DCA89MA074

NTSB accident investigation · Boeing 737-400 · Flushing, NY · September 21, 1989

Accident · FatalClass 1 · MajorFinal report
Date
September 20, 1989, 23:21 local (Sep 21, 1989, 03:21 UTC)
Place
Flushing, NY
Injuries
2 fatal, 3 serious, 18 minor, 40 uninjured
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N416USBoeing 737-400
Weather
Instrument (IMC) · Night/dark
Status
Completed · report October 8, 1992
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19890920035599A
Case key
15921

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The captain's failure to exercise his command authority in a timely manner to reject the takeoff or take sufficient control to continue the takeoff, which was initiated with a mistrimmed rudder. Also causal was the captain's failure to detect the mistrimmed rudder before the takeoff was attempted.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - on ground/waterTakeoff - roll/run
Trim setting - improperPilot in commandCause
OverrunTakeoff - aborted
Aborted takeoff - delayedPilot in commandCause
On ground/water collision with objectTakeoff - aborted
Object - approach light/navaid

Analysis

As the first officer began the takeoff he felt the airplane drift right. The capt noticed the drift also & used nosewheel tiller to help steer. The crew then heard a 'bang' and a continual rumbling noise. The capt then took over & rejected the takeoff but did not stop the airplane before running off the end of the rwy and colliding with a wooden approach lighting pier. The airplane came to rest partially submerged in water. The rudder trim position was found to be 16 deg, or full, left deflection of rudder. The dfdr recorded this position from engine start at the gate. (NTSB/AAR-90/03)

Aircraft

Registration
N416US
Reported as
Boeing 737-400
Category
Airplane
Airframe hours
2,235
Engine
CFM CFM-56-3B2, turbo fan
Damage
Destroyed
Flight
Part 121
Operator
Usair
Registered owner
Usair
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 3, 1989
Destination
Charlotte, NC
Flight plan
IFR
Airport
LGA · La Guardia, runway 31, 7,000 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
36
Certificates
Flight engineer, Military, Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
5,525 total · 2,625 in this make and model · 122 in the last 90 days · 23 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
210° at 4 knots
Visibility
5 statute miles
Lowest ceiling
500 ft overcast
Temperature
73 °F, dew point 73 °F
Altimeter
30.00 inHg
Observed at
LGR, 1 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.