Usair Flight 427, a 737-300, Crashed Near Pittsburgh, PA, Killing 132 People

WITHOUT PREJUDICE Prime Minister Datuk Seri Najib Razak, Malaysia 8-7-2014 Email: [email protected] 5 Cc: Datuk Azharuddin Abdul Rahman (DCA) director-general DEPARTMENT OF CIVIL AVIATION, MALAYSIA No. 27 Persiaran Perdana Aras 1-4 Blok Podium, 62618 Putrajaya Tel : +60388714000 Fax : 603 - 8890 1640 Email : [email protected] 10 Mr Tony Abbott MP (Commonwealth of Australia) [email protected]

Re: 20140708-G. H .Schorel-Hlavka O.W.B. to Datuk Seri Najib Razak Prime Minister of Malaysia & Mr Tony Abbott PM- Re: MISSING PLANE 15 Sir, I understood that MH380 a 737 had previous problems when on a flight from Australia to Kuala Lumpur. At least that is what I understood from a television program about 737 rudder problems. While missing flight HM370 is a 777 it doesn’t mean that a problem that may have occurred in one model (737) may not eventuate in a new model (777). While I understand that 20 MH 380 had its flight from Kuala Lumpur to Guangzhou nevertheless as I recall the program to refer to MH380 - 737 having this rudder problem when flying from Australia to Kuala Lumpur I hold it important to remain open minded. Also, the fact that reportedly (see quotation below) Malaysian Airlines may have financial difficulties one has to consider if then for insurance purposes MH370 disappeared as to be ab le to obtain some cash. It may be held to be a ridiculous 25 consideration but not really when one may consider other factors regarding highly skilled person awaiting approval of a patent, etc, word huge amount of monies and reportedly valuable cargo. And it seems to me utterly ridiculous that the Malaysian Air Force, etc, didn’t bother to check out a mysterious plane as after all by this it placed the lives of Malaysians unduly at risk. In my view, as I referred to within 48 hours of the plane going missing, one must consider the 30 radius that the plane could have flown (and that is without even refuelling) and then eliminate every possible issue that may be considered by disproving it. If it cannot be disproven then so to say it should remain on the cards. That were real human beings on that plane and we owe it to them and all future air travellers to not stop investigating every possible option. 35 As was shown with the altitude and the auto pilot error in many planes that crashed (2009), such as the Turkeys airliner just short of Amsterdam’s Schiphol airport if you ignore proper investigation then people can and will lose their lives. Was such or similar problem existing with the 777 but no one really realized it to be a problem? Was MH370 by radio control or otherwise set on a pre-programmed course of destruction? 40 As for the air safety report Central Air Safety - Accident Investigation (see below) http://cf.alpa.org/mec/aaa/docs/newmectoday/arc/airwaves/aw9904/9904ntsb.htm the real reason was establish about 5 years later to be a jam in the cylinder (operating the rudder) that eventuated at a certain height. It was when a third plane had the same problem but I understood being MH380 737 leaving Australia safely landed that the problem could be established by using 45 hot and cold temperatures on the cylinder, even so neither Wikipedia or the Accident Investigation report refers to this (see quotations below). p1 8-7-2014 INSPECTOR-RIKATI® about the BLACK HOLE in the CONSTITUTION-DVD A 1st edition limited special numbered book on Data DVD ISBN 978-0-9803712-6-0 PLEASE NOTE: You may order books in the INSPECTOR-RIKATI® series by making a reservation, See also Http://www.schorel-hlavka.com Blog at Http://www.scrib.com/InspectorRikati

http://asia.nikkei.com/magazine/20140703-Miracle-workers/Business/How-radical-can-a- stateowned-Malaysia-Airlines-change QUOTE 5 July 3, 2014 12:00 am JST Loss-laden Malaysia Airlines faces hard choices

A Malaysia Airlines jet sits on the tarmac at Kuala Lumpur International Airport. The carrier has posted big losses for three straight years. © Reuters

10 KUALA LUMPUR -- Malaysia Airlines, hit with the loss of one of its flights in March, is also under pressure from shareholders to sort out its finances.

