Air Florida Flight 90 case study, HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) Using HFACS as an accident investigation analysis tool. Classify each of the 11 assertion in the given casestudy

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Aircraft Accident and Investigation. Air Florida Flight 90 case study, HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) Using HFACS as an accident investigation analysis tool. Classify each of the 11 assertion in the given casestudy.

2) You are given a model case study titled Aircraft Accident investigation casestudy, read the given case study and respond to the task accordingly. Presentation will be graded as given below:

Marking Scheme:

Understanding of the brief 5%

Standard and clarity of English and grammar 5%

Quality of presentation 10%

Critical understanding 10%

Use of examples 10%

Critical analysis 20%

Relevance 10%

Organization of response in terms of introduction, body and conclusion 10%

Recommendations and limitation of the work 15%

Bibliography and referencing

Air Florida Flight 90

From Wikipedia, the free encyclopedia

Air Florida Flight 90, an Air Florida flight of a Boeing 737-222 airliner, crashed into the 14th Street Bridge across the Potomac River in Washington, D.C. on January 13, 1982 immediately after takeoff in a severe snowstorm from

Washington National Airport in Arlington County, Virginia.

The aircraft carried 74 passengers and five crew members when it crashed during the failed takeoff attempt. All but five occupants died. The aircraft struck the 14th Street Bridge, which carries Interstate Highway 395 between Washington, D.C., and Arlington County, Virginia. It crushed seven occupied vehicles on the bridge and destroyed 97 feet of guard rail[3] before it plunged through the ice into the Potomac River. The crash occurred less than two miles from the White House and within view of both the Jefferson Memorial and The Pentagon.

Salvage operations of the wreckage on January 19, 1982

U.S. National Transportation Safety Board diagram of flight path for Air Florida flight 90 which crashed on takeoff at Washington,

D.C. on January 13, 1982, killing 78 persons

The accident killed 78 people, including four motorists on the 14th Street Bridge. A few survivors were rescued from the icy river by civilians and professionals; President Ronald Reagan commended these acts during his State of the Union speech a few days later. The National Transportation Safety Board determined that the cause of the accident was pilot error. The pilots failed to switch on the engines` internal anti-icing equipment, used reverse thrust in a snow storm prior to take-off, and failed to abort takeoff per FAA regulations, even after detecting a power problem while taxiing and visually identifying ice and snow buildup on the wings

Weather conditions

On January 13, Washington National Airport (located in Arlington County, Virginia, immediately across the Potomac River from Washington, D.C.) was closed by a heavy snowstorm, then reopened at noon under marginal conditions as the snowfall began to slacken. That same day, the crew of Air Florida Flight 90 had left Miami International Airport at 11:00 a.m. EST and arrived at National Airport about 1:45 p.m. EST.

That afternoon, the plane was to return south to Fort Lauderdale-Hollywood International Airport (FLL), Fort Lauderdale, Florida with an intermediate stop at Tampa International Airport (TPA), Tampa, Florida. The scheduled departure time was delayed about 1 hour 45 minutes due to the temporary closing of the airport. As the plane was readied for departure, a moderate snowfall continued and the air temperature was 24° F.[3]

Delays, poor decisions, crash

The aircraft was de-iced by spraying the wings with the de-icing agent monopropylene glycol but the plane had trouble leaving the gate when the ground services tow motor could not get traction on the ice. For a period of close to five minutes the crew attempted to back away from the gate using the reverse thrust of the 737`s JT8D engines, which proved futile and evidently resulted in the engines ingesting ice and snow. Eventually a tug ground unit properly equipped with snow chains was used to push the aircraft back from the gate. After finally leaving the departure gate the aircraft waited on a taxiway for 49 minutes in line with other aircraft for clearance to use the congested airport`s only instrument-rated runway. This departure runway requires a delicate flight path north following the river and winding between restricted airspace and obstacles such as the Washington Monument and The Pentagon.

The pilot apparently decided not to return to the gate for reapplication of de-icing, fearing the flight`s departure would be even further delayed, and chose to continue waiting to take off. Then, with snow and ice on the airfoil surfaces of the aircraft, the aircraft attempted to take off on the main (and only open) runway in heavy snow at 3:59 p.m. EST. Even though it was freezing and snowing, the crew did not activate the anti-ice systems. Analysis (confirmed by the FBI) of the cockpit voice recorder determined that during the departure checklist, the copilot announced, and the pilot confirmed, that the plane`s own anti-icing system was turned off. This system uses heat from the engines to prevent sensors from freezing and providing inaccurate readings.

