The Charlotte Beech 1900D Crash

 NTSB Reviews Factuals

May 21, 2003 - N.C. Crash Investigators Eye Maintenance

WASHINGTON (USA) - Safety investigators zeroed in Tuesday on airplane maintenance by outside contractors at a hearing into the cause of the plane crash that killed 21 people in Charlotte, North Carolina, on Jan. 8.

At the same time, the National Transportation Safety Board released transcripts of the cockpit voice recorder on doomed US Airways Express Flight 5481, recounting its harrowing last seconds.


The 19-seat Beech 1900, which plunged to earth 37 seconds after takeoff, was found to have improperly set turnbuckles, which control tension on elevator control cables. If a cable is too slack, the pilot does not have full control of the elevator, a tail flap that moves up and down and causes the plane to climb or dive.

The crew of the plane apparently didn't have enough control of the elevator to pull the plane out of a steep climb on takeoff, which caused the wings to lose their lift and the plane to dive, according to the NTSB's investigator in charge, Lorenda Ward. The elevator control cables were adjusted two nights before the crash at a repair station owned by a company other than the airline; that company, in turn, hired mechanics from another company.

The hearing raised the issue of whether the Federal Aviation Administration should oversee outsourced maintenance facilities more closely.Though major airlines, except for Southwest, perform their own maintenance, many smaller airlines, corporate jets and the U.S. military outsource their maintenance. Big airlines struggling to become profitable again are expected to rely more heavily on outsourced maintenance.

Passengers who died in the Charlotte plane crash may not have realized that they were traveling on a

Type of aircraft: Beech 1900D
Engines: 2 turboprop engines
Number of passengers: 19 maximum
Crew: 2
Cruising speed: 280 mph
Maximum speed: 372 mph

The Beech 1900D turboprop that crashed in Charlotte, North Carolina, was operated by Air Midwest as US Airways Express. Air Midwest is a wholly owned subsidiary of Mesa Air Group. Air Midwest is a regional carrier operating as US Airways Express, Frontier JetExpress, and America West Express.

 plane owned by Air Midwest, which had an agreement with US Airways Express."Passengers expect that when the US Airways name appears on any flights, that these flights will be operated and maintained to US Airways' high standards," said David Stempler, president of the Air Travelers Association.

Air Midwest outsourced its maintenance to Raytheon Aerospace, which is 74 percent owned by Veritas Capital Inc. Raytheon Aerospace hired contract mechanics from Structural Modification and Repair Technicians Inc. (SMART). On the night the Beech 1900 underwent maintenance, there were no Air Midwest representatives at the hangar.

The Raytheon supervisor who was teaching the mechanic to adjust the elevator control cables also signed off on his work, a questionable practice under the regulations.

"Air Midwest let US Airways down by not providing proper oversight," Stempler said.Another factor contributing to the crash may have been weight. The plane was judged to be within 100 pounds of its weight limit. Too much weight can change a small plane's center of gravity and make it much more difficult to fly.

The aircraft's data recorder showed an unusual up-and-down motion of the elevator control on all nine flights it took following the maintenance work, investigators have said. The flight that crashed was carrying the heaviest load since the elevator cables were adjusted, investigators said.

The cockpit voice recorder transcripts show Capt. Katie Leslie and co-pilot Jonathan Gibbs discussing the plane's weight. Their conversation turned frantic as the plane took off from Charlotte-Douglas International Airport.

"Help me," Leslie said. Gibbs swore. "Oh, my God," said Leslie, who then radioed the control tower, "We have an emergency." A child yelled, "Daddy!"

Warning horns sounded. "Pull the power back," Leslie said. "Oh my God."The hearing is expected to last two days. The safety board will probably take months to issue a final report and recommendations.

ON THE NET National Transportation Safety Board:

    Air Midwest crash ushers in regionals’ day of disaster

From a humanitarian perspective, regional air transport suffered perhaps its most destructive 24-hour stretch in history last month. Three separate fatal accidents, all unrelated but for the category of aircraft they involved, shook the industry at a time it could least afford the negative reaction. Once rescuers finished counting, the death toll totaled 72 in Turkey, 46 in Peru and 21 in the U.S. The cost in terms of passenger confidence will take somewhat longer to quantify.

