USAir - US Airways

Airbus A320

Before pushback from the gate, the first officer, who was the pilot monitoring, initialized the flight management computer (FMC) and mistakenly entered the incorrect departure runway (27R instead of the assigned 27L). As the captain taxied onto runway 27L for departure, he noticed that the wrong runway was entered in the FMC. The captain asked the first officer to correct the runway entry in the FMC, which she completed about 27 seconds before the beginning of the takeoff roll; however, she did not enter the FLEX temperature (a reduced takeoff thrust setting) for the newly entered runway or upload the related V-speeds. As a result, the FMC's ability to execute a FLEX power takeoff was invalidated, and V-speeds did not appear on the primary flight display (PFD) or the multipurpose control display unit during the takeoff roll. According to the captain, once the airplane was cleared for takeoff on runway 27L, he set FLEX thrust with the thrust levers, and he felt that the performance and acceleration of the airplane on the takeoff roll was normal. About 2 seconds later, as the airplane reached about 56 knots indicated airspeed (KIAS), cockpit voice recorder (CVR) data indicate that the flight crew received a single level two caution chime and an electronic centralized aircraft monitoring (ECAM) message indicating that the thrust was not set correctly. The first officer called "engine thrust levers not set." According to the operator's pilot handbook, in response to an "engine thrust levers not set" ECAM message, the thrust levers should be moved to the takeoff/go-around (TO/GA) detent. However, the captain responded by saying "they're set" and moving the thrust levers from the FLEX position to the CL (climb) detent then back to the FLEX position. As the airplane continued to accelerate, the first officer did not make a callout at 80 KIAS, as required by the operator's standard operating procedures (SOPs). As the airplane reached 86 KIAS, the automated RETARD aural alert sounded and continued until the end of the CVR recording. According to Airbus, the RETARD alert is designed to occur at 20 ft radio altitude on landing and advise the pilot to reduce the thrust levers to idle. The captain later reported that he had never heard an aural RETARD alert on takeoff, only knew of it on landing, and did not know what it was telling him. He further said that when the RETARD aural alert sounded, he did not plan to reject the takeoff because they were in a high-speed regime, they had no red warning lights, and there was nothing to suggest that the takeoff should be rejected. The first officer later reported that there were no V-speeds depicted on the PFD and, thus, she could not call V1 or VR during the takeoff. She was not aware of any guidance or procedure that recommended rejecting or continuing a takeoff when there were no V-speeds displayed. She further said she "assumed [the captain] wouldn't continue to takeoff if he did not know the V-speeds." The captain stated that he had recalled the V-speeds as previously briefed from the Taxi checklist, which happened to be the same V-speeds for runway 27L. The captain continued the takeoff roll despite the lack of displayed V-speeds, no callouts from the first officer, and the continued and repeated RETARD aural alert. FDR data show that the airplane rotated at 164 KIAS. However, in a postaccident interview, the captain stated that he "had the perception the aircraft was unsafe to fly" and that he decided "the safest action was not to continue," so he commenced a rejected takeoff. FDR data indicate that the captain reduced the engines to idle and made an airplane-nose-down input as the airplane reached 167 KIAS (well above the V1 speed of 157 KIAS) and achieved a 6.7 degree nose-high attitude. The airplane's pitch decreased until the nose gear contacted the runway. However, the airplane then bounced back into the air and achieved a radio altitude of about 15 ft. Video from airport security cameras show the airplane fully above the runway surface after the bounce. The tail of the airplane then struck the runway surface, followed by the main landing gear then the nose landing gear, resulting in its fracture. The airplane slid to its final resting position on the left side of runway 27L. The operator's SOPs address the conditions under which a rejected takeoff should be performed within both low-speed (below 80 KIAS) and high-speed (between 80 KIAS and V1) regimes but provide no guidance for rejecting a takeoff after V1 and rotation. Simulator testing performed after the accident demonstrated that increasing the thrust levers to the TO/GA detent, as required by SOPs upon the activation of the "thrust not set" ECAM message, would have silenced the RETARD aural alert. At the time of the accident, neither the operator's training program nor manuals provided to flight crews specifically addressed what to do in the event the RETARD alert occurred during takeoff; although, 9 months before the accident, US Airways published a safety article regarding the conditions under which the alert would activate during takeoff. The operator's postaccident actions include a policy change (published via bulletin) to its pilot handbook specifying that moving the thrust levers to the TO/GA detent will cancel the RETARD aural alert. Although simulator testing indicated that the airplane was capable of sustaining flight after liftoff, it is likely that the cascading alerts (the ECAM message and the RETARD alert) and the lack of V-speed callouts eventually led the captain to have a heightened concern for the airplane's state as rotation occurred. FDR data indicate that the captain made erratic pitch inputs after the initial rotation, leading to the nose impacting the runway and the airplane bouncing into the air after the throttle levers had been returned to idle. Airbus simulation of the accident airplane's acceleration, rotation, and pitch response to the cyclic longitudinal inputs demonstrated that the airplane was responding as expected to the control inputs. Collectively, the events before rotation (the incorrect runway programmed in the FMC, the "thrust not set" ECAM message during the takeoff roll, the RETARD alert, and the lack of required V-speeds callouts) should have prompted the flight crew not to proceed with the takeoff roll. The flight crewmembers exhibited a self-induced pressure to continue the takeoff rather than taking the time to ensure the airplane was properly configured. Further, the captain initiated a rejected takeoff after the airplane's speed was beyond V1 and the nosewheel was off the runway when he should have been committed to the takeoff. The flight crewmembers' performance was indicative of poor crew resource management in that they failed to assess their situation when an error was discovered, to request a delayed takeoff, to communicate effectively, and to follow SOPs. Specifically, the captain's decision to abort the takeoff after rotation, the flight crew's failure to verify the correct departure runway before gate departure, and the captain's failure to move the thrust levers to the TO/GA detent in response to the ECAM message were all contrary to the operator's SOPs. Member Weener filed a statement, concurring in part and dissenting in part, that can be found in the public docket for this accident. Chairman Hart, Vice Chairman Dinh-Zarr, and Member Sumwalt joined the statement.

