USAir Flight 405 was a regularly scheduled American domestic passenger flight between LaGuardia Airport in New York City and Cleveland, Ohio. On March 22, 1992, the Fokker F28 Fellowship operating the flight crashed in poor weather in a partially inverted position in Flushing Bay, shortly after liftoff from LaGuardia. The undercarriage lifted off from the runway, but the airplane failed to gain lift, flying only several meters above the ground. The aircraft then veered off the runway and hit several obstructions before coming to rest in Flushing Bay, just beyond the end of the runway. Of the 51 people on board, 27 were killed, including the captain and a member of the cabin crew.
A similar accident had happened three years before, when Air Ontario Flight 1363 crashed shortly after takeoff at Dryden Regional Airport after ice had accumulated on the wings and airframe.
The subsequent investigation revealed that due to pilot error, inadequate deicing procedures at LaGuardia, and several lengthy delays, a large amount of ice had accumulated on the wings and airframe. This ice disrupted airflow over the wing, increasing drag and reducing lift, which prevented the jet from lifting off the runway. The National Transportation Safety Board concluded that the flight crew was unaware of the amount of ice that had built up after the jet was delayed by heavy ground traffic taxiing to the runway. The report also listed as a contributing factor the fact that the aircraft had begun its takeoff rotation too early at a lower speed than was standard.
Investigators also found that the deicing procedures at LaGuardia were substandard. While the jet encountered a delay up to 35 minutes, they found that the deicing fluid that was being used at the airport, and by the majority of commercial airlines across the United States, was effective for only 15 minutes. The accident led to a number of studies into the effect of ice on aircraft, and several recommendations into prevention techniques.
Flight history
The aircraft involved in the accident was a Fokker 28 airplane manufactured in the Netherlands. A two-engined, medium-range jet, the Fokker 28-4000 is designed for transporting up to 85 passengers. The jet involved in the accident was registered in the United States as N485US. It was first delivered to Piedmont Airlines in August 1986, and was acquired by USAir (US Airways) three years later in August 1989 when Piedmont and USAir merged. N485US had amassed a total of 12,462 flying hours at the time of the accident.
Captain Wallace J. Majure II, 44, who was fully qualified to pilot the F28 and four other commercial aircraft types, had accumulated about 9,820 total flying hours, of which 2,200 hours were in the F28. Majure was initially hired as an F28 first officer by Piedmont Airlines in 1985. He was later reassigned to serve as a first officer and then a captain on a Boeing 737, but finally returned to an F28 captain because of company cutbacks. He previously served for United States Navy from 1969 until 1985.
First Officer John Rachuba, 30, was hired by Piedmont in 1989. At the time of the accident, company records indicate that he had accumulated around 4,507 flying hours, of which 29 hours were in the F28. Rachuba held a flight engineer certificate with ratings for turbojet-powered aircraft and an expired instructor certificate issued on August 16, 1987. He also held a Federal Aviation Administration license for non federal control towers. Previously, he had served as a flight engineer on Boeing 707s and Boeing 727s.
Accident
Poor weather, deicing, taxiing delays
The aircraft took off from Jacksonville International Airport, Florida, several hours before the accident, although the departure from Jacksonville was delayed by poor weather over New York and the removal of the baggage of a passenger who decided not to board the jet. The instrument approach landing was uneventful and the jet was not significantly delayed while in the air waiting to land, but congestion on the taxiways at LaGuardia delayed the arrival of the aircraft at the gate.
One hour and six minutes behind schedule, the jet arrived at Gate B1, where the captain advised a line mechanic that his airplane was "good to go." The flight crew left the aircraft to go to the terminal, and did not perform an aircraft walk around inspection of the aircraft, nor was he required to by company policy. The poor weather did not improve as the jet was deiced with type I fluid, a heated 50/50 water/glycol mixture. Following the completion of this process, one of the two deicing trucks delayed the pushback of the jet when it experienced mechanical problems. The vehicle was immobilized for 20 minutes in such a position that it prevented the aircraft from taxiing to the runway. After the deicing truck was repaired, the pilot requested a second deicing due to the delay. Following the second deicing, LaGuardia ground control granted Flight 405 permission to taxi to Runway 13. The flight crew completed the before-takeoff checklist during the taxi.
Engine anti-ice protection was turned on for the two engines during taxi. The captain announced to passengers that the flaps would remain up during taxi so the aircraft's wheels would not splash slush onto the wings during the taxi, and they should not be worried seeing them in the retracted position. He placed an empty coffee cup on the flap handle as a reminder of the position of the flaps, a procedure used by many flight crews. The captain told the first officer they would use standard USAir contaminated runway procedures that included the use of 18° flaps, and also decided that they would take off with a reduced V1 speed of 110 knots (130 mph; 200 km/h).
At the time of the accident, recorded broadcasts available to pilots contained information that runway 13/31 was coated with a thin layer of wet snow, and that it had been plowed and sanded, and the other runway was closed for snow removal. The previous announcement mentioned that the runways had also been treated with urea.
The first officer described the snowfall as "not heavy, no large flakes." He told accident investigators that snow was sliding off the jet and the nose of the airplane was coated in a watery layer. He used a light positioned on the wing of his jet to check for signs of ice several times before they attempted to take off. Neither the pilot nor he saw any evidence of contamination on the wing or on the black strip, so they decided against a third deicing. He told investigators that he checked the wings "maybe 10 times, but at least three." He said that he did not consider the snowfall heavy, and he did not recall any wind blowing the snow. The first officer stated that as they taxied, they looked back at the wings several times. Near the time of the takeoff, he said, "looks good to me, black strip is clear."
