Factual Information 52 Aircraft Accident Report

Unless otherwise noted, the accident flight simulations used an airplane weight of
17,700 pounds and a CG position of 45.5 percent MAC (based on the results of the Safety
Board’s weight and balance work). Simulator values for engine torque, propeller rpm,
elevator trim tab, and flap position were defined by FDR data from the accident airplane.
Elevator, control wheel, and rudder pedal positions were defined as a function of time to
match the FDR altitude, airspeed, and attitude data.

Simulation results were compared with FDR and FDR-derived data for the portion
of the flight from the takeoff ground roll to shortly before the sound of the stall warning
horn recorded on the CVR (at 0847:10.8). The simulation indicated that the accident
airplane’s uncontrolled pitch maneuver could be reproduced with an elevator position that
was limited to a constant value of about 8° AND.

4.16.2.4.2 Elevator Required to Establish Controlled Flight

The Safety Board evaluated the elevator required to establish controlled flight
from an initial upset condition defined by the data from the accident airplane’s FDR and
CVR. FDR data indicated that, during the uncontrolled pitch maneuver, the flight crew
was commanding AND inputs to stabilize the airplane’s pitch attitude while maintaining
the airplane’s power (engine torque and propeller rpm) and trim tab and flap settings.
These AND commands corresponded with the first officer’s comment, “wuh,” at
0847:02.1; the captain’s comment, “oh,” at 0847:02.2; and evidence that the landing gear
had been completely stowed.

The Beech 1900D simulation indicated that the airplane required an elevator
position of about 9.5° AND to recover from the initial upset and establish controlled flight
at a nearly constant 15° pitch attitude.

1.16.2.4.3 Kinematics Extraction

The Safety Board’s kinematics extraction tool requires that the aircraft motion
(accelerations and attitudes), flight condition, and configuration be specified. The
kinematics extraction tool then calculates the control or control surface inputs required to
produce the specified aircraft motion. For the flight 5481 accident investigation, the
kinematics extraction tool was used to calculate the elevator time histories for four flight
segments flown by the accident airplane before the D6 maintenance check, two flight
segments flown by the accident airplane after the D6 maintenance check, and the accident
flight.

The extracted elevator time histories were compared with the elevator time
histories recorded on the accident airplane’s FDR. The kinematics extraction results
showed that the airplane’s premaintenance pitch control position matched the extracted
elevator time history within about 1° for a range of airplane weights and CG positions, as
previously confirmed by Raytheon Aircraft Company’s flight test certification data (see
section 1.16.2.3.1). The results also confirmed that the postmaintenance pitch control
position was offset from the actual elevator position by about 9° AND. Moreover, an
actual elevator position of 6° to 6.5° AND was required for the postmaintenance flight
before the accident flight that was the most heavily loaded and had the most aft CG position.


Analysis 116 Aircraft Accident Report

maintenance procedures but fail to share this information with other air carriers that
operate the same airplane. If aircraft manufacturers were involved in the process of
reviewing and revising maintenance procedures, safety information would more likely be
shared among air carriers.

In addition, the flight 5481 accident demonstrated that the usability of aircraft
maintenance manuals is as important to safety as the usability of work cards, but Safety
Recommendation A-03-31 did not address the added safety benefit of revising procedures
contained in aircraft maintenance manuals. As a result, the Safety Board classifies Safety
Recommendation A-03-31 “Closed—Superseded.”

The Safety Board concludes that accurate and usable work cards developed jointly
by air carriers and aircraft manufacturers would improve the performance of maintenance
for critical flight systems. Therefore, the Safety Board believes that the FAA should
require 14 CFR 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.

2.5.2 Federal Aviation Administration

2.5.2.1 Oversight of Air Midwest

The Air Midwest PMI had identified several deficiencies in the air carrier’s
maintenance training program during the 2 years before the accident. These deficiencies
included inadequate oversight of training, inadequate record-keeping, inadequate training
procedures, and lack of adherence to company training procedures. In letters to Air
Midwest, the FAA expressed its concerns and urged the air carrier to improve. For
example, in an October 16, 2000, letter, the Air Midwest PMI stated that a recent FAA
inspection conducted at Air Midwest headquarters could not be completed because the air
carrier lacked adequate records to determine whether it was in compliance with 14 CFR
121.371 and 121.375.'* Specifically, the PMI noted that required maintenance training
records were either not at company headquarters or were not up to date and complete. A
followup inspection of Air Midwest’s training files was conducted on December 4, 2000.
This inspection revealed evidence of continuing deficiencies in the air carrier’s training
records as well as deficiencies in its training manual. The PMI gave Air Midwest a
deadline of February 1, 2001, to remedy these deficiencies.

The FAA’s March 2001 RASIP inspection found that deficiencies still existed in
the maintenance training manual and that training was not being conducted in accordance
with company procedures. Specifically, the inspection found that Air Midwest did not
have adequate procedures for verifying the experience of new hires,'* information in the

18 Title 14 CFR 121.371 requires, among other things, that air carriers use only properly trained
personnel for performing required inspections. Title 14 CFR 121.375 requires air carriers to have a training
program that ensures that each person is fully informed about procedures, techniques, and new equipment
and is competent to perform applicable duties.


Factual Information 18 Aircraft Accident Report

Figure 5. Turnbuckle assemblies.

The control cable assemblies are routed through pulleys from the aft bellcrank,
through the rear pressure bulkhead, beneath the rear cargo compartment and cabin floor,
and to the forward bellcrank beneath the cockpit pedestal and the floor under the first
officer’s seat. The forward bellcrank contains two secondary stop bolts (one up and one
down), which have AMM-specified deflection settings that allow slightly more travel than
the primary stop bolts at the elevator control horns. Structure above and below the forward
bellcrank contains holes for a rig pin.2? A forward push-pull tube, located beneath the
cockpit pedestal, connects the forward bellcrank with the bottom of a T-shaped control
column assembly.

Two control wheels—one for the captain and one for the first officer—are located
in front of each cockpit seat. The control wheels (also known as control yokes) are
connected to the top of the T-shaped control column assembly by a shaft and a flexible
coupling. Each shaft passes through a control column support assembly, with a roller
slider assembly mounted inside, providing support to each shaft where it enters the
instrument panel. Each roller slider assembly consists of three rollers, one of which has an
eccentric screw that is adjusted to set roller clearance. The captain’s control column
support and shaft assembly contains a hole for a gust lock pin, which is used only when
the airplane is parked and shut down. The gust lock pin immobilizes pitch and roll controls
to prevent wind damage to the control surfaces and control systems.

2 For this rig pin to be properly positioned, the forward bellcrank rig pin hole must align with two
adjacent rig pin holes in the airplane structure. When the forward bellcrank rig pin is in place, the elevator
should be near 0°.



Aircraft Accident Report

147

Appendix B

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Aircraft Accident Report

142

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Aircraft Accident Report

Loss of Pitch Control During Takeoff
Air Midwest Flight 5481

Raytheon (Beechcraft) 1900D, N233YV
Charlotte, North Carolina

January 8, 2003

a
NTSB/AAR-04/01 +20"
PB2004-910401 National Transportation Safety Board
Notation 7545B 490 L’Enfant Plaza, S.W.

Adopted February 26, 2004 Washington, D.C. 20594



Analysis 112 Aircraft Accident Report

* Ina November 9, 2000, letter, the Air Midwest PMI stated that Air Midwest’s
CASS program did not include a reliable way of charting operational data at
specified intervals to reveal trend-related information.

+ A Regional Aviation Safety Inspection Program (RASIP) inspection,
conducted between March 12 and 29, 2001, found that Air Midwest was not
performing the biannual audits required by the company’s CASS procedures.

* Ina February 19, 2002, letter, the Air Midwest principal avionics inspector
communicated his concern that Air Midwest’s CASS program lacked an
auditor training curriculum.

* Inan April 26, 2002, letter, the Wichita FSDO manager and the Air Midwest
PMI stated that Air Midwest had a written audit program but no dedicated
program manager.

* In an August 19, 2002, letter, the Air Midwest PMI told Air Midwest that
action was needed to ensure that the audit procedures contained in the
company’s audit manual were being followed.

Air Midwest’s CASS program did not identify some maintenance training program
deficiencies. For example, Air Midwest performed its first audit of the HTS maintenance
station on November 5, 2002. One item on the Air Midwest maintenance station audit
guide checklist was to determine whether proper training was being provided for new
hires, training records were being kept up to date, and proper recurrent training was being
provided. An Air Midwest auditor found that those areas were satisfactory; however,
letters from the FAA to Air Midwest (described in sections 1.17.4.2 and 2.5.2.2) indicated
that deficiencies in those areas existed and were well known to Air Midwest officials.
Further, postaccident interviews, training records, public hearing testimony, and findings
from an Air Midwest audit conducted 6 days after the accident indicated that maintenance
training program deficiencies existed at HTS in the months before the accident.

Air Midwest’s CASS program also did not correct deficiencies that were identified
through company audits. For example, the November 2002 audit of HTS found that
supervisory staffing was inadequate; specifically, HTS was only staffed with one quality
assurance inspector and one foreman but should have been staffed with two quality
assurance inspectors and two foremen. In a January 3, 2003, letter to the Air Midwest
quality assurance auditor, the RALLC site manager indicated that staffing at HTS had
increased 20 percent during the last month. During the public hearing on this accident,
however, the RALLC site manager stated that no new quality assurance inspectors or
foremen were hired during that period but that one mechanic was authorized to work as a
foreman.

As stated in section 2.3.3, 14 CFR 121.373 required Air Midwest to have a CASS
program and to correct deficiencies in its maintenance program identified through the
CASS program, including deficiencies in its maintenance manuals. Air Midwest’s
Maintenance Procedures Manual stated that the company’s Vice President/Director of
Maintenance was responsible for ensuring compliance with requirements of the CASS



Factual Information 61 Aircraft Accident Report

The RALLC site manager stated that he reported to the RAMS operations manager
in Little Rock, who reported to the Air Midwest Vice President/Director of Maintenance
in Wichita.”” The primary quality assurance inspector reported to the RAMS quality
assurance manager in Panama City, Florida.” The foreman reported to the RALLC site
manager. According to public hearing testimony, the SMART mechanics reported to a
SMART manager through an HTS on-site coordinator (one of the mechanics).

The RALLC site manager was responsible for the daily operations at the HTS
maintenance station and the work performed there. The foreman assigned maintenance
work and followed the progress of the mechanics in accomplishing the work, and the
quality assurance inspector checked the RIIs.” As previously stated, when the primary
quality assurance inspector was not at work (as on the night of January 6, 2003), the
foreman would assume his duties. A SMART mechanic would then assume the foreman’s
duties.®

The foreman was responsible for providing OJT to the mechanics and for signing
off their OJT records. The quality assurance inspector who was not on duty on the night of
January 6, 2003, stated, in a postaccident interview, that the quality assurance inspector
who was on duty should not have been providing OJT.*!

The RALLC site manager did not personally oversee the work performed by the
mechanics because he worked the day shift. As a result, the site manager depended “very
heavily” on the quality assurance inspector and the foreman for information about the
mechanics’ work. In addition, the site manager indicated that, even though he was the
maintenance administrator, he performed employee job performance reviews for the
quality assurance inspectors. The site manager further stated that the RAMS quality
assurance manager performed the part of the performance review covering quality
assurance issues.

7 The Air Midwest Maintenance Procedures Manual indicated that the RALLC site manager reported
directly to the Air Midwest Vice President/Director of Maintenance.

7 The RAMS quality assurance manager reported to the RAMS Executive Program Manager for
Airline Support in Madison, Mississippi, who reported to the Air Midwest Chief Inspector/Director of
Quality Assurance in Wichita.

” Title 14 CFR 121.365(c) states, “each person performing required inspections in addition to other
maintenance, preventive maintenance, or alterations, shall organize the performance of those functions so as
to separate the required inspection functions from the other maintenance, preventive maintenance, or
alteration functions.” In addition, AC 120-16D states, “a primary concept of the RII function is that the
person performing the work may not perform the required inspection of that item of work.”

59 On the basis of the work schedule in effect at the time of the accident, a SMART mechanic acted as
the foreman 4 nights per week.
8! Air Midwest Maintenance Procedures Manual stated that the foreman’s duties include performing

and documenting OJT on aircraft maintenance practices, company policies, and safety procedures, as
required. The manual did not include these duties as part of the quality assurance inspector’s job description.



Aircraft Accident Report

145

Appendix B

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Factual Information 72 Aircraft Accident Report

On May 12, 2003, the FAA issued Notice 8300.112, “Revision to All Average
Weight Programs,” which required all 14 CFR Part 121, 125, and 135 operators, by
August 11, 2003, either to revise their average weight program or complete an average
weight survey.” Operators that chose to revise their average weight program were to add
10 pounds per passenger for personal items, add 5 pounds for each domestic checked bag,
and use actual weights for U.S. mail and company material.

In addition, the FAA plans to revise AC 120-27C and other related guidance after
considering the advice and recommendations of an Aircraft Weight and Balance Control
Program Aviation Rulemaking Committee. This committee is composed of government,
union, and industry representatives from the aviation community.' The committee will
address several issues, including average passenger, carry-on, and checked baggage
weights; seasonal operations; time interval between average weight validations; oversized
bag weights; and male/female ratios in average weight programs. The committee will also
consider whether the FAA should implement different average weights based on aircraft

passenger seating capacity.

The Aviation Rulemaking Committee provided the FAA with draft revisions to AC
120-27C on January 30, 2004, The FAA expects to release the new version of AC 120-27
(AC 120-27D) for comment at the end of 2004.

1.18.1.2 Air Midwest

Air carriers are required by 14 CFR 119.49(a)(9) to have, in their operations
specifications, FAA authorization for the method of controlling weight and balance of
their aircraft. Paragraph E-96 of Air Midwest’s operations specifications contained the air
carrier’s weight and balance control procedures, which were approved by the Air Midwest
PMI on April 9, 2001. The PMI approved Air Midwest’s average weight program without
validating that the program was viable. During the public hearing on this accident, the air
safety investigator from the FAA’s Air Carrier Operations Branch stated that air carriers
were responsible for evaluating the program’s impact on weight and balance.

The Air Midwest passenger and baggage weight procedures that were in effect at
the time of the accident were detailed in the company’s Flight Operations Procedures
Manual, chapter 7, revision 02-02, dated January 18, 2002. The manual stated the following
under the heading, “Passenger Weight Calculations”:

We are authorized to use average passenger weights in lieu of actual passenger
weights to compute passenger loads over any route, except in those cases where
nonstandard weight passenger groups are carried.

® The operators that participated in the average weight survey under Notice 8400.40 (see table 6) are
exempt from this requirement.

10 The first meeting of the Aviation Rulemaking Committee was held on August 26, 2003, in
Washington, D.C. A second meeting was held on December 3 and 4, 2003, in Washington D.C. Four
steering committee meetings have also been held.


Factual Information Aircraft Accident Report

In addition, the mechanic stated that, while adjusting the cable tension, he
bypassed several steps of the complete elevator control system rigging procedure
(section 27-30-02).!’ The Beech 1900D AMM did not contain a stand-alone procedure for
checking elevator cable tension, as called for on the D6 work card, or for adjusting
elevator cable tension without rigging the entire elevator control system.'® The quality
assurance inspector stated, during a postaccident interview, that he and the mechanic
discussed which steps to bypass and that he allowed the mechanic to adjust only the cable
tension.

The accident airplane returned to service on the morning of January 7, 2003. The
airplane flew a total of nine flight legs before the accident flight.

1.2 Injuries to Persons

Table 1. Injury chart.

Injuries Flight Crew Cabin Crew Passengers Other Total
Fatal 2 0 19 0 21
Serious 0 0 0 0 0
Minor ie) te) 0 1 1
None ie) 0 0 0 0
Total 2 0 19 1 22

Note: The minor injury involved a US Airways mechanic who was treated for smoke inhalation.

1.3. Damage to Airplane

The airplane was destroyed by impact forces and a postcrash fire.

1.4 Other Damage

The airplane struck a US Airways maintenance hangar located on CLT property.

17 Section 1.6.3.1 discusses this procedure, and section 1.6.3.2 discusses the applicable steps that the
mechanic bypassed.

18 After the accident, Raytheon Aircraft Company issued a revised elevator control system rigging
procedure (see section 1.6.3.3), and Air Midwest issued a revised D6 work card (see section 1.17.1.4). As
with the procedure and work card at the time of the accident, the revised procedure and revised work card do
not contain a stand-alone procedure for checking elevator cable tension or for adjusting elevator cable
tension without rigging the entire elevator control system.


Aircraft Accident Report

190

Appendix B

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Analysis 121 Aircraft Accident Report

Wreckage evidence indicated that 4 of the 31 bags aboard flight 5481 weighed
more than 50 pounds. None of these bags were formally recorded on any of the flight’s
paperwork. The heaviest of the four bags weighed 69 pounds, 44 pounds more than the
25-pound average weight value attributed to it for weight and balance purposes. Although
the Director of US Airways Express Training stated, in a postaccident interview, that any
bag weighing up to 70 pounds was accounted for under the average baggage weight
program, the program underestimated the average weight of each of the 31 bags
by 4 pounds and, thus, the total baggage weight by at least 124 pounds.

AC 120-27C permits air carriers to assign the FAA’s standard weight value
(25 pounds) for each checked bag. The AC, however, does not provide guidance to air
carriers regarding what weight cutoff should be used to avoid weight and balance errors
resulting from heavy bags. In addition, flight crews, gate agents, and baggage handlers
have only minimal guidance on how to recognize situations that necessitate the use of
actual rather than average baggage weights.

The average weight of passengers aboard flight 5481 was 185 pounds, 10 pounds
more than the 175-pound average weight value attributed to each passenger. Of the
19 passengers aboard the accident flight, 16 (about 84 percent) were male, and 3 (about
16 percent) were female. AC 120-27C stated that the standard average passenger weights
“cannot be arbitrarily adopted for operations with passenger groups that appreciably differ
from the basis or where the mix of male and female passengers is known to be different
than a 60 percent male/40 percent female operation.” However, neither the FAA’s
guidance nor Air Midwest’s weight and balance program identified specific nonstandard
passenger weight cues or thresholds to indicate when to use actual rather than average
passenger weights.

The Safety Board concludes that the use of average weights does not necessarily
ensure that an aircraft will be loaded within its weight and CG envelope. Therefore, the
Safety Board believes that the FAA should identify those situations that would require the
use of actual instead of average weights in weight and balance computations and should
incorporate this information into AC 120-27, “Aircraft Weight and Balance Control.”

2.5.2.4.1 Approval of Air Midwest’s Weight and Balance Program

On April 9, 2001, the Air Midwest PMI approved the weight and balance
procedures contained in the air carrier’s operations specifications at the time of the
accident. However, the PMI approved Air Midwest’s weight and balance program without
first validating the program. During the public hearing for this accident, an FAA air safety
investigator from the Air Carrier Operations Branch stated that air carriers were
responsible for evaluating the program’s impact on weight and balance. The air safety
investigator also stated that the air carrier was responsible for ensuring that its weight and
balance program complied with the manufacturer’s limitations and that the FAA was
responsible for promoting safety and providing oversight.

According to the Air Midwest PMI, oversight of the air carrier’s weight and
balance program occurred only during en route inspections, when an inspector would



Analysis 127 Aircraft Accident Report

requirement, Safety Recommendation A-02-25 was classified “Open—Acceptable
Response.”

Because the captain and the first officer’s audio panel information was fair to poor
quality with respect to the audio captured from the airplane’s VHF radio systems, it is
possible that important CVR information from flight 5481 might not have been
transcribed if the audio information from the captain’s and the first officer’s hot
microphones had not been excellent to good quality. The Safety Board concludes that,
because the CVR can be one of the most valuable tools used for accident investigation,
reliable daily test procedures are needed to safeguard CVR data. Therefore, the Safety
Board reiterates Safety Recommendation A-02-25.



Aircraft Accident Report

182

Appendix B

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Aircraft Accident Report

171

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Factual Information 67 Aircraft Accident Report

changes could be made.” Air Midwest resubmitted its revised maintenance training
manual on October 9, 2001, but, in a letter dated January 16, 2002, the PAI cited
deficiencies in the manual, some of which had been previously identified, and asked Air
Midwest to make the necessary corrections.

In a February 11, 2002, letter to the Air Midwest Vice President/Director of
Maintenance, the Air Midwest PMI stated that he could still not determine whether Air
Midwest was in compliance with the FARs and asked Air Midwest to develop and initiate
a plan within 2 weeks to address maintenance training program deficiencies in need of
immediate improvement or be subject to an in-depth audit. The Air Midwest Vice
President/Director of Maintenance responded to this letter by notifying the PMI of actions
the air carrier was taking to resolve some of his concerns and by stating that solutions to
other problems would be implemented after the revised maintenance training manual was
accepted by the FAA.

On February 11, 2002, Air Midwest submitted another revised maintenance
training manual for the FAA’s review. In a letter dated February 19, 2002, the PAI again
cited deficiencies in the manual and asked Air Midwest again to make the necessary
corrections. On February 28, 2002, the FAA accepted Air Midwest’s revised maintenance
training manual.

In the February 19, 2002, letter, the Air Midwest PAI also communicated his
concern that Air Midwest’s CASS program lacked an auditor training curriculum. In an
April 26, 2002, letter, the Wichita FSDO manager and the Air Midwest PMI stated that
Air Midwest had a written audit program but no dedicated program manager and that this
and other issues needed to be resolved before Air Midwest would be allowed to change its
route structure.” (The other issues involving Air Midwest included that its infrastructure
had not kept up with its growth, its pilot training program had deficiencies, RASIP issues
were unresolved, and procedures in its General Maintenance Manual were inadequate.) In
an August 19, 2002, letter, the Air Midwest PMI cited deficiencies that Air Midwest
needed to address before route structure changes could be approved, including actions to
ensure that the audit procedures contained in the company’s audit manual were being
followed.

» Air Midwest’s revised training manual and audit manual were submitted to the FAA for review about
the same time. The FAA asked Air Midwest which manual should have priority, and it was decided that the
audit manual would have priority. The audit manual was accepted by the FAA on December 19, 2001.

° The POI was the FAA official responsible for approving any proposed route expansion. His
operations supervisor advised him against delaying Air Midwest’s proposed route changes (see section 1.17.1).
In a January 2004 interview, the operations supervisor told the Safety Board that she could not recall the
details of that conversation. She stated that she did recall that the FAA had sent Air Midwest letters of
concern before a prior route expansion in Dallas, Texas, and that Air Midwest had consistently been willing
to meet with the FAA to address its concerns, had made needed improvements in flight operations, and was
essentially in compliance with the FARs. In a January 2004 interview, the PMI said that Air Midwest had
been responsive in communicating with the FAA but that Air Midwest management did not always
adequately follow through in resolving all of his concerns, including the need for aircraft familiarization
training and better supervision of OJT.



Factual Information 25 Aircraft Accident Report

NOTE

INSURE THAT THREADS ARE VISIBLE THROUGH THE INSPECTION
HOLE AT THE END OF THE PUSHROD, AFTER ADJUSTMENTS ARE
MADE.

i. Adjust the elevator bellcrank pushrod ends as required to obtain 0 readings on
the travel boards for both elevators. Tighten the locknuts.

j. Connect pushrods to the aft elevator bellcrank.
k. Use a cable tensiometer to measure control cable tension.

1. Tighten elevator control cables uniformly to the center of the maximum and
minimum tensions.

m. Slowly adjust the elevator cable(s) as required until the rig pin in the forward
bellcrank will fit with minimum insertion force.

n. Remove the rig pin from the forward bellcrank.

o. Read the cable tension of both cables. Record the values as T up and T down.
The allowable limit for combined cable tension is 66 + 8.0 lbs. Compute the
combined tension load (Tc) by adding the up and down values together and
dividing by 2, or:

Te =(T up + T down) /2
Example:
T up = 57 lbs., T down = 75 Ibs.
Te =(T up + T down) /2
Tc = 57 +75 = 132 = 66 lbs. = acceptable
2 2

p. Compare the combined tension load to cable tension graph.

q. If the combined tension load is above the maximum range, start the procedures
over and set cable tension at the minimum, or shorten the pushrod of the
forward elevator bellcrank and repeat Steps | through p.

r. Install lock clips on turnbuckles.

s. Remove the rig pin from the aft elevator bellcrank.

t. Set the forward elevator bellcrank stop bolts for a clearance of 0.37 + 0.06 inch.

u. Verify the bob weight stop bolt clearance is 0.5 + 0.06 inch. Adjust the stop bolt,
if necessary. The push-pull tube assembly between the control column and the
forward elevator bellcrank may need to be adjusted to achieve the required
clearance (refer to Step e).

y. The forward elevator bellcrank stop bolt is to make contact before the bob

weight stop bolt makes contact with the bob weight. In order to verify that the
forward bellcrank bolt makes contact before the bob weight stop bolt makes



Analysis 96 Aircraft Accident Report

2.3 Restricted Downward Elevator Travel

Flight data recorder (FDR) and CVR data from the accident flight showed that the
airplane was rotating airplane nose up (ANU) after takeoff, even though the flight crew
was pushing the control column fully forward and trimming the airplane in the
airplane-nose-down (AND) direction. Neither of these actions allowed the flight crew to
control the airplane’s pitch attitude.

FDR data, ground test results, and the airplane performance study for this accident
showed that, before the accident airplane’s detail six (D6) maintenance check on
January 6, 2003, at Air Midwest’s HTS maintenance station, the airplane’s full range of
downward elevator travel was available. FDR data, ground test results, and the airplane
performance study also showed that, after the D6 maintenance check, the airplane’s
downward elevator travel was limited to about 7° rather than the 14° to 15° specified in the
Beech 1900D Airliner Maintenance Manual (AMM).

Before the D6 maintenance check, the accident airplane’s actual elevator position
(derived from Beech 1900D aerodynamic characteristics and performance data from the
FDR) was consistent with the pitch contro! position recorded on the FDR. Specifically,
before maintenance, the actual elevator position during a typical cruise flight was 4° AND,
and the pitch control position recorded on the FDR was also 4° AND.

After the D6 maintenance check, the accident airplane’s actual elevator position
(derived from Beech 1900D aerodynamic characteristics and performance data from the
FDR) was not consistent with the pitch control position recorded on the FDR. Specifically,
the actual elevator position during a typical cruise flight was again determined to be
4° AND, but the pitch control position recorded on the FDR was 13° AND. Thus, the FDR
pitch control position sensor (which is attached to structure located to the left of the base
of the control column) indicated a 9° AND shift, even though the actual elevator position
remained at 4° AND. Further, when the maximum elevator available was achieved or
commanded during postmaintenance ground operations and during the accident flight, the
actual elevator position was 7° AND; however, as a result of the 9° AND shift, the FDR
recorded a pitch control position of 16° AND.

The Safety Board examined the maintenance work performed at HTS during the
accident airplane’s D6 maintenance check to determine whether any of the work resulted
in the airplane’s restricted downward elevator movement. Part of the D6 check involved
checking the tension of the elevator control system cables and adjusting the tension if
necessary. The Structural Modification and Repair Technicians (SMART) mechanic who
performed this work had not previously performed it on a Beech 1900D. As a result, the
mechanic was receiving on-the-job training (OJT) from a Raytheon Aerospace, LLC
(RALLC), quality assurance inspector for the tasks associated with that part of the D6
check. (The OJT provided to the mechanic is discussed in section 2.3.2.)

The SMART mechanic determined that the accident airplane’s cables needed to be
adjusted because their average tension was too low. He stated that he adjusted the cables


Factual Information 32 Aircraft Accident Report

1.11:1.1 Safety Recommendations A-97-36 and A-02-25

Beech 1900 series airplanes had previously experienced problems with the low
signal volume of VHF radio messages as recorded by the CVR. On May 22, 1997, the
Safety Board issued Safety Recommendation A-97-36, which asked the FAA to

Promptly require the inspection of the cockpit voice recorder (CVR) and
associated equipment on all Beech 1900 aircraft and ensure that operators take
corrective action to repair deficient CVR systems so that the intelligibility of
recorded communications, including radio transmissions to and from the airplane,
is as high as practicable.

In response to the Safety Board’s recommendation, Raytheon Aircraft Company
issued Service Bulletin (SB) 23-3094, which recommended the incorporation of an
improved CVR amplifier and new circuitry for the wiring. Subsequently, the FAA issued
Airworthiness Directive (AD) 2000-20-07, which required that all applicable Beech 1900
series airplanes comply with Raytheon Aircraft’s SB. On January 30, 2001, the Board
stated that, with the issuance of AD 2000-20-07, the FAA had completed the
recommended action, and, as a result, Safety Recommendation A-97-36 was classified
“Closed—Acceptable Action.” The accident airplane’s maintenance records indicated that
the actions required by the AD were accomplished on March 3, 2001.

On August 29, 2002, the Safety Board issued Safety Recommendation A-02-25 as
a result of longstanding concerns regarding the availability of CVR information for
reportable accidents or incidents. Specifically, the Board was concerned about tape or
memory that had been overwritten by events subsequent to an accident or incident and
recording systems that had malfunctioned or were inoperative at the time of an accident or
incident. Safety Recommendation A-02-25 asked the FAA to

Require that all operators of airplanes equipped with a cockpit voice recorder
(CVR) test the functionality of the CVR system prior to the first flight of each day,
as part of an approved aircraft checklist. This test must be conducted according to
procedures provided by the CVR manufacturer and shall include, at a minimum,
listening to the recorded signals on each channel to verify that the audio is being
recorded properly, is intelligible, and is free from electrical noise or other
interference.

Safety Recommendation A-02-25, which was classified “Open—Acceptable
Response” on January 16, 2003, is discussed in detail in section 2.6.

1.11.2 Flight Data Recorder

The accident airplane was equipped with an L3 Communications Fairchild model
F-1000 FDR, serial number 01110. The FDR used a solid-state flash memory module,
stored in a crash-protected memory case, as the recording medium. The FDR system, as


Aircraft Accident Report

157

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Factual Information

57

Aircraft Accident Report

Air Midwest
Vice President/Director of
Maintenance |
Wichita, Kansas

C l
Raytheon Aerospace Air Midwest
RAMS Chief Inspector/

Operations Manager
Little Rock, Arkansas

Director of Quality Assurance.
Wichita, Kansas.

I

Raytheon Aerospace Air.Midwest Raytheon Aerospace
Site Manager Regional Site Manager RAMS ‘Executive Program
HTS. rr HTS Manager, Airline Support
Madison, Mississippi
Raytheon Aerospace Raytheon. Aerospace.
Foreman RAMS Quality Assurance
HTS Manager
Panama City, Florida
SMART. Raytheon Aerospace
Mechanics Quality Assurance
HTS Inspector:
HTS

Note: RAMS, Regional Airline Maintenance Service.

Figure 10. Organizational structure of Air Midwest's Huntington, West Virginia,
maintenance station operations.

During weekdays at HTS, the overnight shift started about 2200, an airplane
arrived about 2230, and the shift ended about 0630. During weekends at HTS, the
overnight shift started about 1800; an airplane arrived about 1830; and the shift ended
between about 0200 and 0400, depending on the workload. Between five and seven
maintenance personnel normally worked the overnight shift. The maintenance personnel
indicated that they would remain on duty until the work was completed and that they were
not pressured to return an airplane to service.

The RALLC site manager stated that the workload at HTS was “fairly stable.” He
indicated that HTS was scheduled for one airplane per night and that a detail check would
normally be scheduled only on 1 or 2 nights per week. The workload was managed
according to Air Midwest maintenance control’s 3-day forecast.

Seven maintenance personnel (a quality assurance inspector, a foreman, and five
mechanics) were on duty when the accident airplane received its D6 maintenance check
on January 6, 2003. The quality assurance inspector and the foreman had been employed
at HTS since it opened in July 2002. The five mechanics had been employed at HTS
between 2 and 7 weeks. The quality assurance inspector and the foreman had completed



Appendix C 196 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANAUL

LEFT
ELEVATOR
CONTROL HORN

LEFT
ELEVATOR

K
—_
STOP BOLTS
LEFT ELEVATOR
CONTROL HORN peran A
SUPPORT
20° + 1° — O° UP
DEFLECTION FROM
THE NEUTRAL POSITION.
LEFT
ELEVATOR
CONTROL HORN-
SUPPORT

LEFT ELEVATOR
‘CONTROL HORN

14° + 1° — 0° DOWN
DEFLECTION FROM

THE NEUTRAL POSITION
ELEVATOR CONTROL

HORN STOP BOLTS

petan B

1900-18220

Figure 201 - Elevator Control Horn Stop Bolts

as 27-30-02 ravzav2



Aircraft Accident Report

141

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Aircraft Accident Report

Factual Information 28

4.7. Meteorological Information

Weather observations at CLT are made by an automated surface observing system
(ASOS), which records continuous information on wind speed and direction, cloud cover,
temperature, precipitation, and visibility.4' The ASOS transmits an official meteorological
aerodrome report (known as a METAR) that is valid at 51 minutes past each hour and a
special weather observation as conditions warrant; such conditions include a relevant
wind shift, visibility change, and ceiling change (cloud cover or height). Weather
observations are transmitted in coordinated universal time (UTC). Eastern standard time is

5 hours behind UTC time.

The 1251Z*2 METAR (0751 local time) indicated that the winds were 260° at
6 knots, visibility was 10 miles, clouds were scattered at 14,000 feet and broken at 25,000 feet,
the temperature was 3° Celsius (C), the dew point was -7° C, and the altimeter setting was
29.75 inches of mercury (Hg). The 1351Z METAR (0851 local time) indicated that the
winds were 230° at 7 knots, visibility was 10 miles, clouds were scattered at 14,000 feet
and broken at 25,000 feet, the temperature was 4° C, the dew point was -6° C, and the
altimeter setting was 29.76 inches of Hg.

CLT is also equipped with a terminal doppler weather radar system, which
provides windshear and microburst alerts. During the time surrounding the accident, the

system did not transmit an alert.

1.8 Aids to Navigation

No problems with any navigational aids were reported.

4.9 Communications

No communications problems were reported between the pilots and any of the air
traffic controllers who handled the flight.

4.10 Airport Information

CLT is located about 4 miles west of the city of Charlotte at an elevation of
748 feet mean sea level (msl). An average of 1,250 aircraft operate at the airport daily,
about 90 percent of which are scheduled air carrier or air taxi operations; the remainder
are general aviation and military operations. The airport has two parallel runways,
18L/36R and 18R/36L, and a third runway, 5/23. Runway 18R, from which flight 5481

41 Cloud cover is expressed in feet above ground level. Visibility is expressed in statute miles.
42 The “Z” designation that follows the time in a weather observation stands for Zulu, which indicates
UTC time.



Factual Information 60 Aircraft Accident Report

instructions, which if included, could have avoided the elevator mis-rigging.” The letter
detailed numerous deficiencies in the rigging procedure that were identified by Air
Midwest.

On July 18, 2003, Air Midwest revised its D6 work card. The revised work card
included the following steps for performing an elevator cable tension check and blocks
beside each step for the mechanic’s and quality assurance inspector’s stamps:

Let aircraft temperature stabilize for three hours.
Take the temperature reading with the aircraft OAT temperature gauge.
Gain access to the elevator...cables under the cargo compartment floorboard.

Using a calibrated tensiometer with the proper riser installed, take the elevator
cable tension readings I.A.W. [in accordance with] Raytheon Maintenance

Manual.

Compare readings from the aircraft to the proper cable tension charts in the Beech
Maintenance Manual. (For the elevator tension chart, ref. *Raytheon
[Maintenance] Manual Chapter 27-30-02, fig 203....)

If cable tensions are within tolerance, no adjustment to the cable tension is
required.

If tensions are not within tolerance of the tension chart, perform the complete
elevator...control system rigging procedure. (For elevator rigging, ref, *Raytheon
[Maintenance] Manual 27-30-02...) “N/A” [not applicable] this block if no
adjustments were made.

List all work performed on the AMR [aircraft maintenance record of nonroutine
items], if adjustments were made. “N/A” this block if no adjustments were made.

Air Midwest also revised its weight and balance procedures. These revisions are
presented in section 1.18.1.2.1 after a discussion of the procedures that were in effect at
the time of the accident (section 1.18.1.2).

1.17.2 Raytheon Aerospace

RALLC is headquartered in Madison, Mississippi. At the time of the accident,
RALLC provided one site manager, two quality assurance inspectors (one of whom was
designated as the primary quality assurance inspector and the other of whom was
designated as the foreman), and seven SMART A&P-certified mechanics to Air
Midwest’s HTS maintenance station.

Air Midwest paid RALLC for its services. RALLC paid salaries and benefits for
its employees. RALLC also paid SMART for its maintenance personnel, but SMART
employees received their salaries and benefits directly from SMART.



Aircraft Accident Report

183

Appendix B

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Aircraft Accident Report

189

Appendix B

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Analysis 97 Aircraft Accident Report

and performed some, but not all, of the steps of the elevator control system rigging
procedure (section 27-30-02) in the Beech 1900D AMM. However, whenever cable
tension adjustments are made, the entire elevator control system rigging procedure needs
to be performed and not just those steps that apply to cable tensioning. (The issue of
skipped procedural steps is discussed in section 2.3.3.)

Examination of the accident airplane’s pitch control cable turnbuckles as found in
the wreckage revealed that the AND turnbuckle, which measured 7.30 inches in length,
was extended 1.76 inches more than the ANU turnbuckle, which measured 5.54 inches in
length. However, according to data from Air Midwest’s postaccident survey of its entire
fleet of 42 Beech 1900D airplanes, the AND turnbuckle was extended, on average, only
0.04 inch less than the ANU turnbuckle. Further, ground tests showed that turnbuckles
adjusted to the lengths of those found in the wreckage would result in limited downward
elevator travel, although the FDR would indicate that full downward travel was available.

The Safety Board could not determine the exact measurements of the accident
airplane’s ANU and AND cable turnbuckles and other adjustable components’? when the
airplane entered the D6 maintenance check. However, it is clear that the adjustments to the
cable turnbuckles (and possibly other adjustable components) during maintenance resulted
in FDR pitch control measurements that showed a 9° AND loss of travel, which restricted
the accident airplane’s elevator travel to 7° AND.

The Safety Board could not precisely determine the changes that were made to the
elevator control system during the D6 maintenance check to restrict the accident airplane’s
elevator travel to 7” AND. However, during the ground tests, the Board discovered one
scenario that provided results that were reasonably consistent with FDR data from the
accident airplane. Specifically, when the rig pin for the aft bellcrank was not removed
from the test airplane and the cable tension was released and then the rig pin for the
forward bellcrank was installed aft of the bellcrank arm, adjustments to the turnbuckles
resulted in an ANU turnbuckle length of 5.12 inches and an AND turnbuckle length of
7.70 inches. After the aft rig pin was removed, the test airplane’s elevator moved to 7.7° AND.

The Safety Board concludes that the accident airplane entered the D6 maintenance
check with an elevator control system that was rigged to achieve full elevator travel in the
downward direction. The Safety Board further concludes that the accident airplane’s
elevator control system was incorrectly rigged during the D6 maintenance check and that
the incorrect rigging restricted the airplane’s elevator travel to 7° AND, or about one-half
of the downward travel specified by the airplane manufacturer.

2.3.1 Conspicuity of the Elevator Control System Misrig

The only visible sign of the misrig during the first officer’s external preflight
inspection would have been a change in the elevator resting position. The normal elevator

2 The other adjustable components are the forward push-pull tube; the left and right aft pushrods; and
the primary, secondary, and tertiary control stops.



Aircraft Accident Report

160

Appendix B

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Analysis 119 Aircraft Accident Report

AC 120-16D stated that an air carrier’s CASS program should monitor nine
elements of the carrier’s continuous airworthiness maintenance program, including its
maintenance manual. The guidance also stated that a CASS program should include
“detailed policy and procedures” for determining whether an air carrier needed to amend
its maintenance program or manual and for making such amendments. In addition, the
guidance stated, “proactive surveillance and analysis forecasts faults in your [the air
carrier’s] maintenance program or manual through the collection and analysis of a wide
variety of data. It corrects those faults, including human factors issues, in advance of any
specific event, accident, or incident.” Further, the guidance stated that an air carrier’s
“CASS audit schedule should include...all manuals, publications, and forms [to ensure
that they] are useable, current, accurate, and readily available to the user.”

In April 2003, the FAA published AC 120-79, “Developing and Implementing a
Continuing Analysis Surveillance System,” which was a comprehensive guide for the
development of CASS programs. The AC provided information on many CASS-related
topics and described model CASS programs for air carriers in three different size ranges.

The Safety Board commends the FAA for issuing improved, detailed guidance for
the development and implementation of CASS programs. However, the FAA has not yet
included this guidance in FAA Order 8300.10, Airworthiness Inspector's Handbook.'”
Also, the FAA has not completed the development of CASS training for aviation safety
inspectors. The Board notes that, on January 26, 2004, the FAA provided the Board with
the draft lesson plan for the CASS portion of an air carrier indoctrination course that is to
be taught to all new inspectors.'“* The Board hopes that the FAA will complete the
development of CASS training and begin training aviation safety inspectors as soon as
possible.

The Safety Board concludes that updated CASS guidance would help FAA
aviation safety inspectors ensure that CASS programs are being effectively implemented
at 14 CFR Part 121 air carriers. Therefore, the Safety Board believes that the FAA should
include the CASS guidance from AC 120-16D, “Continuing Airworthiness Maintenance
Programs,” and AC 120-79, “Developing and Implementing a Continuing Analysis
Surveillance System,” in FAA Order 8300.10, Airworthiness Inspector's Handbook.

2.5.2.3 Oversight of Maintenance Training Programs

The Safety Board notes that, in contrast to other air carrier training programs, such
as those for pilots, flight attendants, dispatchers, flight instructors, check airmen, and
personnel handling hazardous materials,'*? maintenance training programs do not require
formal approval by the FAA. For those training programs that require formal approval, the
air carrier submits its program plans to the FAA, which reviews those plans and either

147 Inspector guidance on the CASS program is currently found in volume 2, chapter 65, and volume 3,
chapter 37, of the handbook. These handbook sections were developed in 1992 and 1993, respectively.

148 The FAA reported that the initial indoctrination course was taught during the week of January 12,
2004.

149 See 14 CFR 121.401, “Training Program: General.”



Factual Information 38 Aircraft Accident Report

AND Tumbuckle
wpe ee ee " sil Ee ea 20 Wc ceee RO .
ae a i a) a

———— 7.30 inches —-+

ANU Tumbuckle

ee

<—______——_ 5.54 inches |

Tumbuckle Barrel

LM cn
— eA (NaN

Threaded Cable Terminals

Tooling Holes

Figure 6. Turnbuckles as found in the wreckage.

The AND turnbuckle was extended 1.76 inches more than the ANU turnbuckle.
After the accident, Air Midwest surveyed its entire fleet of 42 Beech 1900D airplanes,
which represented 25 percent of the 164 Beech 1900D airplanes active in the North
American fleet. Air Midwest data submitted to the Safety Board indicated that, on
average, the AND turnbuckle was extended 0.04 inch less than the ANU turnbuckle.

The forward bellcrank had fractured into two pieces, and the fractured surface did
not exhibit the soot that covered the bellcrank side surfaces and surrounding structure. The
forward bellcrank forward (AND) stop bolt was bent and measured 0.93 inch in length.
The control cables and the aft end of the forward push-pull tube were attached to the
forward bellcrank.

