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NTSB/AAR-90/03 NATIONAL I ’ T~Spor’T”ATION SAFETY BOARD

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NTSB/AAR-90/03 NATIONAL I ’ T~Spor’T”ATION SAFETY BOARD PB90-910403 NTSB/AAR-90/03 NATIONAL I ’ T~SpOR’T”ATION SAFETY BOARD AIRCRAFT ACCIDENT REPORT USAIR, INC., BOEING 737400 LAGUARDIA AIRPORT FLUSHING, NEW YORK SEPTEMBER 20, 1989 Dok NTSB c JACK R. HUNT MEMORIAL UBRARY DAYTONA BEACH, FLORIDA 32114 l 9042396595 The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated b the Independent Safet Board Act of 1974 to investigate transportation accicrents, determine the proiiable cause of accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safet recommendations, and statistical reviews. Copies of these documents may be pureiased from the National Technical Information Service, 5285 Port Royal Road, Springfield, Virginia 22161. Details on available publications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-52 800 Independence Avenue, 5.W. Washin ton, D.C. 20594 (202)38!-6735 TECHNICAL REPORT DOCUMENTATION PAGE 1. Report No. 2. Government Accession No. 3. Recipient’s Catalog No. I NTSBIAAR-90103 PB90-910403 4. Title and Subtitle Aircraft Accident Report-- 5. Report Date USAir, Inc., Boeing 737-400, LaGuardia Airport, July 3, 1990 Flushing, New York, September 20, 1989 6. Performing Organization Code - - 7. Author(s) 8. Performing Organization Report No. 9. Performing Organization Name and Address 10. Work Unit No. I 5204A National Transportation Safety Board Office of Aviation Safety 11. Contract or Grant No. Washington, D.C. 20594 13. Type of Report and Period Covered Aircraft Accident Report 12. Sponsoring Agency Name and Address September 20, 1989 NATIONAL TRANSPORTATION SAFETY BOARD Washington, D.C. 20594 14. Sponsoring Agency Code 15. Supplementary Notes 16. Abstract This report explains the crash of USAir flight 5050 on September 20, 1989 at New York City’s LaGuardia Airport. The safety issues discussed in the report are the design and location of the rudder trim control on the Boeing 737-400, air crew coordination and communication during takeoffs, crew pairing, and crash survivability. Safety Recommendations addressing these issues were made to the Federal Aviation Administration and the Port Authority of New York and New Jersey 17. Key Words 18. Distribution Statement This document is available to the /i?-( cq‘ 1 r2mz3i-6; I public through the National :;Lx J ~;,J-cf ;. ,p) ,)-Y ->>L Technical Information Service, j&f (y&JCL>; I?!JL”-;y * Springfield, Virginia 22161 /& -/f“ J,r,g L Lv?wJ~~J~Ch 19. Security~lafs!ifi$tion 20. Security Classification 21. No. of Pages 22. Price (of this report) (of this page) UNCLASSIFIED UNCLASSIFIED 98 \lTSB Form 1765.2(Rev. S/88) CONTENTS EXECUTIVE SUMMARY ............................................. FACTUAL INFORMATION ::1 History of the Flight ........................................ Injuries to Persons ........................................... ::: Damage to the Airplane ........................................ Other Damage .................................................. :*z Personnel Information ......................................... 1:5.1 General ....................................................... 1.5.2 The Captain ................................................... 1.5.3 The First Officer ............................................. Airplane Information .......................................... ;*; Meteorological Information .................................... 1:7.1 Surface Observations .......................................... 1.7.2 Rainfall ...................................................... Aids to Navigation ............................................ :-ii Communications ................................................ 1:10 Aerodrome Information ......................................... 1.11 Flight Recorders .............................................. 1.11.1 The Cockpit Voice Recorder .................................... 1.11.2 The Flight Data Recorder ...................................... 1.12 Wreckage and Impact Information ............................... 1.12.1 Main Wreckage ................................................. 1.12.2 Marks on the Runway ........................................... 1.13 Medical and Pathological Information .......................... 1.14 Fire .......................................................... 1.15 Survival Aspects .............................................. 1.15.1 Seat Damage ................................................... 1.15.2 Emergency Exit Damage ......................................... .1.15.3 Evacuation .................................................... 