NTSB Cites Mechanic''s Error in Crash

[JS]

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On 5/21/2003 931 AM DCAflyer wrote:

The trainee mechanic said during the investigation that he skipped several steps in the maintenance manual as he adjusted the cable tension because he felt they were unnecessary.

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Whoa, that''s not good.

 

[DCAflyer]

NTSB Cites Mechanic's Error in Crash
Improperly Adjusted Control Cable Added to Pilots' Struggle With Overloaded Plane

By Don Phillips
Washington Post Staff Writer
Wednesday, May 21, 2003; Page A03


US Airways Express Air Midwest Flight 5481, which crashed at Charlotte-Douglas International Airport on Jan. 8, was overweight and tail-heavy as it left the runway that morning, but it might have made the flight to the Greenville-Spartanburg Airport in South Carolina anyway had it not been for a mechanic's mistake two nights before, according to information made public yesterday by the National Transportation Safety Board.
The Raytheon Beechcraft 1900D turboprop pitched nose-up as Captain Katie I. Leslie and First Officer Jonathan J. Gibbs fought to keep it in the air, but the small plane stalled and plunged to the ground at the corner of a hangar and burst into flame. The two pilots and all 19 passengers were killed.
The Beech 1900D, operated by Air Midwest and being used on Flight 5481, had undergone maintenance on the night of Jan. 6 at a maintenance facility at Huntington, W.Va. Mechanics determined that the tension in the cables connecting the control column to the elevators was not properly set. Using a maintenance manual, a trainee mechanic set the tension, and his work was signed off by an inspector.
The trainee mechanic said during the investigation that he skipped several steps in the maintenance manual as he adjusted the cable tension because he felt they were unnecessary.
Investigators said they had determined that when the tension was set, the control column was set too far forward. That meant that the control column could be pushed forward only a slight distance before hitting its stops. That left the pilots with only about 30 to 40 percent of the normal ability to push the nose down.
The plane made several flights after the maintenance, but it was not loaded near its maximum weight until the accident flight, so there had been no need for a pilot to push the column sharply forward.
But on Jan. 8, the need was there almost immediately. About 10 seconds after liftoff, the pilots began to notice something was wrong. Help me, Leslie said, according to a transcript of the plane's cockpit voice recorder.
Push down, said Gibbs as Leslie could be heard grunting and breathing heavily as she tried to push the control column forward, not knowing that she could never push hard enough to save the plane because mechanics had incorrectly set the cables connecting her control column to the elevators on the horizontal tail section, which help control up and down movements.
The plane pitched nose-up about 75 degrees, almost straight up, rolling sharply to the left and then back to the right as it fell.
Oh my God, she said, making her one radio call to the tower, We have an emergency for Air Midwest five four eight one.
Daddy, came a muffled voice from the passenger cabin.
Safety board staff members said they could not identify the source of the voice, but it was possible it came from 12-year-old Caitlin Albury of the Bahamas, sitting at the rear of the plane in Row 9. Her father and uncle were forward in Row 3.
The crash already has had a profound effect on aviation safety. The Federal Aviation Administration ordered a survey of average passenger weights, discovering that passengers today weigh an average of almost 21 pounds more than in 1995 at the time of the last survey, and they are carrying heavier luggage. The FAA has ordered an increase in the average weights used in calculating aircraft weight and balance and is continuing to study the issue.
Air Midwest was using previous FAA averages at the time of the crash -- 170 pounds for the passenger and carry-on luggage in summer and 175 pounds in winter. After the crash, the airline set a 200-pound average, the new temporary FAA requirement.
Using the new average, the safety board reported the plane would have been overweight. Using actual weights, calculated by forensic examination of passenger remains and baggage, the plane was at least 300 pounds overweight at takeoff, and its center of gravity was at least two inches behind the maximum allowed.
Leslie and Gibbs were concerned about weight as they sat at the gate and taxied out for takeoff. They repeatedly went over weight and balance calculations, finally calculating the takeoff weight as 17,018 pounds. Maximum takeoff weight was listed as 17,400 pounds. The plane was so close to maximum weight that the crew actually calculated the amount of fuel they would burn in taxiing out for a takeoff, subtracting that amount from their calculations.
As the plane taxied out, several pilots and ramp workers reported it looked tail-heavy, and at least one saw the nose wheel bounce off the ground.
We believe the crew filled out the paperwork properly, but that the assumptions used in the paperwork were incorrect, the board said.