The forward push-pull tube and rod end were bent. The push-pull tube was
measured in segments at the Safety Board’s Materials Laboratory, and the total length of
the rod was 15.33 inches. The rod end had six threads visible.

56 The number of visible threads can differ among Beech 1900D airplanes.



Factual Information 80 Aircraft Accident Report

Figure 11 shows flight 5481’s weight and CG information compared with that for
the flight 103 accident airplane. Two data points in the figure show the CG range for the
flight 103 airplane.

18,000
, TI | ] r- Flight | 5484
= ctual

17,500 +— t

| | i | Weight
17,000 f t Sal
16,500 ~ | a - Beech 1900C;
/ Homer, Alaska, 1987

16,000 | “ : 7

15,500

15,000 4 |

14,500 }~ “fe bed — 4 t Z
44,000 - - : i jf lene
13,500 j

13,000 +

12,500 /

12,000

Airplane Weight (pounds)

11,500

i
0246 8 40 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60
CG (percent MAC)

11,000

-Figure 11. Flight 5481 weight and center of gravity information compared with flight 103
weight and center of gravity information.

41.18.4.2 ValuJet Airlines Flight 592, Everglades, Near Miami, Florida

On May 11, 1996, ValuJet Airlines flight 592, a Douglas DC-9-32, N904VJ,
crashed into the Everglades, near Miami, Florida, about 10 minutes after takeoff from
Miami International Airport. The 2 pilots, 3 flight attendants, and all 105 passengers were
killed. Flight 592 was operating under 14 CFR 121 with a scheduled destination of the
William B. Hartsfield International Airport, Atlanta, Georgia.

A fire erupted in the airplane’s class D cargo compartment. The fire was initiated
by the actuation of one or more oxygen generators being improperly carried as cargo. The
oxygen generators were prepared and packaged for carriage aboard flight 592 by
SabreTech, a 14 CFR Part 145 repair station in Miami that performed heavy maintenance
for ValuJet Airlines.


1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

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
(CLT), 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 (GSP), Greer, South
Carolina, and was operating under the provisions of 14 Code of Federal Regulations
(CFR) Part 121 on an instrument flight rules flight plan. Visual meteorological conditions
prevailed at the time of the accident.

The accident airplane had been flown from the Tri-State/Milton J. Ferguson Field,
Huntington, West Virginia (HTS), to CLT on January 7, 2003 (the day before the
accident). Air Midwest records indicated that the accident pilots flew the accident airplane
on six flight legs that day. The first officer (the nonflying pilot) of the flight from HTS to
CLT told the accident first officer, when handing off the airplane, that “everything was
normal” and “it was a good flying airplane.”

The accident pilots began their trip sequence about 1340 and ended their trip
sequence at CLT about 2045. Another flight crew met the accident airplane for a trip that
night from CLT to Lynchburg Regional Airport/Preston Glenn Field (LYH), Lynchburg,
Virginia. That flight crew flew the accident airplane back to CLT the next morning
(January 8th), arriving at 0715. According to postaccident interviews, neither the captain
nor the first officer of those two flight legs noticed anything unusual about the airplane.

On January 8, 2003, the accident flight crew was scheduled to fly two flight legs
on a 1-day trip sequence—CLT to GSP and GSP to Raleigh-Durham International Airport
(RDU), Raleigh-Durham, North Carolina—and then to travel on duty as passengers from
RDU to CLT. An Air Midwest pilot saw the captain in the gate area about 0745 and the
first officer about 0800.

The dispatch release for flight 5481 showed that a maximum of 32 bags was
allowed on the flight. One of the two ramp agents’ working flight 5481 stated, in a
postaccident interview, that 23 bags had been checked and that 8 bags were carried on the

1 Unless otherwise indicated, all times in this report are eastern standard time based on a 24-hour
clock.

? Raytheon Aircraft Company acquired Beech Aircraft Corporation in February 1980.

3 The ramp agents working this flight were employees of Piedmont Airlines, which runs US Airways
Express ground operations at CLT.



Contents iv Aircraft Accident Report

1.12.4.1 Pitch Trim Control System
1.13 Medical and Pathological Information . .. .
1.14 Fire
1.15 Survival Aspects... ..
1.15.1 Emergency Response
1.16 Tests and Research ...
1.16.1 Ground Tests ....
1.16.1.1 Baseline Configuration .
1.16.1.2 Turnbuckle Length Adjustments ......... 06s cece cece e eee cence anes 42
1.16.1.3 Cable Tension Adjustment Procedural Errors
1.16.1.4 Cable Stretch .
1.16.2 Airplane Performance Study... eee cnn eee teen n nee

1.16.2.1 Flight 5481 Weight and Balance Study cena 44
1.16.2.1.1 Air Midwest Weight and Balance Program 44
44

1.16.2.1.2 Airplane Component Buildup Method . .
1.16.2.1.3 Takeoff Ground Roll Weight Analysis ...........--0+eeeeeee seen 46
1.16.2.2 Load Manifest Study 0.0.0.0... 0.00 e cece cece eee nent e ence n eee ees
1.16.2.3 Elevator Control Authority Study
1.16.2.3.1 Relationship Between Pitch Control Position and
Actual Elevator Position .. 2.0... 06.0 e cece eect ener een e ene e ee
1.16.2.3.2 Available Elevator Travel . .
1.16.2.4 Beech 1900D Simulation Studies . .
1,16.2.4.1 Elevator Required to Match Accident Flight Data .............-...5+5 51
1.16.2.4.2 Elevator Required to Establish Controlled Flight .
1.16.2.4.3 Kinematics Extraction...........+.-.
1.16.2.4.4 Simulator Trims..........
1.17 Organizational and Management Information
1.17.1 Air Midwest .
1.17.11 Air Midwest Maintenance Training Program
1.17.1.2 Huntington Maintenance Station Operations........
1.17.1.3 Air Midwest Audits of the Huntington Maintenance Station
1.17.1.4 Postaccident Actions ......... 660s sees eee ee eee eee 59
1.17.2. Raytheon Aerospace:
1.17.2.1 Contract Between Raytheon Aerospace and Air Midwest .
1.17.3 Structural Modification and Repair Technicians
1.17.3.1 Contract Between Structural Modification and
Repair Technicians and Raytheon Aerospace
1.17.4 Federal Aviation Administration Oversight. . . .
1.17.4.1 Continuing Analysis and Surveillance System .
1.17.4.2 Correspondence From the Federal Aviation Administration
to Air Midwest
1.17.5 Raytheon Aircraft Company
1.18 Additional Information. ....... 26.6.6 e cece cece n cence eet eens
1.18.1 Weight and Balance Procedures.

1.18.1.1 Federal Aviation Administration... ....... 6.0: eee e cece eee cence anes 68
1.18.1.1.1 Postaccident Average Weight Survey.........-- 0 esse cece cece e eee 70
1.18.1.2 Air Midwest

1.18.1.2.1 Postaccident Weight and Balance Revisions............6-.0+eeeeeeee 714
1.18.1.3 US Airways Express 6.0.6.0... ccc e cece eee cnet e enn ete e tenes 75



Aircraft Accident Report

143

Appendix B

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Factual Information 35 Aircraft Accident Report

1.12.2 Fuselage

The nose of the airplane was crushed rearward. The cockpit exhibited fire and
impact damage. Between the main entry door and the front wing spar, the lower fuselage
was intact but crushed, and the upper fuselage was consumed by fire. The fuselage
structure above the wing center section was consumed by fire except for the right forward
emergency exit and surrounding structure, which remained intact but was distorted and
fire damaged. The aft fuselage, from just forward of the aft emergency exits to the cargo
compartment partition, had separated from the forward fuselage, with the rudder and
elevator cables stretched between the two sections. The fuselage had also separated near
the cargo compartment partition, and the aft fuselage section containing the cargo
compartment was found on top of the right wing and was mostly consumed by fire. The
portion of the fuselage from the front wing spar to the nose was on a magnetic heading of
about 238°, and the portion of the fuselage from just forward of the aft emergency exits to
the cargo compartment partition was on a magnetic heading of about 90°.

The captain’s four-point, rotary-vaned seatbelt buckle was found unlatched in the
cockpit wreckage. The captain’s fixed (left) lapbelt fitting was the only part attached to the
buckle; the shoulder strap fittings and right lapbelt fitting were missing. The first officer’s
fixed (right) lapbelt fitting and shoulder strap fitting were found attached to his four-point,
rotary-vaned seatbelt buckle. (See section 1.15 for information about the location of the
captain’s and first officer’s bodies.)

On February 24, 2003, the Safety Board examined the captain’s seatbelt buckle at
Pacific Scientific (the manufacturer of the buckle), Duarte, California. The buckle was
charred, and the buckle handle was warped. The buckle handle could be rotated in the
counter-clockwise direction but could not be rotated in the clockwise direction.

The buckle’s five spring-loaded locking pawls, which retain the fittings when they
are inserted into the buckle, were examined. Four of the locking pawls—the left shoulder
harness pawl, the right shoulder harness pawl, the right lap pawl, and the crotch strap
pawl—were depressed.” The left lap pawl (for the left fixed lapbelt fitting) was partially
raised. When the left lap pawl was manually depressed, the left fixed lapbelt fitting
released from the buckle.

Also on February 24, 2003, the Safety Board conducted a test to determine
whether a control wheel could contact and release a pilot’s seatbelt buckle. The test was
conducted at Northrop Grumman, Los Angeles, California, using a Beech 1900C, N19NG,
owned by the company.*! A subject who was 5 feet 4 inches tall and weighed 135 pounds”
sat in the captain’s seat. When the captain’s seat was in the second most forward position

°° The crotch strap pawl was not used because the Beech 1900 does not have a crotch strap.

5! Raytheon Aircraft Company verified that the cockpit seats, seat tracks, control wheels, and crew
restraints installed in NI9NG were representative of those in the accident airplane.

* The captain’s most recent FAA medical certificate indicated that she was 5 feet 6 inches tall and
weighed 148 pounds.



Aircraft Accident Report

154

Appendix B

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Factual Information 66 Aircraft Accident Report

In April 2003, the FAA published AC 120-79, “Developing and Implementing a
Continuing Analysis Surveillance System,” which was a comprehensive guide for the
development of CASS programs.** The AC provided information on CASS-related topics,
including the following: the desired purpose and structure of a CASS program, CASS
policy and documentation, major CASS activities, CASS personnel requirements,
communication between CASS personnel and other departments, comparison of CASS
and other required maintenance programs, CASS program evaluation, and the role of the
FAA in an air carrier’s CASS program. The AC also described model CASS programs for
air carriers in three different size ranges.

4.17.4.2 Correspondence From the Federal Aviation Administration to Air
Midwest

In an October 16, 2000, letter, the Air Midwest PMI stated that a recent FAA
inspection conducted at Air Midwest headquarters could not be completed because the air
carrier lacked adequate records to determine whether it was in compliance with 14 CFR
121.371(a) and 121.375." The PMI noted that, among other things, “required
[maintenance] training records are either not at the Wichita facility or are not up to date
and complete,” and advised Air Midwest of the need to comply with 14 CFR 121.371(a)
and 14 CFR 121.375. The PMI requested a meeting with Air Midwest officials to “avoid
further investigation of these areas,” and this meeting was held on October 26, 2000.

In a November 9, 2000, letter, the Air Midwest PMI stated that Air Midwest’s
CASS program did not include a reliable way of charting operational data at specified
intervals to reveal trend-related information.

In a December 18, 2000, letter, the Air Midwest assistant PMI asked the air carrier
to submit a strategy to resolve the inadequacy of the carrier’s training manual and training
records.” The Air Midwest Vice President/Director of Maintenance indicated that the air
carrier would, by February 1, 2001, audit training records, rewrite its maintenance training
manual, forward copies of training records to company headquarters, and add a manager
to the training department.”!

In a September 6, 2001, letter, the Air Midwest PAI stated that he was returning
Air Midwest’s April 1, 2001, revised maintenance training manual so that numerous

88 AC 120-79 provided one method of compliance with the requirements of 14 CFR 121.373.

8 Title 14 CFR 121.371(a) requires that carriers operating under 14 CFR Part 121 use only persons
who are properly certificated, trained, qualified, and authorized for performing required inspections. See
section 1.17.1.1 for a description of 14 CFR 121.375.

% A followup inspection of Air Midwest’s training files was conducted on December 4, 2000. This
inspection revealed evidence of continuing deficiencies in the training files as well as deficiencies in the air
carrier’s training manual. The PMI gave Air Midwest a deadline of February 1, 2001, to remedy these
deficiencies.

91 A Regional Aviation Safety Inspection Program (RASIP) inspection, conducted between March 12
and 29, 2001, found that deficiencies in the maintenance training manual still existed and that training was
not being conducted in accordance with company procedures. The RASIP inspection also found that Air
Midwest was not performing the biannual audits required by the company’s CASS procedures.



Factual Information 75 Aircraft Accident Report

on May 11, 2003, and effectively reduced the Beech 1900D airplane capacity to a
maximum of 17 passengers. The average weight for adult passengers increased from
175 pounds (November through April) and 170 pounds (May through October) to
200 pounds all year.'"? These passenger weights still include 10 pounds for items that are
normally carried on board by passengers, such as handbags, briefcases, and laptop
computers. Articles that are stored in the coat closet are counted as 10 pounds per bag or
item. The average weight for checked baggage increased from 25 to 30 pounds, and the
average weight for carry-on baggage stowed in the AFT1 cargo compartment decreased
from 25 to 20 pounds. These weight and baggage revisions were incorporated into the
Flight Operations Procedures Manual on June 12, 2003.

Table 8. Air Midwest revised weights compared with previous weights.

Category Revised weight (pounds) Former weight (pounds)

Adult passenger 190 (all year) 165 (winter), 160 (summer)

Carry-on baggage and
personal items in cabin

0 for carry-on baggage, 10 for
personal items

10 for both carry-on baggage and
personal items

Total 200 175 (winter), 170 (summer)
Checked baggage in AFT1 30 25

cargo compartment

Carry-on baggage checked 20 25

at airplane and stored in
AFT1 cargo compartment

Air Midwest also revised its Beech 1900D load manifest form. The revised form
showed the new passenger and checked baggage average weights and added the carry-on
baggage weights. The revised form also included a table to calculate the total weight and
CG index number for the flight crew, which was previously calculated as part of the
airplane’s basic operating weight, and an updated passenger index table. The revised load
manifest form and instructions were incorporated into the Flight Operations Procedures
Manual on April 25, 2003.

1.18.1.3 US Airways Express

Because Air Midwest flight 5481 was operating under a code-share agreement with
US Airways Express, the flight was subject to US Airways Express’ procedures for passenger,
baggage, and cargo loading. Gate and ramp agents use the US Airways Express Load Report,
form OF-11E, to account for all passengers, baggage, and cargo loaded on a US Airways
Express flight. The OF-11E must be given to the flight crew on all flights except for ferry
flights. The flight crew uses this information to complete the load manifest form.

The Air Midwest Flight Operations Procedures Manual and the US Airways
Express Ground Operations Manual, Section 5, “Baggage & Cargo Loading,” dated
September 1, 2002, cited the specific items that needed to be completed on the OF-11E.

1 The average weight for a child passenger between 2 and 12 years of age remained at 80 pounds.



Loss of Pitch Control During Takeoff
Air Midwest Flight 5481

Raytheon (Beechcraft) 1900D, N233YV
Charlotte, North Carolina

January 8, 2003

DISTRIBUTION STATEMENT A
Approved for Public Release
Distribution Unlimited

Aircraft Accident Report
NTSB/AAR-04/01

PB2004-910401
Notation 7545B

BEST AVAILABLE COPY

20040715 198

NS, National
Transportation
i Safety Board

Oe
res
“ery gor Washington, D.C.

Nore

NATIO;
© Va

Ry



Analysis 101 Aircraft Accident Report

of the performance and effectiveness of their maintenance and inspection programs and
for the correction of any deficiency found in those programs. Also, FAA Advisory
Circular (AC) 120-16D, “Continuous Airworthiness Maintenance Programs,” states that
CASS programs must ensure that all elements of an air carrier’s maintenance program are
being accomplished in accordance with its maintenance manual and that any deficiencies
in an air carrier’s manual are identified and corrected. (Sections 2.5.1.3 and 2.5.2.2
provide details about Air Midwest’s CASS program and the FAA’s oversight of CASS
programs, respectively.) The findings of the flight 5481 investigation suggest that air
carriers may not have adequate CASS programs despite the requirements of 14 CFR
121.373.

The Safety Board concludes that, because the RALLC quality assurance inspector
and the SMART mechanic did not diligently follow the elevator control system rigging
procedure as written, they missed a critical step that would have likely detected the misrig
and thus prevented the accident. Therefore, the Safety Board believes that the FAA should
adopt a program for performing targeted surveillance and increased oversight of
maintenance practices at 14 CFR 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. In addition, the Safety
Board believes that the FAA should verify that 14 CFR Part 121 air carriers have
procedures in their CASS 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.

2.3.4 Lack of an Effective Postmaintenance Check

The mechanic indicated that he conducted control sweeps from the cockpit after
the cable tension had been adjusted. He stated that he “ran the elevator full travel a few
times” and then checked the cable tensions to make sure that they had not changed.
However, the mechanic also stated that no one was at the tail of the airplane observing the
elevator travel when he conducted the control sweeps.

The quality assurance inspector stated that he observed the elevator at a neutral
position on the travel board with the rig pin installed at the forward bellcrank. The
inspector also stated that, after the rig pin was removed, he grasped the elevator with the
travel board still attached and moved the elevator throughout the available travel. The
inspector thought that the elevator could be fully deflected with the forward bellcrank rig
pin removed and stated that elevator travel was “within limits.” However, results from the
Safety Board’s investigation, including simulations, ground tests, and FDR data, indicated
that elevator travel could not have been within the limits specified in Beech 1900D AMM
section 27-30-02. The quality assurance inspector further stated that he was present when
the mechanic verified cable tension by attaching a tensiometer on both cables and
checking the tensions.



Aircraft Accident Report

175

Appendix B

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Analysis 124 Aircraft Accident Report

wind, ramp slope, oleo stiction, low hydraulic pressure, and asymmetrical gear loads).
Thus, the Safety Board classified Safety Recommendation A-98-49 “Closed—Acceptable
Action.”

The Safety Board is aware of current efforts in private industry to develop aircraft
onboard weight and balance systems. In fact, the FAA’s Aircraft Weight and Balance
Control Program Aviation Rulemaking Committee is considering adding onboard weight
and balance system certification specifications to the guidance in the next version of
AC 120-27 (AC 120-27D). The Board is also aware of efforts to develop systems to
rapidly weigh and automatically track passenger and baggage weight and location data as
passengers board aircraft. Technological advances in hand-held computing devices,
wireless bar code scanners, inventory tracking algorithms, and overnight package
shipping logistics suggest that it may be feasible to compile actual weight data and
account for the weight location, enabling a rapid and reliable calculation of actual aircraft
weight and balance.

The Safety Board concludes that technology may enable air carriers to accurately
determine weight and effectively control balance while maintaining operational efficiency.
Therefore, the Safety Board believes that FAA should 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. The Safety Board further believes that FAA should 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.

2.5.3 Raytheon Aircraft Company

During its investigation into the Air Midwest and Colgan Air accidents and the
CommutAir incident, the Safety Board identified several areas in the Beech 1900D AMM
(which each operator used as the basis for its maintenance work) that could be improved
to he!p mechanics follow each step completely and accomplish procedures correctly.

Regarding the Air Midwest accident, the elevator cable tension graph (figure 203)
in the elevator control system rigging procedure did not contain instructions on how to
take a temperature reading, which was needed to determine the tension values at which the
cables should be set. Regarding the Colgan Air accident, the elevator trim system rigging
procedure showed an incorrect illustration of the forward elevator trim cable drum. This
error could have resulted in the incorrect installation of the elevator trim cable and
elevator tab operation in the direction opposite of that commanded by the trim wheel.
Regarding the CommutdAir incident, the Beech 1900D AMM did not contain a procedure
for replacing a thrust lever detent pin.!

182 Because the AMM did not contain this procedure, the mechanic used the installation instructions in a
Beech 1900D field service kit for “thrust lever, replaceable detent pin.” However, the installation
instructions did not describe how to remove the thrust lever control assembly from the center pedestal,
which is required to replace a thrust lever detent pin. Also, the installation instructions did not provide any
references to specific maintenance manual sections or procedures for removing the thrust lever control
assembly from the center pedestal.



Aircraft Accident Report

152

Appendix B

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iti Aircraft Accident Report

Contents

Abbreviations «2.0.0.0... 6. ccc ccc cee eee ene enn ene en ene viii

Executive Summary

1. Factual Information
1.1 History of Flight
1.1.1 | Maintenance Events Preceding the Accident Flight .
1.2 Injuries to Persons. .......... 00.0 eee cece eee
1.3 Damage to Airplane
1.4 Other Damage
1.5 Personnel Information.
1.5.1. The Captain
1.5.2 | The First Officer
1.5.3 The Maintenance Personnel... .
1.5.3.1 The Quality Assurance Inspector
1.5.3.2 The Foreman
1.5.3.3. The Mechanic
1.5.3.4 The Raytheon Aerospace Site Manager .
1.5.3.5 The Air Midwest Regional Site Manager .............. 00s eee ee nee e eens 14

1.6 Airplane Information .................5. . 14
1.6.1 Pitch Control System . . 15
1.6.1.1 Pitch Trim Control System .19

1.6.2 Maintenance Program .............4+ ..19
1.6.3 Elevator Control System Rigging Procedure .
1.6.3.1 Rigging Procedure at the Time of the ‘Accident. 7 :
1.6.3.2 Applicable Steps That Were Skipped During Maintenance seeeeee ..22
1.6.3.3 Revised Rigging Procedure
1.6.4 Weight and Balance.......
1.7 Meteorological Information. ........... 06. ccc cece e een een een ene n eee 28
1.8 Aids to Navigation
1.9 Communications. .
1.10 Airport Information. .
1.10.1 Aircraft Rescue and Firefighting ......... 0... c cee cece cence nee eee 29
1.10.2 Air Traffic Control......... 30

1.11 Flight Recorders ....... . 31
1.11.1 Cockpit Voice Recorder. . 231
1.11.1.1 Safety Recommendations A-97-36 and A-02-25, 32

1.11.2 Flight Data Recorder ......
1.11.2.1 Flight Data Recorder Study
1.12 Wreckage and Impact Information
1.12.1 General Wreckage Description
1.12.2 Fuselage
1.12.3. Engines
1.12.4 Pitch Control System ..... 2.6... cece eee eee eee ene ene nen nee 37



Aircraft Accident Report

184

Appendix B

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Analysis 102 Aircraft Accident Report

The postmaintenance checks performed by the quality assurance inspector and the
mechanic were not adequate to detect the elevator control system misrig. As stated in
section 2.3.3, if step u of the rigging procedure (the calibration of the pitch position
potentiometer) had been performed on the accident airplane, it is likely that the quality
assurance inspector and the mechanic would have caught the misrigging problem. Also, if
a functional check had been included at the end of the procedure, the quality assurance
inspector and the mechanic would have had another opportunity to detect the misrigging
problem. A functional check at the end of the procedure would have provided a more
comprehensive, systematic, and direct method to ensure that any misrigging problem was
caught before an airplane was returned to service.'? Such a functional check would
consist of a mechanic in the cockpit pushing the control wheel full forward and then
pulling the wheel full aft while another mechanic, who was at eye level with the horizontal
stabilizer, measured the position of the elevator using a travel board. This process would
determine whether the elevator achieved the correct deflection for the full forward and full
aft movement of the control column.

The Safety Board recognizes that Raytheon Aircraft Company added a
postmaintenance functional check to its revised elevator control system rigging procedure
issued on February 12, 2003. Specifically, step aa indicates that the mechanic is to move
the control wheel aft and forward and verify that the elevator moves up 20° +1°/-0° and
down 14° +1°/-0°, respectively, and that the control stops make contact.

The lack of a functional check at the end of a maintenance procedure is also an
issue with the Colgan Air flight 9446 accident. During the replacement of the elevator trim
tab actuators, the mechanics thought that the forward elevator trim tab cable had become
jammed or kinked and thus needed to be replaced. The mechanics tried to replace the
cable in accordance with Beech 1900D AMM section 27-30-04. This procedure does not
describe in detail how to manipulate the electric and manual trim systems in each direction
and verify that the full range of motion in the commanded direction is observed at the trim
tabs. The mechanics stated, during a postaccident interview, that they moved the trim tabs
through a full range of motion using the electric and manual systems and observed no
anomalies. However, without a detailed procedure to ensure that the trim tabs are moving
in the proper direction, it is possible that the trim tabs could move in a reversed direction
and remain unnoticed.

In addition, the investigation of the October 16, 2003, CommutAir flight 8718
incident determined that the mechanic did not perform a functional test of the elevator
trim control system, as required by FAA Airworthiness Directive (AD) 2003-20-10. A
functional check of the system would have indicated that the elevator trim wheel had been
reinstalled incorrectly.

The Safety Board concludes that a complete functional check at the end of
maintenance for critical flight systems or their components'*? would help to ensure their

132 The Safety Board notes that some elevator control system maintenance procedures do not include an
FDR check and that FDRs can be placed on an air carrier’s minimum equipment list, as was the case with
Colgan Air flight 9446.



Factual Information 23 Aircraft Accident Report

clearance from the stop bolts; and step j, to verify that the forward bellcrank stop bolts
make contact before the bob weight stop bolt makes contact with the weight. The
mechanic stated that he bypassed part of step n, to release cable tension, because he could
adjust cable tension by tightening the cables without releasing them before the adjustment.

The mechanic stated that he bypassed step s, to perform the control column
support roller inspection procedure, because he decided that it was not required. The
quality assurance inspector concurred. The mechanic also stated that he bypassed step u,
to calibrate the F1000 FDR pitch position potentiometer and to perform the FDR pitch
adjustment procedure, because he did not think that the calibration needed to be done. The
quality assurance inspector stated that he did not think that an FDR was installed on the
airplane.*®

During a postaccident interview, the mechanic and quality assurance inspector
further stated that steps c, f, g, h, i, j, n, and s were not required because those steps were
only necessary for cable replacement and not for cable tensioning. The Air Midwest
regional site manager stated, during a postaccident interview, that all of these steps should
have been followed, except for step n (releasing the cable tension before a readjustment of
the cables). The regional site manager thought that loosening the cables would not have
affected the final outcome of a proper rig.

In addition, the mechanic stated that he bypassed the Elevator Control System
Friction Test described in section 27-30-02 of the Beech 1900D AMM because he decided
that the test was not required. The quality assurance inspector concurred.

1.6.3.3 Revised Rigging Procedure

On February 12, 2003, Raytheon Aircraft revised its elevator control system
rigging procedure for the Beech 1900D airplane. The revised procedure is summarized
below and presented in its entirety in appendix D.

36 Most, if not all, Beech 1900D airplanes are outfitted with an FDR. The wiring and the sensor for the
FDR are in the same area of the airplane where maintenance was being performed. Also, the FDR unit is
mounted in the AFT1 cargo compartment and is readily visible. In addition, a circuit breaker for the FDR is
located in the cockpit.



Factual Information 82 Aircraft Accident Report

On October 2, 2000, the FAA stated that it had reviewed the information contained
in its report, Human Factors in Aviation Maintenance and Inspection, Strategic Program
Plan, and that it was amending AC 120-16C, “Continuous Airworthiness Maintenance
Programs,” to include information from the report. The FAA indicated that the revisions to
the AC would also expand on CASS programs. On April 24, 2001, the Safety Board stated
that it was difficult to determine whether the revisions to AC 120-16C would address the
issues in this recommendation. On July 21, 2003, the FAA stated that chapter 10 of AC
120-16D included human factors as part of initial training.

On February 23, 2004, the Safety Board stated that, although AC 120-16D
addressed many of the human factors issues related to training, procedures development,
redundancy, supervision, and work environment, the AC would be significantly
strengthened if the FAA added specific references to its available human factors
information related to aviation maintenance operations, such as the Human Factors Guide
for Aviation Maintenance and Inspection. The Board also stated that it continued to
investigate major accidents in which incorrect maintenance led to a loss of control of the
airplane and that human factors in aviation maintenance was an important safety issue.
Pending the inclusion in AC 120-16D of references to FAA-published guidance on human
factors in aviation maintenance, Safety Recommendation A-97-70 was classified “Open—
Acceptable Response.”

1.18.4.2.2 Safety Recommendation A-97-74

In its final report on the ValuJet Airlines flight 592 accident, the Safety Board
determined that the FAA’s surveillance of ValuJet before the accident did not include any
significant oversight of the air carrier’s heavy maintenance contractors, including
SabreTech. The Board further determined that the FAA’s limited oversight of ValuJet’s
maintenance contractors was not sufficient to detect potential problems. The ValuJet PMI
was not required to conduct surveillance of the air carrier’s contract maintenance
facilities. Thus, the Board concluded that the lack of an explicit requirement for a PMI of
a 14 CER Part 121 air carrier to regularly inspect repair stations that are performing heavy
maintenance for the carrier is a significant deficiency in the FAA’s oversight of the
carrier’s total maintenance program. As a result, the Board issued Safety
Recommendation A-97-74 on September 9, 1997. Safety Recommendation A-97-74
asked the FAA to

Ensure that Part 121 air carriers’ maintenance functions receive the same level of
FAA surveillance, regardless of whether those functions are performed in house or
by a contract maintenance facility.

On April 22, 1998, the FAA stated that it issued Flight Standards Handbook
Bulletin for Airworthiness 96-05C, “Air Carrier Operations Specifications Authorization
to Make Arrangements With Other Organizations to Perform Substantial Maintenance,”
on December 15, 1997. The FAA indicated that the bulletin described



192 Aircraft Accident Report

Appendix C
Air Midwest’s Elevator Control System Rigging
Procedure at the Time of the Accident

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANAUL
ELEVATOR CONTROL RIGGING - MAINTENANCE PRACTICES

ELEVATOR CONTROL SYSTEM RIGGING

Ifa FA2100 Flight Data Recorder System is installed on this aircraft, perform the LINK removal por-
tion of the ELEVATOR SURFACE POSITION SYNCHRO TRANSMITTER (SENSOR) REMOVAL
procedure. Refer to Chapter 31-31-12 in the BEECH 1900D AIRLINER FLIGHT DATA RE-
CORDER (FA2100) MAINTENANCE MANUAL SUPPLEMENT, P/N 129-590000-109.

Where the cables pass through structure, the areas of possible contact between the control cables
and adjacent structure must be protected with grommets, rub strips, block or guide fairings. Where
contact of contro! cables does occur with the protective elements, a force no greater than eight (8)
ounces shall be required to move the cable to a position of no contact. At no time should flight con-
trol cables contact metal structure.

a. Disconnect the autopilot servo cables. Refer to Chapter 22.

b. Locate and remove all access panels from the vertical and horizontal stabilizers to gain access to the aft elevator
beticrank and the elevator cables. Refer to Chapter 6.

c. Locate and remove the flight compartment seats, carpet, and floorboards to gain access to the forward elevator
belicrank. Refer to Chapters 6 and 25.

d. Locate and remove the passenger seats, carpet, and floorboards on the right side of the passenger compart-
ment to gain access to the elevator cable turnbuckles. Refer to Chapters 6 and 25.

e. Install an elevator travel board (5, Chart 1, 27-00-00) on each elevator at station 50.00.

f. Adjust the center-to-center length of the push-pull tube assembly between the control column and the forward
elevator bellcrank to a dimension of 15.12 + 0.06 inch.

g. Adjust the surface stop bolts on the elevator contro! horn support for up-travel of 20° + 1° - 0° and down-trave’
of 14° + 1° - 0°, Refer to Figure 201.

h. Verify the bob weight stop bolt clearance is 0.5 + 0.06 inch. Adjust if necessary. Refer to Chapter 27-30-01,
Figure 201.

i. Adjust the forward bellcrank stops for 0.37 + 0.06 inch clearance from the stop bolts. Refer to Figure 202.

J. _ Verify the forward bellcrank stop bolts make contact before the bob weight stop bolts make contact with the
weight.

k. Install a rig pin in the aft elevator bellcrank. Refer to Chapter 27-30-01, Figure 201.

NOTE

Verify threads are visible through the inspection holes at the ends of the pushrods after adjustments
are made.

A28 27-30-02 ren aa2



Factual Information 77 Aircraft Accident Report

The FAA determined, among other things, that inspections and verifications
should be accomplished on all affected airplanes to ensure that the elevator surfaces had
full travel. Specifically, Emergency AD 2003-03-18 required owners and operators of
Beech 1900 series airplanes, by January 31, 2003, to perform a control column sweep
inspection to verify full elevator travel to the primary up and down stops and a stop bolt
inspection to verify that the stop bolt length was not excessive. For those airplanes that did

“not pass the initial control column sweep and stop bolt inspections, the AD required
another rig of the elevator control system and/or a more detailed inspection of the system.
For those airplanes that did pass the initial control column sweep and stop bolt
inspections, the AD required a more detailed inspection of the elevator control system
within 100 hours time in service. In addition, the AD required that owners and operators
of Beech 1900 series airplanes report the results of the initial inspections and the 100-hour
time-in-service inspection (if applicable).

Air Midwest complied with Emergency AD 2003-03-18 and found that, of the
42 Beech 1900D airplanes in its inventory, 5 airplanes had maximum elevator deflections
that were less than 20° or greater than 21° ANU (design range is between 20° and 21° ANU)
or less than 14° AND (design range is between 14° and 15° AND).'® In addition, one
airplane’s elevator control horn did not contact the left and right AND stop bolts, and
another airplane’s elevator control horn did not contact the left AND stop bolt.

According to the FAA, Raytheon Aircraft Company received 296 reports from the
initial control column sweep and stop bolt inspection. The reports showed that 40 airplanes
failed this initial check and thus required another rig. The FAA also indicated that
Raytheon Aircraft received 227 reports from the 100-hour time-in-service inspection.
According to the reports, 39 airplanes failed the 100-hour inspection, 18 of which failed
by more than 1° in either the ANU or AND direction. Both the left and the right elevators
on 9 of these 18 airplanes had insufficient AND travel. Specifically, the AND travel for
these nine airplanes were as follows: four airplanes had left and right elevator deflections
that were limited to 12° AND; one airplane had left and right elevator deflections limited
to 13° and 11.3° AND, respectively; one airplane had left and right elevator deflections
limited to 12.5° and 10.5° AND, respectively; one airplane had left and right elevator
deflections limited to 12° and 13° AND, respectively; one airplane had left and right
elevator deflections limited to 11.5° and 12.5° AND, respectively, and the airplane with the
worst AND travel had left and right elevator deflections limited to 16.5° AND. The
discrepancies in ANU travel ranged from 16.5° to 26° for the left elevator and from 17.5°
to 26° for the right elevator.

105 The first of the five airplanes had a maximum left elevator deflection of 19° ANU. The second
airplane had a maximum right elevator deflection of 19° ANU. The third airplane had a maximum left
elevator deflection of 21.5° ANU and a maximum right elevator deflection of 22.5° ANU. The fourth
airplane had maximum left and right elevator deflections of 13° AND. The fifth airplane had a maximum left
elevator deflection of 12.5° AND.



Factual Information 5 Aircraft Accident Report

Beechcraft 1900D Maintenance Program Manual BATE: 2,2si00
SIXTH DETAILED INSPECTION PROCEDURES CHECKL' 1p
[ ZONE DESCRIPTION STAMP
AFT FUSELAGE AND EMPENNAGE
882564 | C/W BEECH SB 2564 AS REVISED (ACFT.UE1-UE113) Yh =]
1 | 280.281 | SKIN - Inepect skin for condition and loose or missing| Maoh [sp
311 312 | rivets. If damage is found, check adjacent structure
330 340
320
2 STRUCTURE - Check for cracks, loose or missing rivets
and concealed damage.

3 | 181311 | FLIGHT CONTROL COMPONENTS, CABLES AND
1 |a12 PULLEYS - inspect the control system components
(pushrods, tumbuckles, end fittings, castings, etc for
bulges, spits, bends or cracks.)

Check contro! cables, pulleys and associated equipment
for condition, attachment, alignment, clearance, and
proper operation.

Inspect cables for broken strands of evidence of i)
corrosion per *BE Chapter.20-04-00.

Check cable tension per *BE Chapter 27,

Temperature is degrees F.

3/16" Elevator Cable Tension: UP_S~7_ DOWN_4.22.
1/16" Elevator Tab Cable Tension: Ao, .

3/6" Rudder Cable Tension: LT_75_RT_75~_.

1/16” Rudder Tab Cable Tension: 2 g_.

@at

Se) F

Cis

i

4 {311312 | PLUMBING - Inspect plumbing for condition and
[r= ane

— a —_

Figure 1. Detail six work card at the time of the accident.



Appendix C 198 Aircraft Accident Report
BEECH 1900D AIRLINER MAINTENANCE MANAUL
36" ELEVATOR CABLE TENSION GRAPH
130 icsaanetesses ass
Fre NOTE
120 +E ‘THE RANGE SHOWN IN THIS GRAPH IS ONE- Z
== HALF OF THE TENSION LOAD RESULTING FROM =f
£= COMBINING THE TENSION OF THE UP CABLE
f= WITH THE TENSION OF THE DOWN CABLE.
110 2 EXAMPLE: S7(TENSION + 75 (TENSION OF
=] OFUP CABLE) DOWN CABLE) 3:
= 2 .
100 E 18-= 66 POUNDS
CAUTION: RIG THE TENSION OF ONE
iS CABLE AS NEARLY EQUAL
‘TO THE TENSION OF THE
90 EE OTHER CABLE AS POSSIBLE.
3%
a
% 70
i
2 #
50
« 4
20 HEE
=:
= TOLERANCE:
» £8 POUNDS OF TENSION
le
3
10 Ey
zoe 0s a soe 70% = BOF 0% 100% = 110°
TEMPERATURE °F
Figure 203 - Elevator Cable Tension Graph
Page 207
A28 27 -30 -02 Feb 22/02



Factual Information 47 Aircraft Accident Report

18,000

Teg — Flight! 5484
47,500 Lame etal Weight |

i

17,000
/ Flight 548
Load Manifest

wom eight |

BRB BB
8 8 8 8
i
i
|

Airplane Weight (pounds)

14,000 /

13,000

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] i
12,000 1

|

a
a
8
i
i

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|
11,000 :

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60
CG (percent MAC)

Figure 7. Weight and center of gravity information for flight 5481.

1.16.2.2 Load Manifest Study

The Safety Board reviewed load manifest data for 86 flights of the accident
airplane that occurred between December 22, 2002, and January 8, 2003, and identified
9 flights that were documented to be similarly loaded to the accident flight. As shown in
table 5, flight 5512 on December 27, 2002, was the most closely loaded to the accident
flight. FDR data from flight 5512 were used (along with other data) to validate the Board’s
Beech 1900D simulator and kinematics extraction tool (see section 1.16.2.4).



Aircraft Accident Report

164

Appendix B

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Factual Information 89 Aircraft Accident Report

1.18.5 Human Factors Research

Since 1989, the FAA has sponsored a research program on human factors in
aviation maintenance and produced guidance on countermeasures to mitigate human
factors problems in aviation maintenance. For example, the FAA’s Guide to Human
Factors in Maintenance and Inspection provides information on work shift scheduling
programs, workplace design, and procedural guidance design. The guide also addresses
developing and implementing structured OJT programs, maintenance error reporting
programs, and maintenance resource management training."

The European Joint Aviation Authorities (JAA)!?° association has also sponsored
initiatives addressing human factors problems in aviation maintenance. The JAA focused
its efforts on revising the regulatory framework under which aviation maintenance is
performed. In its May 2001 Human Factors in Maintenance Working Group Report,’! the
JAA proposed revisions to its Joint Aviation Regulations (JARs). These proposed revisions
included the following requirements for maintenance organizations:

* communicate information about deficiencies in maintenance procedures to
aircraft certificate holders,

* publish an organizational safety policy,

* consider human factors principles when writing maintenance procedures,

¢ develop appropriate shift turnover procedures,

* consider human fatigue limitations in the organization’s planning,

* consider performing duplicate maintenance inspections,

+ plan maintenance work better,

* ensure thorough inspection of maintenance work before inspector signoff, and

* require initial and recurrent training of maintenance personnel to ensure that
human factors principles are effectively applied within maintenance
organizations.

In September 2003, the JAA revised JAR Part 145, “Approved Maintenance
Organizations,” to include this information.

"9 AC 120-72, “Maintenance Resource Management Training,” which provides guidelines for
specialized voluntary training programs for improving communication, effectiveness, and safety in
maintenance organizations, is an example of the FAA’s efforts to encourage voluntary human factors
programs in the aviation industry.

120 The JAA is an associated body of the European Civil Aviation Conference, which represents the civil
aviation regulatory authorities of those European States that have agreed to cooperate in developing and
implementing common regulatory safety standards and procedures.

21 Joint Aviation Authorities Maintenance Human Factors Working Group, Human Factors in
Maintenance Working Group Report (Hoofddorp, the Netherlands: JAA, 2001).



Aircraft Accident Report

178

Appendix B

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Aircraft Accident Report

163

Appendix B

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Factual Information 68 Aircraft Accident Report

1.17.5 Raytheon Aircraft Company

On December 10, 2003, the President of Raytheon Airline Aviation Services met
with the Safety Board to discuss Beech 1900 series maintenance initiatives. According to
the Raytheon official, these initiatives were undertaken to reinforce with operators the
importance of properly maintaining Beech 1900 series airplanes. In a December 16, 2003,
facsimile, the Raytheon official summarized the initiatives he discussed at the meeting.
The facsimile included the following initiatives:

* communicating more actively with all levels of Beech 1900 operator
personnel, including the chief executive officer/owner, Director of
Maintenance, and mechanics;

* providing all Beech 1900 operators with a CD-ROM of all Beech 1900 safety
and model communiqués and SBs;

* posting all Beech 1900 safety and model communiqués and SBs on the
Raytheon Aircraft Company Web site;

* conducting Beech 1900 Airliner Operators Conferences, the first of which was
held in Wichita on October 21 through 23, 2003, so that operators, suppliers,
and Raytheon Airline Aviation Services have a forum to discuss maintenance
issues;

+ developing “easy-to-follow” text and illustrations to improve the explanation
of certain procedures, including flight control rigging and functional testing;
subjecting these procedures to “validation and verification;” and issuing
changes to the procedures as temporary revisions to the Beech 1900 AMMs;
and

* sending technical teams to Beech 1900 operators to provide on-site training for
mechanics and launching a Web-based training site that will be accessible to all
Beech 1900 mechanics.

1.18 Additional Information

1.18.1 Weight and Balance Procedures

41.18.1.1 Federal Aviation Administration

Air carriers are required to have procedures in place for the control of weight and
balance of airplanes. Title 14 CFR 121.153 permits air carriers with more than nine
passenger seats to use an approved average weight program instead of actual weights for
aircraft weight and balance calculations. The use of average weights instead of actual
weights allows air carriers to board passengers, load baggage and cargo, and calculate
weight and balance more quickly. Air carriers can use actual weights, average weights
established by survey data, or a combination of both to determine the weight of
crewmembers, crew baggage, passengers and personal items, carry-on baggage, and
checked baggage.”


