On Sunday. March 22. 1992, about 2135 eastern standard time, a Fokker 28·4000 (F--28), N485lJS, operating as USAir flight 405, crashed during an attempted takeoff from runway 13 at LaGuardia Airport,, Flushing, New York. Flight 405 was operating under Title 14, Code of Federal Regulations, Part 121, as a scheduled passenger flight from Jacksonville, Florida, to Cleveland, Ohio, with a stopover at LaGuaudia Airport. There were 47 passengers, 2 flightcrew members and 2 cabincrew members on board. The captain, one of the cabincrewmembers and 25 passengers received fatal injuries. The airplane was destroyed by impact forces and subsequent fire.
We determined that the probable causes of this accident were the failure of the airline industry and the Federal Aviation Administration to provide flightcrews with procedures, requirements, and criteria compatible with departure delays in conditions conducive to airfrarne icing and the decision by the flightcrew to take off without positive assurance that the airplane's wings were free of ice accumulation after 35 minutes of exposure to precipitation following deicing. 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 flightcrew that led to a takeoff rotation at a lower than prescribed air speed.
As a result of this investigation, we made the following new safety recommendations.
To the Federal Aviation Administration:
- If gate holds are required to limit deicing fluid holdover time, encourage air traffic control (ATC) to initiate the gate holds as soon as a deicing operation begins rather than after delays have exceeded 15 1ninutes, as in the current air traffic control definition of gate hold. (A-93-19)
- Where deicing operations are conducted away from the departure runway, report taxi delays in conditions conducive to airfrarme icing in increments that are less than 15 minutes to provide more realistic and useful reports to dispatchers and flightcrews. (A-93-20)
- Require that flight crewrnembers and appropriate ground personnel responsible for the inspection of transport-category airplanes for wing contamination receive specific periodic training that will illustrate what contamination looks like and feels like on a wing and the amount of contamination that is detectable under different light conditions. (A-93-21)
- Study the effects on performance of swept-wving turbojet airplanes when specific amounts of air speed are added to the computed rotation speed (delayed rotation) during takeoffs when wing contamination is possible. (A-93-22)
- 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. (A-93-23)
- In conjunction with the National Aeronautics and Space Administration, establish a wind tunnel or flight test program to study the aerodynarnic degradation of both nonslatted and slatted airplane wings that have upper surface contamination. The study should be sufficient to define lift, drag and pitching moment changes related to ice contamination. (A-93-24)
- In conjunction with the National Aeronautics and Space Administration, determine the diff erences, if any, in effects on takeoff performance and stall margin when upper wing ice contamination is present on slatted and nonslatted airplanes; include consideration of operational and aerodynarnic factors that may explain the disproportionate number of takeoff icing accidents of nonslatted airplanes. (A-93-25)
- Require airlines to establish a way to inform flightcrews of the type of fluid and mixture used, the current moisture accumulation rate, and the available holdover time. (A-93-26)
- Thoroughly research the effects of Type II fluids on runnway surface friction coefficients to ensure that its use does not degrade airplane traction and braking beyond safe limits, and publish guictelines for the use of type II fluids by airport operators. (A-93-27)
- Require that all airports, which miight experience freezing conditions and that are certified under Title I 4 CFR Part 139, establish deicing plans for approval. (A-93-28)
- Study the feasibility of building a frangible ILS antenna array for LaGuardia Airport.(A-93-29)
- Review Fokker 28-11000 passenger safety briefing cards to ensure that they clearly and accurately depict the operation of the two type of forward cabin doors in both their normal and emergency modes and that they describe clearly and accurately how to remove the overwing emergency exit handle cover. (A-93-30)
To the Port Authority of New York and New Jersey:
- Expedite the replacement of the ernergency telephone system between the air traffic rontrol tower and ARFF units at LaGuardia Airport. (A-93-31)
- Modify or replace alI pump houses adjacent to runway 13/31 so that they are not obstructions to airplanes. (A-93-32)
- Reconnnend a review of ernergcncy plans to include contingencies for applying cardiopulrnonary resuscitation (CPR) techniques as soon as a sufficient nurnber of trained personnel arrive at a mass casualty/triage incident. Emphasis should be placed on attempting CPR regardless of whether vital signs are present, especially ,when cold water irrunersion/near drowning is invoived and where traumatic injuries may not indicate death. (A-93-33)
- Review and evaluate, in concert with other New York City en1ergency response agencies, the emergency rnedical response to the crash of UJSAir flight 405 in order to improve agency coordination efforts and to reduce transportation tirnes of injured persons from LaGuardia Airport to area hostpitals. (A-93-34)