Malaysia Airlines CEO Ahmad Jauhari Yahya meets the press June 25 after the annual general meeting in Kuala Lumpur. © Reuters 15

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At a shareholders meeting June 25, the national carrier admitted that it needs to drastically change the way it does business but offered scant details on what it has in mind. When the floor was opened for questions, management faced quite a barrage.

5 According to attendees, most of the queries focused on why the company has performed so badly, posting huge losses for three consecutive years. This despite a number of business plans crafted with the goal of escaping the doldrums.

Another key topic was the financial impact of flight MH370, which went missing en route from Kuala Lumpur to Beijing with 239 people aboard, more than half of 10 whom were Chinese nationals. And shareholders demanded to know how management intends to get the business back on track.

Executives assured the stockholders that the ill-fated flight was insured, barring the damage to the carrier's reputation. Malaysia Airlines has seen a 60% drop in business from China since the plane was lost March 8.

15 As for a turnaround, management would only say it is looking at all options.

"Malaysia Airlines should revamp everything," shareholder Chang Tek Huat, 65, told reporters. He added that the board should take responsibility for the weak results that have plagued the company for 15 years.

During the meeting, minority shareholders voted down one of eight resolutions, covering payment of directors' fees amounting to 396,000 ringgit ($123,000). The resolution was subsequently passed through the polls by the majority shareholders who have control over 70% stake, but the directors ultimately decided to decline 25 the remuneration.

Uncertain path

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With business dwindling and cash running low, analysts have drawn up a few possibilities for recovery, including bankruptcy. Malaysia Airlines is extremely reluctant to go that route.

"We will consider bankruptcy if we are insolvent, but we are not," Chairman 5 Mohamad Nor Yusof said after the meeting. The airline, he said, is still able to pay its debts, with cash reserves of about 3 billion ringgit.

Khazanah Nasional, the majority shareholder, said last month it will unveil a rescue plan in about a year. The national investment fund owns 69% of the airline.

The carrier says fuel accounts for more than 40% of its operation costs, followed 10 by salaries paid to its nearly 20,000 employees. A Malaysian brokerage has suggested that the airline slim down by reducing flights and manpower.

RHB Research Institute, in a recent note, projected that the airline would be able to cut its losses to 349 million ringgit in fiscal 2015 "at the expense of a one-off mutual separation scheme." This downsizing, RHB said, would entail an upfront 15 cost of 750 million ringgit.

In its 42 years of incorporation, Malaysia Airlines has gone through a series of ownership changes. It went from being a wholly owned state company to private hands, and then in 2000 it reverted to majority government ownership. Excessive reliance on the government is considered part of the company's problem.

20 Whatever happened, there was always "a grandfather to fall back on," said an analyst at the Institute for Democracy and Economic Affairs, a local think tank.

(Nikkei)

END QUOTE

25 http://airlineroute.net/2012/08/17/mh-w12update2/ QUOTE Kuala Lumpur – Guangzhou 28OCT12 – 17FEB13 Airbus A330-300 replaces -200, 1 daily eff 18FEB13 Introduction of 2nd Daily service (MH380/381). All 2 daily flights operated by Boeing 30 737-800 MH376 KUL0930 – 1335CAN 738 D MH380 KUL2005 – 0010+1CAN 738 D END QUOTE

35 http://www.flyertalk.com/forum/other-asian-australian-south-pacific-airlines/1465641-mh-a380- kul-lhr-f-mini-tr.html QUOTE MH A380 KUL-LHR F Mini-TR May 9, 13, 11:46 am 40 END QUOTE

http://en.wikipedia.org/wiki/Boeing_737_rudder_issues QUOTE Boeing 737 rudder issues

45 From Wikipedia, the free encyclopedia p4 8-7-2014 INSPECTOR-RIKATI® about the BLACK HOLE in the CONSTITUTION-DVD A 1st edition limited special numbered book on Data DVD ISBN 978-0-9803712-6-0 PLEASE NOTE: You may order books in the INSPECTOR-RIKATI® series by making a reservation, See also Http://www.schorel-hlavka.com Blog at Http://www.scrib.com/InspectorRikati

Jump to: navigation, search This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged

and removed. (March 2008)

Starting in 1991, a number of accidents and incidents involving the Boeing 737 were the result of uncommanded movement of their rudders. The rudder is controlled by the Power Control Unit (PCU). Inside the PCU is a dual servo valve which helps direct hydraulic fluid in order to move 5 the rudder. The PCU is manufactured by Parker Hannifin.