Factual Information 29 Aircraft Accident Report

took off, is 10,000 feet long and 150 feet wide and is made of wire-combed concrete. The
airport was certificated under 14 CFR Part 139.

CLT Airport Operations personnel perform airport inspections two times each day.
The first inspection, which begins about 0800, includes all of the airport movement areas.
The second inspection, which begins about 1600, includes all of the airport movement
areas and the airfield lighting facilities. The self-inspection log sheet indicated no
discrepancies for the first inspection performed on the day of the accident. CLT Airport
Operations personnel performed a special inspection after the accident. The special
inspection, which began about 0906, examined runways 18R/36L and 5/23 and several
taxiways for foreign object debris; none was recorded on the log sheet.

CLT has an airport emergency plan detailing response, recovery, and resolution
actions in the event of an accident or incident involving aircraft at the airport or within the
boundary of Mecklenburg County, North Carolina. (The city of Charlotte is within
Mecklenburg County.) CLT is responsible for conducting a full-scale mock disaster drill
once every 3 years to test this plan. On May 13, 2000, CLT conducted a full-scale triennial
drill with participation from the following organizations: the FAA; CLT Airport
Operations, Airport Law Enforcement, and Aircraft Rescue and Firefighting (ARFF); the
CLT ATCT; the Charlotte-Mecklenburg Police Department; the City of Charlotte Fire
Department (CFD); the North Carolina Air National Guard; the Mecklenburg County
Medical Examiner; the American Red Cross; and US Airways.

1.10.1 Aircraft Rescue and Firefighting

CLT and the North Carolina Air National Guard maintain an index D ARFF
facility on the airfield. The ARFF station (Station 17), which is owned by the Air
National Guard, is continuously staffed with a minimum of nine CFD firefighters. The
station houses eight crash trucks, six of which are owned by the Air National Guard (Blaze 1,
Blaze 2, Blaze 3, Blaze 5, Blaze 8, and Blaze 18) and two of which (Blaze 7 and Engine 17)
are owned by the CFD. An off-airport fire station (Station 30) is the backup facility for all
alerts on airport property.

ARFF personnel receive 56 hours of initial training, including classroom
instruction and a live burn pit/mobile trainer fire exercise. ARFF personnel use the FAA’s
aircraft rescue and firefighter computer-based training program, which covers 13 subject
areas, to accomplish recurrent training. In addition, the State of North Carolina requires
ARFF personnel to have a minimum of 24 hours of continuing education each year in the
13 FAA-required subject areas. To meet this requirement, CFD conducts training during
quarterly sessions consisting of 4 hours of classroom instruction and 5 hours of practical
skills, for a total of 9 hours per quarter and 36 hours per year.

*® According to 14 CFR 139.317, an index D ARFF facility is required to have (1) either one
firefighting vehicle with 500 pounds of sodium-based dry chemical or Halon 1211 or 450 pounds of
potassium-based dry chemical and water with a commensurate quantity of aqueous film forming foam
(AFFF) to total 100 gallons and (2) two firefighting vehicles with water and a commensurate quantity of
AFFF so that the total quantity of water for foam production carried by all three vehicles is at least 4,000 gallons.



Aircraft Accident Report

174

Appendix B

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Factual Information 41 Aircraft Accident Report

airport property but was at Station 17 in place of Engine 17, which was at training. Engine 17,
with four ARFF personnel, left training to respond to the accident.

CED radio logs indicated that the first ARFF unit arrived at the accident site
about 0849:10, about 1 minute 42 seconds after the time of the crash alarm.” A captain
from ARFF Station 17 was the initial fire incident commander at the accident site. He
established a staging area for emergency response vehicles at gate 17, an access point
along the airport perimeter fence, and an initial triage area on a taxiway southwest of the
accident site. The staging area location was later changed to gate 66 when it was
determined that the accident site was located closer to that gate.

ARFF personnel indicated that the first unit on scene (Blaze 2) was directed to
disperse AFFF from the turret nozzle located on the top of the vehicle’s cab. The initial
dispersion consisted of two or three sweeps of the main wreckage area. The ARFF
personnel paused for the visibility to clear and then dispersed AFFF during two more
sweeps. Afterward, ARFF personnel used hand lines from Blaze 2 and Blaze 7 to suppress
and control spot fires and flareups. In addition, ARFF personnel from Engine 17 used
hand lines to suppress the fire along the grass strip on the parking lot side of the airport
perimeter fence and in the gully area.

A CED battalion chief arrived on scene about 0858:49 and assumed control of the
accident site about 0859:21. According to the CFD radio log, a “bulk of fire knock down”
call was transmitted about 0901:45. The CFD radio logs also indicated that a “fire control”
call was transmitted about 0912:25, about 23 minutes after the initial dispersion of AFFF.

US Airways personnel from inside the hangar responded to the accident, and
ARFF personnel observed the US Airways personnel using three portable fire
extinguishers. CLT Airport Law Enforcement and the Charlotte-Mecklenburg Police
Department also responded to the accident. In addition, the Mecklenburg Emergency
Medical Service arrived at the accident scene within 5 to 7 minutes of notification of the
accident. The medical incident commander notified local area hospitals while she was en
route to the accident site and set up a formal triage area near gate 66 when she arrived on
scene. The CFD emergency medical service coordinator told the medical incident
commander that no one had survived the accident, so the medical incident commander
indicated that the additional units responding to the scene and to hospitals should return to
normal operations.

® Title 14 CFR 139.319(i) requires at least one ARFF vehicle (at airports certificated under Part 139) to
be capable of achieving a 3-minute response time from the time of the alarm to the beginning of fire-fighting
agent application. The ARFF vehicle is required to travel from its assigned post to “the midpoint of the
furthest runway serving air carrier aircraft” or “any other specified point of comparable distance on the
movement area which is available to air carriers.” All other ARFF vehicles are required to reach the same
specified point and begin fire-fighting agent application within 4 minutes.



Analysis 110 Aircraft Accident Report

Second, according to Air Midwest’s Maintenance Procedures Manual, the foreman
was responsible for ensuring that OJT was provided to mechanics by someone other than
the quality assurance inspector. However, the quality assurance inspector routinely
provided OJT. In fact, the quality assurance inspector on duty on the night of January 6th
stated that he had received most of his training at Mesa Airlines, Arctic Slope, and Air
Midwest from inspectors and that he believed it was standard practice for inspectors to
provide OJT. Also, the foreman stated that a quality assurance inspector had been
providing OJT to mechanics since he began working for RALLC in December 2001.

The Air Midwest regional site manager was aware that inspectors were providing
most of the OJT because he reviewed maintenance training records on a daily basis.
However, the regional site manager should have been aware that this situation increased
the inspector’s workload (providing OJT and performing RII inspections) and did not
separate maintenance and inspection tasks. The quality assurance inspector stated that the
regional site manager never mentioned to him that inspectors should not provide OJT.

Last, according to Air Midwest’s Maintenance Training Manual and Maintenance
Procedures Manual, the regional site manager was responsible for maintaining training
records and ensuring that the training was properly documented. As previously stated, the
regional site manager reviewed maintenance training records daily, and he indicated that
he attempted to have discrepancies corrected quickly. The regional site manager
forwarded the training records to Air Midwest’s Maintenance Training Coordinator in
Wichita, who reviewed the records for completeness and accuracy. However, an FAA
inspection conducted by geographic inspectors from the Charleston, West Virginia, Flight
Standards District Office (FSDO) 2 days after the accident found that maintenance
training records for employees at HTS were “not complete or current.” Also, the Safety
Board discovered numerous discrepancies in the training records of HTS maintenance
personnel, including the following:

+ The mechanic who performed the elevator control cable work had his training
records signed as complete for the D6 aft fuselage/empennage inspection
procedure and for “rudder, aileron, or elevator cable tension adjustment” by the
quality assurance inspector. However, the mechanic had not been trained on
the rudder and aileron rigging procedures. Air Midwest’s maintenance training
program considered mechanics to be fully trained on all three major control
cable rigging procedures after the mechanics had received training on only one
of the procedures, despite significant differences among the procedures.

+ Another SMART mechanic and the primary quality assurance inspector
incorrectly indicated on that mechanic’s OJT record that he had completed
training on the D6 aft fuselage/empennage inspection procedure on January
6th. The mechanic inspected and checked the engines but did not perform the
entire D6 procedure, including the elevator check.

* The mechanics that were on duty on the night of January 6th had numerous
items (dating as far back as December 14, 2002) signed as complete in their
training records, but these items did not have the required instructor signature
stamps.



Factual Information

46 Aircraft Accident Report

1.16.2.1.3 Takeoff Ground Roll Weight Analysis

Because the accident airplane was partially consumed by a postcrash fire, some of
the wreckage evidence was not recoverable. As a result, the Safety Board used FDR data
from the accident flight and a model of the airplane’s takeoff ground roll dynamics to
calculate the airplane’s actual weight.

The accident airplane’s weight during takeoff was calculated by evaluating the
forces and moments on the airplane during the takeoff ground roll. Engine, groundspeed,
and downrange distance data provided by Raytheon Aircraft Company for three Beech
1900D flight test takeoffs were used to validate this approach. As shown in table 4, the
Safety Board’s force and moment model predicted the actual flight test airplane weights
within about +200 pounds for groundspeeds between the 70- and 100-knot range.

Table 4. Validation of takeoff ground roll model.

Raytheon Aircraft Safety Board
Company flight test calculated weight
Flight test identifier weight (pounds) (pounds) Difference (pounds)
1 17,300 17,510 +210
2 17,510 17,460 -50
3 13,860 14,010 +150

The accident flight’s weight was subsequently derived using FDR data for the left
and right engine rpm, right engine torque, altitude, airspeed, and corrected longitudinal
acceleration.” Thrust was calculated using the FDR airspeed and the radar-derived
groundspeed data. Because of the lack of reliable FDR data for left engine torque, FDR
right engine torque data were used for both of the engines. The FDR left and right engine
rpm values were averaged to define the propeller rpm.

On the basis of these FDR data, radar data, the validated force and moment model,
and component weight and location information, the Safety Board determined that the
accident airplane had an actual weight of 17,700 +200 pounds and an actual CG position
of 45.5 +2 percent MAC. Figure 7 shows the results of the Board’s calculations overlaid
on the Beech 1900D weight and CG envelope.

® The FDR longitudinal acceleration was corrected with a bias term calculated to provide the best
accelerometer integration match for altitude, groundspeed, and position.


Appendix C 197 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANAUL

) BELLCRANK STOP

<
0.37 # .08 mwa Sho)

BELLCRANK
STOP

STOP BOLT STOP BOLT

ELEVATOR FORWARD

BELLCRANK BEyBase

Figure 202 - Elevator Forward Bellcrank Stops

rebzaee 21-30-02 aaa



Conclusions 131 Aircraft Accident Report

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of
this accident was the airplane’s loss of pitch control during takeoff. The loss of pitch
control resulted from the incorrect rigging of the elevator control system compounded by
the airplane’s aft center of gravity, which was substantially 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.



Factual Information 42 Aircraft Accident Report

1.16 Tests and Research

1.16.1 Ground Tests

From July 29 to 31, 2003, the Safety Board conducted ground tests on the pitch
control system of a Beech 1900D, N46YV,® at Raytheon Aircraft Company’s Wichita
facility. One purpose of the tests was to compare the test airplane’s elevator position with
the pitch control position recorded on the FDR for various elevator control system
configurations. Another purpose of the tests was to observe which elevator control system
stops were contacted in each system configuration when the control column was pushed
full forward.

1.16.1.1 Baseline Configuration

For the baseline configuration, the elevator control system was rigged according to
the Beech 1900D AMM revised elevator control system rigging procedure (section 27-30-02).
When the control column was at neutral, the elevator deflection was 0° (as measured by
Raytheon Aircraft’s master travel board), and the pitch control position recorded on the
FDR was 0.1° AND. When the control column was moved full forward, the elevator
deflection was 14.5° AND (as measured by the travel board), the pitch control position
recorded on the FDR was 14.6° AND, and the elevator control system made contact with
the primary stop at the elevator control horn.

1.16.1.2 Turnbuckle Length Adjustments

The test airplane’s elevator cable turnbuckles were adjusted a total of 3.1 inches to
replicate the accident airplane’s 9° AND shift. To achieve this shift, the test airplane’s
elevator cable turnbuckles were adjusted to matching lengths while maintaining proper
cable tension. The elevator was held at the 4° AND position (to replicate the accident
airplane’s premaintenance pitch control position values during cruise flight), and the
turnbuckles were adjusted until the FDR showed that the control column position was
13° AND (to replicate the accident airplane’s postmaintenance pitch control position
cruise values).

While the turnbuckles were being adjusted, the control column moved forward,
and the travel board showed that the elevator did not move, as designed. When the
elevator was released, the control column moved forward and stopped when the elevator
reached 6.8° AND, but the pitch control position recorded on the FDR was 16.3° AND.
The elevator control horns no longer made contact with the primary stops; instead, the
forward bellcrank rested on the secondary stop.

® The complete results of the July 2003 ground tests can be found in the public docket for this accident,
DCA03MA022, on the Safety Board’s Web site at <http://www.ntsb.gov>. See the Systems Group Factual
Addendum for Ground Tests at Raytheon Aircraft Company on July 29-31, 2003. On January 21 and 22,
2003, a set of less extensive ground tests was performed at Raytheon’s Wichita facility on the pitch control
system of another Beech 1900D, N116YV. The results of the January 2003 ground tests can be found in the
Systems Group Factual Report in the public docket for this accident.

“4 The 4° AND position is typical for cruise flight.



Appendix D 202 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANUAL

Te=(T up + T down)/2

Example:

T up = 57 Ibs., T down = 75 Ibs.

Te = (T up + T down)/2

Te = 57 +75 = 132 = 66 Ibs. = acceptable
2 2

p. Compare the combined tension load to cable tension graph. Refer to Figure 203.

q. Ifthe combined tension load is above the maximum range, start the procedures.over and
set cable tension at the minimum, or shorten the pushrod of the forward elevator bellcrank and
repeat Steps | through p.

r._ Install lock clips on turnbuckles.
s. Remove the rig pin from the aft elevator belicrank.

t. Set the forward elevator bellcrank stop bolts for a clearance of 0.37 + 0.06 inch. Refer to
Figure 202.

u. Verify the bob weight stop bolt clearance is 0.5 + 0.06 inch. Adjust the stop bolt, if
necessary. Refer to Chapter 27-30-01, Figure 201. The push-pull tube assembly between the
control column and the forward elevator bellcrank may need to be adjusted to achieve the
required clearance (refer to Step e).

v. The forward elevator bellcrank stop bolt is to make contact before the bob weight stop
bolt makes contact with the bob weight. In order to verify that the forward bellcrank bolt makes
contact before the bob weight stop bolt makes contact with the bob weight it may be necessary
to disconnect the pushrods at the elevator horns in order to allow enough travel to verify this
action, Reconnect the pushrods after this contact has been verified.

w. Gust Lock Pin Check - Install the gust lock pin. Verify the elevator is 7° to 15° down (the
elevator does not need to be on the down stop with the gust lock pin installed). However, if the
elevator is full down and resting on the primary stops, the force required to push on the pilot's
control wheel while inserting the gust lock pin must be a maximum of ten pounds. If the force is
too high, adjust (shorten) the push-pull tube per Step e, then repeat Step u to check the bob
weight clearance. Remove the gust lock pin.

x. Connect the autopilot servo cables to the elevator primary contro! cables. Refer to
Chapter 22

y. Perform the CONTROL COLUMN SUPPORT ROLLER INSPECTION procedure of this
Chapter.

Page 7 of 8
Temporary Revision No. 27-7 Feb 12/03



Factual Information

71

Aircraft Accident Report

Table 6. Federal Aviation Administration Notice 8400.40 survey results by operator.

Average Average

Average carry-on Number of checked Number of

adult Number of baggage carry-on baggage checked

weight adults in weight bags in weight bags in

Operator (pounds) sample (pounds) sample (pounds) sample
A 200.00 3,018 20.00 1,538 30 2,510
B 177.86 148 * * 24 211
Cc 192.60 326 11.03 297 29.88 485
D 184.00 66 9.00 30 24.00 120
E 192.00 739 15.80 488 25.50 828
F 193.60 106 13.90 90 34.00 171
G 164.00 16 5 86 27.29 7
H 193.57 106 13.93 90 33.98 171
I 199.10 132 16.90 108 24.70 125
J 165.00 179 * * * *
K 196.00 365 7 222 * *
L 190.00 216 78 215 24.80 266
M 189.47 77 14.45 59.00 25.54 64
N 191.18 229 18.26 1 29.24 186
oO 187.90 396 14.70 485 30.80 378

Note: Operator “A" is Air Midwest. Operator “J” did not properly conduct the survey; thus, that operator's data are not
reflected in the survey results. The symbol * in this table indicates that the operator used actual weights.

Table 7. Federal Aviation Administration Notice 8400.40 survey results by category.

Category Average weight (pounds) Increase (pounds)
Average adult passenger 195.63 20.63
weight
Average carry-on baggage 15.72 5.72
weight
Average checked baggage 28.81 3.81
weight

If the average sample weights were greater than the average weights in the
operators’ weight and balance program, the operators were to use the new average
weights. If an operator thought that the increased weights were inappropriate, then the
operator could either conduct a new validation survey using the criteria prescribed in
AC 120-27C to determine new average weights or use actual weights. At the public
hearing on this accident, an FAA air safety investigator from the Air Carrier Operations
Branch stated that all 15 operators that used average weight programs adjusted the weights
in one or more categories by 5 to 25 percent.



Factual Information 81 Aircraft Accident Report

The Safety Board’s investigation of the FAA’s oversight of ValuJet Airlines
revealed that inspectors from the Aircraft Maintenance Division within the Office of
Flight Standards had recommended recertification of the airline 3 months before the
accident. Specifically, in a February 14, 1996, summary report, the inspectors indicated,
“consideration should be given to an immediate FAR 121 recertification of this airline”
because of safety-related issues, such as the absence of adequate policies and procedures
for maintenance personnel. The inspectors also indicated that the overall surveillance of
ValuJet Airlines should be increased with special attention directed toward “manuals and
procedures, structural inspections, the adequacy of the maintenance program, and shops
and facilities.”

The Safety Board determined that the probable causes of this accident were (1) the
failure of SabreTech to properly prepare, package, and identify unexpended chemical
oxygen generators before presenting them to ValuJet for carriage; (2) the failure of ValuJet
to oversee its contract maintenance program to ensure compliance with maintenance,
maintenance training, and hazardous materials requirements and practices; and (3) the
failure of the FAA to require smoke detection and fire suppression systems in class D
cargo compartments.

Contributing to the accident was the failure of the FAA to adequately monitor
ValuJet’s heavy maintenance programs and responsibilities, including ValuJet’s oversight
of its contractors, and SabreTech’s repair station certificate; the failure of the FAA to
adequately respond to prior chemical oxygen generator fires with programs to address the
potential hazards; and ValuJet’s failure to ensure that both ValuJet and contract
maintenance facility employees were aware of the carrier’s “no-carry” hazardous
materials policy and had received appropriate hazardous materials training.’

1.18.4.2.1 Safety Recommendation A-97-70

During its investigation of the ValuJet Airlines flight 592 accident, the Safety
Board determined that the SabreTech mechanics had many shortcomings, including their
failure to install safety caps, their improper maintenance entries, their use of improper
tags, and their inadequate communications between the maintenance shop floor and stores
department. In its final report on the accident, the Board indicated that these shortcomings
resulted from human failures that might have been avoided if more attention were given to
human factors issues in the maintenance environment. As a result, the Board issued Safety
Recommendation A-97-70 on September 9, 1997. Safety Recommendation A-97-70
asked the FAA to

Include, in its development and approval of air carrier maintenance procedures
and programs, explicit consideration of human factors issues, including training,
procedures development, redundancy, supervision, and the work environment, to
improve the performance of personnel and their adherence to procedures.

19 For more information, see National Transportation Safety Board, In-flight Fire and Impact With
Terrain, ValuJet Airlines Flight 592, DC-9-32, N904VJ, Everglades, Near Miami, Florida, May 11, 1996,
Aircraft Accident Report NTSB/AAR-97/06 (Washington, DC: NTSB, 1997).



Factual Information 36 Aircraft Accident Report

along the seat track and the subject pulled the control wheel full aft and rotated it
clockwise, the control wheel did not contact the seatbelt buckle. When the captain’s seat
was in the full forward and full up position and the subject pulled the control wheel full aft
and rotated it clockwise, the control wheel contacted the seatbelt buckle and released it.

In addition, the locking pawls from the captain’s and the first officer’s seatbelt
buckles, as well as those from another Air Midwest seatbelt buckle (which had been
removed from service), were examined by microscope at the Safety Board’s Materials
Laboratory. The locking pawls on the captain’s seatbelt buckle did not show any
significant witness marks. The locking pawls on the first officer’s seatbelt buckle showed
impression marks. The locking pawls on the other Air Midwest seatbelt buckle showed
minor wear but no impression marks.

More than 10 years before the flight 5481 accident, engineers from Pacific
Scientific and The Boeing Company designed a guarded seatbelt buckle with a protective
circular guard around the rotary vanes of the seatbelt to prevent the inadvertent release of
the restraint. Because unguarded rotary seatbelt buckles pose an unnecessary safety risk to
flight crewmembers since the buckles may become unlatched, the Safety Board issued
Safety Recommendation A-03-57 on January 2, 2004. Safety Recommendation A-03-57
asked the FAA to “identify all airplanes equipped with unguarded flight crewmember
rotary seatbelt buckles and require replacement with guarded buckles that cannot be
inadvertently unlatched.”

1.12.3 Engines

The left engine was lying upright immediately forward of the engine nacelle and
was displaced about 45° to the left of the airframe centerline. The right engine was lying
on its right side forward of the left wing center spar and was displaced about 90° to the left
of the airframe centerline.

Both propeller assemblies were found outside the main wreckage area and separate
from their respective engines. No impact marks were found on the left propeller assembly
that could positively determine the exact blade pitch angle at the time of the accident.
However, the position of the cylinder buckles around the piston suggested that the piston
was not in reverse or in feather but was at some point within the propeller blade operating
range. One impact mark (a puncture hole) found on the right propeller assembly’s spinner
was consistent in size and shape with a blade counterweight. According to Hartzell
Propeller, the location of the puncture hole in relation to the blade plane of rotation
corresponded to a blade pitch angle of about 22°.

3 The captain’s seat was found in this seat track position, but the seat height could not be determined
because of the damage to the seat.

54 During the on-site investigation of this accident, an Air Midwest Beech 1900 pilot informed the
Safety Board that he had experienced the uncommanded release of his seatbelt when the control wheel was
pulled aft, striking one of the buckle’s vanes. In addition, the Air Line Pilots Association reported five
instances of a pilot’s seatbelt becoming unbuckled when the control wheel was pulled aft and the wheel, or a
clipboard attached to the wheel, contacted a buckle vane.


Analysis 122 Aircraft Accident Report

check the cargo bin, count the number of bags, and look at the size of the bags and then
compare the findings with the information on the load manifest. If the FAA had provided
effective oversight by performing a survey to determine the average passenger and
baggage weights, it would have realized that these weights were significantly different
from the average passenger and baggage weights in Air Midwest’s program and in
AC 120-27C. For example, FAA Notice 8400.40, which was issued less than 3 weeks after
the flight 5481 accident, required 14 CFR Part 121 air carriers with 10- to 19-passenger
seat airplanes and average weight programs (including Air Midwest) to survey passenger
and baggage weights. The survey results showed that the average adult passenger, average
carry-on baggage, and average checked baggage weights were greater than the average
weights included in AC 120-27C by almost 21, 6, and 4 pounds, respectively. As a result,
all 15 operators that were required to participate in the survey had to adjust the weights in
one or more categories of their average weight program by 5 to 25 percent.'°°

It is very likely that, if the FAA had conducted such a survey in 2001 before
approving Air Midwest’s weight and balance program, the FAA could have easily
discovered that the average weight assumptions in its weight and balance program
guidance were flawed. Thus, the Safety Board concludes that the FAA’s average weight
assumptions in AC 120-27C, “Aircraft Weight and Balance Control,” were not correct.

As demonstrated by the results of the FAA Notice 8400.40 survey, periodic
sampling can easily identify and track changing trends in passenger or baggage weights.
Periodic sampling of passenger and baggage weights can also identify and track regional,
seasonal, or passenger demographic variances that may result in loadings that are
significantly different from those based on average weights. In addition, periodic sampling
can identify and track those aircraft or routes that carry passengers or baggage with
weights that are significantly different from the average weights. Analysis of the survey
results would provide a sound basis for future adjustments to average weights so that they
would more closely reflect actual passenger and baggage loads.

The Safety Board concludes that periodic sampling of passenger and baggage
weights would determine whether air carrier average weight programs were accurately
representing passenger and baggage loads. Therefore, the Safety Board believes that,
unless an actual weight program is developed and implemented, the FAA should establish
a weight and balance program that requires 14 CFR 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. In
addition, the Safety Board believes that the FAA should establish a program to
periodically review 14 CFR Part 121 air carrier weight and balance data to ensure that
regional, seasonal, demographic, aircraft, and route trends among carriers are valid.
Further, the Safety Board believes that the FAA should require 14 CFR 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 should audit these data as
necessary.

150 Recent international survey data (see section 1.18.6.3) substantiate the trend of increasing passenger
and carry-on baggage weights.


Analysis 106 Aircraft Accident Report

worked the day shift at the time, so he was not present when the maintenance work was
actually being performed.

As stated in section 2.3.3, 14 CFR 121.367 requires aircraft maintenance,
preventive maintenance, and alterations to be performed in accordance with an air
carrier’s maintenance manual. Also, AC 120-16D indicates that it is the air carrier’s
responsibility to make sure that a contractor is performing maintenance according to the
air carrier’s maintenance program and maintenance manual. Thus, although the SMART
mechanic decided to skip several steps in the elevator control system rigging procedure
and the RALLC quality assurance inspector concurred with the mechanic’s decision to
skip steps, it was still Air Midwest’s responsibility to ensure that its maintenance manual

was being followed.

In its final report on the ValuJet Airlines flight 592 accident, the Safety Board
recognized that air carriers could successfully subcontract maintenance. However, the
Board noted that air carriers engaging in subcontracting had to properly oversee their
contractors to ensure the airworthiness of their airplanes. The Board stated that, although
subcontractors bear independent responsibility for their activities, an air carrier cannot
delegate its responsibility for the safety of its operations and maintenance to its
subcontractors. The Board concluded that ValuJet failed to adequately oversee SabreTech
(a heavy maintenance contractor) and that this failure was causal to the accident.

The Air Midwest flight 5481 accident presents another example of an air carrier
that did not adequately oversee airplane maintenance being performed by contractors.
Title 14 CFR 121.363 states that an air carrier is responsible for ensuring the airworthiness
of the aircraft it operates and that an air carrier is not relieved of this responsibility when
maintenance is contracted to another party. Also, 14 CFR 121.367 states that an air carrier
is responsible for determining that each aircraft released to service is airworthy and has
been properly maintained. Thus, although the SMART mechanic incorrectly rigged the
accident airplane’s elevator control system and the RALLC quality assurance inspector
failed to detect the problem, Air Midwest was ultimately responsible for returning the
airplane to service in an airworthy condition.

The Safety Board concludes that Air Midwest did not adequately oversee the work
performed by RALLC and SMART personnel at its HTS maintenance station and did not
ensure that the accident airplane was returned to service in an airworthy condition.

2.5.1.1 Required Inspection Item Maintenance Tasks and Inspections

Air Midwest’s Maintenance Procedures Manual states that elevator control system
rigging is a required inspection item (RII), which means that maintenance work performed
on the system must be inspected before the airplane can be returned to service. Title 14
CFR 121.371(c) states, “no person may perform a required inspection if [that person]
performed the item of work required to be inspected.” The aircraft maintenance record of
nonroutine items for January 6, 2003, at HTS showed, in a discrepancy block about the
airplane’s low elevator cable tension, an RII stamp and the quality assurance inspector’s
stamp (see figure 2 in section 1.1.1).



Analysis 115 Aircraft Accident Report

Maintenance procedures are developed and are expected to be followed to ensure
that maintenance work is properly performed. When a maintenance procedure contains
multiple steps that are not applicable to the airplane on which a mechanic is working,’ a
mechanic may decide to skip applicable steps. Although well-trained mechanics may be
more capable of distinguishing between steps that are and are not applicable to a particular
aircraft than mechanics with less training, maintenance procedures should be written so
they minimize the possibility that any mechanic would need to make such distinctions.
Exrors can be made if applicable steps are skipped along with inapplicable steps, as
demonstrated by the elevator control system maintenance on the accident airplane.
Mechanics would be less likely to skip applicable steps and more likely to follow a
maintenance procedure in its entirety if the procedure were well written.

The FAA has sponsored human factors research regarding the quality of
maintenance procedures and instructions, and this research has found a link between the
usability of maintenance procedures and the likelihood that mechanics will follow the
procedures. For example, a 2002 survey’ found that only 18 percent of mechanics
thought that their organization’s maintenance manual described the best way to perform a
maintenance procedure. The survey also found that 62 percent of the mechanics had
performed maintenance using methods that they considered to be better than those
detailed in their organization’s written procedures. The results of the survey suggest that
the usability of work cards may be a factor affecting whether mechanics will adhere to
their organization’s accepted procedures when performing maintenance.

In its final report on the Emery Airlines flight 17 accident, the Safety Board
determined that unclear maintenance work card instructions might have contributed to
maintenance errors involved in that accident. The Board concluded that all air carriers
should provide maintenance personnel with more detailed information regarding the steps
or actions that are necessary to satisfactorily accomplish a maintenance task. Also, the
Board issued Safety Recommendation A-03-31, which asked the FAA to “require all
14 CFR Part 121 air carrier operators to revise their task documents and/or work cards to
describe explicitly the process to be followed in accomplishing maintenance tasks.”

The mechanics’ failure to follow the general guidance provided on Air Midwest’s
D6 work card and in the Beech 1900D AMM supports the need for the actions
recommended in Safety Recommendation A-03-31. However, Safety Recommendation A-03-31
focused only on the role of the air carrier in revising work cards and did not consider the
safety benefit of involving the aircraft manufacturer in the process of reviewing and
revising maintenance procedures. Placing this responsibility solely on air carriers raises
the possibility that individual carriers could identify deficiencies in flight-critical

\4| Three steps in section 27-30-02 were not applicable to the accident airplane. Two steps pertained to
the autopilot, but the airplane was not equipped with an autopilot. One step pertained to the removal of
passenger seats and passenger cabin floorboards, but the airplane’s elevator cable turnbuckles were not
located beneath those components.

12 4 Chaparro, and L.S. Groff, “Human Factors Survey of Aviation Maintenance Technical Manuals,”

Proceedings of the 16th Human Factors in Aviation Maintenance Symposium (Washington, DC: FAA,
2002).



Appendix D 203 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANUAL

z. On aircraft equipped with the F1000 Flight Data Recorder, calibrate the Pitch Position
Potentiometer. Perform the FLIGHT DATA RECORDER (FDR) - PITCH ADJUSTMENT
procedure. Refer to Chapter 31-30-00.

NOTE

IF A FA2100 FLIGHT DATA RECORDER SYSTEM IS INSTALLED ON THIS
AIRCRAFT, PERFORM THE LINK INSTALLATION PORTION OF THE ELEVATOR
SURFACE POSITION SYNCHRO TRANSMITTER (SENSOR) REMOVAL
PROCEDURE..REFER TO CHAPTER 31-31-12 IN THE BEECH 1900D AIRLINER
FLIGHT DATA RECORDER (FA2100) MAINTENANCE MANUAL SUPPLEMENT,
P/N 129-590000-109.

aa.Move the control wheel aft and verify the elevator moves up 20° +1°/-0° and that the
surface stops make contact. Move the contro! wheel forward and verify the elevator moves
down 14° +1°/-0° and that the surface stops make contact, If these requirements are not met,
repeat this rigging procedure in its entirety.

ab. Remove the travel boards from the horizontal stabilizers, install floorboards, copilot's
seat, and replace access panels.

Page & of €
Feb 12/63 Temporary Revision No. 27-7



Analysis 120 Aircraft Accident Report

approves them in writing or sends them back to the carrier for revision and resubmission.
FAA staff indicated that managing the content of, and ensuring compliance with, air
carrier training programs that are not approved (such as maintenance training programs)
can be more difficult than for programs that are approved. As a result, the FAA’s oversight
of maintenance training programs may not be as effective as its oversight of air carrier
training programs that are required to be approved.

The Safety Board concludes that, because proper aircraft maintenance is crucial to
safety, air carrier maintenance training programs should be subject to the same standard
that exists for other air carrier training programs (that is, FAA approval). Therefore, the
Safety Board believes that the FAA should require that all 14 CFR Part 121 air carrier
maintenance training programs be approved.

2.5.2.3.1 Programs to Reduce Human Error in Aircraft Maintenance

The FAA’s research program on human factors in aviation maintenance has
primarily resulted in the publication of guidance material and the promotion of voluntary
human factors programs for the aviation industry. The Safety Board commends the FAA
for its efforts to address issues related to human factors in aviation maintenance. However,
major maintenance-related airplane accidents in the United States during the past decade
(see section 1.18.4) suggest that the guidance for voluntary human factors programs may
be insufficient to prevent accidents resulting from human error in aviation maintenance.

The Safety Board concludes that the lessons learned by the FAA through its human
factors research program need to be used to develop mandatory programs to prevent
human error in aviation maintenance. Therefore, the Safety Board believes that the FAA
should require that 14 CFR Part 121 air carriers implement comprehensive human factors
programs to reduce the likelihood of human error in aviation maintenance.

2.5.2.4 Oversight of Weight and Balance Programs

As stated in section 2.4.1, flight 5481 clearly exceeded the Beech 1900D certified
weight limit of 17,120 pounds and aft CG limit of 40 percent MAC, even though the flight
crew adhered to Air Midwest’s weight and balance program in effect at the time of the
accident. In addition, even Air Midwest’s revised weight and balance program could
result, in certain conditions, in an airplane operating with an unacceptably aft CG position.

The Air Midwest weight and balance procedures used by the flight crew were
based on the use of average weights for the flight crewmembers, crew baggage,
passengers, personal items, carry-on baggage stored in the cabin, checked baggage, and
carry-on baggage checked at the airplane and stored in the AFT1 cargo compartment. The
Air Midwest average passenger and checked baggage weight values were consistent with
the FAA guidance detailed in AC 120-27C, “Aircraft Weight and Balance Control,” and
Flight Standards Handbook Bulletin for Airworthiness 95-14 and Flight Standards
Handbook Bulletin for Air Transportation 95-15, “Adherence to Advisory Circular 120-27C,
‘Aircraft Weight and Balance Control.’”” However, as demonstrated by the flight 5481
accident, these values did not ensure that the airplane would be operating within its
certified weight and CG envelope.



Aircraft Accident Report

144

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Aircraft Accident Report

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National ‘Transportation Safety Board. 2004. Loss of Pitch Control During Takeoff, Air Midwest
Flight 5481, Raytheon (Beechcraft) 1900D, N233YV, Charlotte, North Carolina, January 8, 2003.
Aircraft Accident Report NTSB/AAR-04/01. Washington, DC.

Abstract: This report explains the accident involving Air Midwest (doing business as US Airways
Express) flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, which crashed shortly after takeoff from
Charlotte-Douglas International Airport, Charlotte, North Carolina. The safety issues discussed in this
report include maintenance work practices, oversight, and quality assurance; maintenance training; aircraft
weight and balance programs; Federal Aviation Administration oversight; and cockpit voice recorders on
Beech 1900D airplanes.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board
Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study
transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board
makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also
may be obtained from the Web site or by contacting:

National Transportation Safety Board
Public Inquiries Section, RE-S1

490 L’Enfant Plaza, S.W.
Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To
purchase this publication, order report number PB2004-910401 from:

National Technical Information Service
5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports
related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.



138 Aircraft Accident Report

Appendix B
Cockpit Voice Recorder Transcript

The following is the transcript of the Fairchild A-100A cockpit voice recorder,
serial number 61979, installed on Air Midwest flight 5481, a Raytheon (Beechcraft)
1900D, N233YV, which experienced a loss of pitch control during takeoff from Charlotte,
North Carolina, on January 8, 2003.

RDO Radio transmission from accident aircraft, Air Midwest 5481
CAM Cockpit area microphone voice or sound source

PA Voice or sound heard on the public address system channel
HOT Hot microphone voice or sound source’

For RDO, CAM, HOT, and PA comments:

1 Voice identified as the Captain

2 Voice identified as the First Officer

3 unidentified male voice - Ramp employee
4 unidentified female voice - Ramp employee
5 recorded human voice — Auto Briefer

-? Voice unidentified

RMP1 Radio transmission from north ramp control at Charlotte

RMP2 Radio transmission from outbound ramp control at Charlotte
GND Radio transmission from ground control at Charlotte

TWR Radio transmission from the Air Traffic Control Tower at Charlotte
* Unintelligible word

Non-Pertinent word
& Third party personal name (see note 5 below)

# Expletive

‘ This recording contained audio from Hot microphones used by the flightcrew. The voices or sounds on
these channels were also, at times, heard by the CVR group on the CAM channel and vice versa. In these
cases, comments are generally annotated as coming from the source (either HOT or CAM) from which
the comment was easiest to hear and discern.



Analysis 99 Aircraft Accident Report

The quality assurance inspector stated that, after he verified that the forward
bellcrank rig pin had been inserted (he did not actually observe the rig pin being inserted),
he left the mechanic unsupervised during the elevator control cable inspections and
turnbuckle adjustments. The quality assurance inspector indicated that he had to conduct
other duties, which included providing OJT to another mechanic and performing a
borescope inspection on an engine. The inspector also indicated that he returned to inspect
the elevator control system after the mechanic had completed his work. (Section 2.3.4
provides information about the inspector’s inspection.)

Even though the mechanic possessed previous flight control rigging experience, he
had never performed rigging work on the Beech 1900D airplane. As a result, the mechanic
needed more training and supervision than the quality assurance inspector had provided. It
would have been prudent for the quality assurance inspector to have described the
components of the elevator control system; explained the steps in the rigging procedure,
demonstrated the critical steps, and insisted that all steps needed to be accomplished; and
observed the mechanic while he examined the elevator control cable tensions and
performed the rigging work.

The insufficient training and supervision resulted in the mechanic making mistakes
that led to the incorrect rigging and the restricted downward elevator travel. If the quality
assurance inspector had provided better training and supervision, the likelihood of such
errors would have been minimized. The Safety Board concludes that the RALLC quality
assurance inspector did not provide adequate OJT and supervision to the SMART
mechanic who examined and incorrectly adjusted the elevator control system on the
accident airplane.

2.3.3 Skipped Steps in the Elevator Control System Rigging
Procedure

The Beech 1900D elevator control system rigging procedure (section 27-30-02)
does not include provisions for adjusting cable tension as an isolated task. However, the
mechanic decided to adjust the cables as an isolated task and, as a result, did not follow
each step included in the rigging procedure. The quality assurance inspector was aware
that the mechanic was selectively performing steps from the rigging procedure and that he
was only adjusting cable tension. In fact, the inspector stated, during a postaccident
interview, that he did not think the manufacturer intended for mechanics to follow the
entire rigging procedure and that the entire procedure had not been followed when past
cable tension adjustments were made.



Factual Information 59 Aircraft Accident Report

auditor, the Air Midwest regional site manager responded to the audit findings. The letter
stated that the following corrective actions had been accomplished:

+ All of the items on the mechanics’ OJT training that were signed off by the
mechanic but not the instructor had been corrected. The Air Midwest regional
site manager indicated that he explained to the mechanics that, when they sign
for something in their OJT records, the instructor has to sign at the same time.

* The RALLC site manager comes to work for a verbal turnover before the
foreman leaves. The foreman also provides a daily written turnover.

* RALLC was hiring more people so that the total number of maintenance
personnel at HTS would increase from 9 to 11.

* The Air Midwest regional site manager verified that all manual revisions that
HTS received were added to the maintenance manuals and were properly
documented. He also ensured that all manuals were up to date.

1.17.1.4 Postaccident Actions

In February 2003, Air Midwest reassigned the HTS regional site manager to work
the night shift so that his work schedule would be aligned with those of the RALLC and
SMART maintenance personnel. (The regional site managers at the other Air Midwest
maintenance stations were also reassigned to work the night shift.) The regional site
manager stated that the change in shift allowed him to be present at HTS when work was
being performed but prevented him from participating in the maintenance calls. (The
RALLC site manager still worked the day shift; thus, his work schedule still did not align
with the overnight shift of the regional site manager, quality assurance inspector, foreman,
and mechanics.)

Air Midwest removed the quality assurance inspector’s authorization to perform
maintenance and RII inspections on company airplanes. The quality assurance inspector is
still employed by RALLC but is working as a mechanic at the Dubois maintenance
station. Air Midwest also removed the mechanic’s authorization to perform maintenance
on company airplanes. The mechanic no longer works for SMART. The RALLC site
manager is still employed by RALLC but now works as a mechanic at the Panama City
maintenance station. In addition, Air Midwest gave disciplinary time off to another
SMART mechanic and the primary quality assurance inspector at HTS because they
falsely indicated on the mechanic’s OJT record that he had completed training on the D6
aft fuselage/empennage inspection procedure on January 6, 2003. (The primary quality
assurance inspector was not on duty on the night of January 6th. The mechanic inspected
and checked the engines but did not perform the entire D6 maintenance procedure,
including the elevator check.) The mechanic and primary quality assurance inspector were
subsequently retrained and then reinstated to their former positions.

In a February 12, 2003, letter to the Safety Board, the Air Midwest Vice
President/Director of Maintenance expressed the air carrier’s concerns regarding the
manufacturer’s elevator control system rigging procedure. The letter stated, “a review of
the Raytheon Aircraft Beech 1900D Maintenance Manual revealed a lack of explicit



Factual Information 45 Aircraft Accident Report

weight (in the coat closet and the AFT1 and AFT2 cargo compartments); and the fuel
weight. The information sources for the airplane component weights used in the Board’s
weight and balance study are shown in table 3.

Table 3. Information sources for airplane component weights.

Air

Midwest FAA

average | Medical | medical | Next | Wreckage | Actual Load | Dispatch
Component | weights | examiner | certificate | of kin | evidence | weights | manifest! release
Airplane x
empty weight
Crew weight x x x
Crew xX x
baggage
weight
Passenger xX x xX
weight
Carry-on xX xX
baggage
weight
Checked x x
baggage
weight (AFT1)
Cargo weight x
(AFT2)
Coat closet x
weight
Fuel weight x

Note: The Air Midwest average weight program in effect at the time of the accident is discussed in section 1.18.1.2.

The results of the airplane component buildup method for flight 5481’s weight and
CG position were based on the following: the airplane operating empty weight reported on
maintenance records; the flight crew and passenger weights documented by the medical
examiner; the dry weight of personal effects and the dry weight of checked, carry-on, and
crew baggage;® 45 pounds in the AFT2 cargo compartment (the actual weight of a tire
stored in the compartment); 10 pounds in the coat closet; and 2,310 pounds of fuel. On the
basis of this information, the Safety Board estimated that flight 5481 had a minimum gross
takeoff weight of 17,443 pounds and a CG position of 43.3 percent MAC, which was
outside of the Beech 1900D weight and CG envelope.