As expected, the press in the U.S. rekindled an old controversy over the safety of turboprop airplanes after an Air Midwest Beech 1900D crashed into a hangar at Charlotte Douglas International Airport, N.C., on January 8, killing 19 passengers and the two crewmembers. It was the first crash of a

 turboprop in scheduled service in the lower 48 states of the U.S. since January 1997, when the FAA instituted its infamous “One Level of Safety” rule, requiring all Part 135 carriers flying scheduled service with aircraft holding more than nine passenger seats to meet Part 121 standards. Still, the news of the Charlotte crash had barely reached the NTSB in Washington when regional airlines found themselves faced with some of the same questions that gave rise to the Part 121 transition six years ago.

Critics still point to the relative lack of experience of many regional airline pilots as a basis for their skepticism about the safety of regional airlines in general. Few would find fodder for criticism in this case, however, after records showed the turboprop’s 25-year-old captain, Katie Leslie, had accumulated roughly 2,500 hours TT and 1,800 hours in the 1900D. An honors graduate from Louisiana Tech University in 1999, Leslie joined Air Midwest after serving as a flight instructor at her alma mater for nine months.

First officer Jonathan Gibbs, 26, had logged 700 hours in the type. Furloughed by Air Midwest shortly after 9/11, Gibbs moved to Charlotte last May at the behest of parent company Mesa Air Group, which, as part of a plan to lower costs, replaced Jetstream 31s operated by former subsidiary CCAir with Beech 1900s flown by lower-paid Air Midwest crews. Mesa shut down CCAir in July.

Some 35 seconds after Air Midwest Flight 5481 had begun its takeoff roll on Charlotte’s Runway R18 at 8:45 a.m. for a half-hour flight to Greenville-Spartanburg Airport in Greer, S.C., Leslie issued an emergency distress call to ATC. By the time she finished the transmission, the airplane pitched upward from seven degrees nose up to 52 degrees, veered left, turned over and crashed into the corner of a US Airways maintenance hangar. The impact reduced the airplane to a heap of twisted metal and the ensuing inferno burned all the victims beyond recognition.

Exploring All Possibilities
Within five days the NTSB had collected all the wreckage and shipped the evidence to Washington for further analysis. During that time the Board divided the investigation into different groups to explore

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Flight Data Recorder (FDR)
Monitors parameters such as altitude, airspeed and heading. The older analog units use one-quarter inch magnetic tape; newer ones use digital technology and memory chips. By regulation, newly manufactured aircraft must monitor at least 28 parameters such as time, altitude, airspeed, heading, and aircraft attitude. In addition, some FDRs can record the status of more than 300 other in-flight characteristics including items ranging from flap position to autopilot mode to smoke alarms. Investigators can use the data to generate a computer animated video reconstruction of the flight.

• Time recorded: up to 25 hours continuous
• Number of parameters: 5 to 300 plus
• Impact tolerance: 3,400Gs / 6.5 milliseconds
• Fire resistance: 1,100 degrees Celsius / 30 minutes

• Water pressure resistance: submerged 20,000 feet
• Underwater locator beacon: 37.5 kilohertz
• Battery: 6 years shelf life
• 30-day operation

 specific potential factors, including airframe structure, flight crew, maintenance, airport operations and weight-and-balance considerations. Weather reports at 8 a.m. indicated a six-knot wind from 220 degrees, 10 miles of visibility and temperature 35 degrees F.

Within hours of the crash, investigators gleaned 34 minutes of clear conversation from the airplane’s CVR, which recorded the entire ill-fated flight, as well as a portion of the airplane’s previous leg from Lynchburg, Va. Data from the FDR, although more difficult to extract due to the extent of the damage to the device, piqued far more interest, however. According to lead crash investigator John Goglia, the FDR showed erratic elevator movement during takeoff–as it did during all eight flights since mechanics at Raytheon Aerospace’s maintenance facility in Huntington, W.Va., worked on the airplane just two days earlier. However, at press time the Safety Board had not ruled out a false FDR sensor reading.

On Sunday, January 12, investigators removed maintenance records from Air Midwest’s Wichita headquarters for more thorough analysis. Although the airline originally reported that a mechanic at Huntington had replaced an elevator tab two days before the accident, it subsequently said the mechanic had not. Air Midwest expected to finish its inspection of all 43 of its Beech 1900s by January 19.

