ASN Aircraft accident Boeing 7. N6. 2AF Washington- National Airport, DC (DCA) [Potomac River]Narrative: Air Florida Flight 9. Washington National Airport at 1. EST for a flight to Fort Lauderdale International Airport, FL (FLL), with an intermediate stop at the Tampa, FL (TPA). The aircraft had arrived at gate 1.
Flight 9. 5 from Miami, FL, at 1. Because of snowfall, the airport was closed for snow removal from 1. At about 1. 4: 2. Type II because the captain wanted to start the de- icing just before the airport was scheduled to reopen (at 1. Fluid had been applied to an area of about 1.
Between 1. 4: 4. 5 and 1. The left side of the aircraft was de- iced first.
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No covers or plugs were installed over the engines or airframe openings during de- icing operations. At 1. 5: 1. 5, the aircraft was closed up and the jet way was retracted and the crew received push- back clearance at 1. A combination of ice, snow, and glycol on the ramp and a slight incline prevented the tug, which was not equipped with chains, from moving the aircraft.
Then, contrary to flight manual guidance, the flight crew used reverse thrust in an attempt to move the aircraft from the ramp. This resulted in blowing snow which might have adhered to the aircraft. This didn't help either, so the tug was replaced and pushback was done at 1.
The aircraft finally taxied to runway 3. Although contrary to flight manual guidance, the crew attempted to deice the aircraft by intentionally positioning the aircraft near the exhaust of the aircraft ahead in line (a New York Air DC- 9). This may have contributed to the adherence of ice on the wing leading edges and to the blocking of the engines Pt. At 1. 5: 5. 7: 4. New York Air aircraft was cleared for takeoff, the captain and first officer proceeded to accomplish the pre- takeoff checklist, including verification of the takeoff engine pressure ratio (EPR) setting of 2. Takeoff clearance was received at 1. Although the first officer expressed concern that something was 'not right' to the captain four times during the takeoff, the captain took no action to reject the takeoff.
The aircraft accelerated at a lower- than- normal rate during takeoff, requiring 4. The aircraft initially achieved a climb, but failed to accelerate after lift- off. The aircrafts stall warning stick shaker activated almost immediately after lift- off and continued until impact. The aircraft encountered stall buffet and descended to impact at a high angle of attack. At about 1. 6. 0. Street Bridge and plunged into the ice- covered Potomac River. It came to rest on the west end of the bridge 0.
When the aircraft struck the bridge, it struck six occupied automobiles and a boom truck before tearing away a 4. Four persons in vehicles on the bridge were killed; four were injured, one seriously. PROBABLE CAUSE: " The flight crew's failure to use engine anti- ice during ground operation and takeoff, their decision to take off with snow/ice on the airfoil surfaces of the aircraft, and the captains failure to reject the takeoff during the early stage when his attention was called to anomalous engine instrument readings. Contributing to the accident were the prolonged ground delay between de- icing and the receipt of ATC takeoff clearance during which the airplane was exposed to continual precipitation, the known inherent pitch up characteristics of the B- 7. Classification: Icing.
Loss of control. » NTSB- AAR- 8. Official accident investigation reportinvestigating agency: National Transport Safety Bureau (NTSB) - United States of America report status: Finalreport number: NTSB/AAR- 8. August 1. 98. 2duration of investigation: 2.
Air Florida, Inc., Boeing 7. N6. 2AF, Collision with 1. Street Bridge, near Washington Nat'l Airport, Washington, DC, January 1.
NTSB/AAR- 8. 2- 0. Follow- up / safety actions. NTSB issued 2. 1 Safety Recommendations Issued: 0. JAN- 1. 98. 2To: FAAA- 8. ISSUE A MAINTENANCE ALERT BULLETIN TO REQUIRE PRINCIPAL MAINTENANCE INSPECTORS TO EMPHASIZE TO AIR CARRIER MAINTENANCE DEPARTMENTS THAT PROPER MAINTENANCE OF GROUND SUPPORT EQUIPMENT MAY BE CRITICAL TO FLIGHT OPERATIONS AND THE IMPORTANCE OF ADHERING TO MAINTENANCE PRACTICES RECOMMENDED BY THE MANUFACTURERS OF SUCH EQUIPMENT. Closed - Acceptable Action)Issued: 0. JAN- 1. 98. 2To: FAAA- 8.