® The weight of checked, carry-on, and crew baggage; personal effects; and manuals and logs was
1,384 pounds. Because the weight for these items included the weight of AFFF, the items were dried and
reweighed, and the dry weight was 1,199 pounds.



Aircraft Accident Report

166

Appendix B

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94 Aircraft Accident Report

2. Analysis

2.1 General

The captain and the first officer were properly certificated and qualified under
Federal regulations. No evidence indicated any preexisting medical or behavioral
conditions that might have adversely affected their performance during the accident flight.
Flight crew fatigue was not a factor in this accident.

The accident airplane was properly certified and equipped in accordance with
Federal regulations. Except for the elevator control system (which is discussed in section 2.3),
no evidence indicated that the airplane was improperly maintained. The recovered
components showed no evidence of any preexisting structural, engine, or systems failures.

Weather was not a factor in this accident. The air traffic controllers that handled
the accident flight were properly trained and provided appropriate air traffic control
services. The emergency response for this accident was timely and effective. The accident
was not survivable for the airplane occupants because they were subjected to impact
forces that exceeded the limits of human tolerance.

This analysis discusses why the flight crew lost control of the airplane during its
takeoff rotation and initial climb and what effect the airplane’s elevator and center of
gravity (CG) had on this accident. The analysis also examines organizational and
management issues that played a role in the circumstances of this accident and provides
information about an ongoing problem with cockpit voice recorders (CVR) installed on
Beech 1900 series airplanes.

2.2 Loading and Preflight Activities

On the day of the accident, the accident first officer was seen conducting a
walk-around inspection of the airplane. He did not report anything unusual about the
airplane, including its elevator control system.!?°

The accident flight crew filled out the Air Midwest Beechcraft 1900D Load
Manifest form for the flight using the average weight values for passengers and baggage
in Air Midwest’s weight and balance program at the time of the accident.'° The load

25 The three previous flight crews who flew the accident airplane also did not report anything unusual
about the elevator control system. In fact, the first officer of the flight from Huntington, West Virginia
(HTS), to Charlotte, North Carolina, on January 7, 2003, stated that “everything was normal” and “it was a
good flying airplane.”

126 The flight crew made a 10-pound addition error when summing the weights that comprise the zero
fuel weight. This addition error was not a factor in the accident.



Factual Information 19 Aircraft Accident Report

The control column pivots forward and aft on bearings near the cockpit floor. A
bob weight, attached through an interconnect link to the control column, provides control
column feel and flight control stability. The bob weight installation has a tertiary down
stop bolt.

The FDR pitch control position sensor is located beneath the cockpit floor. The
sensor is attached to structure located to the left of the base of the control column (looking
forward). One rubber-cushioned, steel-band clamp (called an Adel clamp) holds the sensor
to the structure. The sensor is connected to the elevator system by a short rod that extends
from the sensor to a bracket attached to the lower part of the control column.

1.6.1.1 Pitch Trim Control System

The accident airplane was equipped with a mechanically operated pitch trim
control system. The pitch trim control system includes a single movable trim tab*° for each
elevator and a cable-driven jackscrew actuator for each tab. The trim tabs, which are
located on the inboard trailing edge of each elevator, relieve the force a pilot must hold on
the control wheel to provide longitudinal control (for example, angle of attack or pitch) of
the airplane. According to the Beech 1900D AMM, the trim tabs move from 5.75° £0.25°
up to 17° +0.5° down. Movement of the trim tabs in the downward direction creates an
upward aerodynamic moment on the elevator and results in an ANU pitching moment.

1.6.2 Maintenance Program

The Air Midwest Maintenance Program Manual describes the company’s
Continuous Airworthiness Maintenance Program. This program incorporates guidance
from the Beech 1900D AMM. The program includes the following inspections:

* Periodic service check. This check is accomplished during an airplane’s
layover when applicable. The check involves a visual inspection of
safety-of-flight items and servicing when necessary.

* Routine check. This check is performed every 100 flight hours. The check
includes a visual inspection and servicing of the airplane’s major components.

* Detail check. This check is divided into six different phases, known as detail
one through detail six, and a different phase is performed every 200 hours
along with a routine check. One major airplane section is inspected during each
phase. Detail one covers the wings, detail two covers the powerplants, detail
three covers the flight compartment and cabin, detail four covers the
environmental systems and nose, detail five covers the landing gear, and detail
six covers the aft fuselage and empennage. Details one through six comprise
one full cycle, and an airplane must complete one full cycle each year.

* Structural check. This check is accomplished when the airplane has
accumulated 12,000 flight hours and then every 3,000 flight hours afterward.

°° The trim tabs on the Beech 1900D are geared tabs, which move in relation to the position of the
elevator.



Factual Information 15 Aircraft Accident Report

side of the fuselage and three emergency exits, two of which were on the right side of the
cabin (at rows 4 and 6) and one of which was on the left side of the cabin (at row 6). The
airplane also had a cargo door on the left aft side of the fuselage. The cargo storage area
began at the partition immediately aft of the triple passenger seat and extended almost to
the aft pressure bulkhead. According to Raytheon Aircraft Company, the airplane’s
interior was installed in 1996 and was certified to meet Federal material flammability
requirements,

The accident airplane was equipped with two Pratt & Whitney Canada PT6A-67D
turbopropeller engines and Hartzell model HC-E4A-3I four-bladed, constant-speed,
full-feathering, reversible propellers. The PT6A-67D turbopropeller engine has a gas
generator module and a power turbine module. The HC-E4A-3I propeller is hydraulically
actuated and has model E10950 composite blades.

The left engine gas generator module, serial number 114328, was installed on the
accident airplane on November 2, 2001. At the time of the accident, the module had
accumulated 14,659 hours and 21,142 cycles since new and 2,445 hours and 3,319 cycles
since overhaul. The left engine power turbine module, serial number 114301, was installed
on the accident airplane on October 25, 2000. At the time of the accident, the module had
accumulated 14,557 hours and 21,514 cycles since new and 4,778 hours and 6,349 cycles
since overhaul.

The right engine gas generator module, serial number 114091, was installed on the
accident airplane on May 28, 2002. At the time of the accident, the module had
accumulated 18,447 hours and 25,612 cycles since new and 1,225 hours and 1,640 cycles
since overhaul. The right engine power turbine module, serial number 114343, was
installed on the accident airplane on May 24, 2002. At the time of the accident, the module
had accumulated 13,548 hours and 22,093 cycles since new and 1,225 hours and 1,640 cycles -
since overhaul.

The accident airplane was not equipped with an autopilot.

1.6.1 Pitch Control System

The Beech 1900D airplane is equipped with a mechanically operated pitch control
system.”’ The three primary elements of the pitch control system are the elevators, the
control column, and the connecting rods and cables. The elevators (left and right) are
attached to the trailing edge of the horizontal stabilizer, which is mounted on top of the
vertical stabilizer in a T-tail configuration. A pilot pushes forward on the control column
to move the elevator trailing edges down (resulting in the airplane pitching AND) and
pulls back on the control column to move the elevator trailing edges up (resulting in the
airplane pitching ANU). Figure 3 shows the elements of the pitch control system, and
figure 4 shows a side view of the airplane’s tail section.

27 The terms “pitch control system” and “elevator control system” are used synonymously in this
report,



Analysis 98 Aircraft Accident Report

resting position is between 14° and 15° AND; after the misrig, the elevator resting position
was about 7° AND. Because the horizontal stabilizer on a parked Beech 1900D is located
about 15 feet above the ground, it would be difficult to detect the change in the elevator
resting position from the ground. In fact, during ground tests, Safety Board investigators,
while on the ground, observed the test airplane’s elevator before and after the elevator
control system was misrigged. The investigators did not observe a conspicuous change in
the elevator resting position. The ground tests also showed that, in both rigging positions,
the control column was fully forward. When the control column was pulled fully aft, the
range of total control column travel for the misrigged position was 1 inch less than for the
properly rigged position. However, the 1-inch reduction in the range of travel was not
noticeable to Board investigators.

The ground tests further showed that the only evidence during flight of the misrig
would have been a forward shift of the control column’s neutral (0°) position by about
0.72 inch. No control column markings or other visual indications would have alerted the
flight crew that the control column position corresponding to the elevator’s neutral
position had changed. In addition, three Beech 1900D type-rated pilots conducted control
sweeps (full forward and full aft movement of the control column) on a test airplane with
the elevator control system rigged according to the Beech 1900 AMM and then with the
system rigged to match the accident airplane. The pilots did not report any noticeable
change in the feel or position of the control wheel between the two sets of control sweeps.

The Safety Board concludes that the changes in the elevator control system
resulting from the incorrect rigging were not conspicuous to the flight crew.

2.3.2 Adequacy of On-the-Job Training Provided to the Mechanic

Five of the six SMART mechanics who were on duty on the night of January 6,
2003, had worked at HTS for less than 8 weeks. None of these mechanics had completed
training for the D6 maintenance check. The mechanic assigned by the foreman (the other
SMART mechanic on duty at HTS on January 6th) to perform the elevator control cable
check was selected for the task because he had previously accomplished flight control
rigging work on DHC-8 airplanes. The RALLC quality assurance inspector, who was
providing the mechanic’s OJT, stated that he did not think he needed to closely supervise
the mechanic because of his previous flight control rigging experience.

The mechanic stated that, before he inspected the elevator control system, the
foreman helped him locate the access panel for the forward bellcrank rig pin and the
elevator cable turnbuckles. The mechanic also stated that he and the quality assurance
inspector discussed the low cable tensions, the need to adjust the tensions, and the steps
that could be skipped. The mechanic indicated that the quality assurance inspector then
left to attend to other duties. The mechanic further stated that another mechanic held the
turnbuckles while he adjusted them and that the quality assurance inspector returned after
the rigging work was completed to observe the final check of the elevator control system.


Aircraft Accident Report

155

Appendix B

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Aircraft Accident Report

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Aircraft Accident Report

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Factual Information 27 Aircraft Accident Report

According to the Air Midwest Beech 1900D load manifest form for flight 5481,
the operating empty weight was 10,673 pounds,” the passenger weight was 3,325 pounds,
the weight in the coat closet was 10 pounds, the AFT1 cargo compartment weight was
775 pounds, the AFT2 cargo compartment weight was 45 pounds, the zero fuel weight
was 14,818 pounds, the fuel weight at takeoff was 2,200 pounds, and the gross takeoff
weight was 17,018 pounds. The flight crew made a 10-pound addition error when
summing the weights that comprise the zero fuel weight. As a result, the calculated zero
fuel weight was actually 14,828 pounds,” and the calculated gross takeoff weight was
actually 17,028 pounds. The Beech 1900D maximum gross takeoff weight is 17,120 pounds.

The load manifest form also indicated that the calculated CG index for the accident
flight was 81 (37.8 percent MAC). The Air Midwest CG takeoff limits range from indexes
of about 23 to 85 (16.7 to 39.2 percent MAC) when a Beech 1900D airplane is at a gross
takeoff weight of 17,028 pounds. The Beech 1900D aft CG limit is 40 percent MAC.

Table 2 shows information reported on Beech 1900D load manifest forms for
flights flown by the accident airplane after the January 6, 2003, D6 maintenance check.
The table shows that the accident flight was calculated to be the most aft loaded of all of
the postmaintenance flights. Table 5 in section 1.16.2.2 provides information from the
load manifest forms of selected flights before the D6 maintenance check.

Table 2. Weight and balance information for the 10 flights after maintenance.

Flight number and Gross takeoff CG (percent Number of Cargo

Date route weight (pounds) MAC)? passengers (pounds)
01-08-03 5481/CLT-GSP 17,028 37.8 19 820
01-08-03 5434/LYH-CLT 16,278 25.9 15 470
01-07-03 5461/CLT-LYH 15,118 19.6 6 195
01-07-03 5441/LYH-CLT 13,303 17.3 2 70
01-07-03 5441/CLT-LYH 14,528 19.0 3 120
01-07-03 5514/LWB-CLT 12,618 12.6 0 45
01-07-03 5514/CLT-LWB 14,653 20.8 7 345
01-07-03 5585/AHN-CLT 14,278 23.7 9 320
01-07-03 5585/CLT-AHN 14,413 24.2 5 455
01-07-03 5428/HTS-CLT 13,318 13.6 0 45

Note: The accident flight appears in bold face print. LWB, Greenbrier Valley Airport, Lewisburg, West Virginia; AHN,
Athens/Ben Epps Airport, Athens, Georgia.

*The CG indexes that correspond to these CG positions are 81, 48, 32, 28, 31, 19, 35, 42, 43, and 20, respectively.
* This figure includes the 10-pound addition error made by the flight crew on the load manifest form.

» The operating empty weight consisted of the airplane’s empty weight, 170 pounds for each pilot, and
20 pounds for each crew bag (one per pilot).

“ The Beech 1900D maximum zero fuel weight is 15,165 pounds.



Aircraft Accident Report

168

Appendix B

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Analysis 108 Aircraft Accident Report

The Safety Board concludes that air carriers that use contractors to perform RII
maintenance tasks and inspections need to provide substantial and direct oversight during
each work shift to ensure that this work is being properly conducted. Therefore, the Safety
Board believes that the FAA should require 14 CFR Part 121 air carriers that use
contractors to perform 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.

2.5.1.2 Maintenance Training Program
2.5.1.2.1 Maintenance Training Guidelines

Air Midwest required mechanics to complete OJT for a procedure before they
could perform that procedure unsupervised. However, Air Midwest had little guidance on
how to effectively provide OJT.

The only guidance in Air Midwest’s Maintenance Training Manual about OJT as a
training method stated that (1) OJT would teach knowledge and practical skills of normal
job-related duties and would include practical situations found every day on the job and
(2) OJT would be performed under the guidance of a qualified technician or staff member
who has documentation of previously received OJT. The Maintenance Training Manual
did not include other issues related to the delivery of OJT, including how many students
should be permitted per instructor, how tasks should be demonstrated before being
performed, how the learning environment should be controlled, and how to ensure that the
skills learned through OJT would be retained.

Because Air Midwest lacked specific OJT guidance, the OJT provided to new
mechanics at the HTS maintenance station varied based on the instructors’ teaching style.
For example, the quality assurance inspector on the night of January 6, 2003, stated,
during a postaccident interview, that it was not necessary to “hold [a mechanic’s] hand” if
he thought the mechanic knew what he was doing based on past experience. Also, the
mechanic who performed the elevator cable inspection and adjustments on the accident
airplane indicated that it was routine for mechanics to work independently during OJT and
receive little supervision. However, a mechanic who assisted the quality assurance
inspector with the engine borescope inspection on the night of January 6th stated that,
when he last received OJT, the instructor (who was at HTS from the Panama City
maintenance station) walked him through the task “step by step.”

The Safety Board concludes that Air Midwest did not have maintenance training
policies and procedures in place to ensure that each of its maintenance stations had an
effective OJT program.

Air carriers are required by 14 CFR 121.367(b) to ensure the competence of their
maintenance personnel for the proper performance of maintenance, preventive


Aircraft Accident Report

187

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Conclusions 129 Aircraft Accident Report

10.

11.

12.

13.

14,

15.

16.

17.

18.

19.

20.

A complete functional check at the end of maintenance for critical flight systems or
their components would help to ensure their safe operation, but no such check is
currently required.

Flight 5481 had an excessive aft center of gravity, which, combined with the reduced
downward elevator travel resulting from the incorrect elevator rigging, rendered the
airplane uncontrollable in the pitch axis.

Air Midwest’s weight and balance program at the time of the accident was not correct
and resulted in substantially inaccurate weight and balance calculations for flight
5481.

Air Midwest’s revised weight and balance program is also unacceptable because it
may result in an inaccurate calculation of an airplane’s center of gravity position.

Air Midwest did not adequately oversee the work performed by Raytheon Aerospace
and Structural Modifications and Repair Technicians personnel at its Huntington,
West Virginia, maintenance station and did not ensure that the accident airplane was
returned to service in an airworthy condition.

When an inspector provides on-the-job training for a required inspection item (RII)
maintenance task and then inspects that same task, the independent nature of the RI
inspection is compromised.

Air carriers that use contractors to perform required inspection item maintenance
tasks and inspections need to provide substantial and direct oversight during each
work shift to ensure that this work is being properly conducted.

Air Midwest did not have maintenance training policies and procedures in place to
ensure that each of its maintenance stations had an effective on-the-job training
program.

It is important that air carrier on-the-job training programs are developed in
accordance with detailed guidance that emphasizes effective training practices.

Air Midwest did not ensure that its maintenance training was conducted and
documented in accordance with the company’s maintenance training program, which
degraded the quality of training and inspection activities at the Huntington, West
Virginia, maintenance station.

Air Midwest’s Continuing Analysis and Surveillance System program was not being
effectively implemented because it did not adequately identify deficiencies in the air
carrier’s maintenance program, including some that were found by the Federal
Aviation Administration before the flight 5481 accident.

Accurate and usable work cards developed jointly by air carriers and aircraft
manufacturers would improve the performance of maintenance for critical flight
systems.



Aircraft Accident Report

170

Appendix B

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Factual Information 51 Aircraft Accident Report
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a 7° AND “[N147° AND |__|
22 :
220-200-518 «16 14 12-10 8 6 4 2 o 2 4 6 8 10 12° 14 1
ANU Actual Elevator (degrees) AND

Figure 9. Elevator travel available before and after the detail six maintenance check.

The Safety Board’s Beech 1900D simulator was subsequently used to derive the
elevator required to (1) match the accident airplane’s flight motion recorded on the FDR
using the actual airplane weight and CG position and (2) establish controlled flight from
an initial upset condition defined by the accident flight profile using the actual airplane
weight and CG position. The results of the simulation studies are presented in sections 1.16.2.4.1
and 1.16.2.4.2, and the results of the kinematics extraction are presented in sections 1.16.2.4.3
and 1.16.2.4.4.

1.16.2.4.1 Elevator Required to Match Accident Flight Data

The Safety Board’s simulator requires that the aircraft flight condition (altitude,
airspeed, weight, and CG), the configuration (flaps and gear), the flight control inputs or
control surface inputs, and engine data be specified.”’ The aerodynamic, propulsion, and
mechanical models were used to compute the forces and moments acting on the airplane.
The integration of the governing equations of motion yielded the resulting aircraft motion
as a function of time.

7 The flight control inputs are the control column, control wheel, rudder pedal, and their respective
trim settings. The control surface inputs are the elevator, aileron, rudder, and their respective tab positions.
The engine data consist of throttle, torque, and propeller rpm.



Analysis 105 Aircraft Accident Report

Table 13 compares the weight and CG position for flight 5481 using Air Midwest’s
weight and balance program that was in effect at the time of the accident and Air
Midwest’s revised weight and balance program with the actual weights and CG positions
that would have been present at takeoff.

Table 13. Weight and center of gravity calculations for flight 5481.

Weight and Calculated Actual weight Calculated CG Actual CG
balance method weight (pounds) (pounds) (percent MAC) (percent MAC)

Air Midwest’s 17,028 17,700 37.8 45.5
weight and
balance program
at the time of the
accident

Air Midwest's 17,106 17,233 35.9 39.9
revised weight
and balance
program*

Air Midwest's 17,016 17,129 36.7 42.1
revised weight
and balance
program off-load
scenario”

* These calculations assume that two passengers seated in the last row of the airplane and three bags from the AFT1
cargo compartment were off-loaded

> These calculations are based on a scenario in which the airplane had 50 fewer gallons of fuel at the time of departure and
eight checked bags were off-loaded.

The Safety Board concludes that Air Midwest’s weight and balance program at the
time of the accident was not correct and resulted in a substantially inaccurate weight and
balance calculation for flight 5481. The Safety Board further concludes that Air Midwest’s
revised weight and balance program is also unacceptable because it may result in an
inaccurate calculation of an airplane’s CG position. Section 2.5.2.4 discusses the FAA’s
oversight of air carrier average weight and balance programs and other sources of error in
weight and balance calculations.

2.5 Organizational and Management Factors

2.5.1 Air Midwest

As previously stated, Air Midwest contracted with RALLC for maintenance work
at HTS, and RALLC contracted with SMART to provide mechanics for this work.
According to AC 120-16D, air carriers can use contractors to accomplish maintenance as
long as the air carrier retains the responsibility for the performance and approval of that
maintenance. Thus, Air Midwest was responsible for all of the maintenance that was
performed on its airplanes. However, none of the seven maintenance personnel who were
on duty at HTS on the night of January 6, 2003, were Air Midwest employees. In fact, Air
Midwest’s sole representative at the HTS maintenance station, the regional site manager,



Factual Information 69 Aircraft Accident Report

The FAA published its aircraft weight and balance guidance in AC 121-5, “Aircraft
Weight and Balance Control,” in January 1965 and then in AC 120-27, “Aircraft Weight
and Balance Control,” in October 1968. The content in AC 120-27 was subsequently
revised three times: AC 120-27A was issued in May 1980, AC 120-27B was issued in
October 1990, and AC 120-27C was issued in November 1995 and was the version in
effect at the time of the flight 5481 accident.®* According to AC 120-27C,

an operator may submit, for inclusion into its operations specifications, any
method and procedure which shows that an aircraft will be properly loaded and
will not exceed approved weight and balance limitations during operation. The
approval of such a weight and balance control system is based on an evaluation of
the program presented for a particular aircraft and of a particular operator’s ability
to implement that program.

The average weight suggested in AC 120-27C for an adult passenger was 180 pounds
in the spring and summer months and 185 pounds in the fall and winter months; both
weights included 20 pounds for carry-on baggage. The average weight suggested in the
AC for checked baggage was at least 25 pounds. The AC warned that the standard average
passenger weights presented were developed for a conventional airline passenger group
and that the weights “cannot be arbitrarily adopted for operations with passenger groups
that appreciably differ from the basis or where the mix of male and female passengers is
known to be different than a 60 percent male/40 percent female operation.”*°

The guidance in AC 120-27C was not intended to address all possible air carrier
weight and balance configurations. As a result, the AC noted that air carriers should
consider conducting a reliable survey to establish average weights for their specific
operations and providing the results of the survey to the FAA. An appendix in the AC
listed procedures for conducting surveys and establishing average passenger and baggage
weights based on statistical analyses. Also, the guidance in AC 120-27C advised air
carriers that their weight and balance program should (1) account for all probable loading
conditions that may be experienced in service, (2) ensure satisfactory loading within the
aircraft weight and CG limits during ground and flight operations, (3) maintain the aircraft
weight and CG limits, and (4) stress that the aircraft must be operated at or below its
maximum certificated operating weight.

PMIs oversee and evaluate air carriers’ weight and balance programs according to
the guidance in FAA Order 8300.10, Airworthiness Inspector's Handbook. The guidance
states that the use of average weights may be authorized as long as the weights are based

* Actual weights are required to be used for the aircraft empty weight, fuel, U.S. mail, and company
material.

°> Flight Standards Handbook Bulletin for Airworthiness 95-14 and Flight Standard Handbook Bulletin
for Air Transportation 95-15, “Adherence to Advisory Circular 120-27C, ‘Aircraft Weight and Balance
Control,” were issued in November 1995 and provided guidance to assist regional air carriers with limited
carry-on baggage programs, such as Air Midwest, with the development of their weight and balance
program.

% AC 120-27C stated that actual passenger weights were to be used for nonstandard weight groups
(such as athletic teams) unless average weights had been established for such groups.



Factual Information 21 Aircraft Accident Report

f. Adjust the center-to-center length of the push-pull tube assembly between the
control column and the forward elevator bellcrank to a dimension of 15.12 + 0.06
inch.

g. Adjust the surface stop bolts on the elevator control horn support for up-travel
of 20° + 1° - 0 and down-travel of 14° + 1°- 0°.

h. Verify the bob weight stop bolt clearance is 0.5 + 0.06 inch. Adjust if necessary.

i. Adjust the forward bellcrank stops for 0.37 + 0.06 inch clearance from the stop
bolts.

j. Verify the forward bellcrank stop bolts make contact before the bob weight stop
bolts make contact with the weight.

k. Install a rig pin in the aft elevator bellcrank.

NOTE

Verify threads are visible through the inspection holes at the end of the pushrods
after adjustments are made.

1. Adjust the pushrods between the aft elevator bellcrank and the elevator to position
the elevator at neutral (0° deflection).

m. Remove the rig pin from the aft elevator bellcrank.
n. Remove the safety clips from the turnbuckles and release cable tension.
o. Move the control yoke to install the rig pin in the forward elevator bellcrank.

p. Tighten the elevator-up cable until the elevator rises to neutral (0° on the travel
board).

q. Tighten the elevator-down cable until the average tension of the up- and
down-cables is 66 + 8 pounds (the sum of up-cable and down-cable tensions,
divided by two). Refer to Figure 203.9)

r. Continue to balance the adjustment of the two cables until the average tension is
66 + 8 pounds while maintaining 0° deflection of the elevator.

s. Perform the CONTROL COLUMN SUPPORT ROLLER INSPECTION
procedure.

t. Install safety clips on the turnbuckles.

* Figure 203 was an elevator cable tension graph included in section 27-30-02 of the Beech 1900D
AMM. The graph did not contain instructions on how to take a temperature reading.


Factual Information 87 Aircraft Accident Report

1.18.4.5.1 Federal Aviation Administration Airworthiness Directive 2003-20-10

On October 15, 2003, the FAA issued AD 2003-20-10, which applied to all Beech
model 1900, 1900C, and 1900D airplanes. The FAA reviewed Raytheon Aircraft’s current
maintenance procedures for the elevator trim system and determined that the figures in the
applicable maintenance manuals depicted the elevator trim cable drum at 180° from the
installed position and showed the open, keyed side of the drum instead of the flat side of
the drum.!!? The FAA’s review of the maintenance procedure also identified the need to
add a step to visually confirm that the trim wheel position and the trim tab position were
consistent. According to the FAA, such a check would detect and correct any problems
with the elevator trim system installation before problems occur during operation.

AD 2003-20-10 warned that an incorrectly installed elevator trim system
component, if not detected and corrected, could result in difficulties in controlling the
airplane or a total loss of pitch control. As a result, the AD required operators of Beech
1900 series airplanes to replace the incorrect figure in the elevator trim system
maintenance procedures with the corrected figure, incorporate a temporary revision to the
applicable maintenance manual that describes the elevator trim operational check, and
perform an elevator trim operational check each time maintenance is accomplished on the
elevator trim system.!"4

1.18.4.6 CommutAir Flight 8718, Albany, New York

On October 16, 2003, CommutAir (doing business as Continental Connection)
flight 8718, a Beech 1900D, N850CA, aborted takeoff from ALB because of an elevator
control system discrepancy. The pilot stated that, during the takeoff roll, the control
column would not move aft when the airspeed reached V,.!!> The intended destination for
the positioning flight, which was conducted under 14 CFR Part 91, was Westchester
County Airport, White Plains, New York. The two flight crewmembers were not injured,
and the airplane was not damaged.

Maintenance was performed on the airplane 1 day before the incident, and the
incident flight was the first postmaintenance flight. Maintenance records showed that a
worn detent pin was replaced on the right thrust lever assembly. The mechanic who
replaced the detent pin stated that he looked in the Beech 1900D AMM for a procedure to
replace the pin or a procedure to access the thrust lever assembly. The mechanic indicated

"3 The FAA indicated that, although the figures in the manuals were incorrectly depicted, the
step-by-step instructions in the procedure, if followed correctly, would result in the proper installation and
action of the elevator trim system. If only the figures were used, a reversing of the action of the elevator
manual trim system could result.

4 Raytheon Aircraft Company addressed these issues in its Safety Communiqué number 234, dated
September 2003.

"5 According to 14 CFR Part 1, “V, means the maximum speed in the takeoff at which the pilot must
take the first action (e.g., apply brakes, reduce thrust, deploy speed brakes) to stop the airplane within the
accelerate-stop distance. V, also means the minimum speed in the takeoff, following a failure of the critical
engine at Vz, [the speed at which the critical engine is assumed to fail during takeoff], at which the pilot can
continue the takeoff and achieve the required height above the takeoff surface within the takeoff distance.”



Factual Information 2 Aircraft Accident Report

airplane. The ramp agent stated that two of the checked bags were heavy, with an
estimated weight of between 70 and 80 pounds. The ramp agent also stated that he told the
captain that some of the bags were heavy, although they were not marked as such.
According to the ramp agent, the captain indicated that the bags were fine because a child
would be on board, which would allow for the extra baggage weight.’ The ramp agent
estimated that the forward cargo compartment was about 98 percent full by volume.*

Cockpit voice recorder (CVR) information early in the recording indicated that the
flight crew was completing the preflight paperwork regarding the airplane’s weight and
balance. Air Midwest records indicated that flight 5481 departed the gate on time about 0830.
The captain was the flying pilot, and the first officer was the nonflying pilot.

Flight data recorder (FDR) data indicated that, beginning about 0835:16, the flight
crew performed a control check of the elevators.° The pitch control position parameter,
which measures the position of the control column, recorded values from 15° ANU to
16.5° AND.’ These values corresponded to elevator positions from full ANU to 7° AND.
About 0837:20, the CVR recorded the first officer contacting the CLT Air Traffic Control
Tower (ATCT) ground controller and informing him that flight 5481 was ready to taxi.
The ground controller instructed the flight crew to taxi to runway 18R.

About 0846:18, the tower (local) controller cleared flight 5481 for takeoff and
instructed the flight crew to turn right to a heading of 230° after takeoff. About 0846:35,
the captain asked the first officer to set the takeoff power, and the first officer stated that

the power had been set.

About 0846:48, the airplane’s airspeed was above 102 knots,® and the elevator
position was 7° AND. About 3 seconds later, the elevator position was 1° AND, and the
pitch attitude of the airplane began to increase. After 0846:53, the pitch trim started
moving AND, and, about 3 seconds later, the captain called for the landing gear to be
retracted. About 0846:57, the elevator position returned to 7° AND, and, about 2 seconds
later, the CVR recorded the sound of the landing gear retracting.

4 In calculating the weight and balance of the airplane, the flight crew used Air Midwest's standard
adult weight figure (175 pounds) for this child, who was 12 years of age.

5 A cargo net separates the forward (AFT1) cargo compartment from the aft (AFT2) cargo
compartment. A ramp agent stated that the cargo net was in place before the accident flight.

6 An elevator is an aerodynamic control surface hinged to the back of the horizontal stabilizer. An
elevator moves up and down to control the airplane’s wing angle of attack, pitch, and climb. Normal elevator
travel for the Beech 1900D is from 20° to 21° airplane nose up (ANU) to 14° to 15° airplane nose down
(AND), and the elevator neutral position is 0°. The elevator control check in the Beech 1900D involves
moving the control column from the full forward position to the full aft position.

7 In a properly rigged elevator control system, the FDR pitch control position parameter accurately
reflects the elevator position. For the accident flight, however, the recorded pitch control positions did not
reflect the actual elevator positions. The recorded pitch control positions were about 9° more AND than the
actual elevator positions. For more information on this 9° AND shift, see sections 1.11.2.1, 1.16.1.2, and
1.16.2.3. In this section, all references to elevator positions reflect the actual elevator positions.

8 According to Air Midwest’s Beech 1900D Performance Manual, the rotation speed during takeoff is
105 knots.



Factual Information 70 Aircraft Accident Report

on acceptable data that were collected during actual operations (for example, by weighing
passengers and baggage and documenting the weights). The order also states that the
average passenger and baggage weights listed in AC 120-27C are not regulatory and do
not constitute authorization as a method for controlling aircraft weight and balance. In
addition, the order states that average passenger and baggage weights must be evaluated
for applicability to individual air carriers. Regardless of the weight and balance program
in place or the source of the data used to establish average weights, the air carrier is
ultimately responsible for ensuring proper aircraft weight and CG loading before each
flight is dispatched.

41.18.1.1.1 Postaccident Average Weight Survey

Because the flight 5481 accident raised concerns about aircraft loading and average
weights used in weight and balance control programs, the FAA issued Notice 8400.40,
“Weight and Balance Control Programs for 10 to 19 Seat Airplanes Operated Under
14 CFR 121,” on January 27, 2003. The notice requested that all operators of 10- to
19-passenger seat airplanes operated under 14 CFR Part 121 conduct a survey to validate
the average weights contained in their weight and balance program.*” Of the 22 operators
that have 10- to 19-passenger seat airplanes, 15 operators used average weight programs,
and 7 operators used actual weight programs.

The survey was to be conducted during a 3-day period that included 2 heavier
traveled days—Sunday and Monday—and 1 lighter traveled day—Tuesday. The survey
was to include 30 percent of the operators’ stations and was to sample 15 percent of the
stations’ flights.°* In conducting the survey, the operators either asked the passengers their
weight and added 10 pounds (for personal items) to the number reported or actually
weighed the passengers. The operators also weighed all checked baggage and all carry-on
baggage that were checked at the airplane. Table 6 shows the results of the survey by
operator, and table 7 shows the overall survey results.

97 Another purpose of the notice was for operators to determine the condition of cargo restraint systems,
such as tie-down rings, locking devices, and cargo nets.

98 Air Midwest indicated that it surveyed 100 percent of its flights during the 3-day period (540 flights)
at 98 percent of its stations.


Factual Information 76 Aircraft Accident Report

These items included the total number of passengers, including children; the total number
of pieces of checked, carry-on, and crew baggage; and the combined weight of all cargo in
each bin. One copy of the OF-11E is left at the station, and the other copy is given to the
flight crew. The US Airways Express manual indicated that the flight crew must be
notified if passengers or bags were added after the OF-11E was completed and given to
the crew. Any changes had to be noted in the “remarks” section of the station copy.

In a postaccident interview, the Director of US Airways Express Training stated
that any bag weighing up to 70 pounds was accounted for under the average baggage
weight program. She also stated that a bag weighing between 70 and 100 pounds was
considered to be an overweight bag. Ticket agents are responsible for putting a “heavy
bag” tag on such bags at check-in but are not required to list the weight of the bags on the
heavy bag tags. Ramp agents are required to indicate “heavy bag” in the remarks section
of the OF-11E for those bags with heavy bag tags. At the time of the accident, no formal
procedures existed for reporting overweight bags in the weight and balance paperwork
(except for military duffle bags, which were considered to have an average weight of
50 pounds).'* The Director of US Airways Express Training further stated that bags that
weigh more than 100 pounds were considered air freight. Procedures were in place for
reporting air freight in the weight and balance paperwork.

According to the US Airways Express Ground Operations Manual, carry-on items
that are too large to fit in the cabin of aircraft operated by US Airways Express must be
tagged with a carry-on tag and placed in the cargo compartment of the aircraft. The items
are to be loaded in the cargo compartment last, off-loaded first, and returned to the
customer upon deplaning.

The US Airways Express Ramp Lesson Plan and Student Workbook states that the
Beech 1900D AFTI cargo compartment has a maximum weight allowance of 1,000 pounds
and that the AFT2 cargo compartment has a maximum weight allowance of 630 pounds.
The workbook cautions that “the rear section of the cargo compartment is only to be used
at the instruction of the crew. The netting must stay in place at all other times.”

1.18.2 Federal Aviation Administration Emergency Airworthiness
Directive 2003-03-18

FAA Emergency AD 2003-03-18, dated January 27, 2003, was sent to all owners
and operators of Beech 1900, 1900C, and 1900D airplanes. The AD indicated that recent
ground testing and a review of the rigging procedures of a 1900D airplane revealed that
the elevator control system could be misrigged to restrict elevator travel if current
maintenance procedures were not properly followed. Such restricted travel might not be
detected until the airplane was operating in a loading condition that required full elevator
authority to control the pitch. The 1900 and 1900C models were included in this AD
because their elevator control system design is similar to that of the 1900D model.

108 The revised Air Midwest average baggage weight guidance states that, in the absence of an actual
weight, an average weight of 60 pounds can be used for each heavy or oversized bag.


Aircraft Accident Report

A&P
AC
AD
AFFF
AFT1
AFT2
ALB
AMM
AMT
AND
ANU
ARFF
ASOS
ATC
ATCT

CAA
CASS
CFD
CFR
CG
CLT
CVR
D6

FAA
FARs

FSDO
GSP
Hg

Abbreviations

airframe and powerplant

advisory circular

airworthiness directive

aqueous film forming foam

forward (cargo compartment)

aft (cargo compartment)

Albany International Airport

Airliner Maintenance Manual

aviation maintenance technician
airplane nose down

airplane nose up

aircraft rescue and firefighting
automated surface observing system

air traffic control

air traffic control tower

Celsius

Civil Aviation Authority

Continuing Analysis and Surveillance System
City of Charlotte Fire Department
Code of Federal Regulations

center of gravity

Charlotte-Douglas International Airport
cockpit voice recorder

detail six (maintenance check)
Fahrenheit

Federal Aviation Administration
Federal Aviation Regulations

flight data recorder

Flight Standards District Office
Greenville-Spartanburg International Airport
mercury

Tri-State/Milton J. Ferguson Field, Huntington, West Virginia



Analysis 104 Aircraft Accident Report

entered a climb before achieving cruise speed, but takeoff and climb, cruise and descent,
and approach and land could have been controllable with the available elevator and
changes in engine power.

The restricted elevator travel alone and the aft CG alone would not have been
sufficient to cause the uncontrolled pitchup that led to the flight 5481 accident. The Safety
Board concludes that flight 5481 had an excessive aft CG, which, combined with the
reduced downward elevator travel resulting from the incorrect elevator rigging, rendered
the airplane uncontrollable in the pitch axis.

2.4.1 Air Midwest’s Weight and Balance Programs

If Air Midwest’s revised (May 2003) weight and balance program had been in
effect for flight 5481, the flight crew would have had to take some action to bring the
airplane within the Beech 1900D certified weight and balance envelope (17,120 pounds
and 40 percent MAC, respectively). If the flight crew had, for example, off-loaded two
passengers seated in the last row of the airplane and three bags from the AFT1 cargo
compartment, a calculated weight of 17,106 pounds and CG position of 35.9 percent MAC
would have resulted. Even though this calculated weight and CG position would have
indicated that the airplane was within the Beech 1900D weight and CG envelope, the
actual weight would have been almost 100 pounds more than the weight limit (17,233 pounds),
and the actual CG position would have been slightly under the aft CG limit (39.9 percent MAC).

Under this scenario, Air Midwest’s revised weight and balance program would
have produced a much safer condition than the weight and balance program that was in
effect at the time of the accident: the revised actual takeoff weight (17,233 pounds) would
have been about 500 pounds less than the accident flight’s actual takeoff weight
(17,700 pounds), and the revised actual CG position (39.9 percent MAC) would have been
about 5 percent MAC closer to the aft CG limit than the accident airplane’s actual CG
position (45.5 percent MAC). However, the revised weight and balance program would have
underestimated the actual CG position by about 4 percent MAC by producing a calculated CG
position of 35.9 percent MAC instead of an actual CG position of 39.9 percent MAC.

The Safety Board considered another hypothetical scenario that showed
unacceptable results when using Air Midwest’s revised weight and balance program. If the
accident airplane had 50 fewer gallons of fuel at the time of departure and eight checked
bags were off-loaded to meet the airplane’s weight limit, the calculated airplane weight
and CG position, based on Air Midwest’s revised weight and balance program, would be
17,016 pounds and 36.7 percent MAC, respectively. Thus, the calculated weight and CG
position for this scenario indicated that the airplane would be within the Beech 1900D
weight and CG envelope. However, the airplane’s actual weight and CG position for this
scenario would be 17,129 pounds and 42.1 percent MAC. As a result, the calculated CG
position would be in error by more than 5 percent MAC, and, more importantly, the CG
position would be aft of the aft limit by more than 2 percent MAC. This calculation shows
that Air Midwest’s current weight and balance program is still susceptible to unacceptable
errors in determining an airplane’s actual CG position.



Factual Information 74 Aircraft Accident Report

The Flight Operations Procedures Manual stated the following under the heading,
“Passenger and Baggage”:

The following average passenger baggage weights may be used in lieu of actual
weights:

1) For each piece of checked baggage, an average of not less than 25 pounds, and
2) For each military duffle, average weight of 50 pounds.
3) Carry-on baggage is assumed at ten pounds per item.

NOTE: Carry-on baggage weight is included in the average passenger weights
shown in Paragraph (c) [in the “Passenger Weight Calculation” section].

The Flight Operations Procedures Manual detailed the method to establish the CG
for a Beech 1900D airplane with a 19-seat configuration. The method required that index
units for the airplane’s basic operating weight, passengers, AFT! and AFT2 cargo
compartments, coat closet, and fuel be computed and added together. The index unit total
was to be cross-referenced with the gross takeoff weight on a weight and CG envelope
graph, and a mark was to be made on the graph to indicate where the gross takeoff weight
and the index unit total intersected. This point of intersection was required to fall within
the forward and aft limits of the CG envelope.

Also, the gross takeoff weight was required to be cross-referenced with the gross
takeoff weight index on the weight and CG envelope graph, and the point of intersection was to
fall within the forward and aft limits for both takeoff and landing. In addition, the zero fuel
weight and the corresponding zero fuel weight index were required to be cross-referenced, and
the point of intersection was to fall within the forward and aft limits of the CG envelope. If the
point of intersection fell within a forward shaded area on the graph, passengers were to be
seated fully aft within the forward and aft sections of the airplane; if the point fell within an aft
shaded area, passengers were to be seated fully forward in both sections.'"!

The Flight Operations Procedures Manual also discussed Air Midwest’s Beechcraft
1900D Load Manifest (form F-0001E). In normal operations, the flight crew is responsible for
filling out most of the information on the form.’ One copy of the form is left at the station,
and one copy remains aboard the airplane. The manual stated that, before takeoff, both flight
crewmembers were responsible for reviewing the manifest for errors and omissions.

1.18.1.2.1 Postaccident Weight and Balance Revisions

After the accident, Air Midwest implemented new average adult passenger and
baggage weights, as shown in table 8, based on the results of the FAA-required survey (see
section 1.18.1.1.1). According to Air Midwest, the new average weights became effective

101 Rows | through 5 are in the airplane’s forward section; rows 6 through 9 are in the airplane’s aft section.

102 Station operations personnel fill out the basic information in the upper right-hand corner of the form,
but flight crewmembers are not precluded from filling out the entire form.



Aircraft Accident Report

181

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Analysis 100 Aircraft Accident Report

The mechanic skipped nine applicable steps in the Beech 1900D elevator control
system rigging procedure (see section 1.6.3.2).'3° One of these steps indicated that, for
airplanes equipped with an F-1000 FDR, the pitch position potentiometer needed to be
calibrated (step u). The mechanic was required to perform this step because the accident
airplane had an F-1000 FDR installed. Step u indicated that, to calibrate the pitch position
potentiometer, the mechanic needed to perform the FDR pitch adjustment procedure
described in another section of the Beech 1900D AMM. This procedure referred the
mechanic to a table that specified eight different elevator settings, ranging from 14° AND
to 20° ANU (including 0°), and instructed the mechanic to record the FDR readout for
these settings. The mechanic, however, would not have been able to move the elevator to
the first setting, 14° AND, because elevator travel was restricted to about 7° AND.