Contents [hide]

 1 Accidents  2 Other suspected 737 rudder PCU malfunction 10  3 SilkAir controversy  4 Boeing 737 rudder upgrade directive  5 Cultural references  6 References  7 External links

15 Accidents[edit]

On March 3, 1991, United Airlines Flight 585, a 737-200, crashed in Colorado Springs, CO, killing 25 people.

On September 8, 1994, USAir Flight 427, a 737-300, crashed near Pittsburgh, PA, killing 132 people.

20 During the course of the investigation of Flight 427, the National Transportation Safety Board (NTSB) discovered that the PCU's dual servo valve could jam and deflect the rudder in the opposite direction of the pilots' input, due to thermal shock caused when cold PCUs are injected with hot hydraulic fluid. As a result of this finding, the Federal Aviation Administration (FAA) ordered that the servo valves be replaced and new training protocol for pilots to handle 25 unexpected movement of flight controls. [1]

Other suspected 737 rudder PCU malfunction[edit]

On June 6, 1992, Copa Airlines Flight 201, a 737-200 Advanced, flipped and crashed into the Darien Gap jungle, killing 47 people. Initially, investigators believed that the flight experienced loss of rudder control, but after an exhaustive investigation, they concluded that the crash was 30 caused by faulty instruments readings.

On April 11, 1994, Continental Airlines pilot Ray Miller reported his aircraft rolled violently to the right; it landed safely.[2]

On June 9, 1996, Eastwind Airlines Flight 517, a 737-200, experienced loss of rudder control while on approach to Richmond, VA.

35 On February 23, 1999, MetroJet Flight 2710, a 737-200, experienced a slow deflection of the rudder to its blowdown limit while flying at 33,000 feet above Salisbury, Maryland. p5 8-7-2014 INSPECTOR-RIKATI® about the BLACK HOLE in the CONSTITUTION-DVD A 1st edition limited special numbered book on Data DVD ISBN 978-0-9803712-6-0 PLEASE NOTE: You may order books in the INSPECTOR-RIKATI® series by making a reservation, See also Http://www.schorel-hlavka.com Blog at Http://www.scrib.com/InspectorRikati

SilkAir controversy[edit]

On December 19, 1997, SilkAir Flight 185 crashed in Indonesia, killing 104 people. While the Indonesian National Transportation Safety Committee, the lead investigating agency, could not determine the cause, the U.S. NTSB, which also participated in the investigation, concluded in a 5 report issued in 2000 that there was no mechanical failure (based on Parker-Hannifin's own examination of the suspected PCU/dual-servo unit recovered from the crash), and that accident was a murder-suicide by a pilot, most likely the captain, intentionally crashing the aircraft by applying sustained nose-down control pressure.[3][4]

In 2004, following an independent investigation of the recovered PCU/dual-servo unit, a Los 10 Angeles jury, which was not allowed to hear or consider the NTSB's conclusions about the accident, ruled that the 737's rudder was the cause of the crash, and ordered Parker Hannifin, a rudder component manufacturer, to pay US$43 million to the plaintiff families. Parker Hannifin subsequently appealed the verdict, which resulted in an out-of-court settlement for an undisclosed amount.[5][6]

15 Boeing 737 rudder upgrade directive[edit]

The FAA ordered an upgrade of all Boeing 737 rudder control systems by November 12, 2002.[7]

Cultural references[edit]

The Boeing 737 rudder control issue, and the two documented crashes associated with it, were profiled in The History Channel show Engineering Disasters 19.

20 The TV series Mayday also profiled these crashes in the episode "Hidden Danger". The Mayday episode included details on Eastwind Airlines Flight 517, which led to NTSB investigators issuing a finding in the earlier events.