Airbus A320

Aircraft experienced an almost complete loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from La Guardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport, Charlotte, North Carolina, and had departed LGA about 2 minutes before the in-flight event occurred. The 150 passengers, including a lap held child, and 5 crew members evacuated the airplane via the forward and overwing exits. One flight attendant and four passengers were seriously injured, and the airplane was substantially damaged.

Boeing 767-200

The aircraft experienced an uncontained failure of the high pressure turbine stage 1 disk in the No. 1 engine during a high-power ground run for maintenance. Because of a report of an in-flight loss of oil, US Airways mechanics had replaced a seal on the n°1 engine’s integral drive generator and were performing the high-power engine run to check for any oil leakage. For the maintenance check, the mechanics had taxied the airplane to a remote taxiway on the airport and had performed three runups for which no anomalies were noted. During the fourth excursion to high power, at around 93 percent N1 rpm, there was a loud explosion followed by a fire under the left wing of the airplane. The mechanics shut down the engines, discharged both fire bottles into the No. 1 engine nacelle, and evacuated the airplane. Although both fire bottles were discharged, the fire continued until it was extinguished by airport fire department personnel. The aircraft was damaged beyond repair.

Boeing 737-300

The aircraft 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, about 6 miles northwest of the destination airport. 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.

Douglas DC-9

USAir Flight 1016 was a domestic flight from Columbia (CAE) to Charlotte (CLT). The DC-9 departed the gate on schedule at 18:10. The first officer was performing the duties of the flying pilot. The weather information provided to the flightcrew from USAir dispatch indicated that the conditions at Charlotte were similar to those encountered when the crew had departed there approximately one hour earlier. The only noted exception was the report of scattered thunderstorms in the area. Flight 1016 was airborne at 18:23 for the planned 35 minute flight. At 18:27, the captain of flight 1016 made initial contact with the Charlotte Terminal Radar Approach Control (TRACON) controller and advised that the flight was at 12,000 feet mean sea level (msl). The controller replied "USAir ten sixteen ... expect runway one eight right." Shortly afterward the controller issued a clearance to the flightcrew to descend to 10,000 feet. At 18:29, the first officer commented "there's more rain than I thought there was ... it's startin ...pretty good a minute ago ... now it's held up." On their airborne weather radar the crew observed two cells, one located south and the second located east of the airport. The captain said "looks like that's [rain] setting just off the edge of the airport." One minute later, the captain contacted the controller and said "We're showing uh little buildup here it uh looks like it's sitting on the radial, we'd like to go about five degrees to the left to the ..." The controller replied "How far ahead are you looking ten sixteen?" The captain responded "About fifteen miles." The controller then replied "I'm going to turn you before you get there I'm going to turn you at about five miles northbound." The captain acknowledged the transmission, and, at 18:33, the controller directed the crew to turn the aircraft to a heading of three six zero. One minute later the flightcrew was issued a clearance to descend to 6,000 feet, and shortly thereafter contacted the Final Radar West controller. At 18:35 the Final Radar West controller transmitted "USAir ten sixteen ... maintain four thousand runway one eight right.'' The captain acknowledged the radio transmission and then stated to the first officer "approach brief." The first officer responded "visual back up ILS." Following the first officer's response, the controller issued a clearance to flight 1016 to "...turn ten degrees right descend and maintain two thousand three hundred vectors visual approach runway one eight right.'' At 18:36, the Final Radar West controller radioed flight 1016 and said "I'll tell you what USAir ten sixteen they got some rain just south of the field might be a little bit coming off north just expect the ILS now amend your altitude maintain three thousand." At 18:37, the controller instructed flight 1016 to ''turn right heading zero niner zero." At 18:38, the controller said "USAir ten sixteen turn right heading one seven zero four from SOPHE [the outer marker for runway 18R ILS] ... cross SOPHE at or above three thousand cleared ILS one eight right approach." As they were maneuvering the airplane from the base leg of the visual approach to final, both crew members had visual contact with the airport. The captain then contacted Charlotte Tower. The controller said "USAir ten sixteen ... runway one eight right cleared to land following an F-K one hundred short final, previous arrival reported a smooth ride all the way down the final." The pilot of the Fokker 100 in front also reported a "smooth ride". About 18:36, a special weather observation was recorded, which included: ... measured [cloud] ceiling 4,500 feet broken, visibility 6 miles, thunderstorm, light rain shower, haze, the temperature was 88 degrees Fahrenheit, the dewpoint was 67 degrees Fahrenheit, the wind was from 110 degrees at 16 knots .... This information was not broadcast until 1843; thus, the crew of flight 1016 did not receive the new ATIS. At 18:40, the Tower controller said "USAir ten sixteen the wind is showing one zero zero at one nine." This was followed a short time later by the controller saying "USAir ten sixteen wind now one one zero at two one." Then the Tower controller radioed a wind shear warning "windshear alert northeast boundary wind one nine zero at one three.'' On finals the DC-9 entered an area of rainfall and at 18:41:58, the first officer commented "there's, ooh, ten knots right there." This was followed by the captain saying "OK, you're plus twenty [knots] ... take it around, go to the right." A go around was initiated. The Tower controller noticed Flight 1016 going around "USAir ten sixteen understand you're on the go sir, fly runway heading, climb and maintain three thousand." The first officer initially rotated the airplane to the proper 15 degrees nose-up attitude during the missed approach. However, the thrust was set below the standard go-around EPR limit of 1.93, and the pitch attitude was reduced to 5 degrees nose down before the flightcrew recognized the dangerous situation. When the flaps were in transition from 40 to 15 degrees (about a 12-second cycle), the airplane encountered windshear. Although the DC-9 was equipped with an on-board windshear warning system, it did not activate for unknown reasons. The airplane stalled and impacted the ground at 18:42:35. Investigation revealed that the headwind encountered by flight 1016 during the approach between 18:40:40 and 18:42:00 was between 10 and 20 knots. The initial wind component, a headwind, increased from approximately 30 knots at 18:42:00 to 35 knots at 18:42:15. The maximum calculated headwind occurred at 18:42:17, and was calculated at about 39 knots. The airplane struck the ground after transitioning from a headwind of approximately 35 knots, at 18:42:21, to a tailwind of 26 knots (a change of 61 knots), over a 14 second period.

