Pilot caution -- keynote of D.C. crash study

More pilot caution in bad weather conditions. Improved procedures for keeping aircraft free of snow and ice just before takeoff. These are likely to emerge as key lessons learned from the tragic crash of an Air Florida jet in Washington, D.C., last January during a snowstorm.

The National Transportation Safety Board (NTSB), which issued a final report on its probe of the Boeing 737 crash that killed 78 people, placed much of the blame on the flight crew. The board acknowledged that it was the flight captain's job -- and a deed not done -- to be sure that the plane was free of ice. Federal Aviation Administration (FAA) rules bar takeoffs if wings are coated with snow or ice, a factor which can greatly affect aerodynamics.

The crew neglected to turn on the engine anti-icer while the plane was on the ground and let 45-to-50 minutes elapse between de-icing of the wings and body and takeoff, says the board. And the captain failed to abort a takeoff during the early stages when it would have been possible.

One key problem as result of the ice-up was frozen cockpit sensors, which erroneously suggested the engine thrust was stronger during takeoff than it actually was. Federal investigators suggest the pilot should nonetheless have been alerted to the need to abort by the unusually high readings.

The board, which has issued its final recommendations on the crash, urged that the FAA issue a maintenance alert bulletin to remind personnel that ground inspection may be ''critical'' and that manufacturer-recommended procedures be followed. American Airlines, which was under contract to Air Florida to provide de-icing and other maintenance work, had no 737s in its own fleet and thus, the board contends, might not have been familiar with pertinent de-icing procedures. The NTSB has agreed to look at the question of the delay between de-icing and takeoff.

The head of Ralph Nader's Aviation Consumer Action Project (ACAP), which has conducted its own independent study of the Air Florida crash and urged improvements, expressed disappointment with the NTSB recommendations.

''The board doesn't really seem to know how to handle the de-icing problem and has punted on a major issue which could have a strong bearing on protecting passengers next winter,'' says ACAP director Matthew Finucane. He says he is also disappointed that the board failed to make tough recommendations on stepping up requirements for crew training and more pilot experience before promotion.

Air Florida officials contend any problems stemmed directly from ''uncontrollable'' design difficulties with the 737. Airlines have told Boeing that the nose of the aircraft tends to pitch upward after takeoff if wings have any snow or ice on them. The NTSB recommends a change in operational procedures (flap-setting and speed) on 737s if a ground thermal anti-ice system is not used.

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