References[edit]

1. Jump up ^ NTSB summary 25 2. Jump up ^ The Seattle Times: Safety at issue: the 737 "Nightmare over Honduras", October 28, 1996 3. Jump up ^ SilkAir 185 - Flight Safety Australia Feb 2008 4. Jump up ^ ASN Accident description of SilkAir Flight 185 5. Jump up ^ Jury blames rudder, not pilot 30 6. Jump up ^ Jones Day Parker Hannifin settlement 7. Jump up ^ B-737 rudder design defect upgrade, , November 12, 2002.

External links[edit]

Aviation portal

1990s portal

 How the 737 rudder works  Boeing 737 Rudder Design Study 35  Abstract of Final Report - USAir 427

Retrieved from "http://en.wikipedia.org/w/index.php?title=Boeing_737_rudder_issues&oldid=613233379" p6 8-7-2014 INSPECTOR-RIKATI® about the BLACK HOLE in the CONSTITUTION-DVD A 1st edition limited special numbered book on Data DVD ISBN 978-0-9803712-6-0 PLEASE NOTE: You may order books in the INSPECTOR-RIKATI® series by making a reservation, See also Http://www.schorel-hlavka.com Blog at Http://www.scrib.com/InspectorRikati

Categories:

 Airliner accidents and incidents caused by design or manufacturing errors  Airliner accidents and incidents in the United States

END QUOTE 5 http://cf.alpa.org/mec/aaa/docs/newmectoday/arc/airwaves/aw9904/9904ntsb.htm QUOTE Central Air Safety - Accident Investigation

NATIONAL TRANSPORATION SAFETY BOARD Public Meeting of March 23-24, 1999 Abstract of Final Report (Subject to Editing)

USAir flight 427 Boeing 737-300, N513AU Aliquippa, Pennsylvania September 8, 1994

This is an abstract from the Safety Board’s report and does not include the Board’s rationale for the conclusions, probable cause and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

Accident summary

On September 8, 1994, about 1903:23 eastern daylight time, USAir (now US Airways) flight 427, a Boeing 737- 3B7 (737-300), N513AU, crashed while maneuvering to land at Pittsburgh International Airport, Pittsburgh, Pennsylvania. Flight 427 was operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled domestic passenger flight from Chicago-O’Hare International Airport, Chicago, Illinois, to Pittsburgh. The flight departed about 1810, with 2 pilots, 3 flight attendants, and 127 passengers on board. The airplane entered an uncontrolled descent and impacted terrain near Aliquippa, Pennsylvania. All 132 people on board were killed, and the airplane was destroyed by impact forces and fire. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.

The safety issues addressed in this report are Boeing 737 rudder malfunctions, including rudder reversals; the adequacy of the 737 rudder system design; unusual attitude training for air carrier pilots; and flight data recorder (FDR) parameters.

Safety recommendations concerning these issues were addressed to the Federal Aviation Administration (FAA). Also, as a result of this accident, the Safety Board issued a total of 17 safety recommendations to the FAA on October 18, 1996, and February 20, 1997, regarding operation of the 737 rudder system and unusual attitude recovery procedures. In addition, as a result of this accident and the United Airlines flight 585 accident (involving a 737-291) on March 3, 1991, the Safety Board issued three recommendations (one of which was designated "urgent") to the FAA on February 22, 1995, regarding the need to increase the number of FDR parameters.

Conclusions

[NOTE: Because the Safety Board’s analysis of this accident also included analysis of the United flight 585 accident and the Eastwind flight 517 incident, some of the findings below pertain to these two events.]

