DCA94MA076

NTSB accident investigation · Boeing B-737-300 · Aliquippa, PA · September 8, 1994

Accident · FatalClass 1 · MajorFinal report
Date
September 8, 1994, 19:03 local (23:03 UTC)
Place
Aliquippa, PA
Injuries
132 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N513AUBoeing B-737-300
Weather
Visual (VMC) · Day
Status
Completed · report November 15, 1999
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19940908026819A
Case key
10987

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

On this page

Probable cause

A loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.

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.

Airframe/component/system failure/malfunctionApproach - vfr pattern - downwind
Flight control,rudder surface - uncommandedCause
Flight control,rudder - jammedCause
Loss of control - in flightDescent - uncontrolled
Aircraft control - not possible
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

The airplane crashed while maneuvering to land at Pittsburgh International Airport. The airplane entered an uncontrolled descent and impacted terrain about 6 miles east of the airport. The airplane struck the ground at an angle of descent of about 80 degrees, in a slight roll to the left, and the airspeed was about 260 knots at impact. The investigation revealed that during the accident sequence, the airplane rudder deflected rapidly to the left and reached its left aerodynamic blowdown limit shortly thereafter. Examination of the rudder system revealed that it is possible, in the main rudder power control unit (PCU) of the airplane (as a result of some combination of tight clearances within the servo valve, thermal effects, particulate matter in the hydraulic fluid, or other unknown factors), the servo valve secondary slide could jam to the servo valve housing at a position offset from its neutral position without leaving any obvious physical evidence and that, combined with rudder pedal input, could have caused the rudder to move opposite to the direction commanded by a rudder pedal input. This condition of the PCU was also consistent with analysis of the cockpit voice recorder, computer simulation, and human performance data, including operational factors

Factual narrative

On September 8, 1994, USAir flight 427, a Boeing 737-300, N513AU, crashed near Aliquippa, PA at about 1903 eastern daylight time. The airplane was destroyed by impact and post crash fire. The 2 pilots, 3 flight attendants and 127 passengers were fatally injured. The flight was being conducted under 14 CFR Part 121. Visual meteorological conditions prevailed at the time of the accident and an IFR flight plan was filed.

The flight crew was in contact with the local controller and was being maneuvered to enter a right downwind pattern for runway 28R at Pittsburgh International Airport, Pittsburgh, PA. The flight crew did not report any problems with the airplane and radar data indicates that the closest other traffic was about 4.5 miles and 1,500 feet vertically separated from flight 427 at the time of the accident.

The airplane struck the ground at an angle of descent of about 80 degrees, in a slight roll to the left, and the airspeed was about 260 knots at impact. The airplane was severely fragmented by the impact. There was an intense postcrash fire. Both engines were producing power at impact and were running symmetrically. The thrust reversers were stowed at impact.

The flaps were at a "Flap 1" setting. At this setting, the leading edge slats and Kreuger flaps are extended. The spoilers were retracted and the landing gear were retracted. These are the expected positions forthe airplane during the initial approach. The horizontal stabilizer was in an intermediate position, consistent with a speed of about 190 knots. The elevator power control unit was at 14 degrees nose up. The rudder was determined to be 2 degrees to the right (airplane nose right) at impact.

Additional Persons (continued)

Mr. Paul Mingler CFM International Flight Safety Office One Neumann Way MD J60 Cincinnati, OH 45215-6301

Mr. Paul M. Rehder AVIALL Technical Services Dallas Engine Services 9311 Reeves Street Dallas, Texas 75235-2095

Mr. William West National Air Traffic Controllers Association Suite 701 1150 17th Street, N.W. Washington, D.C. 20036

Mr. Juergen-Peter Schuetz Transportation Workers Union #545 Operations Coordination/Dispatch 2018 Broad Hill Farms Road Coraopolis, PA 15108

Mr. Terry Kleiser International Association of Machinists and Aerospace Workers 73 Auburn Street Saugus, MA 01906

Ms. Nancy Gilmer Association of Flight Attendants 2244 Commissary Circle Odenton, MD 21113

Mr. Wally Walz Parker Berta Aerospace Parker Hannifin Corporation 14300 Alton Parkway Irvine, CA 92718-1814

