PB93-910402 b NTSB/AAR-S3/02 WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT 1 TAKEOFF STALL IN ICING CONDlVlONS USAIR FLIGHT 405 FOKKER F-28, N485US LAGUARDIA AIRPORT FLUSHING, NEW YORK MARCH 22,1992 The Natuiond 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 by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies invo!ved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. 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Washington, D.C. 20594 (202)382-6735 Safety Board publications ma; be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 NTSBiAAR-93IM NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, DX. 20594 AIRCRAFT ACCIDENT REPORT TAMEOFF STALL IN ICING CONDITIONS USAIR FLIGHT 405 FOKKER F-28, N485US LAGUARDIA AIRPORT FLUSHING, NEB' YOWK MARCH 22,1992 Adopted: February 17,1993 Notation 574211 Abstract: This report explains the crash of USAir flight 405, a Fokker 38-4000, after an attempted takeoff from runway 13 at LaGuardia Airport, Flushing, New York. on March 22, 1992. ??le safety issues in the report focus on the weather, USAir's deichp procedures, industry airframe deicing practices, air naffic contrcl aspects of rhe tiighs, IjSAir's takeoff and preflight procedures, and flightcrew qualifications and training. The airplane's impact with the ground, postaccident survivability. and cnsh/fire/rescue activities are also discussed. Safety recommendations concerning chese issues are addressed io the Federa! Aviation Adminisnation, the Port Authority of New York and New Jersey, the Department of Transportation, and the New York City Health ard Hospitals Corporation. THESE CORRECTIONS SHOULD BE MADE TO THE PREVIOUSLY PUBLISHED REPORT IDENTIFIED AS FOLLOWS: AIRCRAFT ACCiDENT REPORT TAKEOFF STALL IN ICING CONDITIONS USAIR FLIGHT 405 FOKKER F-28, N485US LAGUARDIA AIRPORT FLUSHING, NEW YORK MARCH 22,1992 (NTSBIAAR-93/02 PB93-91Q402) Page 49, paragraph 1, line 13 Change; ...(Q.4 -0.8 inch).... ...(0.04-0.08 inch).... EXECLTIVE SUMMAI2Y ............................................................ vi 1. FACTUAL INFORMATION 1.1 History of Flight ................................................................................. 1 1.2 Injuries to Persons .............................................................................. 6 1.3 Damage to Airplane........................................................................... 6 1.4 Other Damage .................................................................................... 7 1.5 Personnel Information ........................................................................ 7 1.5.I 72-Hwdr Summan,- . Flightmw Activity .............................................. 8 1.6 Airplane Information .......................................................................... 9 1.7 Meteorological Information ................................................................ 12 1.7.1 Surface Observations and Forecast ..................................................... 12 1.7.2 Port Authority Temperature Sensors ................................................... 13 1.7.3 Automatic Terminal Information Service (ATIS) ................................ 13 1.7.4 Precipitation Amount .......................................................................... 14 .. 1.8 Aids to Navlgztion.. ............................................................................. 14 i .9 ComumcaQons................................................................................. 14 t.10 Aerodrome Information ...................................................................... 15 1.10.1 LaGuardia Snow and Ice Control Plan ................................................ 15 1.102 Typz II Anti-icing Fluid Restrictions................................................... 16 1. i0.2.1 LaGuardia Airplane Deicing Operations ............................................. 17 I.iO.3 Runway Safety Area ............................................................................ 17 1.10.4 Air Traffic Control (ATC) .................................................................. 17 1.10.5 Ground Delay Reporting .................................................................... 18 I.IC.6 Gate Hold Procedures ........................................................................ 19 1.11 Flight Recorders .................................................................................. 20 i.ll.1 Cockpit Voice Recorder ..................................................................... 20 1.11.2 Flight Data Recorder .......................................................................... 21 1.12 Wreckage and Impact Information ...................................................... 22 1.12.1 Airframe Damage ............................................................................... 27 1.12.1.1 Wing Leading Edge Damage .............................................................. 28 1.12.1.2 Speedbrake Damage ........................................................................... 28 1.12.2 Systems Damage ................................................................................ 29 1.12.3 Engine Damage .................................................................................. 30 1.12.3.1 Inlet Anti-Ice Valves .......................................................................... 30 1.13 Medical and Pathological Information ................................................ 31 Fire .................................................................................................... 32 iii 1.15 Survival Aspects ................................................................................. 32 1.15.1 Interior Damage and Occupant hjuries............................................... 12 1.15.1.1 The Cockpit ....................................................................................... 32 1.15.1.2 The Passengers and Seals ................................................................... 32 1.15.2 Passenger Safety Briefing Card .......................................................... 33 1.15.3 ARFF Activit.ies ................................................................................. 33 .- 1.15.3.1 Nonrxcation ........................................................................................ 33 . 1.15.3.2 Fire Fighting ....................................................................................... 34 1.15.3.3 Water Rescue .................................................................................... 35 1.15.3.4 Medical Response .............................................................................. 35 1.16 Tests and Research ............................................................................. 36 1.16.1 Effects of Airframe Contamination on Airplane Performance .............. 36 1.16.2 Aerodynamic Effects of DeicingiAnti-icing F!uids .............................. 38 1.16.3 Effect of Wing Contamination on Takeoff Characteristics of the F-28 Mk4OW ........................................................................................... 39 1.16.4 View of Xight Wing From First Officer's Seat .................................... 40 1.17 Addjtional Infomarion ....................................................................... 41 1.17.1 USAir Cold Weather Operations Guidance ......................................... 41 1.17.2 FAA Deicing Regulations ................................................................... 42 2 . ANALYSIS 2.1 General .............................................................................................. 2.2 Prevailing Weather Conditions ........................................................... 47 2.3 Flight Performance of USAir Flight 405 ............................................. 48 2.4 Deicing Fluid Holdover Time and Ice Accumulation ........................... 50 2.5 Flightcrew Performance - Takeoff Procedure and Stall Recovery ........ 53 2.6 USAir Procedures/Guidance ............................................................... 56 2.6.1 Deicing ............................................................................................... 56 2.6.2 Guidance to Flightcrews ..................................................................... 57 2.7 Sirnillation of Optimal Takeoff Procedures ......................................... 60 2.8 Actions to Reduce Contaminated Wing Takeoff Hazard ..................... 61 2.8.1 FAA/lndustry Conference ................................................................... 51 2.8.2 Reducing ATC Delays ........................................................................ 62 2.8.3 Deicing and Anti-icing Fluids ............................................................. 64 2.8.4 Pretakeoff Inspections of Airplane Wings ........................................... 67 2.8.5 New Technology fgr rhe Defection of Confamination