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1. The USAir flight 427 flight crew was properly certificated and qualified, and had received the training and off-duty time prescribed by Federal regulations. No evidence indicated any preexisting medical or behavioral conditions that might have adversely affected the flight crew’s performance during the accident flight. 2. The USAir flight 427 accident airplane was equipped, maintained, and operated in accordance with applicable Federal regulations. The airplane was dispatched in accordance with FAA- and industry- approved practices. 3. All of USAir flight 427’s doors were closed and locked at impact. 4. USAir flight 427 did not experience an in-flight fire, bomb, explosion, or structural failure. 5. Neither a midair collision with other air traffic, a bird strike, clear air turbulence, nor other atmospheric phenomena were involved in the USAir flight 427 accident. 6. Asymmetrical engine thrust reverser deployment, asymmetrical spoiler/aileron activation, transient electronic signals causing uncommanded flight control movements, yaw damper malfunctions, and a rudder cable pull or break were not factors in the USAir flight 427 accident. 7. Although USAir flight 427 encountered turbulence from Delta flight 1083’s wake vortices, the wake vortex encounter alone would not have caused the continued heading change that occurred after 1903:00. 8. About 1903:00, USAir flight 427’s rudder deflected rapidly to the left and reached its left aerodynamic blowdown limit shortly thereafter. 9. Analysis of the human performance data shows that it is likely that the first officer made the first pilot control response to the upset event and manipulated the flight controls during the early stages of the accident sequence; although it is likely that both pilots manipulated the flight controls later in the accident sequence, it is unlikely that the pilots simultaneously manipulated the controls (possibly opposing each other) during the critical period in which the airplane yawed and rolled to the left. 10. Analysis of the human performance data (including operational factors) does not support a scenario in which the flight crew of USAir flight 427 applied and held a full left rudder input until ground impact more than 20 seconds later. 11. Analysis of the CVR, Safety Board computer simulation, and human performance data (including operational factors) from the USAir flight 427 accident shows that they are consistent with a rudder reversal most likely caused by a jam of the main rudder PCU servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide. 12. The flight crew of USAir flight 427 could not be expected to have assessed the flight control problem and then devised and executed the appropriate recovery procedure for a rudder reversal under the circumstances of the flight. 13. The flight crew of USAir flight 427 recognized the initial upset in a timely manner and took immediate action to attempt a recovery, but did not successfully regain control of the airplane. 14. It is very unlikely that the loss of control in the United flight 585 accident was the result of an encounter with a mountain rotor. 15. Analysis of the CVR, computer simulation, and human performance data (including operational factors) from the United flight 585 accident shows that they are consistent with a rudder reversal most likely caused by a jam of the main rudder PCU servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide. 16. The flight crew of United flight 585 recognized the initial upset in a timely manner and took immediate action to attempt a recovery, but did not successfully regain control of the airplane. 17. The flight crew of United flight 585 could not be expected to have assessed the flight control problem and then devised and executed the appropriate recovery procedure for a rudder reversal under the circumstances of the flight. 18. Training and piloting techniques developed as a result of the USAir flight 427 accident show that it is possible to counteract an uncommanded deflection of the rudder in most regions of the flight envelope: such training was not yet developed and available to the crews of USAir flight 427 or United flight 585. 19. During the Eastwind flight 517 incident, the rudder reversed, moving to its right blowdown limit when the captain commanded left rudder, consistent with a jam of the main rudder PCU servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide. 20. It is possible that, in the main rudder PCUs from the USAir flight 427, United flight 585, and Eastwind flight 517 airplanes (as a result of some combination of tight clearances within the servo valve, thermal effects, particulate matter in the hydraulic fluid or other unknown factors) the servo valve secondary slide could jam to the servo valve housing at a position offset from its neutral position, without leaving any obvious physical evidence, and combined with a rudder pedal input, could have caused the rudder to