During the plane`s taxiing, the cockpit voice recorder picked up the following conversation between the captain and first officer, in which they discussed the icing situation.

First-officer: "It`s a losing battle trying to de-ice these things. It gives you a false feeling of security, that`s all it does."

Captain: "Well, it satisfies the Feds [government regulators]."

Adding to the plane`s troubles was the pilots` decision to maneuver closely behind a DC-9 that was taxiing just ahead of the Air Florida aircraft prior to takeoff, due to their mistaken belief that the warmth from the DC-9`s engines would melt the snow and ice that had accumulated on Flight 90`s wings. This action — which went specifically against flight manual recommendations for an icing situation — actually contributed to additional icing on the 737. By sitting behind the preceding aircraft, the exhaust gases melted the snow on the wings. During take off, instead of falling off the plane, this slush mixture then froze on the wings` leading edges and the engine inlet nose cone.[3]

Neither the captain nor the first officer had much experience flying in snowy, cold weather. Additionally, the captain, Larry Wheaton, had failed a flight simulator test the previous year with one of his instructors citing Wheaton`s unfamiliarity with flight rules and regulations.

He took a repeat test soon after and passed.

As it turned out, the failure to operate the plane`s anti-icing system caused exactly what could be expected to happen: the engine pressure ratio (EPR) thrust indicators provided false high readings — when the pilots thought they had throttled up to the correct take-off EPR of 2.04, the actual EPR was only 1.70. The aircraft traveled almost ½ mile (800 m) further down the runway than is customary before liftoff was accomplished. Survivors of the crash indicated the trip over the runway was extremely rough, with one survivor saying that he feared that they would not get airborne and would "fall off the end of the runway".

As the plane began its takeoff roll the first officer noted several times to the captain that the readings he was seeing on the instrument panel did not seem to reflect reality (he was referring to the fact that the plane did not seem to have developed as much power as it needed for takeoff, despite the instruments indicating otherwise.) The captain dismissed the first officer`s concerns and let the takeoff proceed. Investigators later determined that there was plenty of time and space on the runway for the captain to have aborted the takeoff, and criticized his refusal to listen to his first officer, who was correct that the instrument panel readings were wrong. The captain likely felt pressure to depart quickly because he knew another aircraft was on final approach using the same runway. Indeed, that aircraft landed just as the Air Florida plane took off and had Flight 90 aborted its takeoff the aircraft on final would have been instructed by air traffic controllers to execute a missed approach, delaying its arrival.

The following is a transcript of Flight 90`s cockpit voice recorder during the plane`s acceleration down the runway. It is evident that the first officer saw a problem with the instrumentation and that the captain shrugged off his concerns. (CAM-1 is the captain, CAM-2 is the first officer)

15:59:32 CAM-1 Okay, your throttles. 15:59:35 [SOUND OF ENGINE SPOOLUP]

15:59:49 CAM-1 Holler if you need the wipers. 15:59:51 CAM-1 It`s spooled. Real cold, real cold.

15:59:58 CAM-2 God, look at that thing. That don`t seem right, does it? Uh, that`s not right. 16:00:09 CAM-1 Yes it is, there`s eighty.

16:00:10 CAM-2 Naw, I don`t think that`s right. Ah, maybe it is. 16:00:21 CAM-1 Hundred and twenty.

16:00:23 CAM-2 I don`t know

16:00:31 CAM-1 Vee-one. Easy, vee-two.

As the plane became briefly airborne, the flight recorder picked up the following from the cockpit, with the sound of the stick-shaker (an instrument that warns that the plane is in danger of stalling) in the background:


16:00:41 TWR Palm 90 contact departure control.

16:00:45 CAM-1 Forward, forward, easy. We only want five hundred. 16:00:48 CAM-1 Come on forward............................ forward, just barely climb.

16:00:59 CAM-1 Stalling, we`re falling!

16:01:00 CAM-2 Larry, we`re going down, Larry....

16:01:01 CAM-1 I know it!

16:01:01 [SOUND OF IMPACT]

Although the aircraft did manage to become airborne, it attained a maximum altitude of just 352 feet before it began losing altitude. Recorders later indicated that the aircraft was airborne for just 30 seconds. At 4:01 p.m. EST it crashed into the 14th Street Bridge across the Potomac River, 0.75 nautical miles (1400 m) from the end of the runway.

National Transportation Safety Board (NTSB) conclusion

The NTSB determined that the probable cause of this accident was pilot error stating that the flight crew’s failure to use engine anti-ice during ground operation and takeoff, their decision to take off with snow/ice on the airfoil surfaces of the aircraft, and 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 the prolonged ground delay between de-icing and the receipt of ATC takeoff clearance during which the aircraft was exposed to continual precipitation, the known inherent pitch up characteristics of the B-737 aircraft when the leading edge is contaminated with even small amounts of snow or ice, and the limited experience of the flight crew in jet transport winter operations.