The performance of step u would have likely alerted the mechanic or the quality
assurance inspector that the elevator control system was not properly rigged. However, the
mechanic indicated that he skipped step u because he thought the calibration did not need
to be done. The quality assurance inspector stated that he did not think that an FDR was
installed on the airplane, but the inspector should have known that the airplane was
equipped with an FDR because most, if not all, Beech 1900D airplanes were outfitted with
an FDR. Also, the inspector could have easily determined that the airplane was equipped
with an FDR. Specifically, the wiring and the sensor for the FDR were in the same area of
the airplane where maintenance was being performed. Also, the FDR unit is mounted in
the forward (AFT1) cargo compartment and is readily visible. In addition, a circuit breaker
for the FDR is located in the cockpit.

Title 14 Code of Federal Regulations (CFR) 121.367 states that aircraft
maintenance, preventive maintenance, and alterations are to be performed in accordance
with operators’ maintenance manuals. Thus, maintenance personnel are expected to
follow all procedural steps unless authorization has been granted. The SMART mechanic
and RALLC quality assurance inspector were not authorized to decide whether a specific
step of the maintenance manual could be skipped. Air carriers have procedures in place for
making such determinations on a one-time or short-term basis. These determinations are
made by managers and engineers in accordance with the air carrier’s maintenance

manual.!?!

For long-term changes, the Continuing Analysis and Surveillance System (CASS)
is used to change an air carrier’s maintenance procedure if it is deficient or needs
correction. Title 14 CFR 121.373(a), “Continuing Analysis and Surveillance,” requires
operators to establish and maintain a system for the continuing analysis and surveillance

180 The Safety Board is aware of another recent instance in which mechanics skipped a step of a Beech
1900D AMM procedure. Specifically, the investigation into the August 26, 2003, Colgan Air flight 9446
accident determined that the mechanics had to replace both elevator trim tab actuators because of excessive
freeplay. Beech 1900D AMM section 27-30-06 required the mechanics to remove the elevators before the
actuators were replaced. However, the mechanics skipped that procedural step and replaced the actuators
with the elevators installed.

131 The Air Midwest General Maintenance Manual required that deviations to maintenance procedures
be approved by the Federal Aviation Administration (FAA), but the HTS maintenance station did not have
the necessary support during the night shift to receive such approval.



Factual Information 85 Aircraft Accident Report

1.18.4.4.1 Safety Recommendation A-03-31

In its final report on the Emery Airlines flight 17 accident, the Safety Board
discussed the accident airplane’s last B-2 maintenance inspection (the second of four
segmented inspections generally accomplished at 136-hour intervals) on January 21 and 22,
2000. The B-2 inspection includes a visual check of the elevators and tabs for general
condition, corrosion, leakage, and security of attachment. The DC-8 elevator assembly
design requires the elevator control tab inboard fairing to be removed for maintenance
personnel to inspect the inboard hinge fitting and the control tab crank fitting to pushrod
attachment.

During postaccident interviews, Emery Airlines maintenance personnel stated that,
when performing the accident airplane’s last B-2 maintenance, they did not remove the
elevator control tab inboard fairing or inspect the crank fitting to pushrod attachment.
During public hearing testimony, witnesses from Emery Airlines indicated that its B-2
inspection was intended to be a general visual inspection that was to be accomplished
without removing access or inspection panels or fairings. However, witnesses from TTS
stated that removal of the control tab fairing was necessary to satisfactorily perform the
tasks described on the Emery Airlines B-2 work card, even though that step was not
specifically listed on the work card.

The Safety Board noted that several air carriers have tried to clarify the intended
scope of maintenance tasks by including, on their work cards, an enumeration of the
actions that are necessary for the proper accomplishment of the associated work task. The
Board stated that the inclusion of this additional detail on work cards, although not
required by the FAA, should result in more consistent accomplishment of maintenance
tasks. As a result, the Board issued Safety Recommendation A-03-31 on August 18, 2003.
Safety Recommendation A-03-31 asked the FAA to

Require all 14 CFR Part 121 air carrier operators to revise their task documents
and/or work cards to describe explicitly the process to be followed in
accomplishing maintenance tasks.

On January 12, 2004, the FAA stated that Safety Recommendation A-03-31 was
limited to DC-8 operators only. The FAA also stated that the Boeing Company issued
temporary revisions to the DC-8 AMM on May 8, 2002, and that these revisions explicitly
described the maintenance task process to be followed. On January 23, 2004, the Safety
Board classified Safety Recommendation A-03-31 “Open—Response Received.”

1.18.4.5 Colgan Air Flight 9446, Yarmouth, Massachusetts

On August 26, 2003, Colgan Air (doing business as US Airways Express) flight
9446, a Beech 1900D, N240CJ, crashed into water near Yarmouth, Massachusetts. The
two flight crewmembers were killed, and the airplane was substantially damaged. The
repositioning flight, which was conducted under 14 CFR Part 91, departed Barnstable
Municipal Airport, Hyannis, Massachusetts, for Albany International Airport (ALB),
Albany, New York.



Aircraft Accident Report

173

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Aircraft Accident Report

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Factual Information 53 Aircraft Accident Report

The kinematics extraction for the accident flight determined the flight control
deflections required to produce the airplane motion recorded on the FDR. As with the
results of the simulation, about 8° of AND elevator was required to reproduce the motion
recorded during the airplane’s uncontrolled pitch maneuver.

The accident airplane’s motion during takeoff was input into the Safety Board’s
kinematics extraction tool to calculate the elevator sensitivity to CG position for a fixed
airplane weight of 17,700 pounds and CG positions of 43.5, 45.5, and 47.5 percent MAC.
The calculation showed that elevator positions of about 7°, 8°, and 9° AND were required
to reproduce the uncontrolled pitch maneuver for CG positions of 43.5, 45.5, and
47.5 percent MAC, respectively. A 2-percent CG shift in this range required slightly less
than 1° of elevator to trim.

The kinematics extraction tool was then used to calculate the elevator sensitivity to
the accident airplane’s weight for a fixed CG position of 45.5 percent MAC and weights of
17,500, 17,700, and 17,900 pounds. This calculation verified that the weight magnitude
had little to no effect on the elevator required to reproduce the accident airplane’s
uncontrolled pitch maneuver.

1.16.2.4.4 Simulator Trims

The simulation was also used to calculate the Beech 1900D speed stability for the
following conditions: (1) trimmed power for level, free air flight; flaps 17.5°; and gear
deployed; (2) reduced takeoff power, flaps 17.5°, gear deployed, and free air flight (to
determine the effects of power); (3) reduced takeoff power, flaps 17.5°, gear stowed, and
free air flight (to determine the effects of landing gear position); and (4) reduced takeoff
power, flaps 17.5°, gear stowed, full trim tab AND, and free air flight (to determine the
effects of trim tab position).

Condition number 4 simulated the accident airplane’s configuration during the
uncontrolled pitch maneuver. The Safety Board determined that elevator positions of
between 7.5° and 8.5° AND were required to match the airplane’s motion and that elevator
positions of between 9° and 10° AND were required to trim the airplane.



Factual Information 49 Aircraft Accident Report

flight date (before or after the D6 maintenance check) were recorded for each FDR pitch
control position and pitch trim control position data pair.

Raytheon Aircraft Company provided flight test certification data for elevator and
elevator trim tab climb and cruise positions for various Beech 1900D weights and CG
positions. These data were used to verify the absolute position of the accident airplane’s
elevator for a given FDR pitch control position and pitch trim control position pair.

The position of the trim tab is the predominant predictor of elevator position
during climb and cruise flight. Figure 8 shows that a strong correlation exists between
elevator (FDR pitch control position) and trim tab (FDR pitch trim control) data. The
figure shows two distinct data groups: the larger group represents flights before the D6
maintenance check, and the smaller group represents flights after the D6 maintenance
check.

4
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05 1.0 15 2.0 E
FDR Pitch Trim Control (degrees)

Figure 8. Flight data recorder pitch control and pitch trim control positions.

The larger group of data shown in figure 8 (that is, the flights before D6
maintenance) compared well with the Beech 1900D flight test certification data,
indicating that the premaintenance FDR pitch control position data represented the actual
elevator position to within about 1°. However, the smaller group of data (that is, the flights



Factual Information 11 Aircraft Accident Report

same trip sequence as the accident captain. The times that the first officer went to sleep on
the night of January 7th and awoke on January 8th are not known.

1.5.3 The Maintenance Personnel

Sections 1.5.3.1 through 1.5.3.3 provide information about the three HTS
maintenance personnel who were involved with the maintenance of the accident airplane’s
elevator control system. Sections 1.5.3.4 and 1.5.3.5 provide information about the HTS
maintenance managers. For additional information about the maintenance personnel and
the maintenance managers, see sections 1.17.1 through 1.17.3.

1.5.3.1 The Quality Assurance Inspector

The quality assurance inspector, age 50, was hired by RALLC in July 2002. He
was initially hired as a mechanic at the HTS maintenance station and was subsequently
promoted to foreman and secondary (backup) quality assurance inspector.”® He received
his airframe and powerplant (A&P) certificate in January 1985.

On his application for employment with RALLC, the quality assurance inspector
reported that he had between 3 and 4 years of aviation maintenance experience with light
general aviation airplanes. From about 1988 to July 1999, the quality assurance inspector
was not employed in the aviation maintenance field. Between July 1999 and October 2001,
the quality assurance inspector worked on Beech 1900D airplanes at the maintenance
station at Dubois Jefferson County Airport, Dubois, Pennsylvania. (He was employed at
the Dubois maintenance station by Mesa Airlines between July and December 1999,
Arctic Slope”! between December 1999 and September 2001, and RALLC between
September and October 2001.) Between October 2001 and July 2002, the quality
assurance inspector was not employed in the aviation maintenance field.

According to RALLC time cards, the quality assurance inspector worked shifts
from 1700 on January 4 to 1200 on January 5, 2003, and from 2100 on January Sth to
0630 on January 6th. He began work on the night of January 6th at 2100. The quality
assurance inspector stated that he was providing OJT to two mechanics and that it was his
first time training two mechanics while performing inspector duties. In addition, the
quality assurance inspector performed an engine borescope inspection that took about
30 minutes to accomplish. His shift ended at 1230 on January 7th.

The quality assurance inspector described his health as good and stated that he
slept when his shift ended and that he awoke in the afternoon. The quality assurance
inspector reported no significant life events in the months preceding the accident and
stated that nothing affected his performance on the night of January 6th. In a postaccident
interview, the Air Midwest HTS regional site manager (see section 1.5.3.5) stated that he

20 The primary quality assurance inspector was not at work on the night of January 6, 2003, so the
foreman/secondary quality assurance inspector assumed his duties.

21 Arctic Slope was a maintenance contractor.


Factual Information 40 Aircraft Accident Report

1.15 Survival Aspects

Autopsy results from the Mecklenburg County Medical Examiner indicated that
the cause of death for all of the airplane occupants was “multiple blunt force injuries due
to airplane crash.” The captain’s body was found about 4 feet in front of the cockpit
wreckage. The medical examiner did not find any significant markings on her torso that
would have been left by the lapbelt or shoulder harness on airplane impact. The first
officer was found restrained in his seat with his lapbelt and shoulder harness buckled.

1.15.1 Emergency Response

According to the crash phone transcript, the crash alarm sounded at ARFF
Station 17, the CLT Airport Operations Center, and the North Carolina Air National Guard
about 0847:28. The ground control east controller stated, about 0847:37, “an
emergency. .landing right now at the US Air maintenance ramp...right at the corner of the
building. ..there’s a fire.” About 0847:47, a CFD firefighter at the ARFF station asked the
controller what type of airplane had crashed and, about 0847:49, whether the airplane was
commercial or small. About 0847:52, the controller responded that the airplane was a
Gulfstream III. About 0847:55, the controller stated, “no no no,” and a hangup sound was
recorded. One second later, the controller stated that a Beech 1900 had crashed, but, in a
postaccident interview, the controller indicated that she was not able to complete this
transmission before the hangup sound occurred.

About 0848:31, an ARFF captain notified the CFD dispatch center of the airplane
crash. The CFD dispatch center then dispatched CFD fire rescue personnel and notified
the Charlotte-Mecklenburg Police Department and Mecklenburg Emergency Medical
Service dispatch center.”

Four ARFF vehicles (Blaze 1, Blaze 2, Blaze 5, and Blaze 7) and nine ARFF
personnel responded to the initial call to the ARFF station. Blaze 2 had a speed restriction
of 30 mph during emergency operations because the hubs on the vehicle were subject to a
US. Air Force restriction notice.®! One of the firefighters aboard Blaze 2 reported that the
vehicle traveled to the accident site at a speed of about 50 mph.

In addition, Engine 30, with four ARFF personnel, responded to the initial call.
Engine 30 is normally based at the off-airport fire station that responds to emergencies on

*° The crash phone transmissions were recorded in the CLT Airport Operations Center.

© CFD was also responsible for notifying the Charlotte-Mecklenburg Emergency Management Office,
which was responsible for notifying the American Red Cross and the North Carolina Department of
Emergency Management. The Mecklenburg Emergency Medical Service was responsible for notifying area
hospitals and dispatching area ambulances, medical evacuation helicopters, triage teams, medical
examiners, medical mutual aid responders, and volunteer departments.

61 Tn March 1998, the U.S. Air Force issued a restriction notice for all P-23 trucks (such as Blaze 2) in
its fleet because of an increasing number of hub axle failures. Although the P-23 truck, an eight-wheel-drive
vehicle, would remain stable in the event of a hub axle failure, the Air Force determined that a separated
wheel resulting from the failure could be dangerous to people near the truck at the time.


Factual Information 44 Aircraft Accident Report

reference time. The airplane performance study determined that the accident airplane’s
actual weight was 17,700 +200 pounds and that the accident airplane’s actual CG position
was 45.5 +2 percent MAC. The study also determined that the actual elevator travel
available was from about 20° ANU to about 7° AND and that about 9° to 10° AND
elevator was required to establish a controlled climb at the accident airplane’s actual
weight and CG position. The study results are discussed in detail in sections 1.16.2.1
through 1.16.2.4.

1.16.2.1 Flight 5481 Weight and Balance Study

The Safety Board calculated the accident airplane’s weight using three methods:
the Air Midwest weight and balance program, which was used by the flight crew (see
section 1.16.2.1.1); an airplane component buildup based on the available physical
evidence (see section 1.16.2.1.2); and an analysis of the airplane’s takeoff ground roll
dynamics using FDR data (see section 1.16.2.1.3). The Board calculated the accident
airplane’s balance by distributing the calculated airplane weight according to available
component weight and component location information.

1.16.2.1.1 Air Midwest Weight and Balance Program

The load manifest for flight 5481 indicated that the airplane had a calculated gross
takeoff weight of 17,028 pounds and a calculated CG position of 37.8 percent MAC.
According to the Air Midwest weight and balance program at the time of the accident,
flight 5481 was operating within the Beech 1900D weight and CG envelope
(17,120 pounds and 40 percent MAC, respectively).

If the extra weight of the two reportedly heavy bags (see section 1.1) had been
included in the Air Midwest weight and balance program calculation, flight 5481 would
have had a gross takeoff weight of 17,078 pounds and a CG position of 38.8 percent
MAC. Also, if the Air Midwest weight and balance program calculation had accounted for
the two reportedly heavy bags, estimated an additional 110 pounds of fuel at takeoff, and
recorded the 12-year-old passenger’s weight as 80 pounds rather than 175 pounds,” flight
5481 would have had a gross takeoff weight of 17,093 pounds and a CG position of
38.8 percent MAC. Thus, under these two scenarios, flight 5481 would still have been
operating within the Beech 1900D weight and CG envelope.

1.16.2.1.2 Airplane Component Buildup Method

The Safety Board calculated the weight and balance for flight 5481 by adding the
airplane component weights, which included the empty weight; the crew weight,
including crew baggage; the passenger weight, including carry-on baggage; the cargo

6 The flight 5481 dispatch release indicated that the airplane was loaded with 2,420 pounds of fuel
before takeoff. Given Air Midwest’s taxi fuel burn assumption of 110 pounds, the airplane would have had
2,310 pounds of fuel at takeoff. The load manifest indicated 2,200 pounds of fuel at takeoff.

$7 The Air Midwest Flight Operations Procedures Manual at the time of the accident (see section 1.18.1.2)
stated that an average weight of 175 pounds could be used for each adult passenger during the winter and
that an average weight of 80 pounds could be used for children between the ages of 2 and 12 years.


Factual Information 73 Aircraft Accident Report

Either method may be used interchangeably, provided only one method is used
for any flight segment.

1) Actual weight

Actual weight may be determined by scale weighing of each passenger
prior to boarding the aircraft, with such weight including minor articles
carried on board by the passenger. If such articles are not weighed,
account for the estimated weight. The actual passenger weight may also
be determined by asking each passenger his weight, adding ten pounds
per passenger during the calendar period from November 1 through
April 30.

2) Average Passenger Weight

a. An average weight of 170 pounds (summer) may be used for adult
passengers during the calendar period of May 1 through October 31.

db. An average weight of 175 pounds (winter) may be used for each adult
passenger during the calendar period from November 1 through
April 30.

c. An average of 80 pounds may be used for children between the ages of

2 and 12. Two children are counted as one passenger only for entering
the Passenger Index Table and determining the index. When
determining the passenger index, if there is an odd number (1, 3, 5, etc.)
of children in a section, the last child is ignored if seated in the forward
section and counted as an adult passenger if seated in the aft section.
Children above 12 years of age are classified as adults for the purpose
of weight and balance computations. Children less than 2 years old are
considered “babes in arms”.

NOTE: These passenger weights include minor items normally carried
by a passenger and include ten pounds per passenger for carry-on
luggage. These minor items may be stowed under the seats if they are
the size and shape that fit under the seat, or may be stowed in the coat
closet.

The articles stowed in the coat closet will be added as weight at 10 lbs.
estimated weight or actual weight as deemed appropriate by the PIC.
Carry-on luggage not fitting in the seat or in the coat closet will be put
in the aft cargo bin and considered as 25 pounds for weight and balance
purposes. Carry-on baggage/cargo that must be secured in a passenger
seat, (musical instruments, television cameras, etc.) shall be secured
forward of the most forward seated passenger. These items may be
viewed as a child for the purpose of calculating index units.



Recommendations 135 Aircraft Accident Report

4.2 Previously Issued Recommendation Reiterated in
This Report

The Safety Board reiterates the following recommendation to the Federal Aviation
Administration:

Require that all operators of airplanes equipped with a cockpit voice
recorder (CVR) test the functionality of the CVR system prior to the first
flight of each day, as part of an approved aircraft checklist. This test must
be conducted according to procedures provided by the CVR manufacturer
and shall include, at a minimum, listening to the recorded signals on each
channel to verify that the audio is being recorded properly, is intelligible,
and is free from electrical noise or other interference. (A-02-25)

4.3 Previously Issued Recommendation Resulting From
This Accident Investigation

As a result of the investigation of this accident, the Safety Board issued the
following recommendation to the Federal Aviation Administration on January 2, 2004:

Identify all airplanes equipped with unguarded flight crewmember rotary
seatbelt buckles and require replacement with guarded buckles that cannot
be inadvertently unlatched. (A-03-57)

For additional information about this recommendation, see section 1.12.2 of this

report.

4.4 Previously Issued Recommendation Classified in
This Report

Safety Recommendation A-03-31 (previously classified ‘“Open—Response
Received”) is classified “Closed—Superseded” in section 2.5.1.4 of this report.

For more information about this recommendation, see sections 1.18.4.4.1 and
2.5.1.4 of this report.



128 Aircraft Accident Report

3. Conclusions

3.1 Findings

1.

The captain and the first officer were properly certificated and qualified under Federal
regulations. No evidence indicated any preexisting medical or behavioral conditions
that might have adversely affected their performance during the accident flight. Flight
crew fatigue was not a factor in this accident.

The accident airplane was properly certified and equipped in accordance with Federal
regulations. Except for the elevator control system, no evidence indicated that the
airplane was improperly maintained. The recovered components showed no evidence
of any preexisting structural, engine, or systems failures.

Weather was not a factor in this accident. The air traffic controllers that handled the
accident flight were properly trained and provided appropriate air traffic control
services. The emergency response for this accident was timely and effective. The
accident was not survivable for the airplane occupants because they were subjected to
impact forces that exceeded the limits of human tolerance.

The accident airplane entered the detail six maintenance check with an elevator
control system that was rigged to achieve full elevator travel in the downward
direction.

The accident airplane’s elevator control system was incorrectly rigged during the
detail six maintenance check, and the incorrect rigging restricted the airplane’s
elevator travel to 7° airplane nose down, or about one-half of the downward travel
specified by the airplane manufacturer.

The changes in the elevator control system resulting from the incorrect rigging were
not conspicuous to the flight crew.

The Raytheon Aerospace quality assurance inspector did not provide adequate
on-the-job training and supervision to the Structural Modifications and Repair
Technicians mechanic who examined and incorrectly adjusted the elevator control
system on the accident airplane.

Because the Raytheon Aerospace quality assurance inspector and the Structural
Modifications and Repair Technicians mechanic did not diligently follow the elevator
control system rigging procedure as written, they missed a critical step that would
have likely detected the misrig and thus prevented the accident.


Factual Information 6 Aircraft Accident Report

The next step on the D6 work card indicated that the ANU and AND elevator cable
tensions needed to be measured. The mechanic stated that he used a cable tensiometer to
check the tension in each cable and determined that the average tension was too low. The
mechanic stated that he then referred to the Beech 1900D AMM, Section 27-30-02,
“Elevator Control Rigging — Maintenance Practices” (dated February 22, 2002). The
mechanic indicated that he used the elevator cable tension graph in section 27-30-02 to
determine the proper cable tension."

The mechanic stated that he worked under the supervision of the quality assurance
inspector to adjust the cables to the proper tension range. According to the D6 work card,
the mechanic adjusted the ANU cable tension to 57 pounds and the AND cable tension to

62 pounds.’

The aircraft maintenance record of nonroutine items for January 6, 2003,
indicated, in a discrepancy block, that the airplane’s elevator cable tension was low. A
required inspection item (RID)'® stamp appeared in this block, as shown at the bottom of
figure 2. The form also indicated, in a nature of action block, that the elevator cable
tension was adjusted per section 27-30-02 and that the operations check was normal. The
mechanic’s and quality assurance inspector’s stamps appeared in their respective blocks
on the form. In addition, the mechanic’s OJT records indicated that he completed training
on the entire D6 aft fuselage/empennage inspection procedure on January 7, 2003. The
mechanic stated, during a postaccident interview, that he performed the elevator and
rudder checks but not the trim tab check on the night of January 6th.

14 ‘The elevator cable tension graph showed temperature readings (in Fahrenheit) along one axis,
pounds of tension along the other axis, and a reference line for optimum cable tension. The mechanic stated
that he plotted 55° F on the graph and determined that the optimum cable tension would be an average of
61 pounds for the ANU and AND cables. The graph indicated that the tension tolerance was +8 pounds. As
a result, the mechanic could have adjusted the average cable tension to between 53 and 69 pounds.

15 Section 27-30-02 indicated that the ANU and AND cable tensions were to be added and then divided
by two so that the average tension of both cables was 66 +8 pounds (with the elevators at neutral).
According to the Dé work card, the average tension of the accident airplane’s cables was 59.5 pounds.

'6 According to Air Midwest’s Maintenance Procedures Manual (dated November 9, 1999), “Required
Inspection Items are items of maintenance and/or alteration that must be inspected before [the aircraft’s]
return to service, including at least those items that could result in a failure, malfunction, or defect
endangering the safe operation of the aircraft, if not performed properly.” The rigging of elevator cables is
identified in the manual as an RII. According to 14 CFR 121.371(c), “no person may perform a required
inspection if [that person] performed the item of work required to be inspected.”


Conclusions 130 Aircraft Accident Report

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

The Federal Aviation Administration’s failure to aggressively pursue the serious
deficiencies in Air Midwest’s maintenance training program that were previously and
consistently identified permitted the practices that prevailed at the Huntington, West
Virginia, maintenance station and during the accident airplane’s detail six
maintenance check.

Updated Continuing Analysis and Surveillance System (CASS) guidance would help
Federal Aviation Administration aviation safety inspectors ensure that CASS
programs are being effectively implemented at 14 Code of Federal Regulations Part
121 air carriers.

Because proper aircraft maintenance is crucial to safety, air carrier maintenance
training programs should be subject to the same standard that exists for other air
carrier training programs (that is, Federal Aviation Administration approval).

The lessons learned by the Federal Aviation Administration through its human factors
research program need to be used to develop mandatory programs to prevent human
error in aviation maintenance.

The use of average weights does not necessarily ensure that an aircraft will be loaded
within its weight and center of gravity envelope.

The Federal Aviation Administration’s average weight assumptions in Advisory
Circular 120-27C, “Aircraft Weight and Balance Control,” were not correct.

Periodic sampling of passenger and baggage weights would determine whether air
carrier average weight programs were accurately representing passenger and baggage
loads.

Current safety margins in air carrier average weight and balance programs do not
ensure that aircraft will be loaded within their manufacturer-certified and Federal
Aviation Administration-approved weight and center of gravity envelope.

Technology may enable air carriers to accurately determine weight and effectively
control balance while maintaining operational efficiency.

Beech 1900 mechanics would benefit from using Airliner Maintenance Manuals with
more specific instructions for critical flight system procedures.

Because the cockpit voice recorder (CVR) can be one of the most valuable tools used
for accident investigation, reliable daily test procedures are needed to safeguard CVR
data.



Factual Information 48 Aircraft Accident Report

Table 5. Flights documented to be similarly loaded to the accident flight.

Flight number Gross takeoff (porsent Number of Cargo
Date and route weight (pounds) MAC)? passengers (pounds)
01-08-03 5481/CLT-GSP 17,028" 37.8 19 820
01-06-03 5515/GSP-CLT 16,393 34.2 19 595
01-02-03 5464/HTS-CLT 16,444 33.8 15 546
12-29-02 5464/HTS-CLT 16,883 35.4 19 670
12-29-02 5573/AHN-CLT 16,528 34.9 18 TAS
12-27-02 5464/HTS-CLT 16,893 35.7 18 7710
12-27-02 5512/LYH-CLT 17,018 37.8 19 820
12-22-02 5576/CLT-HTS 16,598 33.0 15° 645
12-22-02 5464/CLT-HTS 17,019 32.7 17 656
12-22-02 5573/AHN-CLT 16,433 34.9 18 695

Note: The accident flight appears in bold face print.
® The CG indexes that correspond to these CG positions are 81, 70, 69, 74, 72, 75, 81, 67, 67, and 72, respectively.
» This figure includes the 10-pound addition error made by the flight crew on the load manifest form.

©One of the 15 passengers was a child between 2 and 12 years of age. In calculating the weight and balance of the
airplane, the flight crew used the weight figure for children between 2 and 12 years of age for this passenger (80 pounds).

1.16.2.3 Elevator Control Authority Study

The Safety Board conducted an elevator control authority study based on data
from the accident airplane’s FDR to determine (1) the relationship between the FDR pitch
control position and the actual elevator position and the change in that relationship before
and after the D6 maintenance check and (2) the elevator travel that was available
after maintenance. The results of the elevator control authority study are discussed in
sections 1.16.2.3.1 and 1.16.2.3.2, respectively.

1.16.2.3.1 Relationship Between Pitch Control Position and Actual Elevator
Position

The Safety Board analyzed the pitch control position and pitch trim control
position data that were recorded during the climb and cruise portions of 84 flights
available on the accident airplane’s FDR.” The flight phase (climb or cruise) and the

7 As indicated in section 1.16.2.2, the accident airplane made 86 flights between December 22, 2002,
and January 8, 2003. FDR climb and cruise data with the airplane in a clean configuration (that is, gear up
and flaps up) were available for 84 of those flights.


Contents v Aircraft Accident Report

1.18.2 Federal Aviation Administration Emergency
Airworthiness Directive 2003-03-18
1.18.3. Federal Aviation Administration Guidance
for On-the-Job Training
1.18.4 Other Related Accidents
1.18.4.1 Ryan Air Service Flight 103, Homer, Alaska
1.18.4.2 ValuJet Airlines Flight 592, Everglades,
Near Miami, Florida... 2.0.00... cece cece eee eee eee nee nee eee nee 80
1.18.4.2.1 Safety Recommendation A-97-70.
1.18.4.2.2 Safety Recommendation A-97-74.
1.18.4.3 Fine Airlines Flight 101, Miami, Florida.
1.18.4.3.1 Safety Recommendation A-98-49..... :
1.18.4.4 Emery Airlines Flight 17, Rancho Cordova, California . . 84
1.18.4.4.1 Safety Recommendation A-03-31............
1.18.4.5 Colgan Air Flight 9446, Yarmouth, Massachusetts. .
1.18.4.5.1 Federal Aviation Administration
Airworthiness Directive 2003-20-10.
1.18.4.6 CommutAir Flight 8718, Albany, New York ....
1.18.5 Human Factors Research
1.18.6 Other Passenger and Baggage Weight Information
1.18.6.1 Civil Aviation Authority Report ..............
1.18.6.2 Australian Department of Transport and
Communications Report
1.18.6.3 Civil Aviation Authority of New Zealand Survey

ON) A) |
21 General... 0... ccc ccc cence center n eee :
2.2 Loading and Preflight Activities. . a
2.3 Restricted Downward Elevator Travel 1.96
2.3.1 Conspicuity of the Elevator Control System Misrig ..........0...see eee eeee 97
2.3.2 Adequacy of On-the-Job Training
Provided to the Mechanic. ... 2.0.6... cece cence eee teen eee n cence neees 98

2.3.3. Skipped Steps in the Elevator Control
System Rigging Procedure
2.3.4 Lack of an Effective Postmaintenance Check .
2.4 Aft Center of Gravity and Its Effect on the
Restricted Elevator Travel ..... 0... ese e cece eee e ete eeeee een nee ene e ee
2.4.1. Air Midwest’s Weight and Balance Programs
2.5 Organizational and Management Factors. . . . a
2.5.1 Air Midwest .......6 606s ec ec e eee cen neeenet eee nent e eee
2.5.1.1 Required Inspection Item Maintenance
Tasks and Inspections ........ 0000s eee e cence nee een e ene ene eees
2.5.1.2. Maintenance Training Program .
2.5.1.2.1_ Maintenance Training Guidelines
2.5.1.2.2 Maintenance Training Oversight.........
2.5.1.3 Continuing Analysis and Surveillance System Program..............0-05 111
2.5.1.4 Detail 6 Inspection Procedures Checklist .......... 0s cee cece eee eee e ee 114
2.5.2 Federal Aviation Administration
2.5.2.1 Oversight of Air Midwest ......... 60sec eee cece eect een eens



Aircraft Accident Report

167

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Aircraft Accident Report

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Factual Information 65 Aircraft Accident Report

1.17.4.1 Continuing Analysis and Surveillance System

In 1964, the FAA introduced the requirement for air carriers to have a Continuing
Analysis and Surveillance System (CASS) because maintenance program ineffectiveness
had been identified as a primary causal factor in some maintenance-related air carrier
accidents. Specifically, 14 CFR 121.373, “Continuing Analysis and Surveillance,”
required air carriers to

establish and maintain a system for the continuing analysis and surveillance of the
performance and effectiveness of its inspection program and the program
covering other maintenance, preventive maintenance, and alterations and for the
correction of any deficiency in those programs, regardless of whether those
programs are carried out by the certificate holder or by another person.

Between August 1980 and March 2003, the primary CASS guidance available to
air carriers was contained in AC 120-16C, “Continuing Airworthiness Maintenance
Programs,” and was less than 1 page in length. The guidance stated that a CASS program
should be designed to monitor for, and provide timely corrective action in response to,
decreases in mechanical reliability and should provide a continuous auditing function that
examines a broad range of issues, including the currency and availability of publications,
conformity between maintenance practices and company policies, adequacy of
record-keeping and training, and handling of deferred maintenance items.

In March 2003, the FAA revised AC 120-16C. The revised AC (AC 120-16D)
presented expanded CASS guidance in a dedicated chapter that was several pages in
length. The guidance defined CASS as an “air carrier quality assurance system” designed
to detect and correct air carrier maintenance program deficiencies through a closed-loop,
continuous cycle of surveillance and investigations, data collection and analysis,
corrective actions, and monitoring and feedback. The guidance stated that an air carrier’s
CASS program should monitor the following nine elements of the carrier’s continuous
airworthiness maintenance program: airworthiness responsibility, maintenance manual,
maintenance organization, maintenance schedule, maintenance record-keeping system,
accomplishment and approval of maintenance and alterations, contract maintenance,
CASS, and personnel training.

The CASS guidance in AC 120-16D also stated that a CASS program should
include “detailed policy and procedures” for determining whether an air carrier needed to
amend its maintenance program or manual and for making amendments. In addition, the
guidance stated that, “proactive surveillance and analysis forecasts faults in your [the air
carrier’s] maintenance program or manual through the collection and analysis of a wide
variety of data. It corrects those faults, including human factors*’ issues, in advance of any
specific event, accident, or incident.” Further, the guidance stated that an air carrier’s
“CASS audit schedule should include...all manuals, publications, and forms [to ensure
that they] are useable, current, accurate, and readily available to the user.”

*” The discipline of human factors identifies capabilities and limitations of humans and ways to adapt
human and system components accordingly to increase efficiency, effectiveness, and safety.



Factual Information 20 Aircraft Accident Report

The accident airplane’s last periodic service check and routine check occurred on
January 6, 2003. The airplane’s last detail checks occurred as follows: detail one, July 31,
2002; detail two, September 16, 2002; detail three, October 11, 2002; detail four,
November 7, 2002; detail five, December 5, 2002; and detail six, January 6, 2003. The
airplane’s last structural check occurred on August 27, 2002.

The maintenance paperwork for the accident airplane from January 2001 to
January 2003 was reviewed for discrepancies rélated to elevator or pitch control. No
trends or discrepancies were noted before the accident flight. FAA Service Difficulty
Reports were reviewed for flight control maintenance discrepancies involving the accident
airplane. No trends or discrepancies were noted before the accident flight. In addition, Air
Midwest records indicated no previous accidents involving the airplane.

4.6.3 Elevator Control System Rigging Procedure

As stated in section 1.1.1, the mechanic who performed the cable tension check
bypassed several steps of the elevator control system rigging procedure in
section 27-30-02 of the Beech 1900D AMM (with the quality assurance inspector’s
concurrence). The procedure at the time of the accident is detailed in section 1.6.3.1, and
the applicable steps that the mechanic skipped are discussed in section 1.6.3.2. After the
accident, Raytheon Aircraft Company revised its elevator control system rigging
procedure, and the revised procedure is presented in section 1.6.3.3.

1.6.3.1 Rigging Procedure at the Time of the Accident

The Raytheon Aircraft elevator control system rigging procedure that was in effect
at the time of the accident is summarized below and presented in its entirety in
appendix C.

ELEVATOR CONTROL SYSTEM RIGGING
a. Disconnect the autopilot servo cables.

b. Locate and remove all access panels from the vertical and horizontal stabilizers
to gain access to the aft elevator bellcrank and the elevator cables.

c. Locate and remove the flight compartment seats, carpet, and floorboards to gain
access to the forward elevator bellcrank.

d. Locate and remove the passenger seats, carpet, and floorboards on the right side
of the passenger compartment to gain access to the elevator cable turnbuckles.

e. Install an elevator travel board" on each elevator at station 50.00.

3. An elevator travel board is a template that is unique to a specific airplane design. The travel board
attaches to the horizontal stabilizer to provide a reference for measuring movement of the elevators. The
position of the elevator trailing edge aligns with 1° markings on the travel board that show the angular
position of the elevator in degrees.



Factual Information 63 Aircraft Accident Report

1.17.3.1 Contract Between Structural Modification and Repair Technicians
and Raytheon Aerospace

The contract between SMART and RALLC was signed on March 25, 2002. The
contract contained 22 agreement statements that identified the conditions in which the two
companies would work together.

The contract stated that SMART would provide aircraft maintenance personnel to
perform services at locations designated by RALLC but that the personnel would not be
considered employees of RALLC. The contract also stated that SMART was responsible
for all matters concerning the maintenance personnel’s working conditions, termination,
working hours, vacation and other leave, expenses, wages, and worker’s compensation
insurance. The contract further stated that SMART was responsible for instructing their
employees to follow RALLC policies and regulations as long as they were communicated
in writing in a timely manner.

The contract stated that SMART would use its sole discretion in deciding which
maintenance personnel would be provided to RALLC.* The contract also stated that
RALLC was solely responsible for supervising the work of SMART employees and that
RALLC would provide each SMART employee with a daily time card and would approve
the time cards. In addition, the contract specified that the use of any SMART employee
could be terminated at any time by RALLC® and that, if the employee’s performance in
the first 8 hours of work was not satisfactory, SMART would not charge for the
employee’s services.

1.17.4 Federal Aviation Administration Oversight

The Air Midwest principal operations inspector (POI) has been in that position
since October 1999. The Air Midwest certificate is the only one he oversees. Two assistant
POIs and one aircrew program manager help the POI with his oversight duties. The POI’s
office (the Wichita Flight Standards District Office [FSDO]) is located about 3 miles from
Air Midwest’s office.

The POI indicated that he reviewed Air Midwest’s Flight Operations Procedures
Manual and training program. He stated that oversight of Air Midwest’s weight and
balance procedures was accomplished during en route inspections. The POI indicated that
an en route inspector or geographic inspector would check the cargo bin, count the number
of bags, and look at the size of the bags and then compare the findings to the information
documented on the load manifest form. The inspector would also examine the weight
scales at the stations.

§ The RALLC site manager indicated that he reviewed the résumés of the SMART employees that
worked at the HTS maintenance station before they were hired by SMART.

8° Although RALLC has the right to terminate a SMART employee, RALLC must depend on SMART
to carry out the termination.



Appendix B 139 Aircraft Accident Report

scce Break in continuity or interruption in comment

() Questionable insertion
[] Editorial insertion
= Pause

Note 1: Times are expressed in Eastern Standard Time (EST).
Note 2: Generally, only radio transmissions to and from the accident aircraft were transcribed.

Note 3: Words shown with excess vowels, letters, or drawn out syllables are a phonetic representation of the words
as spoken

Note 4: A non-pertinent word, where noted, refers to a word not directly related to the operation, control or condition
of the aircraft.

Note 5: Personal names of 3” parties not involved in the conversation are generally not transcribed.



Factual Information 56 Aircraft Accident Report

the Chief Inspector/Director of Quality Assurance are both responsible for ensuring that
all required training is performed. The Maintenance Training Coordinator ensures that
training records are properly retained, develops training and testing programs, oversees
indoctrination training, and ensures that OJT is completed and recorded in a timely
manner.

As stated in section 1.17.1, the Air Midwest regional site manager at each of the
contract maintenance stations is responsible for conducting indoctrination training for all
employees, including contractors. The training, which lasts 4 hours, is presented to
employees before they begin work for Air Midwest. The purpose of the training is to
familiarize the employees with Air Midwest’s paperwork, tooling, equipment, safety
policies, and training practices. The employees take a written, 50-question, open-book test
at the end of the training session; a grade of 70 percent is a passing score. Quality
assurance inspectors, foremen, and mechanics are required to take the test each year to
make sure that they have retained the information that was taught during indoctrination
training. The regional site manager forwards indoctrination training records to the
Maintenance Training Coordinator.

Air Midwest does not provide Beech 1900D familiarization classroom training.
All airplane-specific training is learned through OJT.” According to Air Midwest’s
Maintenance Training Manual,

OJT will be used to learn and demonstrate knowledge and practical skills of
normal job related duties. OJT training will be performed under the guidance of a
qualified technician or staff member. The OJT will use practical situations found
everyday [sic] on the job. The person providing the training shall have
documentation of previously completed OJT training.

1.17.1.2 Huntington Maintenance Station Operations

Air Midwest opened the HTS maintenance station in July 2002 after the airline
took over routes previously operated by CC Air, which was owned by the Mesa Air
Group. Figure 10 shows the organizational structure of Air Midwest’s HTS maintenance
station operations.

76 According to training records for HTS maintenance personnel, only one of the quality assurance
inspectors had received formal systems training before his employment with RALLC.


Factual Information 13 Aircraft Accident Report

Between 1994 and 1999, the mechanic was not employed in the aviation
maintenance field. From January to October 2000, the mechanic performed line
maintenance for Piedmont Airlines, Philadelphia, Pennsylvania, on De Havilland Canada
DHC-8 airplanes. From October 2000 to January 2002, the mechanic performed heavy
maintenance for US Airways, Pittsburgh, Pennsylvania, on Boeing 737 and Fokker F.100
airplanes. In October and November 2002, he worked at Stambaugh Air Service,
Harrisburg, Pennsylvania. The mechanic had no previous experience working on Beech
1900D airplanes before beginning work at the HTS maintenance station.

According to SMART time cards, the mechanic worked 17.5 hours from January 4
to 5, 2003, and 8 hours from January Sth to 6th. For the shift from January 6th to 7th, the
mechanic worked 14 hours, during which he performed the D6 maintenance check for the
first time. The mechanic stated that he did not have any previous OJT for that inspection
but that he had previous flight control rigging experience at Piedmont and US Airways.
The mechanic thought that he was “properly trained” for the rigging task because he did
not perceive any differences, in terms of rigging flight controls, between the Beech 1900D
and previous airplanes on which he had worked. He estimated that it took about 7 hours to
complete his assigned tasks for the D6 maintenance check and stated that he received
proper oversight.

In a postaccident interview, the RALLC site manager (see section 1.5.3.4)
described the mechanic as capable. The site manager also stated that he had received
positive reports about the mechanic from inspectors and foremen at the HTS maintenance
station.

1.5.3.4 The Raytheon Aerospace Site Manager

The RALLC site manager” for the HTS maintenance station, age 50, began
working for RALLC in July 2002. He received his A&P certificate in April 1979.

Between June 2001 and July 2002, the RALLC site manager was employed by
SMART as a mechanic assigned to the RALLC maintenance station in Panama City,
Florida, where he worked on Beech 1900D airplanes. He became the foreman and was
responsible for two crews. The RALLC site manager indicated that he had previous
aviation manufacturing and maintenance experience with large commercial airplanes (the
Boeing 727, Airbus A300, Lockheed L-1011, and Douglas DC-8 and DC-9), large
military airplanes (the C-5B, C-130, and P-3), and general aviation airplanes (including
the Learjet 25 and 35).

The RALLC site manager worked from 0800 to 1700 Monday through Friday.
During his shift, the RALLC site manager would typically review the paperwork from the
previous night to identify what work was done and to check that the work had been
properly documented, examine the status and condition of the hangar and its equipment,
review attendance sheets and time cards, and coordinate with the parts manager to ensure
that parts were available to meet maintenance needs. The RALLC site manager would also
interact with other personnel at the HTS maintenance station who worked a day shift,

3 Air Midwest refers to this position as “maintenance manager.”



Factual Information 30 Aircraft Accident Report

1.10.2 Air Traffic Control

The CLT ATCT is an FAA-staffed combined terminal approach radar control
(TRACON)“ and tower with about 500,000 operations per year. The tower cab is
continuously open and is located on the north side of the airport, centered between
runways 18L/36R and 18R/36L. Air traffic control (ATC) radar data are provided by an
airport surveillance radar-9 sensor located midfield on the airport between runways 18R/36L
and 5/23. Radar data processing is performed by an automated radar terminal system-3A

processor.

