then said: "Okay, that's the wrong button pushed" and 9 seconds later said: "All right, I'll set your power." During the takeoff roll the airplane began tracking to the left. The captain initially used the nosewheel steering tiller to maintain directional control. About 18 seconds after beginning the roll a "bang" was heard followed shortly by a loud rumble, which was due to the cocked nosewheel as a result of using the nosewheel steering during the takeoff roll. At 23:20:53, the captain said "got the steering." The captain later testified that he had said, "You've got the steering." The first officer testified that he thought the captain had said: "I've got the steering." When the first officer heard the captain, he said "Watch it then" and began releasing force on the right rudder pedal but kept his hands on the yoke in anticipation of the V1 and rotation callouts. At 23:20:58.1, the captain said: "Let's take it back then" which he later testified meant that he was aborting the takeoff. According to the captain, he rejected the takeoff because of the continuing left drift and the rumbling noise. He used differential braking and nose wheel steering to return toward the centerline and stop. The throttle levers were brought back to their idle stops at 23:20:58.4. The indicated airspeed at that time was 130 knots. Increasing engine sound indicating employment of reverse thrust was heard on the CVR almost 9 seconds after the abort maneuver began. The airplane did not stop on the runway but crossed the end of the runway at 34 knots ground speed. The aircraft dropped onto the wooden approach light pier, which collapsed causing the aircraft break in three and drop into 7-12 m deep East River. The accident was not survivable for the occupants of seats 21A and 21B because of the massive upward crush of the cabin floor.
Probable cause:
The captain's failure to exercise his command authority in a timely manner to reject the take-off or take sufficient control to continue the take-off, which was initiated with a mistrimmed rudder. Also causal was the captain's failure to detect the mistrimmed rudder before the take-off was attempted. Board member Jim Burnett filed the following concurring and dissenting statement: "Although I concur with the probable cause as adopted as far as it goes, I would have added the following as a contributing factor: Contributing to the cause of the accident was the failure of USAir to provide an adequately experienced and seasoned flight crew.
Final Report:

Crash of a Beechcraft H18 in Troxelville: 1 killed

Date & Time: Nov 18, 1980 at 0153 LT
Type of aircraft:
Registration:
N701CC
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
New York-LaGuardia – Pittsburgh
MSN:
BA-740
YOM:
1966
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2100
Circumstances:
En route on a cargo flight from New York-LaGuardia Airport to Pittsburgh, while cruising by night in poor weather conditions, the twin engine airplane entered an uncontrolled descent and crashed on a mountain located near Troxelville, Pennsylvania. The wreckage was found three days later and the pilot, sole on board, was killed. At the time of the accident, the visibility was reduced due to foggy conditions and weather was poor with icing conditions.
Probable cause:
Uncontrolled descent and subsequent collision with ground after the pilot attempted operation with known deficiencies in equipment. The following contributing factors were reported:
- Improper in-flight decisions,
- Ice-propeller,
- Airframe ice,
- Icing conditions including sleet, freezing rain,
- Improperly loaded aircraft,
- Deicing equipment and anti-icing system inoperative,
- Visibility two miles or less.
Final Report: