USAir Flight 405

USAir
Industry	Airline
Headquarters	United States
Products	Air transportation services

USAir Flight 405 was a scheduled domestic route operating between LaGuardia Airport in Queens, New York City, and Cleveland, Ohio. On March 22, 1992, a USAir Fokker F28 (tail number ) crashed shortly after departing LaGuardia during adverse weather conditions, coming to rest partially upside down in Flushing Bay. Although the aircraft became airborne, it failed to gain sufficient altitude, veered off the runway, collided with obstacles, and ultimately settled in the water. Of the 51 individuals aboard, 27 lost their lives, including the captain and a member of the cabin crew.

This incident bore resemblance to the 1989 crash of Air Ontario Flight 1363, which similarly involved ice accumulation on the wings following takeoff.

The investigation concluded that pilot error combined with inadequate deicing practices at LaGuardia amid prolonged delays allowed significant ice to build up on the wings and airframe. This accumulation disrupted airflow over the surfaces, increasing drag and diminishing lift, which prevented a successful climb. The National Transportation Safety Board (NTSB) determined that the flight crew was unaware of the ice buildup after extended taxi delays and noted that rotation began prematurely at a speed below standard.

Furthermore, LaGuardia’s deicing methods were deemed insufficient; the deicing fluid commonly used by most U.S. carriers retained effectiveness for only about 15 minutes, while this flight experienced taxi delays lasting up to 35 minutes. The crash triggered comprehensive research into ice effects on aircraft and resulted in numerous safety recommendations aimed at enhancing prevention measures.

Flight history

The aircraft involved was a Fokker F28 Series 4000, a twin-engine medium-range jet capable of carrying up to 85 passengers. Registered as N485US in the United States, it was originally delivered to Piedmont Airlines in August 1986 and later transferred to USAir (US Airways) in August 1989 following their merger. At the time of the accident, N485US had accumulated 12,462 flight hours.

Captain Wallace J. Majure II, aged 44, held full qualifications on the F28 as well as four additional commercial aircraft types. He had approximately 9,820 total flight hours, including around 2,200 hours on the F28. Majure joined Piedmont as an F28 first officer in 1985 and subsequently served as both first officer and captain on the Boeing 737. Due to company downsizing, he returned to the F28 as captain. The first officer, John Rachuba, aged 30 and hired by Piedmont in 1989, had roughly 4,507 flight hours with only 29 hours on the F28. He possessed a flight engineer certificate for turbojet aircraft and held an expired instructor certificate.

Adverse weather conditions, deicing challenges, and taxi delays

The flight originated from Jacksonville International Airport, Florida several hours earlier but encountered delays caused by poor weather over New York and baggage removal from a passenger who chose not to board. The instrument approach landing proceeded without incident; however, congestion on the ramp at LaGuardia resulted in over an hour’s delay before reaching the gate.

Upon arrival at Gate B1, the captain confirmed to a line mechanic that the aircraft was "good to go." Company policy did not require an external inspection by the crew. The aircraft underwent two deicing treatments using type I fluid—a heated glycol-water mixture—after mechanical problems with a deicing truck caused a 20-minute delay that blocked taxiway access. LaGuardia ground control subsequently cleared Flight 405 for taxiing to Runway 13. During taxi, pre-takeoff checks were completed.

The engine anti-ice systems were engaged while taxiing. The captain informed passengers that flaps would remain retracted during taxi operations to prevent slush splashing and placed an empty coffee cup on the flap handle as a procedural reminder—a common practice. The planned takeoff followed standard USAir contaminated runway procedures with flaps set at 18° and a reduced V₁ speed of .

Pilot communications indicated Runway 13/31 was covered by a thin layer of wet snow that had been plowed and sanded; other runways were closed for snow removal and treated with urea.

The first officer described snowfall as light with minimal wind and observed snow sliding off the nose of the jet. Using wing lights, he performed multiple checks for ice prior to departure; neither pilot detected contamination on wings or black strips and declined requests for additional deicing. Wing conditions were monitored frequently throughout taxi.

The crew discussed deicing procedures used at other airports; the first officer proposed positioning close behind another aircraft to keep wings clear of snow buildup, but the captain rejected this idea due to concerns about refreezing. They noted sand and urea residues present on surfaces.

A Northwest Airlines Boeing 757 pilot taxiing behind Flight 405 reported only light snow accumulation on its fuselage with clear wings. A Trump Shuttle Boeing 727 second officer characterized Flight 405 as "fairly clean" after landing but observed rapid snow accumulation on his own plane.

Despite weather-related ground traffic congestion at LaGuardia causing queues awaiting takeoff clearance, Flight 405 experienced an estimated taxi time between gate and runway ranging from 25 to 45 minutes.^[1]

Crash

Following clearance for takeoff from air traffic control, the flight crew initiated the departure sequence. The first officer issued callouts at 80 knots, then at V₁, and subsequently at V_R. Approximately 2.2 seconds after reaching V_R, the nose gear lifted off the runway. According to the final report, the first officer described the takeoff as routine, with no abnormalities in vibration, acceleration, noise, or directional handling. Nonetheless, some passengers reported a sensation of inadequate speed. The NTSB determined that the rotation speed was approximately 5 knots below the required threshold.

The first officer experienced a feeling akin to a loss of lift. As the captain attempted to level the wings, they applied right rudder input to avoid descending into water beneath them. Both pilots concurred that the aircraft would not achieve sustained flight and coordinated their control inputs accordingly. Their efforts focused on maintaining a nose-up attitude for a flat impact without applying forceful control movements. The first officer refrained from adjusting the power levers, concentrating instead on identifying a safe area for landing.

Just under five seconds post-liftoff, the left wing grazed the runway over a distance of 110 feet, activating six stall warning alerts. The aircraft then banked left, right, and left again mere meters above ground level. It collided with two visual approach slope indicator posts, touched down along approximately 100 feet of runway, lifted off once more, and struck an instrument landing system beacon as well as a water pump building.

The left wing detached prior to the fuselage impacting the edge of Flushing Bay, coming to rest partially inverted with sections submerged underwater. The resulting confusion and entrapment likely contributed to drowning fatalities among passengers who otherwise sustained minor or non-critical injuries. Many passengers failed to adopt brace positions; numerous individuals were either upside down or submerged when the aircraft settled. Several passengers experienced difficulty releasing seatbelts due to disorientation. Fires ignited in both forward left and rear compartments as well as on surfaces of the surrounding water.

Evacuation occurred through large openings in the cabin; the lead flight attendant and first officer exited via an opening near the flight attendant’s station. Several passengers assisted others into knee-deep water; many proceeded on foot to a nearby dike, climbed an embankment, and slid down onto the runway while additional survivors received help from ground personnel.

Rescue attempts, medical operation

The tower cab coordinator on duty witnessed a fireball at the crash location, triggering an alarm that notified Port Authority Police of New York and New Jersey. An investigation revealed technical malfunctions with an emergency telephone at LaGuardia but confirmed these issues did not impede emergency response efforts.

Initially, Port Authority Police dispatched four emergency vehicles. Responders encountered poor visibility caused by snow and fog, delaying immediate identification of the wreckage site. Firefighters located survivors on a nearby dike while police divers found no living individuals in either the water or aircraft. Fire crews managed to extinguish flames roughly ten minutes after arrival despite difficult conditions including icy currents and slippery terrain. The New York Times reported that over 200 emergency personnel contended with severe weather and hazardous ground conditions during rescue operations.

The NTSB report recognized that medical response was effective overall but highlighted coordination challenges. Paramedics prioritized conscious patients with critical injuries and did not attempt resuscitation on victims who appeared drowned or lacked vital signs, presuming cold saltwater immersion was fatal. Around fifteen ambulances transported injured individuals to hospitals; forty additional units remained on standby but were not utilized.

While emergency actions enhanced occupant survival chances, ambulance transport times were prolonged due to suboptimal coordination. The final report emphasized that recent advancements in resuscitating cold-water drowning victims indicate emergency protocols should incorporate CPR for mass casualty events—even when vital signs are absent—especially in cases involving cold-water immersion without traumatic injury clearly indicating death.

Investigation

The NTSB deployed a specialized team to examine the crash location, determining that ice accumulation on the wings disrupted airflow and diminished lift. The investigation spanned just under twelve months.

Ice accumulation

Examiners found no signs of corrosion or malfunction in the flight control systems prior to impact. The final analysis excluded incorrect wing positioning, system malfunctions, or activation of speed brakes as factors in the loss of aerodynamic performance. Additionally, the takeoff roll proceeded normally. The board attributed a significant role to wing ice buildup in causing the accident.

