Aircraft Accident Report - Loss of Pitch Control During Takeoff Air Midwest Flight 5481 Raytheon (Beechcraft) 1900D, N233YV

Charlotte, North Carolina
January 8, 2003

NTSB Number: AAR-04-01
NTIS Number: PB2004-910401
Adopted February 26, 2004
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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.

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.

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.

Recommendations

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)

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)

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)

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)

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.

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.