© 2003 The Washington Post Company

 

[gilbertguy]

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On 5/21/2003 10:53:47 AM networking wrote:


God bless to all the families who lost loved ones in that crash.  Something has to be done about weight in the bags people check.  The luggage manufacturers are making bags bigger and bigger.  I feel there should be a scale every time a passenger checks a bag in and the maximum weight should be set at 50 or 60 pounds.   No, people would not like this but after a while it should be standard practice.  In this accident it sounds like a maintenance error, but max weight played a great factor. 
I


Scales usually are available at many check-ins. There are size/weight limits placed on luggage. Progressive charges are in place for those bags that go beyond those limits set by the airlines....don''t know how vigorous
these monies are collected at check-in...over weight, over limit was a pet peeve of mine and I gladly collected them.....since I had to lift those mini vans some called bags.....

 

[networking]

God bless to all the families who lost loved ones in that crash. Something has to be done about weight in the bags people check. The luggage manufacturers are making bags bigger and bigger. I feel there should be a scale every time a passenger checks a bag in and the maximum weight should be set at 50 or 60 pounds. No, people would not like this but after a while it should be standard practice. In this accident it sounds like a maintenance error, but max weight played a great factor.
I

 

[delldude]

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On 5/21/2003 917 AM JS wrote:

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On 5/21/2003 931 AM DCAflyer wrote:

The trainee mechanic said during the investigation that he skipped several steps in the maintenance manual as he adjusted the cable tension because he felt they were unnecessary.

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hung by his own words.......and U wants 3rd party heavy checks.....

Whoa, that''s not good.

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[cavalier]

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On 5/21/2003 12:31:06 PM PineyBob wrote:


Question(s) To those in the know?

1. Will the inspecting mechanic/supervisor be liable for criminal charges?

YES on Inspector...supervisor I don''t know?

2. Same question for the trainee? what does he/she face?

YES, he is toast, licensed or not.

3. What is the level (If any) of US Airways oversight on maintenance procedures with contract carriers?

Probably zero, really don''t know.

Comment: This really really sucks from where I sit. I fly Air Midwest out of ACY regularly and this concerns me greatly since the Beech 1900D''s used at ACY are so old they are still in the white paint scheme. To me the issue is not who does what check where, but rather who inspects the inspector? For outsourcing to work the controls written into the contract must be very stringent and I have my doubts that US has the controls in place to correctly and safely administer the outsourcing of maintenance.

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[Bob Owens]

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On 5/21/2003 12:31:06 PM PineyBob wrote:


Question(s) To those in the know?

1. Will the inspecting mechanic/supervisor be liable for criminal charges?

Whoever signed for it will hang.

2. Same question for the trainee? what does he/she face?

It depends on whether they signed for it and were licensed. Unfortunately the FARs do not require licensed or trained people to do the work on airplanes, they only require that a licensed repairman signs for the work. The licensed worker who signed is the one responsible for the work. This policy saves the company money and they love to threaten licensed mechanics that they will fire most of the A&Ps and just have one or two sign for the work. FAR 66 will enable companys like that to issue their own non transferrable FAA licenses so non A&P licensed mechanics can sign the logbook . In this case the inspector obviosly screwed up, but here it took at least two people to screw up(two mechanics and several pilots, didnt they notice that they were not getting full elevator deflection?).

Look for more of this in the future as airlines outsource more and more work and reduce maint to save money.

Here in the US A&P licensed mechanics that are hired by airlines go though a 10 year background check, are drug tested and fingerprinted by the FBI. They usually have a history that can be traced back to high school. The same is not true of Foreign repair or to my knowledge MROs. This accident may lead to more FAA oversight of these facilities but that does nothing to help the dead. Unfortunately that is how the FAA works, Tombstone reform.