Mr. Frank P. Jakse Senior Research Specialist Monsanto 800 N. Lindbergh Boulevard St. Louis, MO 63167

Mr. Harvey Patrick PATS, Inc. 9570 Berger Road Columbia, MD 21046-1569

Mr. Jim Eichenlaub Manager Hopewell Township Municipal Building Clark Boulevard Aliquippa, PA 15001

LT James R. Nevill Station Commander Pennsylvania State Police 1400 Brighton Road Beaver, PA 15009

Mr. Joseph L. LaFleur Director Pennsylvania Emergency Management Agency Box 3321 Harrisburg, PA 17105-3321

Mr. Wayne N. Tatalovich Coroner Beaver County Courthouse Third Street Beaver, PA 15009

Aircraft

Registration
N513AU
Reported as
Boeing B-737-300
Category
Airplane
Serial number
24549
Airframe hours
23,846
Engine
CFM CFM65-3-B2/1, 20,000 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Operator
Usair, doing business as Usair
Registered owner
Usair
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 8, 1994 · 274 hours before
Departed
ORD · Chicago, IL
Destination
PIT · Pittsburg, PA
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
45
Certificates
Airline transport, Flight engineer, Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
12,000 total · 12,381 in this make and model · 112 in the last 90 days · 20 in the last 30 days · 8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 0 knots
Visibility
15 statute miles
Lowest ceiling
0 ft unknown
Temperature
73 °F, dew point 52 °F
Altimeter
30.00 inHg

Docket · 602

The files NTSB released with the investigation on July 31, 1995, on NTSB’s docket system: statements, records, photos and specialists’ reports. 491 MB in all.

