Beech 1900DAIR MIDWEST INC
Charlotte, NC, USA · 2003-01-08·N233YV
What happened
NTSB summary, verbatimThe Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-04/01. On January 8, 2003, about 0847:28 eastern standard time, Air Midwest (doing business as US Airways Express) flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport, Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and the airplane was destroyed by impact forces and a postcrash fire. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport, Greer, South Carolina, and was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Photographs
76the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationthe airplane's loss of pitch control during take-off. The loss of pitch control resulted from the incorrect rigging of the elevator system compounded by the airplane's aft center of gravity, which was substaintially aft of the certified aft limit. Contributing to the cause of the accident were (1) Air Midwest's lack of oversight of the work being performed at the Huntington, West Virginia, maintenance station; (2) Air Midwest's maintenance procedures and documentation; (3) Air Midwest's weight and balance program at the time of the accident; (4) the Raytheon Aerospace quality assurance inspector's failure to detect the incorrect rigging of the elevator control system; (5) the Federal Aviation Administration's (FAA) average weight assumptions in its weight and balance program guidance at the time of the accident; and (6) the FAA's lack of oversight of Air Midwest's maintenance program and its weight and balance program.
Safety recommendations
25 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Identify all airplanes equipped with unguarded flight crewmember rotary seatbelt buckles and require replacement with guarded buckles that cannot be inadvertently unlatched.
TO THE FEDERAL AVIATION ADMINISTRATION: Adopt a program for performing targeted surveillance and increased oversight of maintenance practices at 14 Code of Federal Regulations Part 121 air carriers to ensure that maintenance instructions are being followed as written and that maintenance personnel (including, but not limited to, management, quality assurance, tooling, and training personnel, as well as mechanics) are following all steps in the instructions unless authorization has been granted in accordance with the air carrier's maintenance program.
TO THE FEDERAL AVIATION ADMINISTRATION: Verify that 14 Code of Federal Regulations Part 121 air carriers have procedures in their Continuing Analysis and Surveillance System program for identifying deficiencies and incorporating changes to the carrier's maintenance program and that maintenance personnel for these air carriers (including, but not limited to, management, quality assurance, tooling, and training personnel, as well as mechanics) use these procedures.
TO THE FEDERAL AVIATION ADMINISTRATION: Modify (1) appendix G of 14 Code of Federal Regulations (CFR) Part 23 and appendix H of 14 CFR Part 25 and (2) 14 CFR 121.369 to require that the Instructions for Continued Airworthiness and air carrier maintenance manuals, respectively, include a complete functional check at the end of maintenance for each critical flight system.
TO THE FEDERAL AVIATION ADMINISTRATION: Require manufacturers of aircraft operated under 14 Code of Federal Regulations Part 121 to identify appropriate procedures for a complete functional check of each critical flight system; determine which maintenance procedures should be followed by such functional checks; and modify their existing maintenance manuals, if necessary, so that they contain procedures at the end of maintenance for a complete functional check of each critical flight system.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 air carriers to modify their existing maintenance manuals, if necessary, so that they contain procedures at the end of maintenance for a complete functional check of each critical flight system.
TO THE FEDERAL AVIATION ADMINISTRATION: Prohibit inspectors from performing required inspection item inspections on any maintenance task for which the inspector provided on-the-job training to themechanic who accomplished the task.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 air carriers that use contractors to perform required inspection item (RII) maintenance tasks and inspections to have air carrier personnel who are physically present when a substantial amount of the RII planning, tasking, maintenance work, and inspections are performed and are readily available when they are not physically present and who ensure that the processes and procedures used by contractors to perform RII maintenance tasks and inspections are the same as those used by air carrier maintenance personnel.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop detailed on-the-job (OJT) training requirements for 14 Code of Federal Regulations (CFR) Part 121 air carriers that rely on OJT as a maintenance training method. These requirements should include, but not be limited to, best practices, procedures, and methods for accomplishment and administration of this training. Ensure that these OJT requirements are incorporated into 14 CFR Part 121 air carrier maintenance training programs.
TO THE FEDERAL AVIATION ADMINISTRATION: Audit training records for personnel who are currently performing maintenance on Air Midwest airplanes to verify that the training was properly accomplished in accordance with the company's Maintenance Procedures Manual and Maintenance Training Manual.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 air carriers to implement a program in which carriers and aircraft manufacturers review all work card and maintenance manual instructions for critical flight systems and ensure the accuracy and usability of these instructions so that they are appropriate to the level of training of the mechanics performing the work. (Supersedes Safety Recommendation A-03-031)
TO THE FEDERAL AVIATION ADMINISTRATION: Include the Continuing Analysis and Surveillance System guidance from Advisory Circular (AC) 120-16D, "Continuing Airworthiness Maintenance Programs," and AC 120-79, "Developing and Implementing a Continuing Analysis Surveillance System," in Federal Aviation Administration Order 8300.10, Airworthiness Inspector's Handbook.
TO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 121 air carrier maintenance training programs be approved.
TO THE FEDERAL AVIATION ADMINISTRATION: Require that 14 Code of Federal Regulations Part 121 air carriers implement comprehensive human factors programs to reduce the likelihood of human error in aviation maintenance.