It hit six cars and a truck on the bridge, and tore away 97 feet of the bridge`s rail and 41 feet of the bridge`s wall.[3] The wrecked aircraft then plunged into the freezing Potomac River. It fell between two of the three spans of the 14th Street Bridge, between the I-395 northbound span (the Rochambeau Memorial Bridge) and the HOV north and southbound spans, about 200 feet offshore. All but the tail section quickly became submerged.

Of the people on board the aircraft:[3]

  • Four of the five crew members, including both pilots, died
  • One crew member was seriously injured
  • 70 passengers died.[3]

Of the motorists on the bridge involved:[3]

  • 4 received fatal injuries
  • 1 received serious injuries
  • 3 received minor injuries

Clinging to the tail section of the broken airliner with five passengers in the ice-choked Potomac River, flight attendant Kelly Duncan inflated the only flotation device they could find and passed it to one of the more severely injured passengers, Nikki Felch. Joe Stiley assisted fellow survivor Priscilla Tirado, and was trying to tow her to shore when the Park Police helicopter returned to try to pull them to safety.

Emergency response and rescue of survivors

Many Federal Government offices in downtown Washington had closed early the day of the crash in response to quickly developing blizzard conditions. Thus, there was a massive backup of traffic on almost all of the city`s roads, making it almost impossible for ambulances to reach the crash site. The United States Coast Guard`s Capstan (WYTL 65601) a 65-foot harbor tugboat and its crew based nearby whose duties include ice breaking and responding to such a water rescue were considerably further downriver on another search and rescue mission. Emergency ground response was greatly hampered by ice-covered roads and gridlocked traffic. Ambulances attempting to reach the scene were even driven down the sidewalk in front of the White House. Rescuers who reached the site were unable to assist survivors in the water because they did not have adequate equipment to reach them. Below-freezing waters and heavy ice made swimming out to them all but impossible. Multiple attempts to throw a makeshift lifeline (made out of belts and any other things available that could be tied together) out to the survivors proved ineffective. The rescue attempts by emergency officials and witnesses were recorded and broadcast live by local news reporters.

One man, Roger Olian, a sheet-metal foreman at St Elizabeth`s, a Washington hospital for the mentally ill, was on his way home across the 14th Street bridge in his truck when he heard a man yelling that there was an aircraft in the water. He was the first to jump into the water to attempt to contact the survivors. At the same time, several military personnel from the Pentagon, Steve Raynes, Aldo De La Cruz, and Steve Bell, ran down to the water`s edge to help Olian.

He only traveled a few yards and came back, ice sticking to his body. We asked him to not try again, but he insisted. Someone grabbed some short rope and battery cables and he went out again, maybe only going 30 feet. We pulled him back. Someone had backed up their jeep and we picked him up and put him in there. All anyone could do was tell the survivors was to

United States Coast Guard Capstan was too far away on another search and rescue mission downriver to assist the 6 initial survivors of Air Florida Flight 90 which crashed into the 14th Street Bridge and then the ice-choked Potomac River on January 13, 1982. Capstan is seen here with another smaller Coast Guard boat helping with recovery of bodies and salvage operations.

hold on not to give up hope. There were a few pieces of the plane on shore that were smoldering and you could hear the screams of the survivors. More people arrived near the shore from the bridge but nobody could do anything. The ice was broken up and there was no way to walk out there. It was so eerie, an entire plane vanished except for a tail section, the survivors and a few pieces of plane debris. The smell of jet fuel was everywhere and you could smell it on your clothes. The snow on the banks was easily two feet high and your legs and feet would fall deep into it every time you moved from the water.

At this point, flight controllers were only aware that the plane had disappeared from radar and did not respond to radio calls, but had no idea what had happened or where the plane was.

At approximately 4:20 p.m. EST, Eagle 1, a United States Park Police Bell 206L-1 Long Ranger helicopter, N22PP, based at the "Eagles Nest" at Anacostia Park in Washington,

D.C. and manned by pilot Donald W. Usher and paramedic Melvin E. (Gene) Windsor arrived and began attempting to assist the survivors to shore. At great risk to themselves, the crew worked close to the river surface, at one time coming so close to the ice-clogged river that the helicopter`s skids went beneath the surface of the water.

The helicopter crew lowered a line to survivors to tow them to shore. First to receive the line was Bert Hamilton, who was treading water about ten feet from the floating tail. The helicopter pilot moved him across the ice, while avoiding the sides of the bridge. Some fire rescue personnel had arrived but military personnel and civilians were key in pulling the survivors from the shore up to the waiting ambulances. The helicopter returned to the aircraft`s tail, and this time Arland D. Williams Jr., sometimes referred to as "the sixth passenger", caught the line. Instead of wrapping it around himself, however, he passed it to flight attendant Kelly Duncan. On its third trip back to the wreckage, the helicopter lowered two lifelines, fearing that the survivors in the water had only a few minutes before succumbing to hypothermia. Williams again caught one of the lines, and again passed it on, this time to Joe Stiley, the most severely injured survivor. Stiley slipped the line around his waist and grabbed Priscilla Tirado who was hysterical, having lost her husband and baby. Patricia Felch took the second line. Before it reached the shore, both Priscilla Tirado and Patricia Felch lost their grip and fell back into the water.

Priscilla Tirado was too weak to grab the line when the helicopter dropped the line to her again. A watching bystander, Congressional Budget Office assistant Lenny Skutnik, stripped off his coat and boots, and in short sleeves, dove into the icy water, and swam out to assist her. The helicopter then proceeded to where Patricia Felch had fallen and paramedic Gene Windsor dropped from the safety of the helicopter into the water to attach a line to her.

By the time the helicopter crew could return for Williams, the sixth passenger, both he and the plane`s tail section had disappeared beneath the icy surface. He had been in the water for twenty-nine minutes. His body and those of the other occupants were later recovered. According to the coroner, Williams was the only passenger to die by drowning.

As the response of emergency crews to the scene was frustrated by the traffic on surface streets, a half hour after the plane crashed, the Washington Metro suffered its first fatal subway crash which meant that Washington`s nearest airport, one of its main bridges in or out of the city and one of its busiest subway lines were all closed simultaneously, paralyzing the Washington, D.C. area.

Responses in the news media

The first member of the news media to arrive was Chester Panzer of WRC-TV. Minutes later, they were shooting video footage of the crash scene, showing wreckage and survivors in the water along with the arrival of first responders. Chester captured Lenny Skutnik`s memorable plunge to pull Priscilla Tirado from the icy water. His work earned him a position as a 1983 Pulitzer Prize Finalist for spot news photography.

News media outlets followed the story with diligence. Notably, The Washington Post published a story about the unidentified survivor of the impact (the "sixth passenger") who handed the lifeline to others and apparently drowned before he could be rescued himself.

He was about 50 years old, one of half a dozen survivors clinging to twisted wreckage bobbing in the icy Potomac when the first helicopter arrived. To the copter`s two-man Park Police crew he seemed the most alert. Life vests were dropped, then a flotation ball. The man passed them to the others. On two occasions, the crew recalled last night, he handed away a life line from the hovering machine that could have dragged him to safety. The helicopter crew who rescued five people, the only persons who survived from the jetliner, lifted a woman to the riverbank, then dragged three more persons across the ice to safety. Then the life line saved a woman who was trying to swim away from the sinking wreckage and the helicopter pilot, Donald W. Usher, returned to the scene but the man was gone.[4]

National Transportation Safety Board (NTSB) conclusion

The NTSB determined that the probable cause of this accident was pilot error stating that the flight crew’s failure to use engine anti-ice during ground operation and takeoff, their decision to take off with snow/ice on the airfoil surfaces of the aircraft, and 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 the prolonged ground delay between de-icing and the receipt of ATC takeoff clearance during which the aircraft was exposed to continual precipitation, the known inherent pitch up characteristics of the B-737 aircraft when the leading edge is contaminated with even small amounts of snow or ice, and the limited experience of the flight crew in jet transport winter operations."

Regulatory and procedure changes

The investigation following the crash, especially regarding the failure of the pilot to respond to crew concerns about the de-icing procedure, led to a number of reforms in pilot training regulations. It became a widely used case study for both air crews and rescue workers.[5 ] Another result of the accident was the development of an improved rescue harness for use  in helicopter recoveries


  1. 1.    ^ a b "Afterward," The New York Times
  2. 2.    ^ "January 13 This Day in History," The History Channel
  3. ^ a b c d e f g h Full NTSB Accident Report (PDF, 140 pages)
    1. ^ "A Hero - Passenger Aids Others, Then Dies." The Washington Post. January 14, 1982.
    2. ^ Wilber, Del Quentin (2007-01-12). "A Crash`s Improbable Impact: `82 Air Florida Tragedy Led To Broad Safety Reforms", The Washington Post, pp. A01. Retrieved on 21 April 2008.

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