Flight 5481 was handled by three air traffic controllers on the day of the accident:
the clearance delivery controller, the ground control west controller, and the local control
west controller. Two local control east controllers (one of which was at the developmental
level), a ground control east controller, and a tower supervisor were also present at the
CLT ATCT at the time of the accident.

The ground control west controller has been a controller at the CLT ATCT since
June 1982. He was a controller for the U.S. Air Force before beginning work for the FAA.
He first became aware of a problem with flight 5481 when the local control west
controller stated that the airplane might stall. The ground control west controller then
noticed the airplane climbing from about 200 feet. He stated that the climb was steep and
that, at an altitude of about 1,000 feet, the airplane “winged over to the left.” He also
stated that he saw the airplane descend in a nose-down attitude, pick up speed, and level
off at about the height of the US Airways hangar. He thought that the pilot had briefly
recovered control of the airplane, but then its nose went down. He stated that the airplane
hit the hangar and that he then saw a ball of fire. He further stated that both engines
appeared to be running throughout the flight and that he did not notice anything fall from
the airplane.

The local control west controller has been a controller at the CLT ATCT since
1987. He was a controller at the RDU ATCT and with the U.S. Air Force before beginning
work at the CLT ATCT. The local control west controller stated that the airplane lifted off
about 3,200 feet down the runway and started a normal climb that kept getting steeper. He
added that, rather than entering a departure turn to the right, the airplane continued to pitch
higher and was nearly vertical between 800 and 1,000 feet. The local control west
controller stated that he realized something was wrong with the airplane and that he said
aloud, “that guy’s gonna stall.” He stated that the airplane’s rate of pitchup was smooth
and not like an aerobatic demonstration. He saw the airplane fall to the left, in an apparent
stall, and then regain a somewhat-level flight attitude. Next, he saw the airplane roll to the
right, flip upside down, and hit the hangar. He stated that he saw a ball of fire afterward.

The ground control east controller was positioned closest to the crash phone. (The
crash phone links the ATCT directly with ARFF Station 17, the CLT Airport Operations
Center, and the North Carolina Air National Guard.) The controller stated that she heard

#4 TRACON personnel did not interact with the accident flight.


Aircraft Accident Report

150

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Factual Information 50 Aircraft Accident Report

after D6 maintenance) showed that, for a given pitch trim control position value, the
postmaintenance pitch control position value was shifted about 9° AND compared with
the premaintenance pitch control position value.

The flight conditions (that is, altitude, airspeed, weight, and CG) associated with
the postmaintenance flights are similar to the flight conditions associated with the
premaintenance flights. Thus, the actual elevator position as a function of trim tab position
for all 84 flights was consistent, despite the 9° AND shift in indicated elevator position
(FDR pitch control position) for the group of postmaintenance flights.

1.16.2.3.2 Available Elevator Travel

The Safety Board assumed that the D6 maintenance check did not affect the
accident airplane’s elevator hinge moment characteristics, the elevator trim tab hinge
moment characteristics, or the relationship between the elevator trim tab and the elevator.
With the use of these assumptions, FDR pitch control and pitch trim control data for the
flights before the accident flight, and Raytheon Aircraft Company’s flight test certification
data (see section 1.16.2.3.1), the Board derived the accident airplane’s actual elevator
travel range for the accident flight.

The minimum and maximum FDR pitch control position values recorded during
the preflight elevator control checks for the 10 flights that occurred after the D6
maintenance check defined the postmaintenance indicated elevator travel range. The
actual elevator travel range was determined by plotting the postmaintenance indicated
elevator position (FDR pitch control position) against the postmaintenance actual elevator
position for the given FDR pitch trim control position. For example, as shown in figure 8,
a postmaintenance FDR pitch trim control position of 0° corresponded to an indicated
elevator position (FDR pitch control position) of about 13.5° AND and an actual elevator
position of 4.5° AND.

Figure 9 shows flight 5481’s indicated elevator position as a function of its actual
elevator position. The maximum forward postmaintenance indicated elevator (FDR pitch
control position) of 16.5° AND resulted in a maximum forward postmaintenance actual
elevator position of about 7° AND. The maximum aft postmaintenance indicated elevator
position of 15.1° ANU resulted in a maximum aft postmaintenance actual elevator
position of about 21° ANU. The maximum forward premaintenance indicated elevator
position of 15.6° AND resulted in a maximum forward premaintenance actual elevator
position of 14.7° AND. The maximum aft premaintenance indicated elevator position of
20.1° ANU resulted in a maximum aft premaintenance actual elevator position of 21° ANU.

1.16.2.4 Beech 1900D Simulation Studies

The Safety Board requested and obtained Beech 1900D linearized aerodynamic,
propulsion, and mechanical models from Raytheon Aircraft Company. The models and
their supporting data were used to develop a Beech 1900D simulation capability and a
complementary kinematics extraction tool. Simulation results were compared with flight
test certification data provided by Raytheon Aircraft Company to validate the models and
their implementation.



Factual Information 16 Aircraft Accident Report

(Side View)

Primary: Control Stops Elevator.

al : :
—_—

Control Horn

sae gl Bellcrank

—_ Turnbuckles

Figure 3. Beech 1900D pitch contro! system.

Elevators
a

F

Turnbuckles —

: Primary
Control Column Control Stops

= Control Cables

ee Secondary Control Stops
“——— Flight Data Recorder Sensor

Figure 4. Side view of Beech 1900D tail section.


137 Aircraft Accident Report

5. Appendixes

Appendix A
Investigation and Hearing

Investigation

The National Transportation Safety Board was initially notified of this accident on
January 8, 2003, about 0900. A full go-team was assembled and departed at 1300 from
Ronald Reagan National Airport, Washington, D.C., for Charlotte, North Carolina. The
team arrived on scene about 1500. Accompanying the team to Charlotte was Board
Member John Goglia.

The following investigative teams were formed: Aircraft Operations and Human
Performance, Aircraft Structures, Aircraft Systems, Powerplants, Aircraft Maintenance
and Records, Air Traffic Control, Meteorology, Aircraft Performance, Survival Factors,
and Airport and Emergency Response. Specialists were also assigned to conduct the
readout of the flight data recorder and transcribe the cockpit voice recorder at the Safety
Board’s laboratory in Washington, D.C.

Parties to the investigation were the Federal Aviation Administration (FAA);
Raytheon Aircraft Company; Raytheon Aerospace, LLC; Structural Modification and
Repair Technicians, Inc. (SMART); International Association of Machinists; Air Midwest,
Inc.; Air Line Pilots Association; National Air Traffic Controllers Association; and
Hartzell Propeller. Also, in accordance with the provisions of Annex 13 to the Convention
on International Civil Aviation, the Transportation Safety Board of Canada participated in
the investigation as the representative of the State of Design and Manufacture of the
Engines.

Public Hearing

A public hearing was held on May 20 and 21, 2003, in Washington, D.C.
Chairman Ellen Engleman Conners presided over the hearing; Vice Chairman Mark
Rosenker and Members John Goglia, Carol Carmody, and Richard Healing also
participated in the hearing.

The issues presented at the public hearing were average versus actual passenger
and baggage weights; contractor maintenance work practices, oversight, and quality
assurance; maintenance training; and FAA oversight. Parties to the public hearing were
the FAA, Raytheon Aircraft, Raytheon Aerospace, International Association of
Machinists, Air Midwest, Air Line Pilots Association, and SMART.



Factual Information . 83 Aircraft Accident Report

detailed procedures to ensure that surveillance of each 14 CFR Part 121 air
carrier’s maintenance function entails the performance of the maintenance, the
adequacy of the maintenance organization, the competency of maintenance
personnel, and the adequacy of maintenance facilities and equipment, regardless
of whether those functions are performed in-house or by a contract maintenance
facility.

On July 23, 1999, the Safety Board stated that the FAA’s actions met the intent of
Safety Recommendation A-97-74 and classified it “Closed—Acceptable Action.”

1.18.4.3 Fine Airlines Flight 101, Miami, Florida

On August 7, 1997, Fine Airlines flight 101, a Douglas DC-8-61, N27UA, crashed
after takeoff from Miami International Airport. The three flight crewmembers and one
passenger on board the airplane were killed, one person on the ground was killed, and the
airplane was destroyed by impact forces and a postcrash fire. The cargo flight, which had
a scheduled destination of Santo Domingo, Dominican Republic, was operated under
14 CFR Part 121 as a supplemental air carrier.

The accident airplane was loaded incorrectly, which resulted in an aft CG. Also, an
incorrect stabilizer trim setting precipitated an extreme pitchup at rotation.

The Safety Board determined that the probable cause of this accident was the
failure of Fine Air to exercise operational control over the cargo loading process and the
failure of Aeromar (a cargo shipper) to load the airplane as specified by Fine Air.
Contributing to the accident was the failure of the FAA to adequately monitor Fine Air’s
operational control responsibilities for cargo loading and to ensure that known
cargo-related deficiencies were corrected at Fine Air.'!?

1.18.4.3.1 Safety Recommendation A-98-49

In its final report on the Fine Airlines accident, the Safety Board discussed the
Sum Total Aft and Nose (STAN) system, which is an electronic system installed on some
cargo airplanes that allows flight crews to verify an airplane’s weight and balance before
departure. According to the report, the STAN system uses pressure transducers to convert
main gear and nose gear shock strut air pressure to an electronic signal. The system then
provides flight crews with a digital readout in the cockpit (on the flight engineer’s
instrument panel) of the airplane’s gross weight and CG values.

The Safety Board’s final report on the Fine Airlines accident concluded that, if the
flight crew had an independent method in the cockpit for verifying the airplane’s actual
weight and balance and gross weight, it might have alerted them to loading anomalies and
prevented the accident. As a result, on July 10, 1998, the Safety Board issued Safety
Recommendation A-98-49 to the FAA. Safety Recommendation A-98-49 asked the FAA to

"© For more information, see National Transportation Safety Board, Uncontrolled Impact With Terrain,
Fine Airlines Flight 101, Douglas DC-8-61, N27UA, Miami, Florida, August 7, 1997, Aircraft Accident
Report NTSB/AAR-98/02 (Washington, DC: NTSB, 1998).



Aircraft Accident Report

165

Appendix B

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Factual Information 37 Aircraft Accident Report

From January 27 to 31, 2003, the engines were disassembled and examined at
Pratt & Whitney Canada’s facility in St-Hubert, Quebec, Canada. On February 12, 2003,
the propellers were disassembled and examined at Hartzell Propeller’s facility in Piqua,
Ohio. No preexisting defects or anomalies were found that would have prevented normal
operation of the engines or the propellers.

1.12.4 Pitch Control System

The rivets connecting the elevator control horns to the elevator shafts were tight,
and the control horns were solidly fixed to the elevator shafts. The control horns moved
freely in their respective bearings. The primary stop bolts were attached to the elevator
control horn supports and were found safety wired.

The aft end of each aft pushrod was connected to its respective elevator control
horn, and the forward end of each pushrod was connected to the aft bellcrank and its
respective aft bellcrank link. The length of the left aft pushrod was 20.53 inches, and the
length of the right aft pushrod was 20.44 inches.

Most of the structure that contained the rig pin holes for the aft bellcrank was
missing, and the part that remained was heavily fire damaged. The left tension spring was
found with its upper end attached to its attachment link and its lower end attached to
structure. The right tension spring was found with its upper end separated from its
attachment link and its lower end attached to structure. Examination of the right tension
spring at the Safety Board’s Materials Laboratory showed partial surface melting of the
bellcrank adjacent to the right spring attachment link (the upper end of the spring) and
some resolidified metal adjacent to the lower end of the spring. Magnified visual
examination of the unattached end of the right spring and the right attachment link showed
no evidence of unusual wear patterns, scratching, or other damage related to the separation
of the spring from the link.**

The elevator control cables generally had numerous bends and kinks. Two of the
elevator AND cable’s seven spirally wound strands were completely broken and
unwound, and one strand was partially broken and unwound. (These strands were located
near the trailing edge of the wing, where the fuselage had folded toward the right wing
tip.) The unwound sections of the cable were examined at the Safety Board’s Materials
Laboratory, and no evidence of fatigue cracking or a preexisting condition was found.

The ANU turnbuckle was almost fully contracted, and the AND turnbuckle was
almost fully extended. The measurement from the center of the tooling hole in one
threaded cable terminal to the center of the tooling hole in the other cable terminal was
5.54 inches for the ANU turnbuckle and 7.30 inches for the AND turnbuckle. In addition,
the AND turnbuckle had one thread visible, and the ANU turnbuckle did not have any
threads visible. Figure 6 shows the turnbuckles as found in the wreckage and a drawing
that shows a turnbuckle barrel and threaded cable terminals.

55 During ground tests on January 21 and 22, 2003, a tension spring was disconnected from the test
airplane to determine the effect of a disconnected spring on the forces felt at the control column. This test
revealed that about 6 additional pounds of force were required to move the control column forward.



Factual Information 78 Aircraft Accident Report

1.18.3 Federal Aviation Administration Guidance for On-the-Job
Training

The FAA’s Human Factors Guide for Aviation Maintenance and Inspection’
described OJT as follows:

On-the-job training (OJT) is the generic name describing a variety of training
methods in which trainees work while they learn job skills. On-the-job training
follows the apprenticeship model of education where a new employee is mentored
by a seasoned employee thought to be an expert in the field. This is sometimes
called the “buddy” system. Demonstration and supervised practice with
equipment and procedures within the work environment is what is normally

considered OJT.

OIT has several positive aspects: trainees perform many job tasks while becoming
more proficient; trainees observe highly skilled technicians perform the tasks they
are learning; and the trainees have an opportunity to build one-to-one
relationships with mentors.

Improperly used however, OJT can be inefficient from both the points-of-view of
learning and cost. The results of OJT are highly dependent on the trainer’s
teaching and interpersonal skills. In most OJT situations, the trainer is an AMT
[aviation maintenance technician] whose primary job is maintenance, not training.
At its worst, OJT is idiosyncratic, incomplete, haphazard, and time-consuming.

The Human Factors Guide for Aviation Maintenance and Inspection also
explained the following:

Certain aviation maintenance training practices have been frequently criticized.
Recurrent training tends to receive less emphasis than the constant technological
changes in the industry demand. Mechanics sent to school for training on a
specific aircraft may not receive formal training again on that aircraft type for 10
years or more. Training related to technological changes tends to be done on the
job, instead of in formal, structured settings. There is ample evidence that OJT is
not the best training method for a variety of skills needed by today’s AMT.

Even when using OJT is appropriate, the current system has been criticized for its
lax OJT training practices, which tend to be unstructured. Younger mechanics turn
to more senior employees for ad hoc OJT, although there is no systematic way to
ensure that the senior AMTs work or teaching skills are adequate to ensure the
efficient transfer of skills and knowledge.

The Human Factors Guide for Aviation Maintenance and Inspection included
voluntary guidelines for air carriers that wanted to develop OJT programs. These
guidelines recommended that structured OJT be

106 Maddox, M. (Ed.) Human Factors Guide for Aviation Maintenance and Inspection, Version 3.0
(Atlanta: Galaxy Scientific Corporation, 1998).



Aircraft Accident Report

169

Appendix B

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Appendix C 195 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANAUL.

NOTE

It is permissible to trim the edge of the elevator by up to 0.06 inch in order to achieve the required
distance. If trimming is required, the elevator should be checked for balance.

NOTE

If a FA2100 Flight Data Recorder System Is installed on this aircraft, perform the LINK installation
portion of the ELEVATOR SURFACE POSITION SYNCHRO TRANSMITTTER (SENSOR) IN-
STALLATION procedure in Chapter 31-31-12 of the BEECH 1900D AIRLINER FLIGHT DATA RE-
CORDER (FA2100) MAINTENANCE MANUAL SUPPLEMENT, P/N 129-590000-109.

CONTROL COLUMN SUPPORT ROLLER INSPECTION

a, Remove the four screws (9) in each cover (10) that secure the covers over the control column support rollers
where the contro! column passes through the instrument subpanel. Refer to Figure 204.

b. Inspect rollers (3 and 8), eccentric bolts (1) and nuts (5) for condition. Replace rollers with flat spots and replace
damaged parts as required. If a nut is removed, it must be replaced with a new self-locking nut.

Be sure the self-locking nuts (5) at the lower end of the eccentric bolts are properly torqued.
When the adjustment is complete, the eccentric bolts must not turn or change position.

¢. The upper two rollers are mounted on eccentric shaped bolts (1) that allow adjustment. The lower roller (8) is.
mounted on a screw and is not adjustable. Adjust the two eccentric bolts on each crew station around the control
column as necessary to provide a minimum of .010 inch of play between the columns and the rollers. Torque the
self-locking nuts to 15 -19 inch pounds.

d.  Ifapplicable, remove the rig pin from the forward elevator bellcrank.

@. Move the contro! columns all the way in and out to verify they are not too tight and that they do not bind in the
rollers at any position.

, f. _ Install the covers over the contro! column support rollers.

rebzaez 27-30-02 zs



Factual Information 55 Aircraft Accident Report

As an air carrier, you are responsible for the maintenance of your aircraft. Under
FAA’s regulations, you must perform and/or approve all maintenance alterations
on your aircraft. You may arrange for a maintenance provider, such as a repair
station, to perform your maintenance for you. However, you retain responsibility
for the performance and approval of that maintenance even if someone else
performs the work for you....The air carrier also has the option to authorize
another person to perform the maintenance, but the maintenance must be carried
out in accordance with the air carrier’s maintenance program and maintenance
manual. The air carrier still retains the responsibility for the proper
accomplishment of the maintenance.

According to the Air Midwest regional site manager at HTS, the regional site
manager at each contract maintenance station is responsible for quality control functions.
These functions include reviewing all maintenance and engineering paperwork to ensure
that it meets Air Midwest standards. This paperwork is forwarded to company
headquarters on Mondays, Wednesdays, and Fridays. The regional site managers are also
responsible for performing station and fuel audits to ensure that the contractors adhere to
Air Midwest standards. In addition, the regional site managers conduct indoctrination
training. (See section 1.17.1.1 for more information about Air Midwest’s maintenance
training program.) The regional site managers report to the Air Midwest Chief
Inspector/Director of Quality Assurance.

As indicated in section 1.5.3.5, the Air Midwest regional site manager at HTS
worked the day shift at the time of the accident. His tasks included receiving verbal
briefings from the foreman regarding the previous night’s assignments; taking part in
0900, 0930, and 1600 maintenance calls with the other regional site managers and
upper-level managers from Air Midwest and RALLC; and reviewing maintenance
paperwork and OJT records for quality and accuracy. He stated that he did not typically
have direct contact with mechanics except when he was providing training or was
correcting problems with paperwork. The Air Midwest regional site manager stated that
he had “no authority over anybody.” For example, if he had a problem with the mechanics
or their paperwork, he would have to notify the RALLC site manager, who then would
raise the issue with the mechanic and take appropriate action.

There is no backup for the Air Midwest regional site manager position at HTS. If
the regional site manager is not there for an extended period, Air Midwest either sends a
regional site manager from another station to cover the HTS site manager’s duties or the
paperwork that is normally reviewed at HTS by the site manager and sent to Wichita every
Monday, Wednesday, and Friday is sent directly to Wichita for review instead.

1.17.1.1 Air Midwest Maintenance Training Program

Air Midwest is responsible for conducting its maintenance training program in
accordance with 14 CFR 121.375, which requires airline maintenance training programs
to “ensure that each person (including inspection personnel) who determines the adequacy
of work done is fully informed about procedures and techniques and new equipment in use
and is competent to perform his duties.” The Vice President/Director of Maintenance and



Factual Information 79 Aircraft Accident Report

* based on measurable performance standards;

* designed and delivered in a systems framework that includes information
presentation, demonstration, practice, and evaluation;

* designed to provide initial, recurrent, and remedial training;

* used to standardize procedures and to provide consistent training among
workers;

* conducted by experienced employees trained in structured OJT techniques and
adult learning principles;

+ delivered in segments that are planned, scheduled, and frequent and include
keeping complete, up-to-date trainee performance records; and

* audited annually to identify areas in need of improvement.

In addition, the guide recommended that OJT be conducted in the following
sequence: orientation, demonstration, practice, and evaluation and closure.

1.18.4 Other Related Accidents
1.18.4.1 Ryan Air Service Flight 103, Homer, Alaska

On November 23, 1987, Ryan Air Service flight 103, a Beech 1900C,!°” N401RA,
crashed short of the runway during arrival at the Homer, Alaska, airport. Flight 103 was a
scheduled 14 CFR Part 135 flight operating from Kodiak, Alaska, to Anchorage, Alaska,
with intermediate stops in Homer and Kenai, Alaska. The 2 flight crewmembers and
16 passengers were killed, and 3 passengers were seriously injured.

The accident investigation revealed that the airplane was loaded with about
600 pounds more cargo than the first officer had requested. The airplane was 400 to
500 pounds over the airplane’s maximum takeoff weight and 100 to 200 pounds over its
maximum landing weight. In addition, the CG position was 12 to 16 percent MAC aft of
the allowable aft limit, and the flight crew did not comply with company and FAA
procedures in computing the CG position. Even with an extreme aft CG, the airplane was
able to take off and establish cruise flight. Evidence indicated that the flight crew lost
control of the airplane as its flaps were lowered for landing.

The Safety Board determined that the probable cause of this accident was the
failure of the flight crew to properly supervise the loading of the airplane, which resulted
in the CG being displaced to such an aft location that airplane control was lost when the
flaps were lowered for landing.!°*

1°” The Beech 1900C is generally similar in size and capacity to the 1900D. The airplanes have
numerous similar components and share a common FAA type certificate.
1°8 For more information, see National Transportation Safety Board, Ryan Air Service, Inc., Flight 103,

Beech 1900C, N401RA, Homer, Alaska, November 23, 1987, Aircraft Accident Report NTSB/AAR-88/11
(Washington, DC: NTSB, 1988).



Analysis 114 Aircraft Accident Report

deficiencies.”!29 (Section 2.5.2.2 discusses the results of an investigation conducted by the
Department of Transportation Office of Inspector General in response to these findings.)

The Safety Board concludes that Air Midwest’s CASS program was not being
effectively implemented because it did not adequately identify deficiencies in the air
carrier’s maintenance program, including some that were found by the FAA before the
flight 5481 accident.

2.5.1.4 Detail 6 Inspection Procedures Checklist

The Air Midwest D6 inspection procedures checklist (also known as the D6 work
card) was the document that mechanics used for inspecting and adjusting elevator control
cables. The work card referred the mechanics to the Beech 1900D AMM for additional
details regarding the cable inspection and adjustments. The work card and the AMM
contained general instructions to guide the mechanics in performing these tasks.

The D6 work card instructed mechanics to check cable tension according to Beech
1900D AMM chapter 27.'° However, the D6 work card did not specifically refer the
mechanics to section 27-30-02 of the AMM, which contained the only reference—an
elevator cable tension graph—in chapter 27 for determining cable tension. Further, to use
the graph, the mechanic was first required to determine cable temperature, but neither the
D6 work card nor the elevator cable tension graph described how to prepare the airplane
for temperature measurement or how and where to obtain temperature readings. The
Safety Board’s January 2003 ground tests showed that temperature readings varied
depending on the method used by individual mechanics for measuring cable temperature
and that the method used for measuring temperature could affect cable tension.

Interviews with Air Midwest and Raytheon Aircraft Company officials revealed
that, when cable tension was found to be outside of acceptable parameters, mechanics
were expected to perform the entire elevator control system rigging procedure. Neither the
D6 work card nor the Beech 1900D AMM explicitly stated that the entire rigging
procedure needed to be performed or that the elevator cable tension adjustment could not
be accomplished as an isolated task.

139 For more information, see National Transportation Safety Board, Loss of Control and Impact With
Pacific Ocean, Alaska Airlines Flight 261, McDonnell Douglas MD-83, N963AS, About 2.7 Miles North of
Anacapa Island, California, January 31, 2000, Aircraft Accident Report NTSB/AAR-02/01 (Washington,
DC: NTSB, 2002).

440 ‘The only other details provided on the work card regarding elevator cable tensioning were blank lines
on which a mechanic recorded the cable temperature and the number of pounds of tension for the ANU and
AND cables (see figure 1 in section 1.1.1).



Aircraft Accident Report

188

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Analysis 117 Aircraft Accident Report

maintenance training manual was inconsistent and obsolete, mechanics were not
completing OJT within the company’s 2-year time limit,'*° and training was not being
properly documented.

During the next year, discussions between the FAA and Air Midwest continued
regarding the adequacy of the air carrier’s training manuals and the completion of required
training for its maintenance personnel. In an April 26, 2002, letter, the Wichita FSDO
manager and the Air Midwest PMI notified Air Midwest that the FAA intended to delay
the air carrier’s planned expansion to its route structure because of unresolved concerns,
including the air carrier’s CASS and maintenance training programs. The planned route
expansion related to a 2-year contract awarded in July 2002 by the Department of
Transportation to Mesa Air Group (Air Midwest’s parent company) for seven new
essential air service markets in Arkansas, Oklahoma, and Texas. The new markets
included Enid and Ponca City, Oklahoma; Brownwood, Texas; and Harrison, Hot Springs,
El Dorado/Camden, and Jonesboro, Arkansas. The air service was to be provided
beginning in the fall of 2002 by Air Midwest doing business as Mesa Airlines, and four
Beech 1900D airplanes were dedicated to the new routes. Mesa Air Group would receive a
federally guaranteed subsidy of $13.4 million for providing air service during the 2-year
term of the contract.

As of August 2002, the Air Midwest PMI and principal operations inspector had
still planned to delay the expansion; however, an FAA operations supervisor advised them
against the delay. The Safety Board is concerned that, even though deficiencies in Air
Midwest’s maintenance training program were clearly documented by the FAA in its
letters to the air carrier, the FAA did not use Air Midwest’s subsidized route expansion as
leverage to effect improvements in the carrier’s maintenance training program.

The FAA could also have insisted that Air Midwest improve its maintenance
training program before allowing the air carrier to open the HTS maintenance station in
July 2002. The Safety Board’s investigation into the flight 5481 accident found that HTS
had the same persistent problems that had been identified at other Air Midwest
maintenance stations, including the poor quality of OJT. This problem is especially
evident in the training records of the HTS mechanic who examined and adjusted the
elevator control system on the accident airplane. Specifically, on January 7, 2003, the
mechanic was signed off on the entire D6 aft fuselage/empennage inspection procedure,
even though he clearly received none of the orientation, demonstration, practice,
evaluation, and closure that FAA’s guidelines for OJT recommended. In addition, the
mechanic performed the elevator control system adjustment incorrectly, and he did not
perform any of the other tasks associated with the D6 maintenance check.

The Safety Board notes that the flight 5481 accident investigation is the not first
time that the FAA was unable or unwilling to follow the judgment of its aviation safety
inspectors. In its final report on the ValuJet Airlines flight 592 accident, the Board

4 This finding was the only one cited by the RASIP inspection team as a FAR violation.

145 This requirement was replaced in the February 2002 revision of Air Midwest’s maintenance training
manual with a requirement stating that a mechanic would not be assigned work until OJT was accomplished.



Factual Information 24 Aircraft Accident Report

ELEVATOR CONTROL SYSTEM RIGGING

WARNING

THE GUST LOCK PIN MUST NOT BE USED FOR RIGGING THE
ELEVATOR CONTROL SYSTEM EXCEPT WHEN PERFORMING THE
GUST LOCK PIN CHECK PORTION OF THIS PROCEDURE.

NOTE

DISCONNECT THE AUTOPILOT SERVO CABLES TO THE
ELEVATOR PRIMARY CONTROL CABLES.

a. Locate and remove all access panels from the vertical and horizontal stabilizers
to gain access to the aft elevator bellcrank and the elevator cables.

b. Install a rig pin in the aft elevator bellcrank.
c. Remove lock clips from turnbuckles. Release cable tension.

d. Locate and remove the copilot’s seat, carpet, and floorboards to gain access to
the forward elevator bellcrank.

e. Adjust the center-to-center length of the push-pull tube assembly between the
control column and the forward elevator bellcrank to a dimension of 15.17
+0.19/-0.06 inch. This push-pull tube is to be adjusted if needed to mect the
bob weight stop clearance requirement or to meet the gust lock pin check.

f. Install the rig pin in the forward elevator bellcrank (located below the

floorboard forward of the copilot’s seat tracks). Move the control column as
required to align the rig pin holes.

NOTE

CHECK ELEVATOR TRAVEL WITH TRAVEL BOARDS. ONE TRAVEL
BOARD SHOULD BE MOUNTED ON EACH HORIZONTAL STABILIZER
AT HSS [horizontal stabilizer station] 50.00.

g. Disconnect the elevator pushrods from the aft bellcrank.

h. Adjust the surface stops on the control horn support for up travel of 20°
+1°/ -0°; and down travel of 14° +1°/ -0°.



Aircraft Accident Report

149

Appendix B

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Aircraft Accident Report

172

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x Aircraft Accident Report

Executive Summary

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.

The National Transportation Safety Board determines that the probable cause of
this accident was the airplane’s loss of pitch control during takeoff. The loss of pitch
control resulted from the incorrect rigging of the elevator control system compounded by
the airplane’s aft center of gravity, which was substantially 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.

The safety issues in this report focus on maintenance work practices, oversight,
and quality assurance; aircraft weight and balance programs; maintenance training; FAA
oversight; and Beech 1900 cockpit voice recorder problems. Safety recommendations
concerning these issues are addressed to the FAA.



Appendix C 199 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANAUL

1. UPPER BOLT
2. WASHER (2 PLACES)
3. UPPER ROLLER

4, WASHER

6. LOWER SCREW

7. WASHER (2 PLACES)

8. LOWER ROLLER

9. SCREW (4 PLACES)
10. ROLLER SUPPORT COVER
11. SUPPORT, RH

12. SUPPORT, LH
cera A vem
DresAAA

Figure 204 - Control Column Rollers

renzavz 27-30-02 aa



132 Aircraft Accident Report

4. Recommendations

4.1 New Recommendations

As a result of the investigation of this accident, the National Transportation Safety
Board makes the following recommendations 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.
(A-04-4)

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. (A-04-5)

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. (A-04-6)

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. (A-04-7)

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. (A-04-8)



Aircraft Accident Report

140

Appendix B

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Aircraft Accident Report

146

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Factual Information 39 Aircraft Accident Report

The control column was dented and slightly crushed but was intact. The left and
right pivot bearings were found in the wreckage. The captain’s and the first officer’s
control column shaft and support assemblies had separated from the forward subpanel
structure, and their control wheels had separated from the contro] column shaft assembly.
The roller slider assemblies contained within the captain’s control column support
assembly were burned; the shaft was displaced away from the center of the rollers, and the
slider rollers were unable to rotate. The roller slider assemblies contained within the first
officer’s control column support assembly were able to rotate. The roller containing an
eccentric screw rotated freely on its bearing, and a clearance of about 0.06 inch existed
between the rollers and the control column shaft assembly.*”

The bob weight and its surrounding structure were displaced from their normally
rigged positions and exhibited impact damage that was consistent with the impact damage
found on the nose of the airplane. The gap between the head of the stop bolt and the bob
weight could not be measured because of the severe impact damage in that area.

1.12.4.1 Pitch Trim Control System

The elevator trim tab control wheel was intact and was attached in the cockpit. The
pitch trim appeared to be near the full AND position. The pitch trim control cables were
broken. The control cables were in the correct orientation. The left and right drums had
their respective cables wrapped around to the middle position.

1.13 Medical and Pathological Information

Tissue specimens from the captain and the first officer tested negative for ethanol
and a wide range of drugs, including major drugs of abuse. Postaccident drug tests on the
two ramp agents who handled the accident flight and their supervisor as well as the
mechanic and the quality assurance inspector who worked on the accident airplane were
negative for drugs of abuse.°*

1.14 Fire

No evidence of an in-flight fire was found. A postcrash fire developed after
airplane impact. According to interviews with ARFF personnel and a videotape taken by
the CFD and the Charlotte-Mecklenburg Police Department, the main fire was at the
wreckage site, and spot fires occurred along the grass strip on the parking lot side of the
airport perimeter fence and in a gully south of the accident site. Thick black smoke
emanated from the southwest corner of the US Airways hangar. ARFF personnel
estimated that it took about 3 minutes of AFFF application to knock down the main fire.

57 The Beech 1900D AMM specifies a 0.01-inch gap between the rollers and the control column shaft
assembly.

58 Urine samples were obtained on January 8, 2003, at 1530 for one ramp agent, 1745 for the other
ramp agent, 1230 for their supervisor, and 1542 for the quality assurance inspector. The mechanic’s urine
sample was obtained on January 9, 2003, at 1000.



Appendix D 201 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANUAL

d. Locate and remove the copilot’s seat, carpet, and floorboards to gain access to the
forward elevator bellcrank. Refer to Chapters 6 and 25.

e. Adjust the center-to-center length of the push-pull tube assembly between the control
column and the forward elevator bellcrank to a dimension of 15.17 + 0.19/-0.06 inch. This push-
pull tube is to be adjusted if needed to meet the bob weight stop clearance requirement or to
meet the gust lock pin check.

f. Install the rig pin in the forward elevator belicrank (located below the floorboard forward
of the copilot’s seat tracks (Floorboard Panel 122BT in Chapter 6-50-00)). Move the control
column as required to align the rig pin holes.

NOTE

CHECK ELEVATOR TRAVEL WITH TRAVEL BOARDS (5, CHART 1, 27-00-00).
ONE TRAVEL BOARD SHOULD BE MOUNTED ON EAC H HORIZONTAL
STABILIZER AT HSS 50.00.

g. Disconnect the elevator pushrods from the aft bellcrank.

h. Adjust the surface stops on the control horn support for up travel of 20° + 1°/- 0°; and
down travel of 14° + 1° /- 0°. Refer to Figure 201.
NOTE

INSURE THAT THREADS ARE VISIBLE THROUGH THE INSPECTION HOLE AT
THE END OF THE PUSHROD, AFTER ADJUSTMENTS ARE MADE.

i. Adjust the elevator bellcrank pushrod ends as required to obtain 0 readings on the travel
boards for both elevators. Tighten the locknuts.

J. Connect pushrods to the aft elevator bellcrank.
k. Use a cable tensiometer to measure control cable tension

|. Tighten elevator control cables uniformly to the center of the maximum and minimum
tensions. Refer to Figure 203.

m. Slowly adjust the elevator cable(s) as required until the rig pin in the forward bellcrank
will fit with minimum insertion force.

n. Remove the rig pin from the forward bellcrank.

o. Read the cable tension of both cables. Record the values as T up and T down. The
allowable limit for combined cable tension is 66 + 8.0 Ibs. Compute the combined tension load
(Tc) by adding the up and down values together and dividing by 2, or:

Page 6 of 8 .
Feb 12/03 Temporary Revision No, 27-7



Abbreviations ix Aircraft Accident Report

JAA Joint Aviation Authorities (European)

JARs Joint Aviation Regulations

LYH Lynchburg Regional Airport/Preston Glenn Field
METAR meteorological aerodrome report

msl mean sea level

OAT outside air temperature

OJT on-the-job training

PAI principal avionics inspector

PIC pilot-in-command

PMI principal maintenance inspector

POI principal operations inspector

RALLC Raytheon Aerospace, LLC

RAMS Regional Airline Maintenance Service
RASIP Regional Aviation Safety Inspection Program
RDU Raleigh-Durham International Airport

RII required inspection item

SB service bulletin

SMART Structural Modification and Repair Technicians, Inc.
STAN Sum Total Aft and Nose system

TRACON terminal radar approach control

TTS Tennessee Technical Services

UTC coordinated universal time

VHF very high frequency



Factual Information 33 Aircraft Accident Report

delivered by the airframe manufacturer, was designed to record 18 parameters. In
response to a 1997 FAA rule that mandated additional recording requirements, the
airplane’s FDR was upgraded in 2001 to record 4 additional parameters,’ for a total of
22 parameters.

The FDR was sent to the Safety Board’s laboratory for readout and evaluation. The
fire and impact damage to the exterior of the FDR prevented the data from being extracted
in the normal manner. The solid-state memory module, which was in good condition, was
extracted from the crash-protected memory case, and a new connector was attached to the
module. The module was then inserted into a surrogate F-1000 FDR, and the data were
downloaded and decompressed using the manufacturer’s software. About 95 hours of data
were recorded on the FDR, including data from the accident flight. The FDR powered up
for the accident flight just before 0825:00, and the last valid data were recorded just
after 0847:28.

Two parameters—left engine torque and lateral acceleration—did not yield
expected values. The left engine torque parameter did not show any activity during the
accident flight but was intermittently active during other flights for which recorded data
existed. The lateral acceleration parameter exhibited values that were characteristic of
lateral acceleration (based on an examination of the magnetic heading and yaw control
values) but only on an intermittent basis. As a result, these two parameters were deemed
inoperable.

1.11.2.1 Flight Data Recorder Study

The Safety Board conducted an FDR study to examine the relationship between
the 10 flights before the D6 maintenance check on January 6, 2003, and the 9 flights after
the D6 maintenance check. (The accident flight was the 10th flight after D6 maintenance.)
The study results showed that, before maintenance, the pitch control position values
during cruise flight were normally about 4° AND and that, after maintenance, the cruise
values were normally about 13° AND. (As previously stated, the FDR pitch control
position sensor is attached to structure located to the left of the base of the control column;
thus, the pitch control position parameter represents the control column position and not
the elevator position.) Additional information regarding the 9° AND shift in the FDR pitch
control position is discussed in sections 1.16.1 (ground test results) and 1.16.2 (airplane
performance study results).

The FDR study also examined the pitch control position values recorded during
each preflight elevator control check. The study results indicated that, for the 10 flights
before the D6 maintenance check, the full forward position recorded by the FDR was
usually 15.6° AND. The study results further indicated that, for the nine flights after the

46 The 18 parameters were airspeed, comml keying, comm2 keying, flap position, frame counter,
longitudinal acceleration, magnetic heading, pitch attitude, pitch contro! position, pressure altitude, prop
rpm left, prop rpm right, prop reverse left, prop reverse right, roll attitude, torque left, torque right, and
vertical acceleration.

47 The four parameters were lateral acceleration, pitch trim control, roll control, and yaw control.



Analysis 113 Aircraft Accident Report

program and for ensuring that appropriate corrective actions were taken on issues
identified through the CASS program. However, the Safety Board further questioned the
effectiveness of Air Midwest’s CASS program after the Board received a February 12,
2003, letter from the Air Midwest Vice President/Director of Maintenance. This letter
stated, “a review of the Raytheon Aircraft Beech 1900D Maintenance Manual revealed a
lack of explicit instructions, which if included, could have avoided the elevator
mis-rigging.” The letter also described numerous deficiencies in the elevator control
system rigging procedure, including the following:

* Step d, which requires the removal of passenger seats, carpet, and floorboards
on the right side of the passenger compartment to access the elevator control
cable turnbuckles, was not required because the turnbuckles on the Beech
1900D model are located in the tail of the airplane.

* Steps f, g, h, i, and | did not include procedures for making adjustments to the
push-pull tube, elevator control horn stop bolts, bob weight stop bolt, forward
bellcrank stop bolts, and aft pushrods, respectively.

* Step q refers the mechanic to the elevator cable tension graph (figure 203) in
section 27-30-02 for performing cable tensioning, but no instructions were
given regarding whether the airframe, outside air, or cable temperature was to
be taken when determining the amount of cable tension; whether the flight
compartment cabin temperature gauge or an outside air temperature gauge was
to be used in determining the temperature; and what type of device was to be
used to measure cable tension.

Air Midwest and its predecessor companies had been operating Beech 1900D
airplanes since the 1990s; as a result, it is highly unlikely that the maintenance manual
deficiencies that Air Midwest identified in its February 2003 letter first came to light after
the flight 5481 accident. Each of the deficiencies raised in the letter would have been
apparent every time the elevator control system rigging procedure was accomplished.
Thus, Air Midwest’s CASS program was ineffective.

The Safety Board notes that the flight 5481 accident investigation is not the first
time that problems have been found with an air carrier’s CASS program. The Board’s
investigation of the January 31, 2000, Alaska Airlines flight 261 accident found that a
postaccident FAA special inspection of the air carrier revealed deficiencies in its CASS
program,'** and the Board’s final report on the accident concluded that “at the time of the

flight 261 accident, Alaska Airlines’ maintenance program had widespread systemic

38 These deficiencies included that Alaska Airlines’ manuals did not contain facsimiles of audit
checklists to be used in administering its CASS program, data-gathering was periodic rather than
continuous, and audit checklists did not address compliance with regulatory safety standards checklists but
instead were modeled after a generic audit program that was not specifically designed for Alaska Airlines.



Factual Information 12 Aircraft Accident Report

had “a lot of faith” in the quality assurance inspector. At the public hearing for this
accident,”’ the quality assurance inspector testified that he had performed elevator control
system rigging work once.

1.5.3.2 The Foreman

The foreman, age 36, was employed by SMART and had begun working at the
HTS maintenance station in July 2002. He received his A&P certificate in July 1995.

From 1984 to 1987, the foreman worked as a mechanic on B-52 and KC-135
airplanes with the U.S. Air Force. He gained experience as a foreman while working with
the Air Force. Between 1993 and 1999, the foreman worked as a mechanic on general
aviation and commuter airplanes. From December 2001 to July 2002, the foreman was
employed by SMART and was assigned to RALLC at the Dubois maintenance station as a
mechanic working on Beech 1900D airplanes.

The foreman stated that he typically arrived at work between 2100 and 2130, about
30 minutes before the arrival of the airplane that was scheduled for maintenance. He then
reviewed the work scheduled for the shift, organized the paperwork, and reviewed the
personnel and equipment requirements. He assigned mechanics to the required tasks but
did not do any of the maintenance himself. He indicated that work assignments were based
on what work had to be done and which mechanic was best suited for a particular job. The
foreman tried to keep the same mechanics on the same jobs throughout the shift. The
foreman normally communicated with Air Midwest maintenance control about 0400
regarding the status of the airplane undergoing maintenance.

During a postaccident interview, the foreman stated that, if a mechanic had not
done a job before and someone was available who had previously done the job, he would
assign the experienced mechanic to the job and would train the mechanic without
experience as time permitted. The foreman indicated that he tried to train only one
mechanic at a time but that, sometimes, more than one mechanic needed to be trained at
the same time.

According to SMART time cards, the foreman was off duty for the shift from
January 4 to 5, 2003, but worked an 8-hour shift from January 5th to 6th. For the shift
from January 6th to 7th, the foreman worked 15 hours. On the night of January 6th, he
assigned the work tasks for the accident airplane’s D6 maintenance check. The foreman
was aware that, besides he and the quality assurance inspector, none of the mechanics on
duty that night had done an elevator control system rigging check on a Beech 1900D.

1.5.3.3 The Mechanic

The mechanic, age 30, was employed by SMART and began working at the HTS
maintenance station in November 2002. He attended the Pittsburgh Institute of
Aeronautics, Pittsburgh, Pennsylvania, from 1991 to 1993 and received his A&P
certificate in March 1993.

22 Appendix A provides details about the public hearing.


Factual Information 7 Aircraft Accident Report

FORM #M007 UoKixwaye/Bxpress/ Aix Midwest r
DATE 01/06/03 AIRCRAFT MAINT
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Figure 2. Aircraft maintenance record of nonroutine items for January 6, 2003, at the
Huntington, West Virginia, maintenance station.