While taxiing, the flight crew discussed deicing procedures that were used at other airports. The first officer suggested to the pilot that they pull close to the aircraft ahead of them in the queue because it "might keep our wings clear for us." The pilot replied, "it can cause us to refreeze, too ... I don't want to be very close to him." Later, the first officer remarked, "look at all that stuff. What is that?" to which the pilot replied, "sand I guess, urea sand."
The pilot of a jet taxiing behind Flight 405, Northwest Airlines Flight 517, a Boeing 757 bound for Minneapolis–Saint Paul International Airport, stated that he had a good view of the top of Flight 405's wing, and that just enough snow was on the fuselage to "fuzzy" the USAir printing, but that the wings appeared to be clear. He believed that the snow had "all but stopped" and was more concerned about the amount of vehicular traffic, such as sweepers and plows, than he was about the snowfall. The second officer of Trump Shuttle Flight 1541, which had landed around the time Flight 405 was taxiing, said their Boeing 727 had "picked up a lot of snow quickly during my post-landing walkaround, but by the finish it seemed to be more rain." He described Flight 405 as a "fairly clean airplane." He said that he could not comment on clear ice, but that the wings and fuselage were clear of snow.
The jet, already several hours behind schedule, then suffered further delays taxiing to the runway. The weather had created heavy ground traffic at LaGuardia, and queues of aircraft were reported to be waiting for permission for takeoff. Investigators estimated that the plane took between 25 and 45 minutes to taxi from the gate to the runway.
Crash
Following permission for takeoff from controllers, the flight crew initiated the takeoff procedure and the first officer made a callout of 80 knots (92 mph; 150 km/h), and several seconds later, a V1 callout, followed shortly after by a VR callout. Approximately 2.2 seconds after the VR callout, the nose gear left the ground. The final report read, "the first officer described the takeoff as normal through the rotation. He stated that no problem was evident with vibration, rate of acceleration, ambient noise, [or] directional control". However, The New York Times reported that "several passengers sensed that [the airplane] was not going fast enough."
The first officer said it was "just like we lost lift." As the captain attempted to level the wings, the crew used right rudder to maneuver the aircraft back toward the ground and avoid the water below. The accident report found, "the first officer said that they seemed to agree that the airplane was not going to fly and that their control inputs were in unison." Rachuba and Majure continued to try to hold the nose up to impact in a flat attitude, although Rachuba later stated that they made no "heavy control inputs." The final report further noted, "first officer stated that he did not touch the power levers." The first officer later told investigators that the flight crew's primary focus was to find a safe place to land.
Just under five seconds after the undercarriage left the ground, the plane's left wing scraped against the asphalt for 110 feet (34 m), and the stick shaker activated. The crew received six stall warnings, before the jet began banking to the left, then to the right, and then to the left again, still only several meters above the ground. The aircraft struck two visual approach slope-indicator posts, touched down again for about 100 feet (30 m), before lifting off again and striking an instrument landing system beacon and a water pump house.
The left wing then separated from the body of the airplane, before the fuselage struck the edge of Flushing Bay and came to rest in a partially inverted position. Parts of the fuselage and cockpit were submerged in water. Confusion, disorientation, or entrapment most likely caused the drowning of passengers who otherwise sustained only minor injuries and injuries that were not life-threatening. The final report read:
Prior to impact, passengers did not assume the brace position. When the airplane came to rest, many of the passengers in the forward portion of the cabin were upside down; others, who were upright, were submerged in water over their heads. Some passengers tried to move from their seats while their seatbelts were still buckled, and other passengers had difficulty locating and releasing their seatbelt buckles because of disorientation. Following the accident, passengers reported fires in the forward left and aft portions of the airplane, including many small fires on the water. Passengers stated that they escaped through large holes in the cabin. The lead flight attendant and first officer escaped through a hole in the cabin floor near the flight attendant's position. Several passengers reported assisting others out of the cabin and into the knee-deep water. Many of them walked in the water to the dike, climbed up the wall and over an embankment, and slid down a steep hill to the runway. Others were assisted out of the water by ground personnel.
Rescue attempts, medical operation
The tower cab coordinator on duty at the time of the accident stated that he saw a fireball emanating from the crash site following the accident. Upon seeing the flames, he sounded an alarm, alerting the Port Authority of New York and New Jersey Police, who responded. An investigation revealed that technical issues existed with an emergency telephone at LaGuardia, however it was found that these issues did not hinder the emergency response.
The Port Authority of New York and New Jersey Police Department initially sent four vehicles. Personnel in these vehicles reported that snow and fog hampered their visibility while heading to the crash site, and they could not see the destroyed aircraft. One member of the fire crew, though, observed people standing on top of a dike near the crash site. Police divers also entered the water following the crash, although they found no one alive inside the jet or in the water. The firefighters continued spraying the fire, and the incident commander estimated that they had the fire under control 10 minutes after their arrival at the scene. The New York Times reported that:
The accident sent thick, black smoke billowing above the airport as more than 200 emergency workers ... had to contend not only with blustery snow, but [also] the powerful icy current in Flushing Bay ... the tense drama of the rescue continued into the early hours, with firefighters and police officers in water up to their shoulders and helicopters shining spotlights on the wreckage and an ice-covered mound of earth at the end of the runway so slick, the rescue workers needed metal ladders to walk across it.