Despite the aircraft undergoing two proper deicing procedures at the gate, approximately 35 minutes passed between the last deicing and liftoff amid ongoing freezing precipitation. Although the NTSB was unable to measure the exact amount of ice formed, it concluded that contamination during this period was highly probable and contributed directly to the crash.

The conclusive report identified wing ice contamination as the main cause. Although the cockpit’s engine anti-ice switch was found in the 'OFF' position, tests revealed it could be inadvertently moved with slight pressure, ruling it out as a causal factor. Subsequently, USAir issued a maintenance order mandating modifications to F28 engine anti-ice switches to ensure they lock securely in place.

Investigators uncovered a design vulnerability in F28 wings that makes them particularly prone to ice buildup; even minimal icing severely impairs lift due to the wing’s angle of attack. Testing by both NTSB and Fokker demonstrated that ice particles as small as 1–2 millimeters at low density reduced lift by over 20%. Pre-accident documentation from Fokker warned that minor ice deposits could provoke uncontrollable rolling motions on F28 wings.

Flight crew errors

The report indicated that while the flight crew understood that adverse weather conditions might cause ice accumulation, they did not inspect the wing leading edges or upper surfaces. Ground personnel performed deicing, but after a mechanical failure with the deicing vehicle, the captain requested a second deicing. Investigators noted:

... the captain’s decision was judicious and complied with USAir procedures. Following the second deicing, the crew presumably assumed the aircraft was free from contamination. Without precise knowledge of the delay before takeoff, their choice to depart from the gate was reasonable. However, during taxi and prolonged waiting periods, crew discussions reflected awareness and concern about possible ice reformation on the wings.^[2]^: 53

USAir’s operational guidelines and training materials emphasized caution before departure without verifying wing surface condition. Specifically, USAir stated:

... it is incumbent upon the captain to exercise prudence prior to takeoff. If more than 20 minutes have passed since deicing, thorough inspection of surfaces for ice buildup is mandatory to ensure safe departure in compliance with regulatory standards.^[2]^: 42

The final analysis concluded:

The Safety Board holds that Flight 405’s crew should have implemented more rigorous checks to confirm wings were free from contamination, such as inspecting from within the cabin. Although detecting slight ice deposits causing aerodynamic degradation is challenging without tactile verification, cabin observation might have revealed icing and prompted a return to gate procedures. The crew’s failure to undertake such measures and their decision to proceed with uncertain wing conditions contributed to this incident.^[2]^: 54

An NTSB investigator explained during a televised interview that requesting a third deicing would have necessitated leaving the takeoff sequence and returning to parking for another deicing truck, resulting in substantial delay or potential flight cancellation.^[3]

Tests clarified why the first officer was unable to detect ice buildup: with cockpit sliding windows closed (as during this event), visibility of approximately 80% of the wing’s outer area—including a black contrast strip designed for ice detection—was impaired due to glass distortion. Opening the window improved visibility; illumination from ice-detection lights had minimal effect.^[2]

The NTSB also commissioned Fokker to analyze how ice contamination affects F28 aircraft performance. Data indicated that rotation was initiated at 119 knots rather than at the required 124 knots. Cockpit voice recordings confirmed that while the first officer called out rotation speed at 113 knots, the captain began rotation at 119 knots for reasons that remain unexplained.^[2]

Deicing protocols at LaGuardia

The investigation revealed that LaGuardia Airport utilized exclusively type I deicing fluid, which effectively removes ice but offers a shorter holdover duration, instead of type II fluid that inhibits ice accumulation. The use of type II was restricted due to concerns about its potential to diminish runway friction—a critical factor given LaGuardia’s short runways and the proximity of cold water near Runway 13. The report criticized the prevalent dependence on type I fluids among U.S. carriers despite their known shortcomings. Experimental data indicated that both types of fluids tend to wash off the wings during takeoff, raising doubts about their efficacy and environmental consequences. The NTSB also noted that either fluid could temporarily impair aerodynamic performance, decrease stall margins, and increase drag.

Errors in safety briefing cards

The investigation uncovered inaccuracies in the passenger safety briefing cards, which illustrated two varieties of galley service doors, although each Fokker F28 aircraft is equipped with only one type. Additionally, the cards failed to provide guidance on emergency door operation if the standard opening mechanism malfunctioned. The report determined that these inaccuracies did not play a role in the fatalities.