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move opposite to the direction commanded by a rudder pedal input. 21. The upsets of USAir flight 427, United flight 585, and Eastwind flight 517 were most likely caused by the movement of the rudder surfaces to their blowdown limits in a direction opposite to that commanded by the pilots. The rudder surfaces most likely moved as a result of jams of the secondary slides to the servo valve housings offset from their neutral position and overtravel of the primary slides. 22. When completed, the rudder system design changes to the Boeing 737 should preclude the rudder reversal failure mode that most likely occurred in the USAir flight 427 and United flight 585 accidents and the Eastwind flight 517 incident. 23. Rudder design changes to Boeing 737-NG series airplanes and the proposed retrofit of the remainder of the Boeing 737 fleet do not eliminate the possibility of other potential failure modes and malfunctions in the Boeing 737 rudder system that could lead to a loss of control. 24. The dual-concentric servo valve used in all Boeing 737 main rudder PCUs is not reliably redundant. 25. A reliably redundant rudder actuation system is needed for the Boeing 737, despite significant improvements made in the system’s design. 26. The results of this investigation have disclosed that the Boeing 737 rudder system design certificated by the FAA is not reliably redundant. 27. Transport-category airplanes should be shown to be capable of continued safe flight and landing after a jammed flight control in any position, unless the jam can be shown to be extremely improbable. 28. Pilots would be more likely to recover successfully from an uncommanded rudder reversal if they were provided the necessary knowledge, procedures, and training to counter such an event. 29. A neutral rudder pedal position is not a valid indicator that a rudder reversal in the Boeing 737 has been relieved. 30. The training being provided to many Boeing 737 flight crews on the procedures for recovering from a jammed or restricted rudder (including a rudder reversal) is inadequate. 31. The continued use by air carriers of airspeeds below the existing block maneuvering speed schedule presents an unacceptable hazard, and the existing block maneuvering speed for the flaps 1 configuration provides an inadequate margin of controllability in the event of a rudder hardover. 32. The FDR upgrade modifications required by the FAA for existing airplanes are inadequate because they do not require the FDR to be modified to record yaw damper command voltage, yaw damper and standby rudder on/off discrete indications, pitch trim, thrust reverser position, leading and trailing edge flap position, and pilot flight control input forces for control wheel, control column, and rudder pedals. 33. Based on the rudder-related anomalies discussed in this report, FDR documentation of yaw damper command voltage, yaw damper and standby rudder on/off discrete indications, and pilot flight control input forces for control wheel, control column, and rudder pedals is especially important in the case of the 737, and these parameters should be sampled on 737 airplanes at frequent intervals to provide optimal documentation. 34. The FAA’s failure to require timely and aggressive action regarding enhanced FDR recording capabilities, especially on Boeing 737 airplanes, has significantly hampered investigators in the prompt identification of potentially critical safety-of-flight conditions and in the development of recommendations to prevent future catastrophic accidents.

Probable cause

The National Transportation Safety Board determines that the probable cause of the USAir flight 427 accident was a loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder PCU servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.

Safety recommendations

As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations: —to the Federal Aviation Administration:

1. Require that all existing and future 737s have a reliably redundant rudder actuation system. 2. Convene an engineering test and evaluation board to conduct a failure analysis to identify potential

