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Safety Recommendation Details

Safety Recommendation A-93-022
Details
Synopsis: ON SUNDAY, MARCH 22, 1992, ABOUT 2135 EASTERN STANDARD TIME, A FOKKER 28-4000 (F-28), N485US, OPERATING AS USAIR FLIGHT 405, CRASHED DURING AN ATTEMPTED TAKEOFF FROM RUNWAY 13 AT LAGUARDIA AIRPORT, FLUSHING, NEW YORK. THE AIRPLANE WAS OPERATING UNDER TITLE 14, CODE OF FEDERAL REGULATIONS (CFR), PART 121, AS A SCHEDULED PASSENGER FLIGHT FROM JACKSONVILLE, FLORIDA, TO CLEVELAND, OHIO, WITH A STOPOVER AT LAGUARDIA AIRPORT. THERE WERE 47 PASSENGERS, 2 FLIGHTCREW MEMBERS AND 2 CABINCREW MEMBERS ON BOARD. THE CAPTAIN, ONE OF THE CABINCREW MEMBERS, AND 25 PASSENGERS RECEIVED FATAL INJURIES. IMPACT FORCES AND THE SUBSEQUENT FIRE DESTROYED THE AIRPLANE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: STUDY THE EFFECTS ON PERFORMANCE OF SWEPT-WING TURBOJET AIRPLANES WHEN SPECIFIC AMOUNTS OF AIR SPEED ARE ADDED TO THE COMPUTED ROTATION SPEED (DELAYED ROTATION) DURING TAKEOFFS WHEN WING CONTAMINATION IS POSSIBLE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: FLUSHING, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA92MA025
Accident Reports: Takeoff Stall in Icing Conditions USAIR Flight 405, FOKKER F-28, N485US
Report #: AAR-93-02
Accident Date: 3/22/1992
Issue Date: 3/18/1993
Date Closed: 12/20/1994
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/20/1994
Response: THE BOARD RECOGNIZES THAT THE ADOPTION OF A SPECIAL TAKEOFF ROTATION SPEED (VR) TO BE USED ONLY DURING WINTER ICING CONDITIONS WOULD PRESENT SOME OPERATIONAL CONSIDERATIONS THAT MIGHT NOT BE ACCEPTABLE TO THE FAA OR OPERATORS. THESE OPERATIONAL CONCERNS WERE EXPRESSED IN THE FAA LETTERS OF MAY 27, 1993 (IN RESPONSE TO RECOMMENDATION A-93-22), & 3/1/94 (IN RESPONSE TO RECOMMENDATION A-91-127). BASICALLY THESE CONCERNS WERE THE INCREASE IN RUNWAY DISTANCE REQUIRED OR THE SUBSTANTIAL REDUCTION IN PAYLOAD NEEDED TO MEET EXISTING TAKEOFF SAFETY CRITERIA; THE POSSIBILITY OF AN OPERATOR OR FLIGHTCREW INTENTIONALLY DISPATCHING AN AIRPLANE WITHOUT DEICING, ASSUMING THAT THE INCREASED ROTATION SPEED WOULD PROVIDE ADEQUATE COMPENSATION & PROTECTION; & THE INABILITY TO CALCULATE THE EFFECT THAT CONCURRENTLY EXISTING RUNWAY SURFACE CONTAMINATION WOULD HAVE ON THE TOTAL TAKEOFF GROUND ROLL. THE FAA CITED OTHER ACTIONS TAKEN TO ENSURE THAT THE WINGS ARE FREE OF CONTAMINATION AS PRECLUDING THE NEED FOR REVISED OPERATIONAL PROCEDURES. THE ACTIONS CITED WERE THE REQUIREMENTS IMPOSED ON OPERATORS FOR THE GROUND DEICING & ANTI-ICING PROGRAMS &, IN THE CASE OF THE DC-9 SERIES 10, AN AIRWORTHINESS DIRECTIVE TO MODIFY THE WING LEADING EDGE BLEED AIR ANTI-ICE REFORMATION AFTER DEICING. ALTHOUGH NO POSITIVE ACTIONS RESULTED, THE BOARD ACKNOWLEDGES THAT THE FAA UNDERTOOK EFFORTS TO EVALUATE PROCEDURES & STUDY PERFORMANCE IN RESPONSE TO A-91-127 & A-93-22. BASED ON THOSE EFFORTS, THESE RECOMMENDATIONS ARE CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 5/27/1993
Response: THE FAA DOES NOT AGREE WITH THIS RECOMMENDATION. BASED ON THE RESULTS OF THE INTERNATIONAL CONFERENCE ON AIRPLANE GROUND DEICING & ANTI-ICING HELD IN MAY 1992, THEY FEEL THE BEST APPROACH TO ELIMINATE ICING-RELATED TAKEOFF ACCIDENT IS TO PROVIDE ADEQUATE & RECURRENT FIGHTCREW & GROUND PERSONNEL TRAINING, PROVIDE ACCURATE HOLDOVER TIME DATA TO FLIGHTCREW & GROUND PERSONNEL, MINIMIZE THE TIME BETWEEN DEICING/ANTI-ICING & TAKEOFF. INCREASING ROTATION SPEED COULD LEAD TO SITUATION WHERE AN OPERATOR INTENTIALLY DISPATCHES WITH WING CONTAMINATION, ASSUMING THE INCREASED ROTATION SPEED WILL PROVIDE ADEQUATE COMPENSATION & PROTECTION. THEY FEEL THAT STUDYING THE PERFORMANCE IN THIS MANNER WOULD BE VERY COSTLY. HYDRODYNAMIC DRAG MAY INCREASE THE ACCELERATION DISTANCE, SO INCREASING VR WITHOUT ACCOUNTING FOR THE EFFECTS OF RUNWAY SURFACE CONTAIMINATION HAS THE POTENTIAL TO REDUCE SAFETY WITH REGARD TO CLOSE-IN OBSTACLE CLEARANCE. FOKKER FLIGHT SIMULATION STUDIES HAVE SHOWN THAT A REDUCED ROTATION RATE WAS AS EFFECTIVE AS A NORMAL ROTATION RATE INITIATED AT VR+10KNOTS. INCASES WHERE THE AIRPLANE MANUFACTURER HAS PROVIDED DATA TO SUPPORT THE PRACTICE. THE FAA PREFERS USING REDUCED ROTATION RATES IN ICING CONDITIONS RATHER THAN DELAYED ROTATION. THE FAA PLANS NO FURTHER ACTION ON THIS RECOMMENDATION.