An NTSB spokesman told AIN that investigators had completed interviewing personnel at Huntington, but that the agency “may need to re-address some of them.” By the time they shipped all the pertinent materials to Washington, investigators turned their attention to a connecting cable adjustment performed on the doomed 1900D two days before the crash. Although go-team members found the cable intact and all connections in place, an improper adjustment could have caused it to jam, limiting the range of motion of the airplane’s suspect elevators. Loaded to within 100 lb of its 17,000-pound mtow, the airplane may have required more control authority during Flight 5481 than during earlier flights due to the heavy load.

Of course, the weight of the airplane had already become a subject of intense scrutiny when the NTSB received reports that ramp workers had questioned the amount of allowable baggage on the airplane before it taxied for takeoff. According to the NTSB spokesman, the original paperwork sent to the handler for sign-off showed just 26 bags. Another document indicated that handlers had loaded 32 bags. “The handler raised the question because there was a discrepency,” said the spokesman. “The decision was made that there were actually 31 bags, which is within the limit, so he did sign off on it.”

“Unremarkable” Service History
The 1996 airplane had clocked just over 15,000 hours and 21,000 cycles. FAA records show that it was involved in five in-flight incidents where the potential for unsafe operations existed. During one

 incident in November 2000, the right engine lost oil pressure, forcing the crew to shut it down and land. The airplane also experienced at least eight other more minor problems, including a leaky fuel pump, replaced last fall, and faulty hydraulics in the left main landing gear, repaired in May.

Of the 700 or so Beech 1900s manufactured since the line’s introduction in 1984, eight have been involved in fatal accidents, according to Air Transport Association records. The May 1990 crash of an Aerolift Philippines 1900C in Manila also occurred after the aircraft lost control on takeoff. Investigators attributed that accident to engine failure. In the November 24 crash of a Ryan Air Service 1900C in Homer, Alaska, the NTSB found that improper loading of cargo caused loss of control just after the crew lowered the flaps for landing.

NTSB officials estimate that it could take between six and nine months to collect all the pertinent facts surrounding the 1900’s most recent crash. Of course, analysis of the data and a determination of the cause could take years.


from this link

    WASHINGTON (CNN) -- The cockpit voice recording from the crash of Air Midwest Flight 5481 in Charlotte, North Carolina, reveals that the crew discussed the plane's weight before taking off.

All 19 passengers and two crew members were killed just 37 seconds after takeoff from Charlotte-Douglas International Airport January 8.

The National Transportation Safety Board, which Tuesday began the first of two planned days of public hearings, believes the aircraft was within 100 pounds of its 17,000 pound maximum weight.

The weather was clear at the time of the crash, and the NTSB is trying to determine if cables controlling the up and down motion of the plane contributed to the fatal accident or if weight and balance on the aircraft played a role.

The hearing is a fact-finding exercise, and the NTSB said it does not expect to rule on the cause of the crash before the end of the year.

Information released at the hearing from the flight data recorder revealed a conversation between the pilots of the twin-engine, turboprop Beech 1900D in which they calculated weight and tried to determine where to place baggage.

A ramp worker asks, "How many we gotta take off?"

Capt. Katie Leslie responds: "We're figuring it out. We don't think we have to take anything off."

The plane's first officer said: "He's probably lookin' at our... tail. Like 'bout ready to hit the ground right now, with all the bags back there," after which laughter is heard.

'We have an emergency'
As the plane took off, it climbed much more steeply than normal and the crew was unable to level it off. The plane banked and crashed, clipping a maintenance hangar on the way down and erupting in a ball of fire. Investigators told CNN the plane virtually disintegrated.

The recording shows moments of growing panic as the pilots struggle to control the plane.

As the plane takes off, Leslie says in a loud voice: "Push the nose down ... Oh, my God." She then radioed in: "We have an emergency for Air Midwest 5481."

The cockpit voice recorder captured the voice of a young child yelling, "Daddy!"

Then the captain again: "Pull the power back." Seconds later, "Oh my God, ah!"

The co-pilot: "Uh, uh, God, ah. (expletive.)"

The recording ends two seconds later.

Federal crash investigators are looking into maintenance done on the plane's elevators two days before the crash. The elevators control the airplane's pitch, or up-and-down movement. The NTSB said in January that the tension in the "up" and "down" elevator cables was off by nearly 2 inches.

Safety experts said the problem with the elevators -- along with the fact that the pitch was down when it should have been in a neutral position -- would have made the aircraft difficult, if not impossible, to control, particularly if weight shifted in the cargo hold.

Investigators will hear this week from officials with Air Midwest, the Federal Aviation Administration and executives at Raytheon, which built the plane and did its maintenance.