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failure modes; a component and sub-system test to isolate particular failure modes found during the failure analysis; and a full-scale integrated systems test of the rudder actuation and control system of the Boeing 737 to identify potential latent failures and to validate operation of the system without regard to minimum certification standards and requirements in FAR Part 25. Participants in the board should include the FAA, NTSB technical advisors, the Boeing Company , other manufacturers as appropriate, and experts from other government agencies, industry, and academia. A test plan should be prepared that includes installation of original and redesigned Boeing 737 main rudder PCUs and related equipment and exercises all potential factors that could initiate anomalous behavior (such as thermal effects, fluid contamination, maintenance errors, mechanical failure, system compliance, structural flexure, etc.) The work of the engineering board should be completed by March 31, 2000, and should be published by the FAA. 3. Ensure that future transport category airplanes certificated by the FAA provide a reliably redundant rudder actuation system. 4. Amend 14 CFR Section 25.671(c)(3) to require that transport-category airplanes be shown to be capable of continued safe flight and landing after jamming of a flight control at any deflection possible, up to and including its full deflection, unless such a jam is shown to be extremely improbable. 5. Revise AD 96-26-07 so that procedures for addressing a jammed or restricted rudder do not rely on the pilots’ ability to center the rudder pedals as an indication that the rudder malfunction has been successfully resolved, and require Boeing and U.S. operators of Boeing 737s to amend their Airplane Flight Manuals and Operations Manuals accordingly. 6. Require all 14 CFR Part 121 air carrier operators of the Boeing 737 to provide their flight crews with initial and recurrent flight simulator training in the "Uncommanded Yaw or Roll" and "Jammed or Restricted Rudder" procedures in Boeing’s 737 Operations Manual. The training should demonstrate the inability to control the airplane at some speeds and configurations by using the roll controls (the crossover speed phenomenon) and include performance of both procedures in their entirety. 7. Require Boeing to update its Boeing 737 simulator package to reflect flight test data on crossover speed; then require all operators of the Boeing 737 to incorporate these changes in their simulators used for Boeing 737 pilot training. 8. Evaluate the Boeing 737’s block maneuvering speed schedule to ensure the adequacy of airspeed margins above crossover speed for each flap configuration; provide the results of the evaluation to air carrier operators of the Boeing 737 and the Safety Board, and require Boeing to revise block maneuvering speeds to ensure a safe airspeed margin above crossover speed. 9. Require that each 737 airplane operated under 14 CFR Parts 121 or 125 that currently has a FDAU be equipped, by December 1999, with a flight data recorder system that records, at a minimum, the parameters required by FAA Final Rule 121.344, 125.226 dated July 17, 1997, applicable to that airplane plus the following parameters: pitch trim, trailing edge flaps, leading edge flaps, thrust reverser position (each engine), yaw damper command, yaw damper on/off discrete, standby rudder on/off discrete, and control wheel, control column, and rudder pedal forces (with yaw damper command, yaw damper on/off discrete, and control wheel, control column, and rudder pedal forces sampled at a minimum rate of twice- per-second). 10. Require that all 737 airplanes operated under 14 CFR Parts 121 or 125 not equipped with a FDAU be equipped, at the earliest time practicable, but no later than August 2001, with a flight data recorder system that records, at a minimum, the parameters required by FAA Final Rule 121.344, 125.226 dated July 17, 1997 applicable to that airplane plus the following parameters: pitch trim, trailing edge flaps, leading edge flaps, thrust reverser position (each engine), yaw damper command, yaw damper on/off discrete, standby rudder on/off discrete, and control wheel, control column, and rudder pedal forces (with yaw damper command, yaw damper on/off discrete, and control wheel, control column, and rudder pedal forces sampled at a minimum rate of twice-per-second).

Back to Article US AIRWAVES - April 1999

END QUOTE 5 http://en.wikipedia.org/wiki/USAir_Flight_427 QUOTE

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USAir Flight 427

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USAir Flight 427

A USAir Boeing 737-3B7 similar to the one involved.

Occurrence summary

Date September 8, 1994

Summary Rudder malfunction

Hopewell Township, Beaver County, Pennsylvania Site 40°36′14″N 80°18′37″W40.60393°N 80.31026°WCoordinates: 40°36′14″N 80°18′37″W40.60393°N 80.31026°W

Passengers 127

Crew 5

Fatalities 132 (all)

Survivors 0

Aircraft type Boeing 737-3B7

Operator USAir

Registration N513AU

Flight origin O'Hare International Airport

Stopover Pittsburgh International Airport

Destination West Palm Beach Int'l Airport

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USAir Flight 427 was a scheduled flight from Chicago's O'Hare International Airport to Pittsburgh, with a final destination of West Palm Beach, Florida. The flight crashed on Thursday, September 8, 1994, killing 132 on board. The Boeing 737-3B7 flying the route, registered N513AU, and previously registered as N382AU, was approaching runway 28R of Pittsburgh International Airport, located in Findlay Township, Allegheny County, Pennsylvania, 5 which was at the time the largest hub for the airline.

Contents [hide]

 1 Crash  2 Investigation 10  3 Dramatization  4 See also  5 References  6 External links  7 Books

15 Crash[edit]

The sister aircraft of N513AU, a USAir (rebranded and repainted as US Airways) Boeing 737-3B7, registration N527AU.

20 Captain Peter Germano, 45, was hired by USAir in February 1981. First Officer Charles B. "Chuck" Emmett III, 38, was hired in February 1987 by Piedmont Airlines. Both the captain and first officer were regarded as excellent pilots. They were both very experienced, with approximately 12,000 flight hours and 9,119 flight hours, respectively. Flight Attendant Stanley Canty was hired in May 1989 by Piedmont Airlines. Flight Attendant April Slater was hired by Piedmont in March 1989. Flight Attendant Sarah Slocum-Hamley was hired in October 1988. 25 Piedmont merged with USAir in 1989.