Fokker F28 Fellowship

USAir flight 405 was scheduled to depart Jacksonville, FL (JAX) at 16:35 but was given a ground delay because of poor weather in the New-York-LaGuardia (LGA) area and was further delayed in order to remove the baggage of a passenger who chose to deplane. The Fokker F-28 jet departed Jacksonville at 17:15 and was cleared into the LaGuardia area without significant additional delays. The first officer accomplished an ILS approach to LaGuardia's runway 04 to minimums and initiated braking on the landing roll. Ramp congestion delayed taxiing to the parking gate. The airplane was parked at Gate 1 at approximately 19:49, 1 hour and 6 minutes behind schedule. After the airplane was parked at Gate 1, the line mechanic who met the flight was advised by the captain that the aircraft was "good to go." The captain left the cockpit and the first officer prepared for the next leg to Cleveland , OH (CLE) that had originally been scheduled to depart at 19:20. Snow was falling as the F-28 was prepared for departure. The airplane was de-iced with Type I fluid with a 50/50 water/glycol mixture, using two trucks. After the de-icing, about 20:26, one of the trucks experienced mechanical problems and was immobilized behind the airplane, resulting in a pushback delay of about 20 minutes. The captain then requested a second de-icing of the airplane. The airplane was pushed away from the gate to facilitate de-icing by one de-icing truck. The second de-icing was completed at approximately 21:00. At 21:05:37, the first officer contacted the LaGuardia ground controller and requested taxi clearance. The airplane was cleared to taxi to runway 13. At 21:07:12, the flightcrew switched to the LaGuardia ground sequence controller, which they continued to monitor until changing to the tower frequency at 21:25:42. The before-takeoff checklist was completed during the taxi. Engine anti-ice was selected for both engines during taxi. The captain announced that the flaps would remain up during taxi, and he placed an empty coffee cup on the flap handle as a reminder. The captain announced they would use US Air's contaminated runway procedures that included the use of 18 degrees flaps. They would use a reduced V1 speed of 110 knots. The first officer used the ice (wing) inspection light to examine the right wing a couple of times. He did not see any contamination on the wing or on the black strip and therefore did not consider a third de-icing. Flight 405 was cleared into the takeoff and hold position on runway 13 at 21:33:50. The airplane was cleared for takeoff at 21:34:51. The takeoff was initiated and the first officer made a callout of 80 knots, and, at 21:35:25, made a V1 callout. At 21:35:26, the first officer made a VR callout. Approximately 2.2 seconds after the VR callout, the nose landing gear left the ground. Approximately 4.8 seconds later, the sound of stick shaker began. Six stall warnings sounded. The airplane began rolling to the left. As the captain leveled the wings, they headed toward the blackness over the water. The crew used right rudder to maneuver the airplane back toward the ground and avoid the water. They continued to try to hold the nose up to impact in a flat attitude. The airplane came to rest partially inverted at the edge of Flushing Bay, and parts of the fuselage and cockpit were submerged in water. After the airplane came to rest, several small residual fires broke out on the water and on the wreckage debris.

Douglas DC-9

At the time of the accident, gusty winds were forecast for the surface to higher altitudes. The copilot was flying and configured the airplane about four miles out for landing on runway 24. The flightcrew received progressive wind information during the approach; the last report was wind at 310° and 25 knots. The approach speed was v ref + 10. According to the flightcrew, during the landing flare a wind gust occurred, and the airplane lifted in a nose down attitude. The gust stopped and then the airplane descended to the runway and landed hard. The examination of the airplane revealed the fuselage cracked near where the wings were attached and the aft fuselage was bent down about 7°. Two passengers were seriously injured.

Boeing 737-300

SKW5569, N683AV, had been cleared to runway 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared US1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.

Boeing 737-200

As engine power was increased for takeoff, the n°1 engine accelerated beyond target epr. Engine shut down had to be done with the fuel shut off lever. The asymmetric thrust was controlled with nose wheel steering. Before the airplane could be stopped the nose wheels separated from the landing gear. The investigation revealed that the fuel pump output spline to the fuel control had stripped. It occurred at such a time that the fuel control sensed an underspeed and increased Fuel flow. Misalignment of the spline shaft resulted from improper machining during pump modification. The nose gear inner cylinder failed in fatigue in an area of excessive grinding during overhaul. Two passengers were slightly injured.