Boeing submission-attachment 62-ASRS 279517 August of 1994Item 1 · PDF · 1 page · 64 KBBoeing submission-attachment 63-ASRS 251874 September of 1993Item 2 · PDF · 1 page · 36 KBBoeing submission-attachment 64-ASRS 288796 November of 1994Item 3 · PDF · 1 page · 56 KBBoeing submission-attachment 65-ASRS 190748 October of 1991Item 4 · PDF · 1 page · 89 KBBoeing submission-attachment 66-ASRS 156250 August of 1990Item 5 · PDF · 1 page · 79 KBBoeing submission-attachment 67-ASRS 149927 June of 1990Item 6 · PDF · 1 page · 64 KBBoeing submission-attachment 68-ASRS 256700 November of 1993Item 7 · PDF · 1 page · 37 KBBoeing submission-attachment 69-ASRS 276427 July of 1994Item 8 · PDF · 1 page · 42 KBBoeing submission-attachment 70-ASRS 145972 may of 1990Item 9 · PDF · 1 page · 28 KBBoeing submission-attachment 71-ASRS 189664 September of 1991Item 10 · PDF · 1 page · 32 KBBoeing submission-attachment 72-ASRS 216232 July of 1992Item 11 · PDF · 1 page · 40 KBBoeing submission-attachment 73-ASRS 285274 October of 1994Item 12 · PDF · 1 page · 40 KBBoeing submission-attachment 74-ASRS 299779 March of 1995Item 13 · PDF · 1 page · 82 KBBoeing submission-attachment 75-ASRS 271385 may of 1994Item 14 · PDF · 1 page · 37 KBBoeing submission-attachment 76-british airways ususual attitude recoveryItem 15 · PDF · 11 pages · 827 KBBoeing submission-attachment 77-ASRS 260432 January of 1994Item 16 · PDF · 2 pages · 80 KBBoeing submission-attachment 78-alan stokes flight stressItem 17 · PDF · 2 pages · 144 KBBoeing submission-attachment 79-ASRS 63448 January of 1987Item 18 · PDF · 1 page · 83 KBBoeing submission-attachment 80-ASRS 92829 August of 1988Item 19 · PDF · 1 page · 67 KBBoeing submission-attachment 81- ASRS 276165 July of 1994Item 20 · PDF · 1 page · 36 KBBoeing submission-attachment 82-NTSB 427 CVRItem 21 · PDF · 33 pages · 903 KBBoeing submission-attachment 83-R schmidt unintended accelerationItem 22 · PDF · 23 pages · 733 KBBoeing submission-attachment 84-W reinhart unintended accelerationItem 23 · PDF · 6 pages · 195 KBBoeing submission-attachment 85-daniel serfaty adaptation to stress in team decisionItem 24 · PDF · 1 page · 149 KBBoeing submission-attachment 86-FAA safety analysis of uncommanded rollsItem 25 · PDF · 5 pages · 152 KBBoeing submission-attachment 87-T-3A training flights halted pending crash investigationItem 26 · PDF · 2 pages · 257 KBBoeing submission-attachment 88Item 27 · PDF · 1 page · 31 KBBoeing submission-attachment 89-August of 1997 737 eventItem 28 · PDF · 1 page · 139 KBBoeing submission-attachment 90-September of 1995 737 eventItem 29 · PDF · 1 page · 61 KBBoeing submission-attachment 91-August of 1995 737 eventItem 30 · PDF · 1 page · 35 KBBoeing submission-attachment 92-usair selected events training programItem 31 · PDF · 15 pages · 601 KBBoeing submission-attachment 93-THE NASA ASRS loss of control chartItem 32 · PDF · 1 page · 109 KBBoeing submission-attachment 94-THE NASA ASRS loss of control factorsItem 33 · PDF · 1 page · 67 KBBoeing submission-attachment 95-November of 1995 737 eventItem 34 · PDF · 1 page · 48 KBBoeing submission-attachment 96-April of 1993 737 eventItem 35 · PDF · 1 page · 126 KBBoeing submission-attachment 97-donald widman I learned aboutnightmare on finalItem 36 · PDF · 5 pages · 546 KBBoeing submission-attachment 98-questions for usair standard-trainingItem 37 · PDF · 1 page · 82 KBBoeing submission-attachment 99-medical examiner reportItem 38 · PDF · 1 page · 41 KBBoeing submission-attachment 100-wake vortex flight test FDRItem 39 · PDF · 2 pages · 241 KBParker hannifin corporation party submissionItem 40 · PDF · 7 pages · 74 KBAir line pilots association party submissionItem 41 · PDF · 74 pages · 4.0 MBUs airways inc party submissionItem 42 · PDF · 48 pages · 368 KBUs airways inc supplemental party submissionItem 43 · PDF · 81 pages · 2.1 MBBoeing party submission-executive summaryItem 44 · PDF · 6 pages · 104 KBBoeing party submission-description of the accident flightItem 45 · PDF · 8 pages · 550 KBBoeing party submission--road map-for understanding possible causeItem 46 · PDF · 3 pages · 73 KBBoeing party submission-rudder system scenariosItem 47 · PDF · 15 pages · 342 KBBoeing party submission-flight crew scenariosItem 48 · PDF · 11 pages · 196 KBBoeing party submission-ntsb determination of probable causeItem 49 · PDF · 2 pages · 50 KBBoeing party submission-recommendationsItem 50 · PDF · 3 pages · 44 KBBoeing party submission-appendix a-kinematic analysis of flight 427 dfdrItem 51 · PDF · 16 pages · 650 KBBoeing party submission-appendix b-summary of investigated failure possibiltiesItem 52 · PDF · 1 page · 13 KBBoeing party submission-appendix c-other incidents and accidentsItem 53 · PDF · 12 pages · 750 KBBoeing party submission-appendix d-operational evidence regarding crew performanceItem 54 · PDF · 3 pages · 43 KBBoeing party submission-appendix e-boeing-recommended training and proceduresItem 55 · PDF · 2 pages · 33 KBBoeing party submission-appendix f-boeing-recommended design changesItem 56 · PDF · 3 pages · 54 KBSubmission of federal aviation administration usair flight 427 crash near aliquippa PennsylvaniaItem 57 · PDF · 2 pages · 24 KBBoeing search lettersItem 58 · PDF · 13 pages · 226 KBErrata sheet to October 24 1996 systems factual report of group chairmanItem 59 · PDF · 4 pages · 106 KBCorrespondence from Boeing to john clark concerning usair 737-300Item 60 · PDF · 4 pages · 363 KB
All 602 files on NTSB’s docket

FAA reports on this event · 1

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