Contents vi Aircraft Accident Report

2.5.2.2 Oversight of Continuing Analysis and
Surveillance System Programs .........
2.5.2.3 Oversight of Maintenance Training Programs. ..............0eeeeee eee 119
2.5.2.3.1 Programs to Reduce Human Error
in Aircraft Maintenance.
2.5.2.4 Oversight of Weight and Balance Programs
2.5.2.4.1 | Approval of Air Midwest’s Weight and
Balance Program... .. 6... cece cece eee eee ene e nen n eens
2.5.2.4.2 Use of Average Weights .
2.5.2.4.3 Technological Advances.......... 60. e eee e cece e eee ene nneee
2.5.3. Raytheon Aircraft Company ......... 6... e cece cence eee nee e enn ete
2.6 Cockpit Voice Recorders Installed in Beech 1900
Series Airplanes 2.0.0.0... ccc cece een e een n nee e een enes 125

3. Conclusions
3.1 Findings ...
3.2 Probable Cause

4, Recommendations................. 0c eee eens
4.1 New Recommendations

4.2 Previously Issued Recommendation Reiterated in This Report............--.+++ 135
4.3 Previously Issued Recommendation Resulting From
This Accident Investigation ........ 0... c ese c cece cece e eee e eee nena eee 135
4.4 Previously Issued Recommendation Classified in This Report ..............-005 135
5. Appendixes

A: Investigation and Hearing. . . aS 137

B: Cockpit Voice Recorder Transcript . .
C: Air Midwest’s Elevator Control System Rigging Procedure
at the Time of the Accident

D: Air Midwest’s Revised Elevator Control System Rigging Procedure................ 200



Analysis 125 Aircraft Accident Report

The Safety Board notes that Beech 1900 series airplanes have been in service since
1984 and have accumulated about 11 million flight hours without significant problems
with the AMMs.!5? However, the three recent events involving Beech 1900D airplanes
raise concerns that the Beech 1900 series AMMs may no longer be adequate in the current
air carrier maintenance environment (less experienced mechanics, an increased prevalence
of contracting out maintenance work, and an increased number of startup operations).

On December 10, 2003, the President of Raytheon Airline Aviation Services met
with the Safety Board to discuss Beech 1900 maintenance initiatives. On December 16,
2003, the Raytheon official sent the Board a facsimile detailing the initiatives the
company would be taking to help Beech 1900 operators “achieve the best possible
maintenance and safety practices.” The facsimile stated, among other things, that
Raytheon Airline Aviation Services would be “developing easy-to-follow text and
illustrations designed to improve the explanation of certain procedures, including flight
control rigging and functional testing, which are then subject to ‘validation and
verification.”” The facsimile also stated that Raytheon would issue these changes as
temporary revisions to its Beech 1900 series AMMs.

Because the three recent events involving Beech 1900D airplanes demonstrated
that mechanics for the three operators did not adequately perform their duties, the Safety
Board concludes that Beech 1900 mechanics would benefit from using AMMs with more
specific instructions for critical flight system procedures. Therefore, the Safety Board
believes that the FAA should ensure that Raytheon Aircraft Company revises the
maintenance procedures for critical flight systems in its Beech 1900, 1900C, and 1900D
AMMs to ensure that the procedures can be completely and correctly accomplished.

2.6 Cockpit Voice Recorders Installed in Beech 1900
Series Airplanes

Before the flight 5481 accident, Beech 1900 series airplanes had experienced
problems with the low signal volume of very high frequency (VHF) radio messages that
were recorded by CVRs installed on the airplanes. As a result, the Safety Board issued
Safety Recommendation A-97-36 on May 22, 1997. Safety Recommendation A-97-36
asked the FAA to require the inspection of CVRs aboard Beech 1900 airplanes and ensure
that the operator take corrective actions so that the intelligibility of recorded
communications was as high as practicable.

Raytheon Aircraft Company issued Service Bulletin (SB) 23-3094, which
recommended the incorporation of an improved CVR amplifier and new circuitry for the
wiring. Subsequently, the FAA issued AD 2000-20-07, which required that all applicable
Beech 1900 airplanes comply with Raytheon Aircraft’s SB. On January 30, 2001, the
Safety Board classified Safety Recommendation A-97-36 “Closed—Acceptable Action.”

133 The Safety Board’s accident and incident database included two Beech 1900 events in which
inadequate maintenance manual procedures were part of the probable cause. For information about these
events, see MIAQ0IA266 and NYCOOIA150 on the Safety Board’s Web site.



Analysis 103 Aircraft Accident Report

safe operation, but no such check is currently required. Therefore, the Safety Board
believes that the FAA should modify (1) appendix G of 14 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. The Safety
Board also believes that the FAA should require manufacturers of aircraft operated under
14 CFR 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. The Safety Board further believes that the FAA should
require 14 CFR 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.

2.4 Aft Center of Gravity and Its Effect on the Restricted
Elevator Travel

The airplane performance study for flight 5481 determined that the accident
airplane’s actual weight was about 17,700 pounds and that its actual CG position was
about 45.5 percent MAC. As a result, flight 5481 had exceeded the Beech 1900D certified
weight limit of 17,120 pounds and the certified aft CG limit of 40 percent MAC.

Of the accident airplane’s 10 flights after the D6 maintenance check, the accident
flight was by far the most aft loaded.!*4 When an airplane is loaded so that the CG is aft of
the aft limit, greater-than-normal AND pitch control is required.

The Safety Board made several calculations to determine the conditions under
which the accident airplane would have been flyable during different flight segments. The
calculations showed that, with full elevator travel (14° to 15° AND) and the accident
airplane loaded to the weight and balance of the accident flight, the airplane should have
been able to maintain flight during the takeoff and climb (requiring 9° to 10° AND
elevator), cruise and descent (requiring 5° to 6° AND elevator), and approach and land
(requiring 8° to 9° AND elevator) segments. The calculations also showed that, with
reduced elevator travel (7° to 8° AND) and the accident airplane loaded to, but not
exceeding, the Beech 1900D weight and CG limits, the airplane might have been able to
fly during the takeoff and climb (requiring 7° to 8° AND elevator), cruise and descent
(requiring 4° to 5° AND elevator), and approach and land (requiring 7° to 8° AND
elevator) segments. Even if the required AND elevator slightly exceeded the available
AND elevator, the airplane would have been controllable. The airplane would have

'33. A flight system or component is considered critical if its failure can be catastrophic.

'4 Although the other nine flights after the D6 maintenance check had a CG position that was farther
forward, the airplane was still being operated in a potentially dangerous situation as a result of the restricted
downward elevator travel.



Factual Information 62 Aircraft Accident Report

1.17.2.1 Contract Between Raytheon Aerospace and Air Midwest

The contract between RALLC and Air Midwest was a 60-month agreement that
became effective on January 1, 2003." The contract contained 29 statements of
understanding and 3 appendixes that detailed the conditions of the agreement.

The contract stated that RALLC would provide a manager, foremen, mechanics,
and inspectors to Air Midwest to meet its maintenance requirements and that RALLC
would confer with Air Midwest before any changes were made to the number of personnel
provided. No language in the contract prevented RALLC from contracting with another
party for maintenance personnel.

The contract stated that scheduled maintenance and unscheduled on-call
maintenance would be performed according to the procedures in Air Midwest’s
maintenance manuals and that all maintenance actions, parts, and documentation would
meet Federal Aviation Regulations (FARs) and Air Midwest requirements. The contract
further stated that RALLC would work toward achieving a 99-percent reliability rate for
scheduled maintenance.

According to the contract, Air Midwest would supply all parts, materials, and
equipment and would be responsible for technical data management, quality
control/quality assurance inspection, a technical library, and a tracking system for
time-compliance and hard-time items.

The contract specified the allocation of cost at each of the Air Midwest
maintenance stations. According to the contract, Air Midwest was solely responsible for
the hangar facility at HTS.

1.17.3 Structural Modification and Repair Technicians

SMART, which is headquartered in Edgewater, Florida, recruits maintenance
personnel for its aviation industry clients. SMART accepts résumés through recruiters or
on its Web site and then qualifies applicants by conducting a 5-year background check, a
10-year security check,* and drug testing. SMART mechanics indicated that the company
does not interview applicants in person to determine their experience level, but public
hearing testimony by SMART’s Director of Recruiting indicated that the company
conducts telephone interviews to make such determinations.

Applicants that pass the reference checks and the drug testing are hired as SMART
employees. They bid on open job postings for placement with an aviation industry client.
SMART employees work for SMART and not the aviation industry client. SMART does
not oversee, evaluate, or direct its employees at the client’s work site.

82 The contract between RALLC and Air Midwest was originally negotiated in September 2001 and
‘was renegotiated in September 2002.

83 SMART employees that were hired before September 11, 2001, were subject to a 5-year security
check.


200 Aircraft Accident Report

Appendix D
Air Midwest’s Revised Elevator Control System Rigging

Procedure

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANUAL

Manual Affected: Beech 1900D Airliner Maintenance Manual (129-590000-15A)
Instructions: Insert pages 5 through 8 prior to page 201, Chapter 27-30-02.

Reason: The ELEVATOR CONTROL SYSTEM RIGGING procedure is replaced by
the data in this Temporary Revision.

ELEVATOR CONTROL SYSTEM RIGGING

THE GUST LOCK PIN MUST NOT BE USED FOR RIGGING THE ELEVATOR
CONTROL SYSTEM EXCEPT WHEN PERFORMING THE GUST LOCK PIN
CHECK PORTION OF THIS PROCEDURE.

If a FA2100 Flight Data Recorder System is installed on this aircraft, perform the LINK removal
portion of the ELEVATOR SURFACE POSITION SYNCHRO TRANSMITTER (SENSOR)
REMOVAL procedure. Refer to Chapter 31-31-12 in the BEECH 1900D AIRLINER FLIGHT
DATA RECORDER (FA2100) MAINTENANCE MANUAL SUPPLEMENT, P/N 129-590000-109.

Where the cables pass through structure, the areas of possible contact between the control
cables and adjacent structure must be protected with grommets, rub strips, block or guide
fairings. Where contact of control cables does occur with the protective elements, a force no
greater than eight (8) ounces shall be required to move the cable to a position of no contact. At
no time should flight contro! cables contact metal structure.

NOTE

DISCONNECT THE AUTOPILOT SERVO CABLES TO THE ELEVATOR PRIMARY
CONTROL CABLES. REFER TO CHAPTER 22.

a. Locate and remove all access panels from the vertical and horizontal stabilizers to gain
access to the aft elevator bellcrank and the elevator cables. Refer to Chapter 6.

b. Install a rig pin in the aft elevator belicrank. Refer to Chapter 27-30-01, Figure 201.

c. Remove lock clips from turnbuckles. Release cable tension.

. Page 5 of 8
Temporary Revision No. 27-7 Feb 12/03



Factual Information 17 Aircraft Accident Report

The inboard end of each elevator has a control horn that is connected to the
elevator surface by a shaft. Four primary stop bolts (left upper, left lower, right upper, and
right lower) are mounted on airplane structure. The limit of travel for each of the elevator
control horns is contact with an up stop bolt or a down stop bolt. The Beech 1900D AMM,
section 27-30-02, indicates that the elevator primary stop deflection settings are 20°
+1°/-0° up from the neutral position and 14° +1°/-0° down from the neutral position. The
elevator’s neutral position is the point at which the position of the trailing edge of the
elevator is aligned with the chord plane of the horizontal stabilizer.

The left and right elevator control horns are connected by independent aft
pushrods to the aft bellcrank, which is located near the junction of the horizontal and
vertical stabilizers. Left and right tension springs connect the aft bellcrank arm to airplane
structure and orient the pitch control system toward the AND direction. Attachment links
connect the springs to the aft bellcrank arm. Structure adjacent to the aft bellcrank
contains holes for a rig pin.”

Control cable assemblies (one ANU and one AND) connect the aft bellcrank to the
forward bellcrank. The control cable assemblies have two cable sections joined by
turnbuckle assemblies located in the base of the vertical stabilizer. Each control cable
assembly comprises seven spirally wound strands and has one long and one short
component. The turnbuckle assemblies establish the correct tension in the cables. Each
turnbuckle assembly consists of a barrel and two threaded cable terminals. Figure 5 shows
the ANU and AND turnbuckle assemblies.

Each turnbuckle assembly can be lengthened or shortened during elevator rigging.
Depending on the direction of the turnbuckle barrel’s rotation, both threaded cable
terminals extend from or contract into the barrel at the same time. A tooling hole in the
barrel is used by mechanics to rotate the barrel, and tooling holes in the terminals are used
to hold the terminals in place while the turnbuckle barrel rotates. According to FAA
Advisory Circular (AC) 43.13-1B, “Acceptable Methods, Techniques, and Practices —
Aircraft Inspection and Repair” (dated September 27, 2001), up to three threads of a
terminal can be visible on a tumbuckle assembly when maintenance is complete. A safety
clip holds the terminals in place in the barrel after maintenance to ensure that the length of
the turnbuckle assembly does not change.

28 A rig pin is a maintenance tool that is inserted into a flight control system to immobilize movable
components at a specific position. A rig pin must be removed before maintenance is complete. For a rig pin
to properly penetrate the aft bellcrank rig pin holes, the bellcrank must be moved to align with the holes in
the structure on both sides of the bellcrank. The rig pin must enter the bellcrank through a hole on one side
of the vertical stabilizer, pass through the bellcrank, and then pass through structure on the other side of the
vertical stabilizer. When the aft bellcrank rig pin is in place, the elevators can be set to 0° by adjusting the aft
pushrods.



Recommendations 136 Aircraft Accident Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ELLEN ENGLEMAN CONNERS JOHN J. GOGLIA
Chairman Member
MARK V. ROSENKER CAROL J. CARMODY
Vice Chairman Member
RICHARD F. HEALING
Member

Adopted: February 26, 2004


Factual Information 3 Aircraft Accident Report

About 0847:02, the first officer stated, “wuh,” and the captain stated, “oh.”
About 0847:03, the captain stated, “help me.” At that point, the airplane was about 90 feet
above ground level, and FDR data showed that the airplane’s pitch attitude was 20° ANU
and airspeed was 139 knots. About 0847:04, the CVR recorded the captain asking, “you
got it?” and FDR data indicated that the flight crew was forcefully commanding AND.
During the next 8 seconds, the CVR recorded multiple statements and sounds from both
flight crewmembers associated with their efforts to push the airplane’s nose down. Also,
about 0847:09, the CVR recorded a change in engine/propeller noise and, about 1 second
later, the beginning of a sound similar to the stall warning horn.

About 0847:13, the FDR recorded a maximum pitch attitude of 54° ANU.
About 0847:16, the captain radioed the ATCT and stated, “we have an emergency for Air
[Midwest] fifty four eighty one,” and the CVR recorded the end of the sound similar to the
stall warning horn. About 0847:18, the airplane’s pitch attitude decreased through 0°, and
the elevator position began to move ANU. By 0847:19, the airplane was about 1,150 feet
above ground level, and the FDR recorded a maximum left roll of 127° and a minimum
airspeed of 31 knots. About 1 second later, the FDR recorded a pitch attitude of 42° AND.

About 0847:21, the captain stated, “pull the power back,” the elevator position
reached full ANU, and the airplane’s pitch attitude was 39° AND. At 0847:21.7, the CVR
recorded the beginning of a sound similar to the stall warning horn, which continued to the
end of the recording. About 0847:22, the airplane’s roll attitude stabilized at about 20° left
wing down; the pitch attitude began to increase; and the elevator position moved in the
AND direction, reaching about 8° ANU. About 1 second later, the elevator position began
moving in the ANU direction. About 0847:24 the airplane rolled right through wings
level, and the pitch attitude increased to about 5° AND.

About 0847:26, the FDR recorded a maximum right roll of 68° and a maximum
vertical acceleration of 1.9 Gs.° About the same time, the captain stated, “oh my god ahh,”
and the first officer stated something similar to, “uh uh god ahh [expletive].” The CVR
recording ended at 0847:28.1. The FDR’s last recorded pitch attitude was 47° AND; roll
attitude was 66° to the right; and pitch control position was 19.2° ANU, which
corresponded to an elevator position of full ANU.

The airplane struck a US Airways maintenance hangar on CLT property and came
to rest about 1,650 feet east of the runway 18R centerline and about 7,600 feet beyond the
runway 18R threshold. ATCT controllers heard an emergency locator transmitter signal
beginning about 0847:29."° The accident occurred at 35° 12' 25" north latitude and 80° 56!
46.85" west longitude during daylight hours.

° One G is equivalent to the acceleration caused by the earth’s gravity (32.174 feet/second’).

© See section 1.10.2 for information about the tower controllers’ observations regarding the accident
flight.



Recommendations 134 Aircraft Accident Report

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.” (A-04-17)

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. (A-04-18)

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.
(A-04-19)

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. (A-04-20)

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. (A-04-21)

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. (A-04-22)

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.
(A-04-23)

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. (A-04-24)



Aircraft Accident Report

177

Appendix B

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Factual Information 22 Aircraft Accident Report

u. On aircraft equipped with the F1000 Flight Data Recorder, calibrate the Pitch
Position Potentiometer. Perform the FLIGHT DATA RECORDER (FDR) — PITCH

ADJUSTMENT procedure.)
vy. Remove the travel boards from the horizontal stabilizers.
w. Connect the autopilot servo cables to the elevator primary control cables.
x. Install the seats, carpet and floorboards.

y. Replace all access panels.

Step a, to disconnect the autopilot servo cables, and step w, to connect the autopilot
servo cables to the elevator primary control cables, were not applicable to the accident
airplane because it did not have an autopilot. Step d, to locate and remove the passenger
seats, carpet, and floorboards on the right side of the passenger compartment to gain
access to the turnbuckles, was not applicable because the elevator cable turnbuckles for
the Beech 1900D model are not located under the passenger compartment floorboards.**

1.6.3.2 Applicable Steps That Were Skipped During Maintenance

The mechanic indicated that he bypassed step c, to locate and remove the flight
compartment seats, carpet, and floorboards to gain access to the forward elevator
belicrank, because the quality assurance inspector told him that the flight compartment
seats and floorboards did not need to be removed to comply with the rigging procedure. In
fact, the mechanic stated that access to the rig pin hole was adequate without removing the
seats and the floorboards because the foreman showed the mechanic a small access panel
that needed to be opened to access the forward bellcrank rig pin hole. The mechanic also
stated that he bypassed step f, to adjust the center-to-center length of the forward push-pull
tube to a dimension of 15.12 inches +0.06 inch, with the quality assurance inspector’s

concurrence.

The mechanic indicated that he bypassed step g, to adjust the stop bolts on the
elevator control horn supports for a deflection setting of 20° +1°/-0° up and 14° +1°/-0°
down, because he did not think that cable tensioning required a measurement of the
deflection settings. The mechanic stated that he had manually pushed the elevators up and
down before rigging to determine if the elevator control horns were hitting the stops.

The mechanic stated that he decided, and the quality assurance inspector
concurred, that the following steps were not required: step h, to verify the bob weight stop
bolt clearance and adjust if necessary; step i, to adjust the forward bellcrank stops for

33 The pitch adjustment procedure involves setting the elevator to eight different data points, ranging
from 14° AND to 20° ANU (including 0°), and recording the FDR readout.

34 The turnbuckles for the Beech 1900C model are located under the passenger compartment
floorboards.

35 During ground tests (see section 1.16.1), Safety Board investigators noted that it was easier to view
the inserted rig pin when the floorboard in front of the first officer’s seat was removed, as directed in part by
step c of the rigging procedure, rather than when just the small access panel was opened.


Aircraft Accident Report

159

Appendix B

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Aircraft Accident Report

179

Appendix B

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Factual Information 91 Aircraft Accident Report

3 pounds less than the CAA’s female passenger weight at the time (about 143 pounds).
The average weight for carry-on baggage was 5 pounds more than the CAA’s carry-on
baggage weight at the time (about 7 pounds).

1.18.6.2 Australian Department of Transport and Communications Report

The Flight Standards Division of the Australian Department of Transport and
Communications conducted a project to investigate the methodology of standard weights
and weight surveys. The Flight Standards Division was concerned about the use of
170 pounds (converted from kilograms) as the standard adult passenger weight in aircraft
of all passenger capacities. The 170-pound figure, which was derived from a survey
conducted in 1946, made no distinction between male and female passengers and included
carry-on baggage.

The Flight Standards Division found that the adult standard weight of 170 pounds
was based on inaccurate and outdated passenger weight data. The 1988 report on this
project'”’ included a discussion of the following issues:

¢ the need for new weight surveys,

* the basic statistics theory applicable to standard weights,

+ the errors in the criteria used to determine the then-current standard weights,
¢ the maximum probability of overload and its relation to safety,

* the effect on the maximum probability of overload when the standard
passenger weight was constant,

« the effect on standard passenger weight when the maximum probability of
overload was constant,

* a proposed method for calculating future standard passenger weights (a
sliding-scale formula that based passenger weight on the maximum seating
capacity of the airplane), and

* interim standard weights based on then-current data from the Australian
National Heart Foundation for adult males and females and the Australian
National Health and Medical Research Council for infants (under 3 years of
age), children (4 to 12 years of age), and adolescent males and females (13 to
16 years of age).

The Flight Standards Division concluded that the use of one adult standard weight
for all aircraft capacities was no longer acceptable because smaller aircraft had a
significant risk of being overloaded and larger aircraft were being unnecessarily
penalized. The Flight Standards Division further concluded that all aircraft should have a
similar level of safety with respect to the uncertainty of passenger load and that a

3 For more information, see Airworthiness Branch, Flight Standards Division, Department of
Transport and Communications, Standard Weights for Passenger and Baggage in Australian Aircraft,
Airworthiness Report AF 51 (Canberra: Department of Transport and Communications, 1988).



Recommendations 133 Aircraft Accident Report

Prohibit inspectors from performing required inspection item inspections
on any maintenance task for which the inspector provided on-the-job
training to the mechanic who accomplished the task. (A-04-9)

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. (A-04-10)

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. (A-04-11)

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. (A-04-12)

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.
(A-04-13)

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. (A-04-14)

Require that all 14 Code of Federal Regulations Part 121 air carrier
maintenance training programs be approved. (A-04-15)

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. (A-04-16)



Factual Information 84 Aircraft Accident Report

Evaluate the benefit of the STAN (Sum Total Aft and Nose) and similar systems
and require, if warranted, the installation of a system that displays airplane weight
and balance and gross weight in the cockpit of transport-category cargo airplanes.

On December 30, 1998, the FAA stated that it had completed an evaluation of the
reliability of onboard weight and balance systems. The FAA found that some operators
had reliability and accuracy concerns with such systems because of factors such as wind,
ramp slope, oleo stiction, low hydraulic pressure, and asymmetrical gear loads. The FAA
stated that the results of its evaluation did not support imposing a requirement to install a
system that displays airplane weight and balance and gross weight in the cockpit of
transport-category cargo airplanes. On January 11, 2000, the Safety Board stated that, on
the basis of the FAA’s evaluation and subsequent determination that onboard weight and
balance systems do not yet meet the quality standards for a mandatory system, Safety
Recommendation A-98-49 was classified “Closed—Acceptable Action.”

1.18.4.4 Emery Airlines Flight 17, Rancho Cordova, California

On February 16, 2000, Emery Airlines flight 17, a McDonnell Douglas DC-8-71F,
N8079U, crashed in an automobile salvage yard shortly after takeoff while attempting to
return to Sacramento Mather Airport, Rancho Cordova, California, for an emergency
landing. Flight 17 was a scheduled 14 CFR Part 121 cargo flight from Sacramento to
James M. Cox Dayton International Airport, Dayton, Ohio. The two pilots and the flight
engineer were killed, and the airplane was destroyed.

The Safety Board’s investigation of this accident determined that the bolt attaching
the accident airplane’s right elevator control tab crank fitting to the pushrod was
improperly secured and inspected during either the airplane’s most recent D inspection
(heavy maintenance accomplished every 12 years) or subsequent maintenance. Tennessee
Technical Services (TTS), an Emery Airlines maintenance contractor, performed the
accident airplane’s last D inspection between August 27 and November 17, 1999. Eight
days after the D inspection was completed, a pilot reported increased control column
forces. Emery maintenance personnel found that the left and the right elevator dampers
were reversed, and the maintenance logbook indicated that the maintenance personnel
moved the dampers to their correct positions. Emery maintenance personnel could have
come in contact with the bolt at the control tab crank fitting while troubleshooting the
reported problem.

The Safety Board determined that the probable cause of the accident was a loss of
pitch control resulting from the disconnection of the right elevator control tab. The
disconnection was caused by the failure to properly secure and inspect the attachment
bolt.1!!

1M For more information, see National Transportation Safety Board, Loss of Pitch Control on Takeoff,
Emery Worldwide Airlines, Inc., Flight 17, McDonnell Douglas DC-8-71F, N8079U, Rancho Cordova,
California, February 16, 2000, Aircraft Accident Report NTSB/AAR-03/02 (Washington, DC: NTSB,
2003).


Aircraft Accident Report

186

Appendix B

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Factual Information 4 Aircraft Accident Report

1.1.1 Maintenance Events Preceding the Accident Flight

Between the night of January 6 and the morning of January 7, 2003, the accident
airplane underwent a detail six (D6) maintenance check!! at Air Midwest’s HTS
maintenance station. Air Midwest contracted with Raytheon Aerospace, LLC (RALLC),”
to provide mechanics, quality assurance inspectors, and a site manager for the HTS
maintenance station. RALLC contracted with Structural Modification and Repair
Technicians, Inc. (SMART), to supply the mechanic workforce.

The RALLC quality assurance inspector on duty the night of January 6th was
providing on-the-job training (OJT) to two SMART mechanics on specific tasks
associated with the D6 maintenance check. Neither mechanic had previously performed

the complete D6 check.

One of the mechanics receiving OJT was assigned to inspect and check the
elevator control cable tension. The D6 inspection procedures checklist (also known as the
D6 work card), dated August 25, 2000, indicated that the cable tension was to be checked
according to the procedures in chapter 27 of the Raytheon Aircraft Beech 1900D Airliner
Maintenance Manual (AMM), as shown in figure 1. The first step on the D6 work card
indicated that a temperature reading needed to be taken (to determine the tension values at
which the control cables should be set) but did not specify how to take the temperature.'°
The work card showed that the mechanic recorded the temperature as 55° Fahrenheit (F).

1! ‘The D6 maintenance check comprises an elevator check, a rudder check, and a trim tab check.

2 On June 20, 2003, RALLC changed its name to Vertex Aerospace, LLC. On December 1, 2003, L-3
Communications acquired Vertex Aerospace and named the new business unit L-3 Communications
AeroTech, LLC.

3 Tn a postaccident interview, the mechanic stated that he obtained a temperature reading from the
outside air temperature (OAT) gauge located beneath the captain’s side window, but the quality assurance
inspector subsequently indicated that the temperature was actually read from an OAT gauge that was going
to be installed on the accident airplane during the maintenance visit. The quality assurance inspector
provided the Safety Board with the following written statement, dated February 25, 2003: “at the time the
cable tensions were adjusted on A/C [aircraft] 233 [the accident airplane] the OAT gage [sic] reading was
taken while it was laying on the top shelf of the podium. The podium was located at the nose of the A/C
approximately 6 ft from the right avionics bay door.”


Factual Information 90 Aircraft Accident Report

1.18.6 Other Passenger and Baggage Weight Information

1.18.6.1 Civil Aviation Authority Report

The Civil Aviation Authority (CAA), the FAA’s counterpart in the United
Kingdom, conducted a survey between November 1981 and January 1982 to determine
the distribution of passengers and their carry-on baggage aboard scheduled air carrier
flights. The survey was conducted 18 times at Heathrow Airport because of its high
turnover during the day and its wide variety of international and domestic flights.
Departing international and domestic passengers and their carry-on baggage were weighed
on a scale with a digital readout; testing at the beginning and the end of the survey found
that the scale was accurate to within 0.5 percent.

International passengers were asked about where they were traveling, whether they
were traveling for business or leisure, and whether they had checked any baggage. The
international passengers and their carry-on baggage were then weighed. Domestic
passengers were asked whether they had checked any baggage, and then the passengers
and their carry-on baggage were weighed. The CAA’s survey results appear in table 9.12

Table 9. Results of the Civil Aviation Authority's weight and carry-on baggage survey.

Category Number surveyed Average weights (in pounds)*
International Domestic
Male passenger 1,928° 178 181
Female passenger 769° 141 140
Child passenger 728 56 56
Infant passenger 63 25 25
Carry-on baggage 2,775° 12 12

® For this report, the average weights were converted from kilograms to pounds and then were rounded to the nearest

whole number.

© Of the 1,928 male passengers surveyed, 1,632 were international passengers, and 296 were domestic passengers.
© Of the 769 female passengers surveyed, 692 were international passengers, and 77 were domestic passengers.

4 The child and infant passengers surveyed were not categorized according to whether they were international or domestic
passengers. A child was considered to be between 2 and 11 years of age, and an infant was considered to be under 2 years

of age.

® The carry-on baggage was not categorized according to whether the bags belonged to international or domestic

passengers.

According to the CAA’s report, the average weight for male passengers was
between 13 and 16 pounds more than the CAA’s male passenger weight at the time of the
survey (about 165 pounds). The average weight for female passengers was between 2 and

122 For more information, see Civil Aviation Authority, Passenger and Hand Baggage Weight Survey,
Heathrow Airport — Winter 1981/1982, CAA Paper 83003 (London: CAA, 1983).



Aircraft Accident Report

180

Appendix B

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Analysis 95 Aircraft Accident Report

manifest indicated a taxi fuel burn of 220 pounds, even though Air Midwest assumes a
taxi fuel burn of 110 pounds. These figures resulted in a calculated airplane weight of
17,028 pounds and a CG position of 37.8 percent mean aerodynamic chord (MAC), which
were within the Beech 1900D certified weight and CG limits of 17,120 pounds and
40 percent MAC, respectively.

The two ramp agents assigned to the accident flight handled the baggage according
to company procedures and interacted appropriately with the flight crew. In a postaccident
interview, one of the ramp agents reported that he told the captain that 2 of the 31 bags
aboard the airplane had an estimated weight of between 70 and 80 pounds. However, the
bags did not have a heavy bag tag attached to them. (Gate agents use these tags to indicate
an overweight bag, that is, a bag that weighs between 70 and 100 pounds.) Also, the bags
were not identified as overweight on the OF-11E form (the US Airways Express Load
Report that is used to account for all passengers, baggage, and cargo loaded on a US
Airways Express flight). As a result, the flight crew was not required to account for the
extra weight of the reportedly heavy bags on the load manifest form.

Even if the flight crew had (1) accounted for the two reportedly heavy bags or
(2) accounted for the two heavy bags, estimated an additional 110 pounds of fuel at
takeoff,!2” and recorded the 12-year-old passenger’s weight as 80 pounds rather than 175
pounds, '”* the Air Midwest weight and balance program would still have indicated that
flight 5481 was within the Beech 1900D certified weight and CG limits, as shown in table
12. However, for the second scenario, flight 5481’s calculated weight would have
exceeded the Beech 1900D weight limit if the 12-year-old passenger’s weight had
remained 175 pounds.

Table 12. Calculations for Air Midwest flight 5481 using the weight and balance program
in effect at the time of the accident.

Load manifest plus two bags and 110
Load manifest plus two pounds of fuel but with 80 pounds for
Load manifest bags the child passenger
Weight CG Weight CG Weight CG (percent MAC)
(pounds) (percent (pounds) (percent (pounds)
MAC) MAC)
17,028 37.8 17,078 38.8 17,093 38.8

27 According to the flight 5481 dispatch release, the airplane was loaded with 2,420 pounds of fuel
before takeoff. Given Air Midwest’s taxi fuel burn assumption of 110 pounds, the airplane would have had
2,310 pounds of fuel at takeoff. The load manifest indicated that the airplane had 2,200 pounds of fuel at
takeoff.

18 The Air Midwest Flight Operations Procedures Manual at the time of the accident (see section 1.18.1.2)

stated that an average weight of 175 pounds could be used for each adult passenger during the winter and
that an average of 80 pounds could be used for children between the ages of 2 and 12 years.



Appendix C 194 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANAUL
take the higher of the two readings, and multiply it by a factor of 0.108. For example:
Fs(max) = 0.106 X Highest Cable Tension
Example:

Highest Cable Tension = 98 Ibs.
Fs(max) = 0.106 X 98 Ibs.
Fs(max) = 10.4 Ibs.

g. With the maximum allowable system friction established, use the force measurements to calculate the actual
system friction. System friction value is obtained by dividing the difference of the up and down force values by 2, or:

Fs = (F up - F down) +2
Example:

F up = 48 Ibs., F down = 32 Ibs

Fs = (F up - F down) +2

Fs = (48-32) +2=16 +2=8 = acceptable.

h. Combined downspring and bob-weight-force range (Fc) is 40.0 + 1.5 Ibs.

i. Combined downspring and bob weight force is obtained by adding the up and down values then dividing by 2, or:
Fo =(up + down) +2

Example:

F up = 48 Ibs., F down = 32 Ibs.

Fo =(F up + F down) +2

Fe = (48 + 32) +2=80 +2=40= acceptable

j. If Ecis above the range of 40.0 # 1.5 Ibs., decrease the downspring tension by moving it further out on the ad-

justment link. If Fc is below the proper range, increase tension by moving it further in on the adjustment link.

NOTE

If system friction-force cannot be brought under the limit, check cable installation, pulley bearings,
bellcrank bearings, push-pull rod ends, the control yoke, control column support rollers and all link-
ages associated with the elevator control.

k. Verify that the elevator installation is within the following limitations:

4. With the elevator deflected fully up or down, the distance at the closest point between the trailing edge of
the horizontal stabilizer and the elevator skin shall be 0.187 +0.1/ -0.05 inch.

2. The minimum gap between the inboard edge of the elevator and the vertical stabilizer shall be 0.12 inch.

as 27-30-02 Fes2202


Aircraft Accident Report

185

Appendix B

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Analysis 111 Aircraft Accident Report

* The foreman’s training records indicated that he had received OJT for the
detail 2 through detail 5 checks all on the same day. It is unrealistic for any
mechanic to have completed OJT for all those tasks on a single day because
one detail check generally takes an entire shift to complete.

Further, the Air Midwest principal maintenance inspector (PMI) stated that the
FAA has had longstanding concerns with Air Midwest’s management of its maintenance
training program. These concerns included that mechanics received no formal (classroom)
training, OJT records were not being properly maintained, no one was adequately
monitoring the quality of the OJT provided, and the training was not consistent with
guidelines set forth in Air Midwest’s Maintenance Training Manual. Letters from the FAA
to Air Midwest showed that, during a 2-year period beginning in October 2000, the FAA
had encouraged Air Midwest to improve its maintenance training program (see section 2.5.2.1
for more information). However, evidence discovered during the investigation of the flight
5481 accident showed that deficiencies still existed in Air Midwest’s maintenance training

program.

The Safety Board concludes that Air Midwest did not ensure that its maintenance
training was conducted and documented in accordance with the company’s maintenance
training program, which degraded the quality of training and inspection activities at the
HTS maintenance station. Because of the numerous discrepancies in the training records
of HTS maintenance personnel, the Safety Board believes that the FAA should 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.

2.5.1.3 Continuing Analysis and Surveillance System Program

The Safety Board identified numerous deficiencies in Air Midwest’s maintenance
program during the investigation of the flight 5481 accident. These deficiencies included
inadequate oversight of maintenance at the HTS maintenance station, poorly designed
maintenance procedures, lack of adherence to maintenance procedures, inadequate
inspection of accomplished maintenance, and poorly developed policies and procedures
for training maintenance personnel. During the public hearing on this accident, the FAA’s
Technical Advisor for Aircraft Maintenance stated that Air Midwest’s primary tool for
detecting and correcting such deficiencies should have been its CASS program. However,
FAA and Air Midwest documents indicated that deficiencies existed in Air Midwest’s
CASS program, which prevented it from fulfilling its intended purpose.

The FAA notified Air Midwest about CASS deficiencies several times, including
the following:



Factual Information 58 Aircraft Accident Report

training for the D6 maintenance check, but the five mechanics had not completed the
training.

The Air Midwest regional site manager stated that HTS had experienced a high
turnover of its mechanic workforce. The RALLC site manager at HTS estimated that the
average tenure for SMART employees was about 3 months. Both site managers indicated
that the turnover occurred because mechanics received better contracts, wanted to work
closer to their home, or wanted to work in another part of the country. The RALLC site
manager did not think that there was any difference in the attitude, tenacity, skills, or
competency between RALLC and SMART employees but thought that RALLC
employees might have a greater level of commitment to the company. The Air Midwest
regional site manager also did not think that there was any difference between RALLC
and SMART employees, except that SMART personnel “come in for a couple months and
leave.”

1.17.1.3 Air Midwest Audits of the Huntington Maintenance Station

On November 5, 2002, an Air Midwest auditor from Wichita conducted an audit of
the HTS maintenance station using the Air Midwest maintenance station audit guide
checklist. One item on the checklist was to determine whether proper training was being
provided for new hires, training records were being kept up to date, and proper recurrent
training was being provided. The auditor found that those areas were satisfactory. The
auditor also determined that overall staffing was not sufficient. Specifically, the auditor
indicated on the checklist that HTS had only one foreman and one quality assurance
inspector but should have two foremen and two inspectors.

A letter from Air Midwest’s quality assurance auditor, dated November 21, 2002,
to the RALLC site manager detailed the audit findings and indicated that HTS had 30 days
to respond to the findings. The letter also stated that the quality assurance auditor needed
to know, in writing, when resolution of the findings was complete. In a January 3, 2003,
letter to the quality assurance auditor, the RALLC site manager indicated that HTS had
increased its maintenance staff by 20 percent in the last month. At the public hearing on
this accident, the RALLC site manager indicated that two mechanics had been hired but
that an inspector and a foreman had not been hired.

On January 14, 2003, an Air Midwest auditor from Wichita conducted another
audit of the HTS maintenance station. The auditor had concerns about whether proper
training was being provided for new hires and training records were kept up to date,
whether the shift overlap was adequate and verbal turnovers were used properly, and
whether sufficient staff existed for each shift. The auditor determined that maintenance
manual revisions were not complete and that foremen were not ensuring that training
forms were properly stamped by instructors.

A letter from Air Midwest’s quality assurance auditor, dated January 17, 2003, to
the Air Midwest regional site manager detailed the audit findings and indicated that HTS
had 30 days to respond to the findings. In a February 20, 2003, letter to the quality assurance


Factual Information 64 Aircraft Accident Report

The Air Midwest principal maintenance inspector (PMI) began work for the FAA
in 1988 and has been in his current position, which is based in Wichita, since December 1998.
The Air Midwest certificate is the only one the PMI oversees. Two assistants help the PMI
carry out his responsibilities. During postaccident interviews, the PMI stated that he had
40 years of aviation-related experience, including 30 years as an A&P mechanic and
25 years as a maintenance inspector.

The PMI stated that he tried to visit all of the Air Midwest maintenance stations
two to three times per year for at least 3 days each time. The PMI stated that he rarely
announced his inspections of Air Midwest’s maintenance stations. The PMI stated that he
usually took a morning flight to a maintenance station, visited the station after arriving,
and met with the maintenance managers to discuss any of their concerns. The PMI also
stated that he would return to the station at night to observe maintenance operations.

The PMI visited the HTS maintenance station before it opened in July 2002. The
PML also visited HTS in September 2002. According to postaccident interviews, the PMI
spoke with the quality assurance inspector and the foreman but did not speak with the
mechanics. Also, the RALLC site manager and the Air Midwest regional site manager
stated that the PMI reviewed training records and other documentation and observed
maintenance operations during the overnight shift. The RALLC site manager further
stated that the PMI told him that the mechanics “seemed very competent.”*° In a
postaccident interview, the PMI stated that, before the accident, he was unaware that
third-party maintenance contractors were being used at HTS.

During public hearing testimony, the PMI stated that he would not readily find
problems concerning OJT at the maintenance stations and that the only way he would
discover such a problem would be to “work some kind of a spreadsheet where [he] could
correlate whoever signed it [the OJT] off on the job card versus the training folder,” which
was “a little bit of work.” The PMI did state his concern that HTS personnel did not follow
the Air Midwest maintenance manual while conducting OJT.

In addition, the RALLC site manager and the Air Midwest regional site manager
stated that flight standards inspectors from the Charleston, West Virginia, FSDO had
visited HTS once for an informal introduction and that the visit was not an inspection of
the facility. The Air Midwest regional site manager further stated that airworthiness
inspectors from the Charleston FSDO visited HTS once while he and the RALLC site
manager were at lunch.

Finally, in addition to the POI and PMI, a principal avionics inspector (PAI) was
assigned to the Air Midwest certificate. The PAI, who was based in Wichita, reviewed all
of Air Midwest’s maintenance training manual submissions. The PMI stated, in a January 2004
interview, that the PAI had worked as a maintenance inspector before becoming an
avionics inspector and that he understood both areas very well.

86 The RALLC site manager also stated that, about the time of the PMI’s visit, HTS “had people
training us from other sites on a regular basis and so we had two guys that were really knowledgeable, plus
the staff that we normally had.”


Appendix C 193 Aircraft Accident Report

Raytheon Aircraft

BEECH 1900D AIRLINER MAINTENANCE MANAUL

1. Adjust the pushrods between the aff elevator bellcrank and the elevator to position the elevator at neutral (0°
deflection).

m. Remove the rig pin from the aft elevator bellcrank.

n. Remove the safety clips from the turnbuckles and release cable tension.

0. Move the control yoke to install the rig pin in the forward elevator bellcrank.

p. Tighten the elevator-up cable until the elevator rises to neutral (0° on the travel board).

Tighten the elevator-down cable until the average tension of the up- and down-cables is 66 + 8 pounds (the sum
Gf up-eable and down-cable tensions, dvided by two). Refer to Figure 203.

r. Continue to balance the adjustment of the two cables until the average tension is 66 + 8 pounds while main-
taining 0° deflection of the elevator.

s. Perform the CONTROL COLUMN SUPPORT ROLLER INSPECTION procedure of this Chapter.
t. Install safety clips on the turnbuckles.

u. On aircraft equipped with the F1000 Flight Data Recorder, calibrate the Pitch Position Potentiometer. Perform
the FLIGHT DATA RECORDER (FDR) - PITCH ADJUSTMENT procedure. Refer to Chapter 31-30-00.

v. Remove the travel boards from the horizontal stabilizers.
w. Connect the autopilot servo cables to the elevator primary control cables. Refer to Chapter 22.
x. Install the seats, carpet and floorboards. Refer to Chapters 6 and 25.

y. Replace all access panels.
ELEVATOR CONTROL SYSTEM FRICTION TEST

NOTE

Take all force readings with the elevator control system completely installed: downsprings attached,
cables rigged with tension applied, bob weight mounted on control yoke, and autopilot servo cables
attached.

a. Use a hand-held force gage attached and centered between inboard grips of the pilot's and copilot’s contro!
wheels,

b. Take five force-measurements by pulling the control wheels straight in line with the column from the fully forward
(elevator down) position, through neutral, to the fully aft (elevator up) position. Read the force gage as the control
wheels pass through neutral.

c. Average the five readings and record this value as F up.

d. Take five force-measurements by pushing the control wheels straight in line with the column from the fully aft
(elevator up) position, through neutral, to the fully forward (elevator down) position. Read the force gauge as the
control wheels pass through neutral.

e. Average the five readings and record this value as F down.

f. To determine the maximum allowable system friction, Fs(max), measure the tension of both elevator cables,

rebzze2 27-30-02 nas



Factual Information 9 Aircraft Accident Report

1.5 Personnel Information

1.5.1 The Captain

The captain, age 25, was hired by Air Midwest in March 2000. She held an airline
transport pilot certificate and a Federal Aviation Administration (FAA) first-class medical
certificate dated November 19, 2002, with no limitations. The captain received a type
rating on the Beech 1900D in March 2001.

