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Safety Recommendation Details

Safety Recommendation A-93-023
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: REQUIRE FOKKER TO DETERMINE HOW TAKEOFF PERFORMANCE AND STALL MARGIN WOULD BE AFFECTED BY USING A LOWER INITIAL TARGET PITCH ATTITUDE ON F-28 AND F-100 AIRPLANES IN THE EVENT THAT UNDETECTED UPPER WING ICE CONTAMINATION IS PRESENT, AND CHANGE THE NORMAL OPERATING PROCEDURES IF TAKEOFF PERFORMANCE REQUIREMENTS CAN BE MET WHILE THE STALL MARGIN IS IMPROVED.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 7/17/1995
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Icing, Upset Recovery, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/17/1995
Response: THE BOARD NOTES THAT THE FAA ISSUED AIRWORTHINESS DIRECTIVE 94-25-03 ON 11/30/94, APPLICABLE TO FOKKER F-28 SERIES AIRPLANES. THIS AD REQUIRES A REVISION TO THE AIRPLANE FLIGHT MANUAL THAT PROHIBITS TAKEOFF IN CERTAIN ICING CONDITIONS UNLESS EITHER A TACTILE INSPECTION OF THE WING IS PERFORMED OR SPECIFIC TAKEOFF PROCEDURES ARE FOLLOWED. THE NETHERLAND AIRWORTHINESS AUTHORITY HAS ALSO REVISED ITS AD TO BE CONSISTENT WITH AD 94-25-03. THEREFORE, THE BOARD CLASSIFIES A-93-23 "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: FAA
To: NTSB
Date: 2/27/1995
Response: THE FAA RECONSIDERED ITS POSITION IN RESPONSE TO THIS RECOMMENDATION & ON 11/30/94, ISSUED AIRWORTHINESS DIRECTIVE 94-25-03 APPLICABLE TO FOKKER F28 SERIES AIRPLANES. THIS AD BECAME EFFECTIVE 12/21/94, & REQUIRES A REVISION TO THE AIRPLANE FLIGHT MANUAL THAT PROHIBITS TAKEOFF IN CERTAIN ICING CONDITIONS UNLESS EITHER A TACTILE INSPECTION IS PERFORMED OR SPECIFIC TAKEOFF PROCEDURES ARE FOLLOWED. I BELIEVE THAT AD 94-25-03 ADDRESS THE FULL INTENT OF THIS RECOMMENDATION. CONSEQUENTLY, I CONSIDER THE FAA'S ACTION TO BE COMPLETED, & I ASK THAT THE BOARD CLASSIFY THIS RECOMMENDATION AS CLOSED ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 12/20/1994
Response: WHILE THE BOARD ACKNOWLEDGES THAT THE ACTIONS NOW BEING PROPOSED BY THE FAA WOULD MEET THE FULL INTENT OF A-93-23 WITH REGARD TO FOKKER AIRPLANES, THE BOARD IS CONCERNED THE PROLONGED TIME TO COMPLETE THE FINAL RULEMAKING PROCESS WILL MEAN THAT THIS SAFETY MEASURE WILLL NOT IMPOSED DURING THE FORTHCOMING WINTER SEASON. THEREFORE, THE BOARD CLASSIFIES A-93-23 "OPEN--UNACCEPTABLE RESPONSE" PENDING EXPEDITIOUS ACTION TO ADOPT A FINAL OR INTERIM RULE THAT WOULD BE EFFECTIVE FOR THE 1994/1995 WINTER SEASON.

From: FAA
To: NTSB
Date: 7/13/1994
Response: Fokker conducted a simulation study to investigate the effect of takeoff rotation parameters on takeoff performance and stall margin. In each simulated takeoff the airplane was rotated at an essentially constant pitch rate to the target pitch attitude which was maintained for the remainder of the takeoff. The test matrix included a systematic variation of the following takeoff rotation parameters at several different aircraft weights: (1) rotation airspeed, (2) pitch rate, and (3) initial target pitch attitude. The results of the study are summarized as follows: Increasing rotation airspeed, reducing pitch rate, and reducing the initial target pitch attitude contribute to improved stall margin (i.e., reduced peak angle of attack) at the expense of increasing the distance necessary to achieve a height of 35 feet above the runway. Increasing rotation airspeed, reducing pitch rate, and reducing the initial target pitch attitude affect stall margin and takeoff distance to different degrees. Reducing the initial target pitch attitude was found to be most effective in improving stall margin with the least effect on takeoff distance. Reducing the pitch rate was found to be less effective in improving stall margin with a much greater effect on takeoff distance. Increasing the rotation airspeed was found to be the least effective in improving stall margin with the largest increase in takeoff distance. The simulations of takeoffs with degraded lifting characteristics due to ice contamination on the wing produced results similar to a clean wing providing the angle of attack did not exceed the lower stall angle of the contaminated wing. The Federal Aviation Administration (FAA) reviewed the Fokker simulation study and agrees that takeoff performance requirements cannot be met using any of the alternatives that were examined. Consequently, the FAA does not plan to mandate a Data Source: NTSB Recommendations to FAA and FAA Responses revision to the normal operating procedures of the F-28 or the F-100 airplanes to require the use of a lower initial target pitch attitude, increased rotation airspeed, or reduced pitch rate. The FAA has met the intent of this safety recommendation, and I consider the FAA's action to be completed.

From: FAA
To: NTSB
Date: 5/27/1993
Response: THE FAA ISSUED A LETTER ON 7/13/94 STATING THAT THEY REVIEWED THE FOKKER SIMULATION STUDY & AGREED THAT TAKEOFF PERFORMANCE REQUIREMENTS CANNOT BE MET USING ANY OF THE ALTERNATIVES THAT WERE EXAMINED. CONSEQUENTLY, THE FAA DOES NOT PLAN TO MANDATE A REVISION TO THE NORMAL OPERATING PROCEDURES OF THE F-28, OR F-100 AIRPLANES TO REQUIRE THE USE OF A LOWER INITIAL TARGET PITCH ATTITUDE. THE FAA CONSIDERS ACTION COMPLETED. HOWEVER, THE DUTCH GOVERNING AUTHORITY (RLD) ISSUED AN AIRWORTHINESS DIRECTIVE GIVING OPERATORS THE OPTION OF USING THE LOWER INITIAL PITCH ATTITUDE. BASED ON THE DUTCH AD, THE FAA IS DRAFING AN NPRM TO REQUIRE THIS PROCEDURE IN THE USA.