# NTSB DCA92MA025: Fokker 28-4000, N485US, Flushing, NY, March 23, 1992 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: March 22, 1992, 21:35 local (Mar 23, 1992, 02:35 UTC) - Place: Flushing, NY - Location: 40.7772° N, 73.8726° W: Placed by OpenAirDocs at LAGUARDIA (LGA), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=40.7772&lon=-73.8726&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 27 fatal, 9 serious, 12 minor, 3 uninjured - Status: Completed, report January 31, 1994 - Report: Approved by Office Director - Investigation class: Class 1 - NTSB office: Major Investigations Division - Safety recommendations: Yes - NTSB case key (mKey): 10967 - NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA92MA025.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10967/pdf - Board report AAR9302 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9302.pdf - Page: https://openairdocs.org/ntsb/DCA92MA025 ## Probable cause THE FAILURE OF THE AIRLINE INDUSTRY AND THE FEDERAL AVIATION ADMINISTRATION TO PROVIDE FLIGHTCREWS WITH PROCEDURES, REQUIREMENTS, AND CRITERIA COMPATIBLE WITH DEPARTURE DELAYS IN CONDITIONS CONDUCIVE TO AIRFRAME ICING AND THE DECISION BY THE FLIGHTCREW 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. THE ICE CONTAMINATION ON THE WINGS RESULTED IN AN AERODYNAMIC STALL AND LOSS OF CONTROL AFTER LIFTOFF. CONTRIBUTING TO THE CAUSE OF THE ACCIDENT WERE THE INAPPROPRIATE PROCEDURES USED BY, AND INADEQUATE COORDINATION BETWEEN, THE FLIGHTCREW THAT LED TO A TAKEOFF ROTATION AT A LOWER THAN PRESCRIBED AIRSPEED. (NTSB REPORT AAR-93/020) ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - weather condition - icing conditions (contributing factor) - wing - ice (contributing factor) - ice/frost removal from aircraft - not identified, pilot in command (cause) - information insufficient, company/operator management (cause) - information insufficient, faa(other/organization) (cause) - procedures/directives - not followed, pilot in command (contributing factor) - procedures/directives - not followed, copilot/second pilot (contributing factor) - crew/group coordination - inadequate, pilot in command (contributing factor) - crew/group coordination - inadequate, copilot/second pilot (contributing factor) - In flight collision with terrain/water, takeoff - initial climb ## Analysis THE AIRPLANE HAD BEEN DEICED 2 TIMES BEFORE LEAVING THE GATE. HOWEVER, 35 MINUTES HAD ELAPSED BETWEEN THE 2ND DEICING & TAKEOFF DURING WHICH TIME ICE ACCUMULATED ON THE WING. THIS TIME PERIOD EXCEEDED THE TYPE I DEICING FLUID SAFE HOLDOVER TIME (11 MIN). THE 1ST OFFICER CALLED VR 11 KTS EARLY, AND THE CAPT ROTATED ABOUT 5 KTS EARLY. AFTER LIFTOFF THE AIRPLANE STALLED AND CAME TO REST PARTIALLY INVERTED AND SUBMERGED IN THE BAY. AT THE TIME OF THE ACCIDENT, THE OPERATOR DID NOT REQUIRE A SPECIFIC EXTERIOR INSPECTION FOR ICE CONTAMINATION OF F-28 AIRPLANES DURING PERIODS OF FREEZING PRECIPITATION. ACCIDENT HISTORY SHOWS THAT NONSLATTED, TURBOJET, TRANSPORT-CATEGORY AIRPLANES HAVE BEEN INVOLVED IN A DISPROPORTIONATE NUMBER OF TAKEOFF ACCIDENTS WHERE UNDETECTED UPPER WING ICE CONTAMINATION HAS BEEN CITED AS THE PROBABLE CAUSE OR SOLE CONTRIBUTING FACTOR. ## Factual narrative PLEASE SEE NATIONAL TRANSPORTATION SAFETY BOARD BLUE COVER REPORT AAR-93/02 FOR DETAILS. ## Aircraft - Registration: [N485US](https://openairdocs.org/deregistered/N485US-2008-06-06), registration cancelled 2008-06-06, S/N 11235, built 1986 (OpenAirDocs) - Reported make and model: FOKKER 28-4000 - Registry model: [Fokker F.28 MK4000](https://openairdocs.org/model/fokker-f-28-mk4000) (registry code 4990810) (OpenAirDocs) - Registry engine: [Rolls-Royce SPEY-555-15](https://openairdocs.org/engine/rolls-royce-spey-555-15) (registry code 54521, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 11235 - Airframe hours: 12462 - Engines: ROLLS-ROYCE SPEY M555-15P 9900 lbs thrust turbo fan - Damage: Destroyed - Fire: On-Ground - Flight: Part 121 - Operator: Usair, Inc. - Airworthiness certificate: Standard, Transport - Destination: CLE, CLEVELAND, OH - Flight plan: IFR - Airport: LGA, Laguardia, runway 13, 7,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; airline transport, flight engineer, commercial, flight instructor; 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: 9,820 total, 2,200 in this make and model ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 60° at 13 knots - Visibility: 0.75 statute miles - Lowest ceiling: 700 ft - Temperature: 32 °F, dew point 30 °F - Altimeter: 29.00 inHg - Observed at: LGA ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19920322006959A](https://openairdocs.org/incident/19920322006959A), Mar 22, 1992: Fokker F28MK4000, New York, NY, Destroyed, 27 fatal. Tried departed iced up lifted early. Stalled into bay off lga. Non slated turbojets poor ops with iced airframe. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.