TO THE FEDERAL AVIATION ADMINISTRATION: Identify those situations that would require the use of actual instead of average weights in weight and balance computations and incorporate this information into Advisory Circular 120-27, "Aircraft Weight and Balance Control."
TO THE FEDERAL AVIATION ADMINISTRATION: Unless an actual weight program is developed and implemented, establish a weight and balance program that requires 14 Code of Federal Regulations Part 121 air carriers to periodically sample passenger and baggage weights and determine appropriate statistical distribution characteristics for regional, seasonal, demographic, aircraft, and route variances.
TO THE FEDERAL AVIATION ADMINISTRATION: Establish a program to periodically review 14 Code of Federal Regulations Part 121 air carrier weight and balance data to ensure that regional, seasonal, demographic, aircraft, and route trends among carriers are valid.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 air carriers to retain all survey data and products, as well as documentation of the methodology used to justify their average weight programs, and audit these data as necessary.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 air carriers that use average weight and balance programs to develop and implement weight and center of gravity safety margins to account for individual passenger and baggage variances.
TO THE FEDERAL AVIATION ADMINISTRATION: Conduct or sponsor research to develop systems that are capable of delivering actual aircraft weight and balance data before flight dispatch. These systems should rapidly provide accurate and reliable weight and balance data.
TO THE FEDERAL AVIATION ADMINISTRATION: Promote the use of systems that deliver accurate weight and balance data as a preferred alternative to the use of average weight and balance programs.
TO THE FEDERAL AVIATION ADMINISTRATION: Ensure that Raytheon Aircraft Company revises the maintenance procedures for critical flight systems in its Beech 1900, 1900C, and 1900D Airliner Maintenance Manuals to ensure that the procedures can be completely and correctly accomplished.
TO THE FEDERAL AVIATION ADMINISTRATION: Issue a CertAlert to all Airport Certification and Safety Inspectors and operators of airports certificated under 14 Code of Federal Regulations (CFR) Part 139, describing the potential hazards with the existing P-23 hub assembly. The CertAlert should emphasize the need for inspection of the P-23 hub assemblies after any use of the vehicles, the retention of inspection results, and the timely replacement (upon availability of safe and reliable replacement assemblies) of all existing P-23 hub assemblies. In addition, the CertAlert should emphasize the importance of Federal Aviation Administration Airport Certification and Safety Inspectors ensuring that affected airports can still meet 14 CFR Part 139 response time requirements when aircraft rescue and firefighting personnel are restricted to operating P-23 vehicles at speeds less than 30 mph during emergency operations, and less than 15 mph for all nonemergency operations (as indicated in the United States Air Force’s restriction notice).
TO THE FEDERAL AVIATION ADMINISTRATION: Require all airports that use P-23 aircraft rescue and firefighting vehicles to meet 14 Code of Federal Regulations Part 139 certification requirements to install an enhanced wheel hub assembly on all P-23 vehicles in the timeliest manner possible upon availability of suitable replacement assemblies.
TO THE NATIONAL FIRE PROTECTION ASSOCIATION: Issue an advisory notifying all firefighting communities about the potential hazards with the P-23 aircraft rescue and firefighting (ARFF) vehicle hub assembly, and the eventual necessary replacement of the hub on the P-23 ARFF vehicle.
Sequence of events
10 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- just before 08:25 ESTpre-flightp.4DFDR powered up for the accident flight with the right engine running; left prop RPM increased soon after 08:30 to match the right
- 08:35:16 ESTtaxip.4Control check of ailerons and elevators; pitch control position recorded -16.5 to +15 degrees
- 08:46:21 ESTtakeoff rollp.4Takeoff roll: on magnetic heading 186 deg with pitch trim +2.2 deg, prop RPM then engine torque increased
- about 08:46:50 ESTrotationp.4As airspeed passed 102 kts the first movement of pitch control position was recorded, from -16.4 to -9.5 deg, and pitch attitude began to increase (rotation)
- 08:46:53-08:47:03 ESTinitial climbp.4Pitch trim moved nose down, reaching -5.2 deg at 08:47:03, when pitch was +20 deg, pressure altitude 990 ft and airspeed 139 kts; pitch control position returned to -16.4 deg at 08:46:57 for about a second, then decreased to about -17.2 deg (full forward)
- 08:47:13 ESTclimb/upsetp.4Maximum pitch attitude +54 deg recorded
- 08:47:16 ESTupsetp.4Comm 1 keying switched on (radio transmission - distress call)
- 08:47:17-08:47:19 ESTstall/upsetp.5Maximum left roll -127 deg, maximum pressure altitude 2,090 ft and minimum airspeed 31 kts; as pitch decreased through 0 deg the pitch control position moved aft to +18.8 deg
- 08:47:26 ESTdescentp.5Maximum right roll +68 deg and maximum vertical acceleration +1.9 g
- just after 08:47:28 ESTimpactp.5Last valid data: pitch -47 deg, roll +66 deg, pitch control position +19 deg
NTSB analysis
from the final reportThe Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-04/01. On January 8, 2003, about 0847:28 eastern standard time, Air Midwest (doing business as US Airways Express) flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport, Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and the airplane was destroyed by impact forces and a postcrash fire. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport, Greer, South Carolina, and was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.