In an earlier post, I said that ”…my motive in saying what I’m saying (and what I’ve said previously), is in no way intending to impugn the fine reputation or the integrity of the NTSB or of the dedicated and professional employees at the Safety Board.”
…and you respond with ”There you have it! It not just their integrity, dedication and professionalism that counts, it is their expertize laid open in their reports for all world to see and discuss.”
..and that is all I am doing. Taking their integrity, dedication, and professionalism … and discussing the conclusions they reached… which are the following.
The National Transportation Safety Board determines that:
The
probable cause of this accident was
1) the flightcrew’s failure to use engine anti-ice during ground operation and takeoff,
2) their decision to take off with snow/ice on the airfoil surfaces of the aircraft, and
3) the captain’s failure to reject the takeoff during the early stage when his attention was called to anomalous engine instrument readings.
Contributing to the accident were
1) the prolonged ground delay between deicing and the receipt of ATC takeoff clearance during which the airplane was exposed to continual precipitation,
2) the known inherent pitchup characteristics of the B-737 aircraft when the leading edge is contaminated with even small amounts of snow or ice, and
3) the limited experience of the - flightcrew in jet transport winter operations.
Probable Causes … one at a time:
1. “…the flightcrew’s failure to use engine anti-ice during ground operation and takeoff…”
Just the other day, one of the PPRuNe Forum participants,
J.O. posted the following:
Many years ago I met a member of the NTSB team that investigated Palm 90. I asked him if he believed that the accident would have been avoided if the crew had applied full thrust. His response was that if they'd have had full thrust, all it would have done was make an unflyable airplane unflyable a little bit sooner.
Clearly, this person must also have the same level of integrity, dedication, and professionalism as other members of the NTSB investigation team … right? Well … where was this person’s comments in the report? Selective editing? Comments are inserted on the basis of what … votes?
2. “…their decision to take off with snow/ice on the airfoil surfaces of the aircraft…”
While I know some will cringe once again – but facts are facts … there were other airplanes in that same takeoff line – exposed to exactly the same snow fall as the accident airplane was exposed … why the difference? You all know what I’m going to say … the difference was that no other airplane that day was deiced / anti-iced by the same deicing vehicle that deiced that accident airplane. Where was that comment in the report?
3. “…the captain’s failure to reject the takeoff during the early stage when his attention was called to anomalous engine instrument readings.”
This is another path we’ve been down several times. I’ve always wondered why it was that the NTSB was under the impression that the Captain’s attention was called to “anomalous engine instrument readings.” The F/O is the one who was asking questions. Did he say anything about the engines? No. He
was rather vocal about something … no doubt. But he also seemed to be vacillating between questioning something and believing everything was OK. This issue was going on for quite a while – something like 20 seconds or so. Yet, nothing conclusive was ever said - and the engines were not mentioned. The interesting note here is that when the F/O made what I would call his first “declaration” and no longer questioning, when he said “Ah, that’s not right.” That’s not a question. But it was that F/O who 2 seconds later, apparently satisfied himself … he said “(Well”). Two seconds later the Captain said “Yes it is. There’s eighty.” A quick question for you aviators out there. Where was the accident airplane when the Captain said “Yes it is. There’s eighty”? How far down the runway do
you get when your airplane gets to "eighty knots?" I ask because a scant 2 seconds later, the B-727 landing behind them called “Fourteen fifty-one cleared to land - over the lights.” Where was this B-727? Where was the accident airplane? If you were the Captain … would you have said “I’ve got the airplane” … taken over the controls … and the F/O would have to release control of the airplane (primarily getting his feet off of the rudder pedals). The Captain would then have gone through the abort procedures … bringing the throttles to idle smartly … and then into reverse, while applying as much toe brakes as he could muster … keeping the control column firmly forward (not too much) so that the nose gear would be firmly on the ground through all that ice and snow on the runway … maintain rudder pedal steering down the runway … while the F/O would have grabbed the microphone, raised it to his mouth and said something like “Palm 90 … aborting on the runway!” Where would that B-727 have been at THAT time? Again, I ask, if you were the Captain, knowing what that Captain knew, would you have aborted? I know a lot of folks who answered “yes” and a lot who answered “no.”
Contributing Causes … one at a time:
1. “…the prolonged ground delay between deicing and the receipt of ATC takeoff clearance during which the airplane was exposed to continual precipitation…”
Guess what gang … same response as provided in #2, above … there were other airplanes in that same takeoff line – exposed to exactly the same snow fall as the accident airplane was exposed … why the difference? Same answer … again … You all know what I’m going to say … the difference was that no other airplane that day was deiced / anti-iced by the same deicing vehicle that deiced that accident airplane. Where was that comment in the report?
2. “…the known inherent pitchup characteristics of the B-737 aircraft when the leading edge is contaminated with even small amounts of snow or ice…”
Whoa there folks! What is this? A characteristic of the airplane to pitch up – without any input from the crew? When would this happen? Oh … when there were “even small amounts of snow or ice” on the leading edge of the wing? Well … THIS could be really significant … right? Well, no actually … the NTSB decided that this was merely a contributing factor … not a “cause” of the accident. Really? I mean … really!?
Again, just the other day, another one of the PPRuNe Forum participants, this time it was
M.Mouse posted the following:
The 'pitch up, roll off' characteristic of the B737 was well known. BA had a serious incident caused by this very phenomenon on take off out of Helsinki on a B737-200. It directly led to an increased speed procedure (possibly unique to BA), whose details I forget, in given conditions. The training captain who completed my training on the B737 was the co-pilot on the incident flight out of Helsinki and his description of the event when he related it to me in 1989 was as vivid and scary as it was when it occurred many years earlier.
Hmm … another “serious” incident … the NTSB had no interest in this or any other information about similar circumstances … even though they acknowledge – right there in the report – that this airplane type is KNOWN to do this? And it’s not significant enough to look any further? Really! Really?
3. “…the limited experience of the flightcrew in jet transport winter operations…”
This is easily one of the most questionable comments in the entire report. First, let’s look at what NTSB says about their experience. The report says the following:
The Safety Board reviewed the winter operations conducted by the captain and first officer and found that the captain, after upgrading to captain in B-737 aircraft, had flown eight takeoffs or landings in which precipitation and freezing or near-freezing conditions occurred, and that the first officer had flown two takeoffs or landings in such conditions during his employment with Air Florida, Inc.
Hmm… sounds pretty skinny … right? Let me ask a question of each pilot out there. Do you remember your first takeoff in ice or snow conditions? How experienced were you in making that kind of takeoff? How much experience should be required of pilots in making takeoffs in ice and snow before we should let them make takeoffs in ice and snow? Did the NTSB examine what the Captain and F/O did for a living before coming to work at Air Florida? Would that … could that have been an important issue? Don’t know about you … but I do. Unfortunately, I don’t know what the Captain had done in his years of flying prior to working at Air Florida … and I wonder if he had made any takeoffs or landings in ice and snow when he was a First Officer for Air Florida. Would that have made an interesting fact? Hmm… What was the F/O doing prior to coming to work at Air Florida? Well, he was an all-weather fighter/interceptor pilot, flying F-15’s, out of Minot, North Dakota. Hmm … probably not much ice or snow in Minot, North Dakota … right? (Shessh)
So ... we've had the "official" NTSB Accident Report for almost 30 years now. Will anything I say cause anything in that report to be changed ... no, certainly no. Does that mean that everything they said in that report is accurate and complete ... same answer ... no, certainly no. Why bring it up? Simple answer (not chacteristic of me but...) because I think the truth deserves its time in the light.