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NTSB Accident Report TRANSPORTATION SAFETII! BOARD AIRCRAFT ACCIDENT l$EPOfiT,, . !!;, , I,_ .: I ‘/ AlR FLORIIDA, INC. -: BOEING 737-222, N62AF ‘, .- COLLISION WITH 14TH STRFET BRIIDGE, -c ,+ . NEAR WASHINGTON NATIONAL AIRPO!iT .I . - WASHINGTON, I).C. JANUARY 13,1982 .---.--NTSB-AAR-82-8 --.__.._- _ ,c. I i e __- ’ ‘““‘Y’ED STATES GOVERNMENT I / f -4 . -~~sB-qjAR-82-8 1 PB82-910408 & . Ti t le and Subt i t le Aircraft -4ccident Report-- S.Report Date Air Florida, Inc., Boeing 737-222, N62AF, Collision August lo-, 1982 with 14th Street Bridge, Near Washington National 6.Performing Organization Airport, Washington, D.C., January 13. 1982. Code 7. Author(s) 8.Performing Organization Report No. I I I q. Performing Organization Name and Address 1 lO.Work Unit No. 3453-B I National Transportation Safety Board 11 .Contract or Grant No. Bureau of Accident Investigation H I Washington, D.C. 20594 / 13.Type of Report and 1 Period Covered 12.Sponsoring Agency Name and Address Aircraft Accident Report January 13, 1982 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20594 14.Sponsoring Agency Code . lY.Supplementary Notes 16.Abstract On January 13, 1982, Air Florida Flight 90, a Boeing 737-222 (N62AF), was a scheduled- flight to Fort Lauderdale, Florida, from Washington National Airport, Washington, D.C. There were 74 passengers, including 3 infants, and 5 crewmembers on board. The flight’s scheduled departure time was delayed about 1 hour 45 minutes due to a moderate to heavy snowfall which necessitated the temporary closing of the airport. Following takeoff from runway 36, which was made with snow and/or ice adhering to the aircraft, the aircraft at 1601 e.s.t. crashed into the barrier wall of the northbound span of the 14th Street Bridge, which connects the District of Columbia with Arlington County,” Virginia, and plunged into the ice-covered Potomac River. It came to rest on the west side of the bridge 0.75 nmi from the departure end of runway 36. Four passengers and one crewmember survived the crash. When the aircraft hit the bridge, it struck seven occupied vehicles and then tore away a T section of the bridge barrier wall and bridge railing. Four persons in the vehicles were killed; four were injured. 17.tiey Words 18.Distribution Statement Deicing/anti-icing; engine anti-ice system; This document is available i takeoff with snow/ice; engine instruments; to the public through the blocked Pt2; B-737 pitchup/rollover; winter National Technical Informa- operations; gate-hold procedures; ATC separation tion Service, criteria; airport certification; crash/fire/rescue; Springfield, Virginia 22161 water rescue; flightcrew performance. lY.Security Classification 20.Security Classification 21.No. of Pages 22.Price (of this report) (of this page) 141 UNCLASSIFIED UNCLASSIFIED I NTSB Form 1765.2 (Rev. 9/74) Abstract continued i The National Transportation Safety Board determines that the probable cause of this !’ accident was the flightcrew’s failure to use engine anti -ice during ground operation and takeoff, their decision to take off with snow/ice on the airfoil surfaces of the aircraft, and the captain’s failure to reject the takeoff during the early stage when his attention ’ was called to anomalous engine instrument readings. Contributing to the accident were the prolonged ground delay between deicing and the receipt of ATC takeoff clearance during which the airplane was exposed to continual precipitation, the known inherent * pitchup characteristics of the B-737 aircraft when the leading edge is contaminated with ’ even small amounts of snow or ice, and the limited experience of the flightcrew in jet transport winter operations. c/ ii SYNOPSIS . this and FACTUAL INFORMATION. .................. i, 1. ‘. ,\ aft, 1.1 ’ History of the Flight ..................... 1 ’ ltion Injuries to Persons ...................... 10 1.2 \ Nere 1.3 Damage to Aircraft ...................... 10 ‘\ ante 1.4 Other Damage ........................ 10 <rent 1.5 Personnel Information .- .................... 10 with 1.6 Aircraft Information ............... ./. .... 11 2 jet 1.7 Meteorological Information. .................. 12 1.8 Aids to Navigation ...................... 14 1.9 Communications ....................... 14 1.10 Aerodrome and Ground Facilities ................ 14 1.11 Flight Recorders ....................... 15 1.12 Wreckage .......................... 17 1.13 Medical and Pathological Information .............. 20 1.14 Fire. 21 1.15 Survival Aspects.................................... 1’............ 21 1.16 Tests and Research ...................... 22 1.16.1 Tests of Flight Instruments. .................. 22 1.16.2 \ Sound Spectrum Analysis. ................... 