Boeing 737-400

A USAir Boeing 737-401, registration N416US, was scheduled to depart from Baltimore/Washington (BWI) as flight 1846 at 15:10, but air traffic inbound to New York-LaGuardia (LGA) delayed the takeoff until 19:35. Holding on the taxiway at BWI for 1.5 hours required the flight to return to the terminal area for fuel. The Boeing 737-400 left BWI uneventfully and arrived at LGA's Gate 15 at 20:40. Weather and air traffic in the LGA terminal area had caused cancellations and delayed most flights for several hours. The USAir dispatcher decided to cancel the Norfolk leg of Flight 1846, unload the passengers, and send the flight to Charlotte (CLT) without passengers. Several minutes later, the dispatcher told the captain that his airplane would not be flown empty but would carry passengers to Charlotte as USAir flight 5050. This seemed to upset the captain. He expressed concern for the passengers because more delays would cause him and the first officer to exceed crew duty time limitations before the end of the trip. While passengers were boarding, the captain visited USAir's ground movement control tower to ask about how decisions were made about flights and passengers. The captain returned to the cockpit as the last of the passengers were boarding, and the entry door was closed. After the jetway was retracted, the passenger service representative told the captain through the open cockpit window that he wanted to open the door again to board more passengers. The captain refused, and flight 5050 left Gate 15 at 22:52. The 737 taxied out to runway 31. Two minutes after push-back, the ground controller told the crew to hold short of taxiway Golf Golf. However, the captain failed to hold short of that taxiway and received modified taxi instructions from the ground controller at 22:56. The captain then briefed takeoff speeds as V1: 125 knots, VR: 128 knots, and V2: 139 knots. The first officer was to be the flying pilot. He was conducting his first non supervised line takeoff in a Boeing 737. About 2 minutes later, the first officer announced "stabilizer and trim" as part of the before-takeoff checklist. The captain responded with "set" and then corrected himself by saying: "Stabilizer trim, I forgot the answer. Set for takeoff." Flight 5050 was cleared into position to hold at the end of the runway at 23:18:26 and received takeoff clearance at 23:20:05. The first officer pressed the autothrottle disengage and then pressed the TO/GA button, but noted no throttle movement. He then advanced the throttles manually to a "rough" takeoff-power setting. The captain then said: "Okay, that's the wrong button pushed" and 9 seconds later said: "All right, I'll set your power." During the takeoff roll the airplane began tracking to the left. The captain initially used the nosewheel steering tiller to maintain directional control. About 18 seconds after beginning the roll a "bang" was heard followed shortly by a loud rumble, which was due to the cocked nosewheel as a result of using the nosewheel steering during the takeoff roll. At 23:20:53, the captain said "got the steering." The captain later testified that he had said, "You've got the steering." The first officer testified that he thought the captain had said: "I've got the steering." When the first officer heard the captain, he said "Watch it then" and began releasing force on the right rudder pedal but kept his hands on the yoke in anticipation of the V1 and rotation callouts. At 23:20:58.1, the captain said: "Let's take it back then" which he later testified meant that he was aborting the takeoff. According to the captain, he rejected the takeoff because of the continuing left drift and the rumbling noise. He used differential braking and nose wheel steering to return toward the centerline and stop. The throttle levers were brought back to their idle stops at 23:20:58.4. The indicated airspeed at that time was 130 knots. Increasing engine sound indicating employment of reverse thrust was heard on the CVR almost 9 seconds after the abort maneuver began. The airplane did not stop on the runway but crossed the end of the runway at 34 knots ground speed. The aircraft dropped onto the wooden approach light pier, which collapsed causing the aircraft break in three and drop into 7-12 m deep East River. The accident was not survivable for the occupants of seats 21A and 21B because of the massive upward crush of the cabin floor.

Douglas DC-9

During arrival, the crew of USAir flight 499 landed on runway 24, which was covered with snow. Reportedly, while landing, the aircraft touched down approximately 1,800 to 2,000 feet beyond the displaced threshold. Altho armed, the spoilers did not autodeploy, so the captain operated them manually. He lowered the aircraft's nose, actuated reverse thrust and applied brakes. The brakes were not effective. Subsequently, the aircraft continued off the end of the runway, ran over a runway end id light, struck a fence and came to rest straddling a road. The crew had planned on making an ILS approach to runway 06, but the RVR was only 2,800 feet and a minimum RVR of 4 000 feet was requested for that runway. The crew elected to land on runway 24, since 1/2 mile visibility was sufficient for that runway. However, the approach was made with a qtrg tailwind and approximately 10 knots above Vref. Tailwind landings were not authorized on runway 24 in wet/slippery conditions. The runway braking action was reported as fair-to-poor. The pilot's handbook cautioned the crew to monitor the spoilers when landing on slippery runways, since the spoilers auto-deploy only with wheel spin-up or when the nose wheel is on the ground. A passenger was slightly injured while 22 other occupants were uninjured.