During its arrival into Pittsburgh, Flight 427 was sequenced behind Delta Airlines Flight 1083, a Boeing 727-200. At no time was Flight 427 closer than 4.1 miles from Delta 1083, according to radar data.[1] During the approach, Flight 427 encountered wake turbulence from Delta 1083; however the FAA determined "the wake vortex encounter alone would not have caused the continued heading change that occurred after 1903:00."[2] At 7:02:57 PM, there were 30 three sudden thumps, clicking sounds, a louder thump, and then the 737 began to bank and roll to the left. The aircraft stalled, and rolled upside down. Germano exclaims, "Hold on" numerous times, as Emmett says "Oh sh*t" frequently. Germano says, "What the hell is this?" As air traffic control noticed Flight 427 descending without permission, Germano, keyed the mic and stated, "Four-twenty-seven, emergency!" The aircraft then rolled back upright, but after a few seconds on its side, the aircraft continued to roll while pitched nose down at the ground. 35 Germano and Emmett began frantically shouting, "God", "No!" and screaming. At 7:03:25 PM, the 737 slammed into the ground and exploded, in an 80 degree nose down position, while banked 60 degrees to the left, and traveling at 300 mph (480 km/h) in Hopewell Township, Beaver County,[3] near Aliquippa, Pennsylvania, killing all 127 passengers and 5 crew members. The plane just barely missed the Green Garden shopping plaza, and the Aliquippa exit of the Beaver Valley Expressway (I-376, then PA-60), which was crowded with cars of people driving home 40 from work, crashing onto a private gravel driveway and hillside on Pettita Lane in an area protected against trespassing. There is a memorial that has been put on the site where the aircraft impacted.

Flight 427 has the third highest death toll of any aviation accident involving a Boeing 737-300 after the crash of Flash Airlines Flight 604 and China Southern Airlines Flight 3943. When it occurred, it was the second deadliest accident involving a Boeing 737 and is currently the sixth deadliest. It was also the seventh deadliest aviation

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disaster in the history of the United States at the time it occurred; as of 2012, it now ranks ninth.[citation needed] In the period from 1989 to 1994, it was the company's fifth crash.[4]

After the crash, USAir encountered difficulties in determining who was on board the aircraft. The company faced confusion regarding five or six passengers. Several employees of the U.S. Department of Energy had tickets to take 5 later flights, but used them to fly on Flight 427. One young child was not ticketed.[4] Due to the severity of the impact, the bodies of the passengers and crew were severely fragmented, leading investigators to declare the site a biohazard.

Investigation[edit]

After one of the longest accident investigations in aviation history — lasting more than four and a half years — the 10 concluding statement said:

The National Transportation Safety Board determines that the probable cause of the USAir flight 427 accident was a loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and 15 overtravel of the primary slide.[5]

The National Transportation Safety Board concluded that similar rudder problems caused the previously mysterious March 3, 1991 crash of United Airlines Flight 585 and the June 9, 1996, incident involving Eastwind Airlines Flight 517, both of which were Boeing 737s. As a result of the investigation, pilots were warned of and trained how to deal with insufficient aileron authority at an airspeed at or less than 190 knots (352 km/h), formerly the usual approach 20 speed for a Boeing 737. Four additional channels of information — pilot rudder pedal commands — were incorporated into flight data recorders, while Boeing redesigned the rudder system on 737s and retrofitted existing craft until the affected systems could be replaced. The United States Congress also required airlines to deal more sensitively with the families of crash victims.[6]

US Airways 427 is no longer a valid flight number on US Airways as of January 2011.

25 Flight 427 was the second fatal crash in a little over two months at the company (the other being USAir Flight 1016 at Charlotte-Douglas Airport in July 1994). The crashes contributed to the financial crisis USAir was experiencing at the time.[7]

Among the victims of the crash was noted neuroethologist Walter Heiligenberg.[8]

Dramatization[edit]

30 The accident was featured on the Discovery Channel Canada/National Geographic Channel television series Mayday (also known as Air Emergency or Air Crash Investigation in various countries) series 4 episode entitled "Hidden Danger" ("Mystery Crashes"), alongside United Airlines Flight 585 and Eastwind Airlines Flight 517.