23 1.16.3 y Engine Tests With Blocked Inlet Pressure Probe (Pt,) 24 1.16.4 Flight Simulator Tests .. ... .... .. ................. 24 1.16.5 Tests on Deicer Fluid Samples ................. 28 1.16.6 Metallurgical Examination of Wing Leading Edge Slat Skin ..... 28 1.17 Additional Information. .................... 29 1.17.1 ---. Engine Anti-ice System .................... 29 1.17.2 History of the Use of Ethylene Glycol as a Deicing Agent ....... 30 1.17.3 The Trump Deicer Vehicle ................... 30 1.17.4 American Airlines Deicing Procedures .............. 31 1.17.5 Jet Exhaust Data ....................... 32 1.17.6 Boeing 737 Maintenance Manual Instructions for Ice and Snow Conditions. ..................... 32 1.17.7 Air Florida Maintenance Manual Instructions for Winter Operations . 34 1.17.8 -. Boeing 737 Wing Leading Edge Contamination and Roughness .... 34 1.17.9 Other Boeing 737 Operations Manual Information ......... 37 1.17.10 Air Florida Flightcrew Training ................. 38 1.17.11 Air Traffic Control Handling of Flight 90. ............ _40 j 1.17.11.1 ATC Information to Pilots .................. 40 I 1.17.11.2 Separation Criteria ..................... 43 1.17.11.3 Controller Experience. ................... 44 I, 1.17.11.4 Gate-Hold Procedures .................... 44 ’ 1.17.12 Ground Proximity Warning System. ............... 45 i; 1917.13 Human Performance Data ................... 45 1.18 New Investigative Techniques. ................. 45 ’ 2. ANALYSIS. ......................... 46 2.1 Aircraft and Crew ...................... 46 2.2 The Accident ........................... 46 2.3 Factors Affecting Aircraft Acceleration and Climb Performance . 46 I iii ;@!p> Icing of Engine (Pressure) Probe. ............... 477 Airframe Ice ........................ 48 Aircraft Capability to Climb or Accelerate after Liftoff ...... 51 Effects of Wing Leading Edge Contamination on Aircraft Longitudinal Trim. ... .. ..... : .. 52 i Analysis of These Factors as they Affected Flight 90 ............... 53 I 2.4 Analysis of Events Preceding Takeoff .............. 54 Deicing Operations ..................... 55 Deicing of Flight 90 ..................... 57 ,- Ground Operations After Deicing ............... 58 ’ 2.5 Flightcrew Performance .................... 58 Inspection of Aircraft Following Deicing . .+. ......... 59 Use of Reverse Thrust During Pushback ............ 59 Use of Engine Anti-ice System ................ 60 Spacing Between Taxiing Aircraft ............... 61 Initiating Takeoff With Visible Snow Adhering to Aircraft .... 62 Continuation of Takeoff With Instrument Anomalies ....... 63 Reaction to Stall Warning After Takeoff ............ 65 2.6 * Flightcrew Experience and Training ............... 66 2.7 Other Factors Relevant to the Accident . .‘ ........... 68 B-737 Known Inherent Pitchup Characteristics With Wing Leading Edge Contamination and Related Boeing Actions ....................... 68 Washington National Airport ................. 69 Flow of Traffic Into Airport ................. 71 Traffic Separation ..................... 72 Takeoff Acceleration Monitor ................ 73 Crash Dynamics and Injury Analyses .............. 76 Rescue Efforts ....................... 3. CONCLUSIONS. ....................... 3.1: Findings ........................... 3.2 - Probable Cause ........................ 82 4. RECOMMENDATIONS. .................... 82 5. APPENDIXES ........................ 89 Appendix A-Investigation and Hearing. ............. 89 Appendix B-Personnel Information ............... 90 Appendix C-Aircraft Information. ............... 92 Appendix D--Airport Bulletin DCA 7/45 ............. 93 Appendix E--Flight Data Recorder Graph ............ 99 Appendix FL-Cockpit Voice Recorder Transcript ......... 100 Appendix G--FBI Report 95-247269 ............... 134 Appendix H--Excerpt from B-737 Operations Manual ....... 136 iv NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT Adopted: August lo,1982 AIR FLORIDA, INC., BOEING 737-222, N62AF, COLLISION WITH 14TH STREET BRIDGE NEAR WASHINGTON NATIONAL AIRPORT WASHINGTON, D.C. JANUARY 13, 1982 SYNOPSIS 1% On January 13, 1982, Air Florida Flight 90, a Boeing 737-222 (N62AF) was a scheduled flight to Fort Lauderdale, Florida, from Washington National Airport, Washington, D.C. There were 74 passengers, including 3 infants, and 5 crewmembers on board. The flight’s scheduled departure time was delayed about 1 hour 45 minutes due to a moderate to heavy snowfall which necessitated the temporary closing of the airport. -- ; :4 d Following takeoff from runway 36, which was made with snow and/or ice 8 adhering to the aircraft, the aircraft crashed at 1601 e.s.t. into the barrier wall of the 9 northbound span of the 14th Street Bridge, which connects the District of Columbia with 1 Arlington County,--Virginia, and plunged into the
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