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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 Douglas DC-9-31 in Elmira

Date & Time: Jan 18, 1992 at 1028 LT
Type of aircraft:
Operator:
Registration:
N964VJ
Survivors:
Yes
Schedule:
Ithaca - Elmira
MSN:
47373
YOM:
1969
Flight number:
US305
Crew on board:
5
Crew fatalities:
Pax on board:
36
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
19000
Captain / Total hours on type:
9500.00
Aircraft flight hours:
59251
Circumstances:
At the time of the accident, gusty winds were forecast for the surface to higher altitudes. The copilot was flying and configured the airplane about four miles out for landing on runway 24. The flightcrew received progressive wind information during the approach; the last report was wind at 310° and 25 knots. The approach speed was v ref + 10. According to the flightcrew, during the landing flare a wind gust occurred, and the airplane lifted in a nose down attitude. The gust stopped and then the airplane descended to the runway and landed hard. The examination of the airplane revealed the fuselage cracked near where the wings were attached and the aft fuselage was bent down about 7°. Two passengers were seriously injured.
Probable cause:
The aircraft encountered a sudden wind gust during landing flare, which resulted in a hard landing.
Final Report:

Crash of a Boeing 737-3B7 in Los Angeles: 22 killed

Date & Time: Feb 1, 1991 at 1807 LT
Type of aircraft:
Operator:
Registration:
N388US
Survivors:
Yes
Schedule:
Columbus - Los Angeles
MSN:
23310
YOM:
1985
Flight number:
US1493
Crew on board:
6
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
16300
Captain / Total hours on type:
4300.00
Copilot / Total flying hours:
4316
Copilot / Total hours on type:
982
Circumstances:
SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Probable cause:
The failure of the los angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the faa air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (lc2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the faa to provide effective quality assurance of the atc system.
Final Report:

Crash of a Boeing 737-222 in Kinston

Date & Time: Jul 22, 1990 at 1455 LT
Type of aircraft:
Operator:
Registration:
N210US
Flight Phase:
Survivors:
Yes
Schedule:
Kinston - Charlotte
MSN:
19555
YOM:
1968
Crew on board:
5
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10100
Captain / Total hours on type:
3300.00
Aircraft flight hours:
51264
Circumstances:
As engine power was increased for takeoff, the n°1 engine accelerated beyond target epr. Engine shut down had to be done with the fuel shut off lever. The asymmetric thrust was controlled with nose wheel steering. Before the airplane could be stopped the nose wheels separated from the landing gear. The investigation revealed that the fuel pump output spline to the fuel control had stripped. It occurred at such a time that the fuel control sensed an underspeed and increased Fuel flow. Misalignment of the spline shaft resulted from improper machining during pump modification. The nose gear inner cylinder failed in fatigue in an area of excessive grinding during overhaul. Two passengers were slightly injured.
Probable cause:
Failure of the fuel pump control shaft because of improper machining by the repair facility during maintenance modification of the pump and improper procedures during overhaul of the nose landing gear.
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 Douglas DC-9-31 in Erie

Date & Time: Feb 21, 1986 at 0859 LT
Type of aircraft:
Operator:
Registration:
N961VJ
Survivors:
Yes
Schedule:
Toronto - Erie
MSN:
47506
YOM:
1970
Flight number:
US499
Crew on board:
5
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8900
Captain / Total hours on type:
5900.00
Aircraft flight hours:
42104
Circumstances:
During arrival, the crew of USAir flight 499 landed on runway 24, which was covered with snow. Reportedly, while landing, the aircraft touched down approximately 1,800 to 2,000 feet beyond the displaced threshold. Altho armed, the spoilers did not autodeploy, so the captain operated them manually. He lowered the aircraft's nose, actuated reverse thrust and applied brakes. The brakes were not effective. Subsequently, the aircraft continued off the end of the runway, ran over a runway end id light, struck a fence and came to rest straddling a road. The crew had planned on making an ILS approach to runway 06, but the RVR was only 2,800 feet and a minimum RVR of 4 000 feet was requested for that runway. The crew elected to land on runway 24, since 1/2 mile visibility was sufficient for that runway. However, the approach was made with a qtrg tailwind and approximately 10 knots above Vref. Tailwind landings were not authorized on runway 24 in wet/slippery conditions. The runway braking action was reported as fair-to-poor. The pilot's handbook cautioned the crew to monitor the spoilers when landing on slippery runways, since the spoilers auto-deploy only with wheel spin-up or when the nose wheel is on the ground. A passenger was slightly injured while 22 other occupants were uninjured.
Probable cause:
Occurrence #1: overrun
Phase of operation: landing - roll
Findings
1. (f) weather condition - low ceiling
2. (f) weather condition - snow
3. (f) weather condition - fog
4. (f) weather condition - tailwind
5. (c) planning/decision - improper - pilot in command
6. (f) airspeed(vref) - exceeded - pilot in command
7. (f) airport facilities, runway/landing area condition - displaced threshold
8. (f) proper touchdown point - not attained - pilot in command
9. (f) airport facilities, runway/landing area condition - snow covered
10. (c) go-around - not performed - pilot in command
----------
Occurrence #2: on ground/water collision with object
Phase of operation: landing - roll
Findings
11. (f) object - runway light
12. (f) object - fence
----------
Occurrence #3: on ground/water encounter with terrain/water
Phase of operation: landing - roll
Findings
13. (f) terrain condition - rough/uneven
Final Report: