January 13, 1982 was a bitter winter's day
at Washington's National Airport with
temperatures reaching only minus five
degrees Celsius by the afternoon. Cloud
ceilings were 400ft with visibility
limited to just over half a mile in snow
showers. Among the many aircraft scheduled
to depart National that day was Air
Florida's 737 service to Ft. Lauderdale,
call-sign Palm 90. Piloting that day's
2:15pm flight was Captain Larry Wheaton
and First Officer Roger Pettit, both
fairly young pilots enjoying their new
jobs with Air Florida, a fairly new
airline which expanded rapidly as the
result of deregulation.
......Just before 1:40pm, the airport was
closed so crews could plough off
National's one instrument runway,
scheduled to re-open at 2:30pm. Air
Florida elected to begin boarding
regardless and by 2:30pm, all of the 74
passengers were on board the aircraft.
Meanwhile, Wheaton had asked for Palm 90
to be de-iced in preparation for
departure. The tower told the aircraft
that there would be further delay and that
Palm 90 was number eleven in priority when
the airport did re-open. Wheaton then
instructed the de-icing to be
discontinued, the port side have just been
started. Half an hour later, Wheaton again
called for de-icing as the airport was
about to re-open.
By 3:10pm, de-icing was complete and
ground personnel reported to Wheaton that
there was only a "light dusting" or snow
on the wings. Snow was still falling at
national at the time. At 3:23pm, Palm 90
was cleared to push from the gate. The tug
tried to push the 737, but snow that had
accumulated on the ground caused it's
tires to spin. Wheaton then suggested
that, contrary to policy, they would use
the aircraft's reverse thrust to assist in
the push. The reversers were engaged for
about a minute and a half, but were only
successful in throwing up slush and snow.
Another tug was brought in with chains and
the aircraft was successfully pushed back.
......Palm 90 then taxied into position
behind a New York Air DC-9 which was the
last of sixteen aircraft in line for
takeoff. Fifteen minutes later the New
York Air aircraft was cleared for takeoff
and Palm 90 was instructed to taxi into
position and hold, being prepared for
immediate takeoff. At 3:59pm, Palm 90 was
cleared for takeoff as it was still
positioning itself on the runway,
visibility now down to a quarter mile.
......The departure from runway 36
requires aircraft to make a left 40 degree
turn shortly after becoming airborne so as
to follow the Potomac River and avoid
flying over the Washington monument and
the White House. The tower lost sight of
Palm 90 during it's roll due to the
reduced visibility, but radar showed it
airborne and the tower controller
instructed Palm 90 to contact the
departure controller. Less than a minute
after taking off, Palm 90 descended at low
airspeed into the Rochambeau bridge and
ploughed through into the Potomac river,
only it's tail not submerged. Rescue crews
attempted to reach the survivors, but icy
conditions prevented the passengers from
being reached except by helicopter. In the
end, only six people survived.
......Crews were able to recover both the
FDR and CVR from the bottom of the river
and both devices proved critical in
solving the puzzle of Palm 90. Knowing
that it had been nearly 50 minutes between
the aircraft's de-icing and takeoff,
investigators were curious as to what had
gone on in the aircraft in that span.
Their first clue came when, during the
after engine start checklist, the captain
replied "off" to the First Officer's call
for anti-ice. Though it seems hard to
believe that the captain would reply "off"
to anti-ice, extensive audio enhancement
has given validity to the tape.
While waiting in line
for takeoff, Wheaton positioned the
aircraft behind the New York Air DC-9,
attempting to use the aircraft's exhaust
to melt the ice off Palm 90's fuselage and
wings. Though Wheaton thought this a sound
practice, in reality the exhaust will just
melt the ice and blow it back over the
wing, allowing it to re-freeze further
back in areas which the aircraft's
anti-ice system can not clear. While this
information gave evidence of airframe
icing, further analysis showed other
problems with Palm 90. Shortly before
takeoff, the crew have a brief discussion
concerning anomalies in the engine
instrument readings.
Pettit suggested that the hot (less dense)
exhaust from the DC-9 ahead was causing a
lower than normal reading on one of the
EPR gauges. The indications seemed to
return to near normal as Palm 90 got
closer to takeoff. Just before takeoff,
Pettit began the brief, calling out
takeoff power as EPR 2.04, V1 as 138kts,
Vr as 140kts, and V2 as 144kts. As Palm 90
was cleared for takeoff, Pettit advanced
the throttle and immediately remarked at
the abnormal indications from the EPR
gauges again. Pettit remarked several time
that it was "real cold", indicating that
the engines indicated the takeoff EPR of
2.04 quickly before the throttles were
fully advanced. Spectrum analysis of the
engine sounds from the CVR indicated that
the engines were actually running at an
approximate EPR of 1.70 throughout the
takeoff.
In studying the engines
for signs of the anomaly, investigators
found that the engine de-ice system was
turned off. In re-creating the conditions,
investigators confirmed that ice on the
compressor inlet pressure probe would
cause a higher than actual thrust reading
on the EPR gauges. First Officer Pettit
seemed to be aware of the anomaly during
takeoff, but did not appear to have any
idea what was causing it. Pettit remarked
several times that "that doesn't seem
right", meaning that the low throttle
setting was producing a high EPR reading
while the aircraft was not accelerating
properly.
Still, 45 seconds into
the takeoff roll, Palm 90 reached it's
rotation speed and pitched up abruptly,
causing Captain Wheaton to exclaim "Easy!"
and then, as the stall warning came on,
"Forward! Forward!", indicating to Pettit
to lower the nose to prevent the stall.
Investigators found that ice build up in
the wing leading edge and slats could
cause an abrupt nose up pitch on takeoff.
Pettit apparently believed that the
engines were producing max thrust because
at no time during the 30 second flight
were the throttles advanced to provide
more power to prevent stall.
The recording ended
with the crew's final acknowledgement of
the severity of their situation.
"Larry-we're going down Larry!". "I know
it!".