The captain received her private pilot certificate in February 1997 while she was
an aviation student at Louisiana Tech University, Ruston, Louisiana. From February 1999
to March 2000, the captain was a flight instructor and flight school supervisor at the
university. The captain’s résumé for employment with Air Midwest indicated that she had
accumulated 925 hours total flying time (625 of which were as pilot-in-command [PIC]
and 101 hours of which were in a multiengine airplane) in Beech 76 and Cessna 152, 172,
and 310 airplanes.

Air Midwest records indicated that the captain had accumulated 1,865 hours total
company flying time, including 1,100 hours as a Beech 1900D PIC. She had flown
approximately 134, 32, and 6 hours in the 90 days, 30 days, and 24 hours, respectively,
before the accident. The captain’s last Beech 1900D proficiency check occurred on
August 20, 2002; her last recurrent ground school occurred on September 18, 2002; and
her last line check occurred on November 26, 2002. FAA records indicated no accident or
incident history or enforcement action, and a search of the National Driver Register
database found no record of driver’s license suspension or revocation.

In postaccident interviews, Air Midwest pilots who had flown with the captain
made favorable comments about her piloting skills. A check airman stated that the captain
had no difficulties during upgrade training and that she demonstrated very good
knowledge of the airplane’s systems and very good judgment. Another check airman
described the captain as one of the better company pilots and stated that she made very
good decisions about flying. First officers stated that the captain was a thorough and
methodical pilot who controlled the airplane well and involved them with the flight by
asking for opinions and letting them review paperwork.

The captain was single and lived in the Charlotte area. She was reported to be in
good health. She did not smoke and would occasionally have a glass of wine with dinner.
Her personal situation was reported to be stable and her financial situation to be adequate
during the months preceding the accident. She was described by her boyfriend as “healthy,
happy, and not tired” on the morning of the accident.

Between 0810 and 1144 on January 5, 2003, the captain traveled on duty as a
passenger from CLT to Key West, Florida, for a trip that originated there. From
about 1230 to 2330, the captain flew six flight legs and accumulated about 6 hours of
flight time. She arrived at her hotel about 0035 on January 6th and, from about 1130 to
1600, traveled on duty as a passenger from Key West to CLT.



Aircraft Accident Report

153

Appendix B

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Factual Information 92 Aircraft Accident Report

sliding-scale method of calculating standard weights particular to the aircraft capacity
should be adopted.

The Flight Standards Division proposed passenger standard weights to be used
when actual passenger weights are not used. The proposed standard weights for adult
males and females, infants, children, and adolescent males and females decreased as the
maximum seating capacity of the airplane increased. The standard weights for an airplane
with a maximum seating capacity of 15 to 19 passengers and crewmembers are shown in
table 10. (The Beech 1900D has a maximum seating capacity of 19 seats.)

Table 10. Australian Department of Transport and Communications proposed standard
passenger weights for airplanes with a maximum seating capacity of 15 to 19 seats.

Category Standard weight (in pounds)*
Adult male 187
Adult female 152
Infant 35
Child 95
Adolescent male 139
Adolescent female 126

*® For this report, the average weights were converted from kilograms to pounds and then were rounded to the nearest
whole number.

1.18.6.3 Civil Aviation Authority of New Zealand Survey

In 2003, the CAA of New Zealand commissioned a survey to identify the current
average weight of domestic passengers traveling aboard large airplanes with more than
30 passenger seats, medium-sized airplanes with 10 to 30 passenger seats, and helicopters
and airplanes with 9 or fewer passenger seats. Previous passenger weight surveys by the
CAA of New Zealand showed that the current standard weight at the time—equivalent to
about 170 pounds—was out of date. A 1999 study showed that the average weight for
passengers traveling aboard airplanes with more than 30 passenger seats was equivalent to
about 187 pounds. Also in 1999, the New Zealand Ministry of Health found that the
average weight of New Zealanders was increasing by 3 kilograms (6.6 pounds) per
decade.

During October and November 2003, 15,414 domestic passengers who were
13 years of age and older were weighed, first with their carry-on baggage and then without
the baggage. Most of the passengers were weighed at three major airports—Auckland,
Wellington, and Christchurch—and a small number of passengers were weighed at the
Queenstown airport. Of the 15,414 survey participants, 8,491, or 55 percent, were male,
and 6,923, or 45 percent, were female. The results of the survey are shown in table 11.


Factual Information 14 Aircraft Accident Report

including the Air Midwest regional site manager. In addition, the RALLC site manager
would participate in daily maintenance conference calls that addressed, among other
things, upcoming maintenance needs. (RALLC site managers from the four other Air
Midwest maintenance stations” and Air Midwest maintenance personnel also participated
in the daily conference calls.) The RALLC site manager stated that he occasionally visited
the hangar at night.

1.5.3.5 The Air Midwest Regional Site Manager

The Air Midwest regional site manager, age 44, has been employed by Air
Midwest for 22 years and has been the regional site manager at the HTS maintenance
station since August 2002. He received his A&P certificate in February 1995.

Before his HTS assignment, the Air Midwest regional site manager worked for
8 years as a quality assurance inspector at the company’s Wichita, Kansas, maintenance
station.?> He has performed aviation maintenance on various turboprop commuter
airplanes.

At the time of the accident, the Air Midwest regional site manager normally
worked from 0830 to 1700 Monday through Friday. During his shift, he would typically
review the previous night’s paperwork to determine if it had been properly signed off and,
if he noted any discrepancies, would either speak with the RALLC site manager or write
up a noncompliance form. He also participated in the daily maintenance conference calls
and daily conference calls with Air Midwest flight operations personnel. The regional site
manager stated that he occasionally visited the hangar at night.

1.6 Airplane Information

Beech 1900 series airplanes entered service in 1984 and have accumulated more
than 11 million flight hours since then. The Beech 1900D is a low-wing, twin-engine,
propeller-driven, pressurized airplane. It has an overall length of 57 feet 10 inches, a
height of 14 feet 11 inches, and a wingspan of 57 feet 11 inches.

The accident airplane, serial number UE-233, was delivered new to Air Midwest
from Raytheon Aircraft Company on August 30, 1996. The airplane was registered as
N233YV on November 20, 1996. At the time of the accident, the airplane had 15,003 total
flight hours and 21,332 total cycles. 6

The accident airplane was configured with a captain’s seat, a first officer’s seat,
16 single passenger seats, and a triple passenger seat in the rear of the airplane (for a total
of 19 passenger seats in 9 rows). The airplane had a main entry door on the left forward

24 These maintenance stations are located in Dubois, Pennsylvania; Farmington, New Mexico; Little
Rock, Arkansas; and Panama City, Florida.

25 Air Midwest closed its Wichita maintenance station on September 30, 2002, because of flight
schedule changes.

26 An airplane cycle is one complete takeoff and landing sequence.



Factual Information 43 Aircraft Accident Report

1.16.1.3 Cable Tension Adjustment Procedural Errors

This test altered or omitted specific steps in the elevator control system rigging
procedure. Some of these alterations or omissions were intended to replicate actions
reported by the mechanic who adjusted the elevator cable tension on the accident airplane
and the quality assurance inspector who was providing OJT to the mechanic.

The forward and aft pushrod lengths and elevator control stop settings were
adjusted so they matched those found in the accident airplane wreckage. A rig pin was
installed in the aft bellcrank, and the cable tensions were released, which allowed the
control column to move forward while the elevator was held at neutral by the aft rig pin.
The forward bellcrank rig pin was installed without engaging the bellcrank arm. The rig
pin was not in the rig pin hole of the forward bellcrank arm but was aft of the arm. The
control column could not be returned from forward to neutral because the aft side of the
forward bellcrank arm would contact the forward rig pin. Elevator tension was then
increased by tightening the turnbuckle on the AND cable (which is located above the
ANU cable). This adjustment caused the forward bellcrank to move aft until the aft side of
the bellcrank arm contacted the forward rig pin. The turnbuckle barrels were then rotated
to maintain this position while establishing cable tension.

When the aft rig pin was removed and the control column was moved full forward,
the ANU turnbuckle length was 5.12 inches, and the AND turnbuckle length was
7.70 inches. The elevator deflection was 7.7° AND (as measured by the travel board), and
the pitch control position recorded on the FDR was 13.3° AND. The elevator control horns
didnot contact the primary stops; instead, the forward bellcrank rested on the secondary stop.

1.16.1.4 Cable Stretch

This test was performed to measure the amount of cable stretch that could be
introduced by applying force to the control column while the forward bellcrank engaged
the secondary up and down stops. (In the misrigged position, the forward bellcrank
contacted the secondary down stop.) When 120 pounds of forward force was applied to
the control column, the FDR recorded a column position that was 0.5° AND beyond the
point at which the elevator stopped moving. The amount of aft force required to pull the
control column from its resting position to the up stop was 37 pounds. When an additional
87 pounds of aft force was applied to the control column, the FDR recorded a column
position that was 2.4° ANU beyond the point at which the elevator stopped moving.

1.16.2 Airplane Performance Study

The Safety Board conducted an airplane performance study for the accident
airplane. The study included a weight and balance study, a load manifest study, an
elevator control authority study, and Beech 1900D simulations. As part of the study, ATC
transcript, ATC radar, CVR transcript, and FDR data were correlated to a common

The complete airplane performance study can be found in the public docket for this accident,
DCA03MA022, on the Safety Board’s Web site.



Factual Information 88 Aircraft Accident Report

that the Beech 1900D AMM did not contain either procedure, so he looked in a
CommutAir manual that contained a list of the manufacturer’s field service kits, found a
reference to a field service kit for “thrust lever, replaceable detent pin,” and obtained the
kit.

The field service kit installation instructions included a step to remove the thrust
control assembly from the center pedestal, but the instructions did not provide information
about how to access the thrust lever assembly so that it could be removed from the
pedestal. The instructions also did not provide any reference to technical documents that
contained instructions for the removal and installation of the thrust lever assembly.

The mechanic stated that he accessed the thrust lever assembly by removing the
elevator trim wheel and an access panel from the left side of the cockpit pedestal. No
writeup was generated for the trim wheel removal, and no markings or tags were placed on
the trim wheel to ensure proper reinstallation. The investigation of this incident
determined that, when the elevator trim wheel was reinstalled, the mechanic did not
properly align the elevator trim tab position indicator with the elevator trim tab position.""6
As a result, the trim wheel was reinstalled incorrectly. The mechanic did not perform a
functional test of the elevator trim control system, as required by AD 2003-20-10 (see
section 1.18.4.5.1).!"7

The Safety Board and Raytheon Aircraft Company performed a functional check
of the elevator trim control system. The check verified that the elevator trim tab position
indicator did not accurately reflect the elevator trim tab position. Specifically, when the
elevator trim tab position indicator was set at 3 units of ANU trim, the elevator trim tab
was deflected 4.6° AND from its neutral position. (The elevator trim tab’s full AND
position is 5.5° from neutral.) The functional check determined that the elevator trim tab
position indicator pointer was off by about 6 units, which equates to about 8.8° of elevator
trim tab, or about 37 percent of the trim tab’s full range of travel.

After the cause of the elevator trim control system discrepancy was determined, a
CommutAir mechanic properly aligned the elevator trim tab position indicator to the
elevator trim tab position. Elevator and elevator trim control system functional tests were
accomplished to verify that the systems were operating according to the requirements
described in the Beech 1900D AMM. A high-speed taxi test and a flight test were
accomplished to verify the functionality of the elevator and elevator trim control
systems.'!8

116 When the elevator trim tab position indicator is at 0°, the elevator trim tab position should also be at 0°.

‘7 The quality assurance inspector also did not perform a functional test of the elevator trim control
system. The inspector stated that he did not know that the mechanic’s work involved the trim system.

18 Additional information about this incident, NYC04IA010, can be found on the Safety Board’s Web
site.


Factual Information 26 Aircraft Accident Report

contact with the bob weight it may be necessary to disconnect the pushrods at
the elevator horns in order to allow enough travel to verify this action. Reconnect
the pushrods after this contact has been verified.

w. Gust Lock Pin Check - Install the gust lock pin. Verify the elevator is 7° to 15°
down (the elevator does not need to be on the down stop with the gust lock pin
installed). However, if the elevator is full down and resting on the primary
stops, the force required to push on the pilot’s control wheel while inserting the
gust lock pin must be a maximum of ten pounds. If the force is too high, adjust
(shorten) the push-pull tube per Step e, then repeat Step u to check the bob
weight clearance. Remove the gust lock pin.

x. Connect the autopilot servo cables to the elevator primary control cables.
y. Perform the CONTROL COLUMN SUPPORT ROLLER INSPECTION procedure.

z. On aircraft equipped with the F1000 Flight Data Recorder, calibrate the Pitch
Position Potentiometer. Perform the FLIGHT DATA RECORDER (FDR) - PITCH
ADJUSTMENT procedure.

aa. Move the control wheel aft and verify the elevator moves up 20° +1°/-0° and
that the surface stops make contact. Move the control wheel forward and
verify the elevator moves down 14° +1°/-0° and that the surface stops make
contact. If these requirements are not met, repeat this rigging procedure in its
entirety.

bb. Remove the travel boards from the horizontal stabilizers, install floorboards,
copilot’s seat, and replace access panels.

1.6.4 Weight and Balance

This section discusses the accident airplane’s calculated weight and balance, which
was determined using Air Midwest’s FAA-approved weight and balance program (see
section 1.18.1.2), and the loading conditions that existed on the day of the accident.
Section 1.16.2.1 discusses the airplane’s actual weight and balance.

The accident airplane’s last weighing on September 8, 2002, determined that the
airplane’s empty weight was 10,293 pounds. The airplane’s balance was determined by
the location of the center of gravity (CG), which is usually described as a given number of
inches aft of the reference datum.”” At the time of the airplane’s weighing, the CG was
determined to be located 282.1 inches aft of the reference datum, which corresponds to a
CG location of 14.4 percent mean aerodynamic chord (MAC).**

37 The reference datum is an imaginary vertical plane, arbitrarily fixed somewhere along the
longitudinal axis of the airplane, from which all horizontal distances are measured for weight and balance
purposes.

38 According to the FAA’s Aircraft Weight and Balance Handbook, the MAC is the chord of an
imaginary airfoil that has all of the aerodynamic characteristics of the actual airfoil. The chord is drawn
through the geographic center of the plan area of the wing. The location of the CG with respect to the MAC
is important because it predicts the handling characteristics of the aircraft.


Aircraft Accident Report

161

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Analysis 126 Aircraft Accident Report

The accident airplane’s maintenance records indicated that the actions required by
the AD were accomplished on March 3, 2001. However, the volume of the incoming VHF
radio messages during the accident flight was extremely low compared with the volume of
the audio captured by the flight crew’s hot microphones. Because the audio from the
captain’s, or first officer’s, hot microphone was recorded on the same channel as the audio
from the VHF radio, the two audio signals could not be isolated from each other on the
recording.

On August 29, 2002, the Safety Board issued Safety Recommendation A-02-25 as
a result of its longstanding concerns about the availability of CVR information after
reportable accidents or incidents. Safety Recommendation A-02-25 asked the FAA to

Require that all operators of airplanes equipped with a cockpit voice recorder
(CVR) test the functionality of the CVR system prior to the first flight of each day,
as part of an approved aircraft checklist. This test must be conducted according to
procedures provided by the CVR manufacturer and shall include, at a minimum,
listening to the recorded signals on each channel to verify that the audio is being
recorded properly, is intelligible, and is free from electrical noise or other
interference.

On December 12, 2002, the FAA stated current regulations (14 CFR 23.1457 and
25.1457) require CVR equipment to have “an aural or visual means for preflight checking
of the recorder for proper operation.” The FAA also stated that it would survey current
maintenance practices of air carrier and general aviation aircraft to determine if
corrections to the operators’ maintenance programs were necessary to ensure expected
recorder reliability. On January 16, 2003, the Safety Board stated its concern that that the
FAA’s maintenance survey would address only one part of the CVR reliability problem.
The Board’s safety recommendation letter stressed that it was the flight crew’s
responsibility to check the CVR for proper operation each day before the first flight;
consequently, the Board encouraged the FAA to include maintenance procedures and crew
checklist operational procedures in its survey.

The Safety Board was concerned that the FAA might have misunderstood the
portion of the recommendation concerning a daily test of the equipment. Even though the
FAA stated that 14 CFR 23.1457 and 25.1457 required CVR equipment to have “an aural
or visual means for preflight checking of the recorder for proper operation,” the Board
stated that it was unaware of any CVR installations that did not have the ability to monitor
the audio using a headphone jack in the cockpit. The Board indicated that the intended
minimum for the daily test outlined in the safety recommendation would be similar to the
procedures outlined in FAA Order 8300.10, Chapter 143, “Monitor Cockpit Voice
Recorders.” This chapter states, among other things, to “check all channels to ensure that
the quality of the reproduction has not deteriorated below an optimal audible level.”!**
The Board urged the FAA to ensure that a similar check is required before the first flight
of the day in all aircraft equipped with a CVR. Pending full implementation of this

154 The Safety Board’s letter also cited an example of a required daily check in the FAA’s Flight
Standards Information Bulletin for Airworthiness 99-04. The bulletin indicated that the Beech 1900C
Airplane Flight Manual contained a preflight inspection by the flight crew, which included monitoring the
area microphone.


Factual Information 10 Aircraft Accident Report

On January 7, 2003, the captain was on reserve duty for the airline. She awoke
between 0900 and 0930 and was notified by crew scheduling, about 1000, that she would
be flying a six-leg trip sequence with the accident first officer. The first leg of the trip
sequence was scheduled to depart about 1200 but did not depart until 1340. The last leg of
the trip sequence was scheduled to arrive at CLT about 1910 but did not arrive until 2045.
The captain accumulated 6 hours of flight time during the trip sequence. She went to bed
that night about 2230 and awoke about 0625 on January 8th to get ready for that day’s trip
sequence.

1.5.2 The First Officer

The first officer, age 27, was hired by Air Midwest in May 2001. He held a
commercial pilot license dated November 12, 2000, and an FAA first-class medical
certificate dated December 10, 2002, with no limitations.

From August 1999 to February 2001, the first officer was enrolled at San Juan
College, Farmington, New Mexico, as part of the Mesa Airlines’? Pilot Development
Program. On his application for employment with Air Midwest, the first officer reported
that he had accumulated 390 hours total flying time in Beech 36, 58, and 1900; Aeronca
Champion; and Citabria airplanes.

Air Midwest records indicated that the first officer had accumulated 706 hours
total company flying time on Beech 1900D airplanes. He had flown approximately 210,
59, and 6 hours in the 90 days, 30 days, and 24 hours, respectively, before the accident.
The first officer’s last line check occurred on August 20, 2001, and his initial Beech
1900D proficiency check occurred on May 4, 2002. FAA records indicated no accident or
incident history or enforcement action, and a search of the National Driver Register
database found no record of driver’s license suspension or revocation.

In postaccident interviews, Air Midwest pilots who had flown with the first officer
made favorable comments about his piloting skills. Pilots described the first officer as a
talented and very precise pilot with good attention to detail and good communication
skills. Pilots also stated that the first officer possessed good situational awareness and
good knowledge of the Beech 1900D.

The first officer was single and lived in the Charlotte area. He was reported to be in
excellent health. He did not smoke and consumed alcohol occasionally in social settings.
His personal and financial situations during the months preceding the accident were
reported to be stable. ,

On January 5, 2003, the first officer was off duty until 2035, when he departed
CLT for a flight to LYH, which arrived about 2130. About 0620 on January 6th, the first
officer flew back to CLT, arriving about 0715. On January 7th, the first officer flew the

'9 Mesa Airlines is one of four airline liveries operated by Mesa Air Group, Inc., which is the parent
company of Air Midwest. See section 1.17.1 for more information.



Factual Information 54 Aircraft Accident Report

1.17 Organizational and Management Information

1.17.1 Air Midwest

Air Midwest, Inc., is a domestic Part 121 air carrier based in Wichita. The
company was founded in May 1965 and became a wholly owned subsidiary of Mesa Air
Group,” which is based in Phoenix, Arizona, in 1991. At the time of the accident, the
airline had 743 employees and 43 Beech 1900D 19-seat airplanes (including the accident
airplane). The airline operated its fleet under code-share agreements with US Airways
Express, America West Express, Mesa Airlines, and Midwest Express (now known as
Midwest Airlines), with 389 daily departures to 72 destinations.

Air Midwest conducted its maintenance program according to guidance in three
company manuals: Manual 210, Maintenance Procedures Manual; Manual 240,
Maintenance Training Manual; and Manual 260, Maintenance Program Manual.”
Mechanics working on Air Midwest airplanes at the contract maintenance stations (HTS;
Dubois, Pennsylvania; Farmington, New Mexico; Little Rock, Arkansas; and Panama
City, Florida) were required to be familiar with the policies and procedures in these
manuals.”

Although Air Midwest’s maintenance work was distributed among regional main-
tenance stations and was performed exclusively by contracted maintenance personnel, the
air carrier remained responsible for the airworthiness of its airplanes and all of the mainte-
nance performed. Specifically, 14 CFR 121.363 states that an air carrier is responsible for
ensuring the airworthiness of the aircraft it operates and that an air carrier is not relieved
of this responsibility when maintenance is contracted to another party. Also, AC 120-16D,
“Continuous Airworthiness Maintenance Programs,” states the following: 7

® According to a July 11, 2002, press release posted on the Mesa Air Group Web site
(http:/Awww.mesa-air.com), Mesa Air Group was awarded a contract by the Department of Transportation in
July 2002 for seven new essential air service markets in Arkansas, Oklahoma, and Texas. (The essential air
service program ensured that, after the Airline Deregulation Act was enacted in 1978, smaller communities
would retain a link to the national air transportation system.) The new markets include Enid and Ponca City,
Oklahoma; Brownwood, Texas; and Harrison, Hot Springs, El Dorado/Camden, and Jonesboro, Arkansas.
According to the press release, the air service was to be provided beginning in the fall of 2002 by Air
Midwest operating as Mesa Airlines, and four Beech 1900D airplanes were dedicated to the new routes.
Also, Mesa Air Group would receive a federally guaranteed subsidy of $13.4 million for providing this air
service during the 2-year term of the contract.

3 Title 14 CFR 121.367(a) states that aircraft maintenance, preventive maintenance, and alterations are
to be performed in accordance with operators’ maintenance manuals. Title 14 CFR 121.369(b) states that
operators’ maintenance manuals must describe the method to be followed in performing routine and
nonroutine maintenance, preventive maintenance, and alterations and the method to be followed in
performing RII inspections. Title 14 CFR 25.1529 requires manufacturers to prepare “Instructions for
Continued Airworthiness” for operators of transport-category airplanes. Appendix H of Part 25 contains
these instructions, which often become the basis for the operators’ maintenance manuals required by
Section 121.369.

7 Air carriers are required by 14 CFR 121,367(b) to ensure the competence of their maintenance
personnel for the proper performance of maintenance, preventive maintenance, and alterations.

75 Additional information about AC 120-16D appears in section 1.17.4.1.


Analysis 123 Aircraft Accident Report

2.5.2.4.2 Use of Average Weights

The Safety Board is concerned that air carrier average weight programs do not
generally account for variances in passenger and baggage weights and weight
distribution.'*! As a result, it is possible for a flight crew to mistakenly determine that an
airplane is within its certified weight and CG envelope when the airplane is actually
outside the envelope. The use of a predetermined average weight assumes that, although
an individual passenger or bag may weigh more or less than the average weight, the
variance will be appropriately distributed throughout an aircraft. However, deviations
from the average weight value and average weight distribution can negatively affect an
aircraft’s CG if the heavier passengers and baggage are not appropriately distributed.
Further, it is possible that some airplane types may be more susceptible than others to
errors in CG loading. Specifically, the FAA air safety investigator from the Air Carrier
Operations Branch stated, during public hearing testimony, “aircraft that have a larger
seating capacity have the ability to spread the deviation from standard across a larger
population. So...aircraft with...a smaller seating capacity could have...a greater chance
for error than a larger aircraft.”

Several factors besides aircraft type (including region of travel, season, passenger
mix, number of bags, and amount of personal items) can influence the accuracy of average
weight assumptions, and no current method of calculating passenger and baggage weights
can ensure, with 100-percent certainty, that an airplane’s loading will not exceed its
certified weight and CG limits. An airplane’s susceptibility of operating outside its weight
and CG limits could be minimized if additional safety margins were determined and
factored into weight and balance calculations.

The Safety Board concludes that the current safety margins in air carrier average
weight and balance programs do not ensure that aircraft will be loaded within their
manufacturer-certified and FAA-approved weight and CG envelope. Therefore, the Safety
Board believes that the FAA should require 14 CFR Part 121 air carriers that use average
weight and balance programs to develop and implement weight and CG safety margins to
account for individual passenger and baggage variances.

2.5.2.4.3 Technological Advances

As a result of its findings from the August 7, 1997, Fine Airlines flight 101
accident (see section 1.18.4.3), the Safety Board issued Safety Recommendation A-98-49
in July 1998. Safety Recommendation A-98-49 asked the FAA to evaluate and, if
warranted, require the installation of a system that provides a cockpit display of weight
and balance information for transport-category cargo airplanes. One such system at the
time was the Sum Total Aft and Nose system (commonly referred to as the “STAN”
system), which derived weight and balance information from pressure transducers on the
main gear and nose gear shock struts. The FAA evaluated onboard weight and balance
systems and found that the existing systems could not meet the reliability and accuracy
standards for a mandatory system (because of unresolved operational challenges such as

151 The average passenger, checked baggage, and carry-on baggage weights suggested by the FAA in
AC 120-27C also do not consider weight variances and weight distribution variances.



Analysis 107 Aircraft Accident Report

RII maintenance tasks that are not performed properly could result in a failure,
malfunction, or defect that would endanger the safe operation of the airplane. Thus, it is
imperative to have an independent inspection of RII maintenance tasks by a second, fully
qualified mechanic to ensure that the work has been properly completed. Current
regulations do not explicitly prohibit inspectors from training a mechanic on a task and
then inspecting that same task.'*° However, the inspectors cannot properly fulfill their RII
responsibilities in such a situation. The purpose of an RII inspection is to provide “a
second set of eyes” to ensure that any error made in performing maintenance work is
detected and corrected before an airplane is returned to service. The Safety Board
concludes that, when an inspector provides OJT for an RII maintenance task and then
inspects that same task, the independent nature of the RII inspection is compromised.
Therefore, the Safety Board believes that the FAA should prohibit inspectors from
performing RII inspections on any maintenance task for which the inspector provided OJT
to the mechanic who accomplished the task.

According to AC 120-16D, Air Midwest was responsible for overseeing the
performance of RII inspections. In fact, Air Midwest acknowledged in its contract with
RALLC that Air Midwest would be responsible for quality control and quality assurance
inspections. However, oversight of the quality assurance function at HTS went through
two different levels of management at RALLC (the Regional Airline Maintenance Service
[RAMS] quality assurance manager in Panama City, Florida, and the RAMS Executive
Program Manager for Airline Support in Madison, Mississippi) before becoming the
responsibility of the Air Midwest Chief Inspector/Director of Quality Assurance in
Wichita, Kansas (see figure 10). In addition, the only Air Midwest employee at HTS (the
regional site manager) normally worked the day shift, and he was only sporadically
present when the maintenance work and inspections were being accomplished. As a result,
Air Midwest was not sufficiently overseeing the RII inspections at HTS, which is
especially troublesome considering the importance of these inspections.

Sufficient oversight of RII maintenance tasks and inspections requires air carrier
personnel to maintain an on-site presence and to be thoroughly involved in, and familiar
with, all aspects of a maintenance facility’s operations relating to RII tasks and
inspections. Such oversight requires, at a minimum, that air carrier personnel be
physically present when a substantial amount of the RII planning, tasking, maintenance
work, and inspections are performed and that air carrier personnel be readily available
when they are not physically present. In addition, air carriers need to 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.

85 On March 26, 2003, the quality assurance inspector at HTS on the night of January 6, 2003, was
advised that the FAA would be investigating the inspector’s actions in “giving on-the-job training after work
was assigned.” On September 30, 2003, the FAA notified the inspector that the investigation “did not
establish a violation of the Federal Aviation Regulations [FAR].” (The FAA also investigated the mechanic’s
actions “involving work being accomplished” and the foreman’s actions “involving work being assigned,”
and the investigation found that their actions did not violate the FARs.)



Analysis 109 Aircraft Accident Report

maintenance, and alterations. However, according to AC 120-16D, FAA regulations
contain the flexibility necessary to allow each air carrier to develop a training program
that fits its particular needs. Many air carriers have provided, and will continue to provide,
airplane-specific maintenance training through OJT programs.

During a 1993 Safety Board public hearing on commuter airline safety,
representatives from the commuter airline industry indicated that the quality of air carrier
maintenance training varied throughout the industry, with some airlines doing an excellent
job of training mechanics and other airlines providing mechanics with only minimal
training." Also, a 1998 FAA study of personnel training and qualifications at aviation
maintenance facilities'”* found that, although airline mechanics reported that they were
generally satisfied with the maintenance training provided by their companies, one area of
concern involved informal OJT. Specifically, a significant number of mechanics indicated
that they would prefer OJT that was more formal, with task objectives, checklists, and
specific task signoffs. In addition, the FAA’s 1998 Guide for Human Factors in Aviation
Maintenance and Inspection (see section 1.18.3) stated that OJT had several positive
aspects but that OJT practices were lax and tended to be unstructured.

The FAA’s Guide for Human Factors in Aviation Maintenance and Inspection
contained voluntary guidelines for developing structured OJT programs. However, air
carriers are not currently required to follow these guidelines when developing OJT
programs. The Safety Board concludes that it is important that air carrier OJT programs
are developed in accordance with detailed guidance that emphasizes effective training
practices. Therefore, the Safety Board believes that the FAA should develop detailed OJT
requirements for 14 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. The
Safety Board also believes that the FAA should ensure that these OJT requirements are
incorporated into 14 CFR Part 121 air carrier maintenance training programs.

2.5.1.2.2 Maintenance Training Oversight

The Safety Board identified deficiencies in Air Midwest’s oversight of its
maintenance training program. First, because only one RALLC quality assurance
inspector and one RALLC foreman (the backup quality assurance inspector) worked at
HTS at the time of the accident, a SMART mechanic was appointed as foreman 4 nights
per week (when the quality assurance inspector was not on duty and the foreman assumed
the inspector’s responsibilities). One of the foreman’s responsibilities was to follow the
progress of the mechanics in accomplishing the assigned maintenance work. However, the
SMART mechanic who was the foreman on the night of January 6, 2003, had not
completed OJT for the Beech 1900D.

86 For more information, sec National Transportation Safety Board, Commuter Airline Safety, Special
Study NTSB/SS-94/02 (Washington, DC: NTSB, 1994).

'87 R.P. Goldsby and J. Watson, Comparative Study of Personnel Training and Qualifications at Aviation
Maintenance Facilities (Washington, DC: Office of Aviation Medicine, FAA, 1998).



vii Aircraft Accident Report

Figures
1. Detail six work card at the time of the accident .........6. 60.6 cece eee eee eee eee 5
2. Aircraft maintenance record of nonroutine items for January 6, 2003, at the Huntington,
West Virginia, maintenance station. ...... 6.6.0 eee cece eee eee eee teen eee 7
3. Beech 1900D pitch control system ........ 66.6 ce eee eee cece eee e een e eens 16
4, Side view of Beech 1900D tail section. ....... 6.06. eee c eee eee ete n een e eens 16
5. Turnbuckle assemblies........0. 00.0 e eee eee eee een tne n nee eens 18
6. Turnbuckles as found in the wreckage.
7. Weight and center of gravity information for flight 5481. .......... 0. +s see ee eee 47
8. Flight data recorder pitch control and pitch trim control positions. ..............+++5+ 49
9. Elevator travel available before and after the detail six maintenance check............- 51
10. Organizational structure of Air Midwest’s Huntington, West Virginia, maintenance station

11

Operations 2... ce ee ee nee ene n nee e een e nee ee 57

Flight 5481 weight and center of gravity information compared with flight 103 weight and
center of gravity information. . .



Factual Information 86 Aircraft Accident Report

Shortly after takeoff, the flight crewmembers declared an emergency and reported
a trim problem. The airplane had reached an altitude of about 1,100 feet msl. The flight
crew requested to land on a specific runway, and the controller cleared the flight to land on
any runway. No further transmissions were received from the flight crew. FDR data
indicated that the airplane’s airspeed continued to increase to about 250 knots and that the
airplane’s last recorded altitude was about 300 feet msl.

The accident airplane’s FDR pitch trim control position parameter had been placed
on the minimum equipment list (deferred maintenance) for the flight because the
parameter was not calibrated. The Safety Board’s airplane performance study for this
accident determined that the recorded pitch trim control positions did not reflect the actual
pitch trim control positions. The difference between the recorded and actual pitch trim
control positions was about 2.1° ANU.

According to the airplane performance study, the airplane began the flight with a
pitch trim control position of about 0.5° ANU. Shortly after takeoff, the pitch trim control
position moved to about 0.8° AND and remained there for about 10 seconds. The pitch
trim control position then moved to about 5° AND and remained there for the rest of the
flight. Calculations showed that the airplane would have required about 200 pounds of aft
(pulling) control force to maintain level flight in the out-of-trim condition.

The accident flight was the first flight after maintenance had been performed on
the airplane. The maintenance work included replacement of both elevator trim tab
actuators (because of a failed freeplay check) in accordance with Beech 1900D AMM
section 27-30-06, “Elevator Trim Tab Actuator, Removal and Installation and the Actuator
Cable Replacement.” The procedure required that the elevator be removed before the
actuators were replaced. The Safety Board’s investigation of this accident determined that
the mechanics skipped this procedural step and replaced the actuators with the elevators

installed.

The mechanics thought that the forward elevator trim tab cable had become
jammed or kinked during the replacement of the trim tab actuator. The mechanics then
tried to replace the cable according to the procedure in Beech 1900D AMM section 27-30-04,
“Elevator Trim Tab Cables, Removal and Installation.” A postaccident examination ofa
section of the forward elevator trim cable revealed evidence consistent with a misrouted
cable, The Beech 1900D AMM and Colgan Air work cards did not include a trim system
check at the end of the elevator trim tab cable procedure. Although the mechanics stated
that they checked the trim system, evidence was consistent with the trim system operating
in a direction opposite from the command of the trim wheel.!!?

The Safety Board’s investigation of this accident revealed that the illustration of
the forward elevator trim tab cable drum appeared backward in section 27-30-04 in the
Beech 1900D AMM. On October 22, 2003, Raytheon Aircraft Company revised its Beech
1900D AMM elevator trim tab cable rigging procedure to show the correct illustration for
the forward elevator trim tab cable drum.

122 Additional information about this accident, NYCO3MA 183, can be found on the Safety Board’s Web
site.



Factual Information 31 Aircraft Accident Report

someone yell, “crash phone,” and that she picked up the phone while the airplane was still
in the air. The controller stated that she saw the airplane “wiggle,” “go nose down,” and
crash just as the phone was answered. Emergency response information is detailed in
section 1.15.1.

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The accident airplane was equipped with a Fairchild model A-100A CVR, serial
number 61979. The exterior of the CVR was heavily covered with soot and showed
evidence of significant heat exposure. The interior surfaces and components were covered
with soot. Some of the internal components appeared to be partially melted. The exterior
of the case that housed the tape spool assembly was covered with soot but was generally
intact, with little or no mechanical damage noted. The tape spool assembly and other
components inside the case were not damaged and were generally in good condition. No
apparent evidence of heat or mechanical damage to the tape was found.

The CVR was sent to the National Transportation Safety Board’s audio laboratory
in Washington, D.C., for readout and evaluation. The tape was played back normally and
without difficulty. The CVR data started about 0815:41 and continued uninterrupted until
0847:28.1. The recording consisted of four separate channels of audio information: the
cockpit area microphone, the captain’s and first officer’s audio panels, and the public
address system. Hot microphone transmissions from the captain and the first officer were
also captured on their respective audio channels.

The cockpit area microphone and public address system information were good
quality.** The captain’s and first officer’s audio panel information was fair to poor quality
with respect to the audio captured from the airplane’s very high frequency (VHF) radio
systems, but the audio information from the captain’s and the first officer’s hot
microphones was excellent to good quality. A transcript was prepared of the entire
31-minute 47-second recording (see appendix B).

The volume of the incoming VHF radio messages during the accident flight was
extremely low compared with the volume of the audio captured by the flight crew’s hot
microphones. Because the audio from the captain’s (or first officer’s) hot microphone was
recorded on the same channel as the audio from the VHF radio, the two audio signals
could not be isolated from each other on the recording. (The mixing of these two audio
signals onto the same CVR channel is normal and is not unique to this CVR system.)

45 The Safety Board rates the quality of CVR recordings according to a five-category scale: excellent,
good, fair, poor, and unusable. See appendix B for a description of these ratings.



Aircraft Accident Report

151

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Analysis 118 Aircraft Accident Report

criticized the FAA for its failure to act on its inspectors’ concerns about that air carrier and
found that the FAA’s inability to provide adequate oversight of ValuJet and its
maintenance contractors contributed to the cause to the accident.

It is critical that proper FAA oversight is provided for every air carrier
maintenance training program to ensure that any program deficiencies are identified. It is
even more critical for the FAA to forcefully pursue maintenance training program
improvements when deficiencies have been identified. The Safety Board concludes that
the FAA’s failure to aggressively pursue the serious deficiencies in Air Midwest’s
maintenance training program that were previously and consistently identified permitted
the practices that prevailed at the HTS maintenance station and during the accident

airplane’s D6 maintenance check.

2.5.2.2. Oversight of Continuing Analysis and Surveillance System
Programs

The FAA developed the requirement for air carrier CASS programs so that the
carriers would have internal quality control systems to reduce safety hazards and improve
operational performance. However, the regulation requiring air carrier CASS programs—
14 CFR 121.373—did not describe program requirements in detail. The primary CASS
program guidance that was in effect at the time of the flight 5481 accident was contained
in FAA AC 120-16C, “Continuing Airworthiness Maintenance Programs,” and was less
than 1 page in length.

After the Alaska Airlines flight 261 accident and the FAA’s postaccident
inspection of the air carrier, the Department of Transportation Office of Inspector General
conducted an investigation of the FAA’s oversight of CASS programs. The office’s
December 12, 2001, report on the investigation stated that the findings of the FAA’s
postaccident inspection raised questions regarding why the FAA’s routine surveillance had
not identified deficiencies in Alaska Airlines’ CASS program and ensured that they were
corrected. The report also stated that the FAA “placed limited emphasis on CASS in its
oversight” and recommended that the FAA improve CASS program oversight and expand
existing program guidance to better describe what an effective CASS program should
include.'° In its comments on a draft of the report (dated October 4, 2001), the FAA
agreed, among other things, to revise existing guidance for CASS development and
implementation, conduct annual CASS inspections, develop CASS training for inspectors,
and require that all inspectors be trained by January 2004.

In March 2003, the FAA revised AC 120-16C. The revised AC (AC 120-16D)
presented expanded CASS guidance in a dedicated chapter that was several pages in
length. The guidance indicated that an air carrier’s CASS program should detect and
correct air carrier maintenance program deficiencies through a closed-loop, continuous
cycle of surveillance and investigations, data collection and analysis, corrective actions,
and monitoring and feedback.

146 UJ. Department of Transportation, Office of the Secretary of Transportation, Office of Inspector
General, Oversight of Aircraft Maintenance, Continuing Analysis and Surveillance Systems, Federal
Aviation Administration (Washington, DC: Department of Transportation, 2001).


Factual Information 93 Aircraft Accident Report

Table 11. Results of the Civil Aviation Authority of New Zealand’s weight and carry-on
baggage survey.

Category Average weight (in pounds)?
Male passenger 195
Female passenger 159
Male passenger with carry-on baggage 207
Female passenger with carry-on baggage 169

* For this report, the average weights were converted from kilograms to pounds and were then rounded to the nearest
whole number.

The 2003 average weight for male passengers with their carry-on baggage
increased from the 1999 figure by about 3 pounds. The 2003 average weight for female
passengers with their carry-on baggage increased from the 1999 figure by about 7 pounds.

According to the survey report,'”4 the results of the survey will be incorporated
into proposed rule amendments that are expected to become effective in the second quarter
of 2004.

124 2003 Survey of Passenger Weights Market Research Report (Lower Hutt, New Zealand: CAA, 2003).



Factual Information 34 Aircraft Accident Report

D6 maintenance check, the full forward position recorded by the FDR was usually
16.5° AND.‘* During the accident flight, the FDR recorded a maximum full forward
position of 17.2° AND and a maximum full aft position of 19.2° ANU.”

In addition, the FDR study examined the maximum aft pitch control position that
the FDR recorded during the takeoff rotation. Before the D6 maintenance check, the
maximum aft pitch control position value at rotation ranged from 2.7° AND to 7.1° ANU;
after the D6 maintenance check, the value ranged from 4.2° AND to 0.2° ANU. During the
accident flight, the maximum aft pitch control position value at rotation was 9.5° AND.

1.12 Wreckage and Impact Information

1.12.1 General Wreckage Description

The airplane’s main wreckage was located about 30 feet west of the southwest
corner of the US Airways maintenance hangar. The debris path extended from the main
wreckage site about 160 fect to the southwest and about 170 feet to the southeast. In
addition, a few airplane parts were found north of the main wreckage. All of the airplane
structure was accounted for along the debris path.

The postcrash fire destroyed most of the airplane structure. The main wreckage
site contained the remnants of the fuselage, both wings, both engines, and the empennage.
The forward section of the fuselage, the left wing, and the inboard right wing were found
in a normal, upright orientation. The fuselage from the trailing edge of the wing to the
forward edge of the cargo door was found in an inverted position. The fuselage
surrounding the cargo compartment was lying on its right side. The horizontal stabilizer
was found inverted (that is, lying on its upper surface). Remnants of fire-damaged
elevators and trim tabs remained attached to the horizontal stabilizer.

A large portion of the northwest front side of the hangar wall showed severe fire
and impact damage. The wall, which was constructed of reinforced cinder block and
exterior metal flashing that extended from about 20 feet above the ground to the roof, had
a 19- by 38-inch hole and was cracked vertically and horizontally. Also, a 16- by 17-foot
section of the wall was displaced inward. In addition, wall debris was scattered about the
base of the wall, and several pieces of wall material were found mixed with the airplane
wreckage at the main wreckage site.

48 For these nine postmaintenance flights, the elevator position was limited to a maximum of
about 7° AND.

# Ground testing (sce section 1.16.1) showed that these values exceeded the usual values and were
consistent with high forces applied to the control column, resulting in cable stretch.