Final assessment

The NTSB determined the probable cause as follows:

... the failure by both the airline industry and FAA to equip flight crews with procedures suited for departure delays under icing conditions, combined with the crew’s decision to initiate takeoff without verifying that the wings were free of ice after 35 minutes of precipitation following deicing. Ice contamination led to an aerodynamic stall and loss of control shortly after liftoff. Contributing factors included inadequate procedures and poor crew coordination that resulted in rotation at airspeeds below recommended levels.

NTSB directives

The NTSB recommended that the FAA mandate regular, targeted training for flight crews and ground staff focused on recognizing wing contamination across various lighting environments. They also urged airlines to implement systems that provide crews with detailed information about deicing fluid types, mixtures, moisture buildup, and holdover intervals.

Concerning obstacles struck during the incident, the NTSB called for alterations or removal of pump houses adjacent to Runway 13/31 to eliminate hazards. They further proposed evaluating the possibility of installing frangible ILS antenna arrays at LaGuardia Airport. Additionally, they advised reviewing Fokker F28-4000 passenger safety briefing cards to ensure clear instructions regarding forward cabin doors and over-wing emergency exits.

Allegations from Dryden report

The accident was featured in National Geographic Channel’s Mayday episode titled Cold Case, which compared it with Air Ontario Flight 1363’s crash in Dryden, Ontario—another tragedy caused by insufficient deicing. Canadian investigators expressed surprise at the parallels between these two incidents.

The Dryden inquiry criticized existing deicing practices, advocating for type II fluid instead of type I, relocating deicing trucks closer to runways rather than gates, and requiring crews to inspect wings from both cockpit and cabin perspectives. It concluded that deregulation-induced competitive pressures undermined safety standards and encouraged hazardous industry behaviors.

Virgil P. Moshansky, lead investigator of the Dryden crash, appeared in the documentary asserting that adherence to his report’s recommendations might have averted the USAir accident. He claimed his findings were disregarded by the FAA. Another investigator voiced frustration over recurring errors despite previous warnings.

The FAA denied ever receiving Moshansky’s report and dismissed his claims. On March 31, 1992, Gordon Haugh, spokesperson for the Dryden Commission of Inquiry, acknowledged that the second interim report was never forwarded to the FAA but only submitted to Canada’s Prime Minister’s office. The government also failed to share it with ICAO, limiting its circulation within aviation authorities.

International Conference on Airplane Ground Deicing

In the aftermath of the Flight 405 and Air Ontario accidents near Dryden, the FAA launched initiatives to enhance airport deicing protocols and mitigate ice-related incidents. From May 28 to 29, 1992, more than 750 specialists convened in Reston, Virginia, at the International Conference on Ground Deicing to evaluate industry practices and explore safety enhancements.

The FAA highlighted the critical need for comprehensive knowledge of aircraft ground deicing to establish effective safety standards. The sessions addressed various aspects such as deicing fluids, equipment, and methodologies, reaffirming that pilots retain final authority over takeoff decisions but must be backed by adequate operator training and established guidelines.

As a result of the conference, the FAA revised its regulations mandating airlines to adopt FAA-sanctioned ground deicing or anti-icing procedures whenever ice, snow, or frost is present. These updated requirements became effective on November 1, 1992.

Advancements in Deicing Technology

Following these incidents, airlines transitioned to using type IV deicing fluid, which remains effective on aircraft surfaces for up to two hours and provides enhanced protection compared to types I and II. Chicago O'Hare International Airport led the way by introducing runway deicing facilities, now a standard feature at major airports.

Contemporary aircraft such as the Boeing 737 incorporate sophisticated anti-ice systems that utilize engine bleed air to heat critical components like wing leading edges and engine intakes. These systems function automatically during flight to prevent ice accumulation.

Ground-based deicing methods have also progressed, with infrared (IR) technology emerging as a notable innovation. IR employs electromagnetic radiation to directly warm aircraft surfaces without raising ambient air temperature, enabling faster ice removal than traditional convection or conduction techniques.

Deicing equipment has seen significant improvements: large tanker trucks transport concentrated fluids that are diluted on-site based on temperature conditions and are equipped with cherry picker cranes for swift application. A single vehicle can fully treat a Boeing 737 in less than ten minutes. Additionally, runway deicing utilizes sprayers with extended arms capable of covering entire runways in one pass, reducing operational delays.

Notable passengers

Richard Lawson – actor in film and television (survived accident)

External links

'An Icy Night Is No Time To Wing It' Newsweek, April 6, 1992

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