1.15.4 Emergency Response ............................................ 1.16 Tests and Research ............................................ 1.16.1 Powerplant Examination ........................................ 1.16.2 Rudder Trim Examination ....................................... 1.16.3 Brake and Anti-skid Examination ............................... 1.16.4 Simulation Studies ............................................ 1.17 Other Information ............................................. 1.17.1 Aircraft Systems Descriptions ................................. 1.17.1.1 The Nosewheel Steering System ................................. 1.17.1.2 The Rudder Trim System ........................................ 1.17.1.3 The Autothrottle System ....................................... 1.17.1.4 The Autobrake System .......................................... 1.17.2 USAir 8-737-300/400 Pilots Handbook Excerpts .................. 1.17.3 FAA Oversight of USAir ........................................ 1.17.4 Airplane Performance .......................................... 1.17.5 Inadvertent Rudder Trim Anomalies ............................. 1.17.6 Corrective Actions . 1.17.7 FAA Drug and Alcohol Post-accident Testing Requirements . f X 1.17.8 Public Hearing Testimony on Accident-Related Subjects . 31 . 111 1.17.9 Pilot Experience and Pairing ................................... 31 1.17.10 Rejected Takeoff Special Investigation ........................ :P 1.17.11 Runway Safety Areas ............................................ 1.17.12 Overwater Emergency Equipment .................................. 35 ANALYSIS ;:1 General ....................................................... 38 Activation of the Rudder Trim ................................. i-3 Crew Failure to Detect the Mistrimmed Rudder .................. ii 2:4 Rudder Trim Control Design ................................... 2.5 Directional Control Difficulty ................................ t : The RTO Decision .............................................. 43 I:; Braking Performance ........................................... Engine Performance ............................................ d"6 i*i The "Bang" and Rumble on the CVR .............................. 2:10 Crew Coordination During the Takeoff Run ....................... t: 2.10.1 Cockpit Resource Management Training .......................... 47 2.10.2 Pre-takeoff Emergency Procedures Briefings .................... 2.10.3 Crew Coordination During the Takeoff Run ...................... t; 2.10.4 Pilot Experience and Pairing .................................. 50 2.11 Making Runway Overruns Safer .................................. 51 2.12 Survival Factors .............................................. 52 2.13 Postaccident Toxicological Testing ........................... 2.14 Postaccident Aircrew Availability ........................... ;s CONCLUSIONS ;*1 Findings ...................................................... 55 3:2 Probable Cause ................................................ 57 4. RECOMMENDATIONS ............................................... 58 5. APPENDIXES Appendix A--Investigation and Hearing ......................... Appendix B--Personnel Information ............................. f: Appendix C--Airplane Information .............................. 63 Appendix D--Cockpit Voice Recorder Transcript ................. 64 Appendix E--Synopsis of Fire and Rescue Critiques and Post- Accident Improvements ............................. 94 iv EXECUTIVE SUMMARY On September 20, 1989, USAir, Inc. flight 5050 was departing New York City's LaGuardia Airport, Flushing, New York, for Charlotte Douglas International Airport, Charlotte, North Carolina. As the first officer began the takeoff on runway 31, he felt the airplane drift left. The captain noticed the left drift also and used the nosewheel tiller to help steer. As the takeoff run progressed, the aircrew heard a "bang" and a continual rumbling noise. The captain then took over and rejected the takeoff but did not stop the airplane before running off the end of the runway into Bowery Bay. Instrument flight conditions prevailed at the time and the runway was wet. The National Transportation Safety Board determines that the probable cause of this accident was the captain's failure to exercise his command authority in a timely manner to reject the takeoff or take sufficient control to continue the takeoff, which was initiated with a mistrimmed rudder. Also causal was the captain's failure to detect the mistrimmed rudder before the takeoff was attempted. The safety issues discussed in this report were the design
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