ISSUE A MAINTENANCE ALERT BULLETIN TO REQUIRE PRINCIPAL MAINTENANCE INSPECTORS TO REVIEW CONTRACT AGREEMENTS BETWEEN AN AIR CARRIER OPERATING INTO A FACILITY AT WHICH ANOTHER AIR CARRIER OR MAINTENANCE CONTRACTOR IS PROVIDING MAINTENANCE SERVICES TO ASSURE THAT THE RESPONSIBILITIES OF BOTH PARTIES AND KEY PERSONNEL ARE CLEARLY DEFINED AND THAT THE CONTRACTOR PROVIDING THE MAINTENANCE IS THOROUGHLY FAMILIAR WITH THE MAINTENANCE OF THE TYPE OF AIRCRAFT INVOLVED. Closed - Acceptable Action)Issued: 0.
JAN- 1. 98. 2To: FAAA- 8. ISSUE AN OPERATIONS ALERT BULLETIN TO REQUIRE PRINCIPAL OPERATIONS INSPECTORS TO REQUIRE THAT AIR CARRIER TRAINING PROGRAMS ADEQUATELY COVER THE EFFECTS OF AIRCRAFT LEADING EDGE CONTAMINATION ON AERODYNAMIC PERFORMANCE, PARTICULARLY AS IT AFFECTS THE RELATIONSHIP BETWEEN AIRSPEED AND ANGLE OF ATTACK AND THOSE FUNCTIONS WHOSE ACTIVATION IS DEPENDENT ON THE ANGLE OF ATTACK, SUCH AS STALL WARNING SYSTEMS AND AUTOTHROTTLE SPEED COMMAND SYSTEMS. Closed - Acceptable Action)Issued: 0. JAN- 1. 98. 2To: FAAA- 8. REQUIRE REVISION OF THE B- 7.
APPROVED FLIGHT MANUAL TO ADD "ANTI- ICE" TO THE NORMAL TAXI AND TAKEOFF CHECKLIST. REVIEW THE CHECKLISTS FOR ALL AIR CARRIER AIRCRAFT TO ENSURE THAT ALL ACTION ITEMS REQUIRED FOR A SUCCESSFUL TAKEOFF ARE INCLUDED ON THE APPROPRIATE CHECKLIST. SPECIAL CONSIDERATION SOULD BE GIVEN TO ITEMS WHOSE FUNCTIONS MAY BE AFFECTED BY ENVIRONMENTAL CONDITIONS SUBJECT TO CHANGE DURING GROUND DELAY PERIODS. Closed - Acceptable Action)Issued: 0. JAN- 1. 98. 2To: FAAA- 8. ISSUE AN AIRWORTHINESS DIRECTIVE TO IMPLEMENT THE NECESSARY AIRPLANE MODIFICATIONS AND/OR CHANGES IN OPERATIONAL PROCEDURES FOR B- 7. AIRCRAFT TAKEOFF OPERATIONS DURING WEATHER OR RUNWAY CONDITIONS CONDUCIVE TO THE FORMATION OF LEADING EDGE FROST, SNOW, OR ICE CONTAMINATION TO REQUIRE EITHER (Closed - Unacceptable Action)Issued: 0.
JAN- 1. 98. 2To: FAAA- 8. AMEND AIR TRAFFIC CONTROL COORDINATION PROCEDURES AND PRACTICES TO REQUIRE THAT TERMINAL AND EN ROUTE FACILITIES PROVIDE THE CENTRAL FLOW CONTROL FACILITY (CFCF) WITH CURRENT AND ACCURATE INFORMATION REGARDING CONGESTION AND THAT CFCF ACT ON THAT INFORMATION IN A POSITIVE MANNER TO MINIMIZE AIRPORT SATURATION AND EXTENSIVE TRAFFIC DELAYS.
REVIEW IMPLEMENTATION OF PRESCRIBED GATE- HOLD PROCEDURES AND REQUIRE THEIR USE WHEREVER POSSIBLE. Closed - Acceptable Alternate Action)Issued: 0.
JAN- 1. 98. 2To: FAAA- 8. ISSUE A GENERAL NOTICE TO TERMINAL AREA AIR TRAFFIC CONTROL FACILITIES TO EMPHASIZE TO CONTROLLERS THAT THE SEPARATION CRITERIA SET FORTH IN FAA AIR TRAFFIC CONTROL HANDBOOK 7. C WHICH REQUIRE A MINIMUM OF 2 MILES SEPARATION DO NOT PERMIT DEVIATION BASED UPON THE ANTICIPATED ACCELERATION DIFFERENCES BETWEEN LANDING AND DEPARTING TRAFFIC. Closed - Unacceptable Action)Issued: 0. JAN- 1. 98. 2To: FAAA- 8. EVALUATE THE CRITERIA AND CURRENT PRACTICES OF AIR TRAFFIC CONTROL FACILITIES REGARDING THE DECLARATION AND REPORTING OF OPERATIONAL ERRORS TO ENSURE THAT ALL SUCH ERRORS ARE REPORTED AND ARE INVESTIGATED. Closed - Acceptable Action)Issued: 0.
