USAir Flight 405

On March 22, 1992, a USAir Fokker F28, registration N485US,[2] flying the route, crashed in poor weather in a partially inverted position in Flushing Bay, shortly after liftoff from LaGuardia.

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.

[1]: 77  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.

[1]: 3  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).

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.

[1]: 6 [4] 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.

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.

It described how paramedics attended to those who were conscious with life-threatening injuries, but did not make any attempts to resuscitate victims who appeared drowned or lacked vital signs because they believed that they could not be revived because they had succumbed to the cold salt water.

The report reads, "the evidence did not support improper wing configuration, airframe or system defects, or deployment of the speed brakes as reasons for the loss of aerodynamic efficiency."

However, about 35 minutes elapsed between the second time that the aircraft was deiced and the initiation of takeoff during which the airplane was exposed to continuing precipitation in below-freezing temperatures.

"[1]: 53 "The Safety Board views the evidence as conclusive that the primary factor in this accident was the reduced performance of the wing due to ice contamination.

[1]: 49–50 The report found that the flight crew was aware that the poor weather was likely to cause ice buildup, but neither of them took any action to check the condition of the wing leading edge and upper surface.

After taxiing, when it became evident that they would be delayed for a prolonged period, conversations between the crew showed that they were aware of and probably concerned about the risk of reaccumulating frozen contamination on the wing.

[1]: 53 They also found that USAir guidance and flight-crew training was sufficient and should have alerted the flight crew to the risk of attempting a takeoff while they were unaware of the condition of the wing.

If the elapsed time since deicing exceeds 20 minutes, careful examination of the surfaces should be conducted to detect the extent of accumulation [of ice] and to assure that the takeoff can be made safely and in compliance with existing [regulations].

The Safety Board believes that the flight crew's failure to take such precautions and the decision to attempt takeoff while unsure of wing cleanliness led to this accident and is a cause of it.

At the time of the accident, LaGuardia had prohibited the use of type II deicing fluid because tests suggested that if it fell onto runways, it reduced friction.

[1]: 64–65  The board stated that tests have shown that both fluids do flow off the wings of a treated airplane in significant amounts during the initial takeoff ground run.

[1]: 64 While it was not named as a cause of the accident, investigators also found that the passenger safety briefing cards in the airplane showed two types of galley service doors.

"[1]: 76 The final report, published by the NTSB, cited the probable cause of the accident to be: ... the failure of the airline industry and the Federal Aviation Administration to provide flight crews with procedures, requirements, and criteria compatible with departure delays in conditions conducive to airframe icing and the decision by the flight crew to take off without positive assurance that the airplane's wings were free of ice accumulation after 35 minutes of exposure to precipitation following deicing.

Contributing to the cause of the accident were the inappropriate procedures used by, and inadequate coordination between, the flight crew that led to a takeoff rotation at a lower than prescribed air speed.

[1]: 78  They also recommended "airlines to establish a way to inform flight crews of the type of [deicing] fluid and mixture used, the current moisture accumulation rate, and the available holdover time.

[1]: 80  They also recommended a study on the "feasibility of building a frangible ILS antenna array for LaGuardia Airport"[1]: 79  Further, they recommended a review of Fokker F28-4000 passenger-safety briefing cards "to ensure that they clearly and accurately depict the operation of the two types of forward cabin doors in both their normal and emergency modes and that they describe clearly and accurately how to remove the over-wing emergency exit and cover.

The program opened by saying that Canadian investigators were "stunned" to hear of the USAir accident, as it mirrored the Air Ontario flight that had occurred three years earlier.

The report concluded that competitive pressures caused by commercial deregulation cut into safety standards, and that many of the industry's sloppy practices and questionable procedures were placing pilots in difficult situations.

[13] On 31 March 1992, Gordon Haugh, a spokesman for the Commission of Inquiry into the crash in Dryden who initially claimed that the second interim report was sent to the FAA, admitted that it was not sent to them, only to the Prime Minister's office.

A report on the conference by the FAA read: A better understanding of airplane ground deicing and anti-icing issues is a crucial prerequisite to the implementation of feasible and effective safety improvements.

To achieve this goal, the FAA sponsored a conference at which the international aviation community could exchange thoughts and offer recommendation on a variety of issues concerning safe winter operations.

The new regulations stated that airlines should put in place FAA-approved ground deicing or anti-icing procedures anytime weather conditions of ice, snow, or frost prevailed.

An NTSB diagram of Flight 405's attempted takeoff, showing it veered off the left of the runway and hit a water pump
Flushing Bay, New York , where the aircraft came to rest in a partially inverted position
Injury and death map of flight 405
The crash site of USAir Flight 405 is highlighted by the white oval.
These ice formations on the propeller and fuselage surfaces of a test unit installed in the Icing Research Tunnel at the Aircraft Engine Research Laboratory of the National Advisory Committee for Aeronautics , Cleveland, Ohio, show what may happen to an aircraft in flight under certain atmospheric conditions.