JAN- 1. 98. 2To: FAAA- 8. PROVIDE FOR ESSENTIAL EQUIPMENT AND INCREASED PERSONNEL TRAINING TO IMPROVE THE WATER RESCUE CAPABILITIES AT THE WASHINGTON NATIONAL AIRPORT IN ALL ANTICIPATED WEATHER CONDITIONS, AND PROVIDE NECESSARY FUNDING FOR SURROUNDING COMMUNITIES AND JURISDICTIONS WHICH WILL BE CALLED ON TO SUPPORT THE AIRPORT\'S RESCUE RESPONSE.
Closed - Acceptable Action)Issued: 0. JAN- 1. 98. 2To: FAAA- 8. SURVEY ALL CERTIFIED AIRPORTS HAVING APPROACH AND DEPARTURE FLIGHTPATHS OVER WATER AND EVALUATE THE ADEQUACY OF THEIR WATER RESCUE PLANS, FACILITIES, AND EQUIPMENT ACCORDING TO THE GUIDANCE CONTAINED IN ADVISORY CIRCULAR 1. AND MAKE RECOMMENDATIONS FOR IMPROVEMENT AS NECESSARY TO APPROPRIATE AIRPORT AUTHORITIES. Closed - Acceptable Alternate Action)Issued: 0. JAN- 1. 98. 2To: FAAA- 8.
AMEND 1. 4 CFR 1. TO REQUIRE ADEQUATE WATER RESCUE CAPABILITIES AT AIRPORTS HAVING APPROACH AND DEPARTURE FLIGHTPATHS OVER WATER WHICH ARE COMPATIBLE WITH THE RANGE OF WEATHER CONDITIONS WHICH CAN BE EXPECTED. Closed - Acceptable Alternate Action)Issued: 2. JAN- 1. 98. 2To: FAAA- 8. IMMEDIATELY NOTIFY ALL AIR CARRIER OPERATORS OF THE POTENTIAL HAZARD ASSOCIATED WITH ENGINE INLET PRESSURE PROBE ICING, AND REQUIRE THAT THEY PROVIDE FLIGHTCREWS WITH INFORMATION ON HOW TO RECOGNIZE THIS HAZARD AND REQUIRING THAT FLIGHTCREWS CROSS- CHECK ALL ENGINE INSTRUMENTS DURING THE APPLICATION OF TAKEOFF POWER. Closed - Acceptable Action)Issued: 2.
JAN- 1. 98. 2To: FAAA- 8. IMMEDIATELY REVIEW THE PREDEPARTURE DEICING PROCEDURES USED BY ALL AIR CARRIER OPERATORS ENGAGED IN COLD WEATHER OPERATIONS AND THE INFORMATION PROVIDED TO FLIGHTCREWS TO EMPHASIZE THE INABILITY OF DEICING FLUID TO PROTECT AGAINST REICING RESULTING FROM PRECIPITATION FOLLOWING DEICING. Closed - Acceptable Action)Issued: 2. JAN- 1. 98. 2To: FAAA- 8. IMMEDIATELY REVIEW THE INFORMATION PROVIDED BY AIR CARRIER OPERATORS TO FLIGHTCREWS ENGAGED IN COLD WEATHER OPERATIONS TO ENSURE COMPREHENSIVE COVERAGE OF ALL ASPECTS OF SUCH OPERATIONS, INCLUDING THE EFFECTS OF A RUNWAY CONTAMINATED BY SNOW OR SLUSH ON TAKEOFF, AND METHODS TO BE USED TO OBTAIN MAXIMUM EFFECTIVENESS OF ENGINE ANTI- ICE DURING GROUND OPERATIONS AND TAKEOFFS. Closed - Acceptable Action)Issued: 2.
JAN- 1. 98. 2To: FAAA- 8. IMMEDIATELY REQUIRE FLIGHTCREWS TO VISUALLY INSPECT WING SURFACES BEFORE TAKEOFF IF SNOW OR FREEZING PRECIPITATION IS IN PROGRESS AND THE TIME ELAPSED SINCE EITHER DEICING OR THE LAST CONFIRMATION THAT SURFACES WERE CLEAR EXCEEDS 2. MINUTES TO ENSURE COMPLIANCE WITH 1. CFR 1. 21. 6. 29(B) WHICH PROHIBITS TAKEOFF IF FROST, SNOW OR ICE IS ADHERING TO THE WINGS OR CONTROL SURFACES. Closed - Reconsidered)Issued: 2.
JAN- 1. 98. 2To: FAAA- 8.
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