FAR 145 should cause even more concern to the flying public. It allows Foreign Repair and heavy checks of US flown aircraft. For all we know they may be employing Osama Bin Laden to work on aircraft. Several areas that are accessed during heavy checks are not normally inspected or accessed during line maint. It would not be too difficult for them to sabotage (a pencil could do the trick) or plant a bomb on aircraft.

3. What is the level (If any) of US Airways oversight on maintenance procedures with contract carriers?

Comment: This really really sucks from where I sit. I fly Air Midwest out of ACY regularly and this concerns me greatly since the Beech 1900D's used at ACY are so old they are still in the white paint scheme. To me the issue is not who does what check where, but rather who inspects the inspector? For outsourcing to work the controls written into the contract must be very stringent and I have my doubts that US has the controls in place to correctly and safely administer the outsourcing of maintenance.

They can write all they want into the contract but what it all boils down to is having a responsible, trained worker doing the job. A worker who knows that he has more to lose by doing shoddy work than by dissapointing a stressed out supervisor with the news that his aircraft is not ready. In the 23 years I've been in aircraft maintenance I've seen mechanics pressured and threatened to do illegal things. I've even been threatened myself. My response is "you can fire me but I will still have my license". (That will not be true for those licenced though their employer under the proposed FAR66). That normally does the trick, but thats with licenses and a union.

The theory behind making flying safe, which is inherantly dangerous, is redundancy and overbuilding. This involves costs. In order for disaster to happen several reliable things have to fail. The more reliable each thing is the less likely that several of them will fail. Having reliable A&P licensed mechanics performing all critical work, and not just signing for others is the best way to start off right. The move by airlines to save money on maintenance which is being taken to the extreme by getting rid of in house A&Ps and sending critical work to third party maintenance (both domestic and foreign) who in turn are trying to put out their product as cheaply as possible is dangerous.

Enjoy your cheap seats that were provided though cheap non-union, unlicensed labor. You get what you pay for. The bargain of a shortened lifetime.

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[WSurf]

Comment: This really really sucks from where I sit. I fly Air Midwest out of ACY regularly and this concerns me greatly since the Beech 1900D''s used at ACY are so old they are still in the white paint scheme. To me the issue is not who does what check where, but rather who inspects the inspector? For outsourcing to work the controls written into the contract must be very stringent and I have my doubts that US has the controls in place to correctly and safely administer the outsourcing of maintenance.

Old! Those 1900D''s are not old (a lot newer the the 737''s), and age has nothing to do with it! If you want old, get on one of our (Piedmont) Dash 8 out of CLT, now thats old.

 

[757fixer]

My guess is that mechanic could be looking at 21 counts of manslaughter.His own words are going to nail him to the wall.

 

[flyin2low]

They should just ''skip some of the steps'' [court proceedings] and just lock the trainee and the inspector up for a long time......It''s too bad the case wasn''t solved sooner. They could have made the two of them attend every funeral that was held.

 

[wings396]

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On 5/21/2003 11:07:11 AM gilbertguy wrote:

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On 5/21/2003 10:53:47 AM networking wrote:


God bless to all the families who lost loved ones in that crash.  Something has to be done about weight in the bags people check.  The luggage manufacturers are making bags bigger and bigger.  I feel there should be a scale every time a passenger checks a bag in and the maximum weight should be set at 50 or 60 pounds.   No, people would not like this but after a while it should be standard practice.  In this accident it sounds like a maintenance error, but max weight played a great factor. 
I


Scales usually are available at many check-ins. There are size/weight limits placed on luggage. Progressive charges are in place for those bags that go beyond those limits set by the airlines....don''t know how vigorous
these monies are collected at check-in...over weight, over limit was a pet peeve of mine and I gladly collected them.....since I had to lift those mini vans some called bags.....


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Scales are there, but only used when you suspect a bag may exceed the 70lb limit. Most bags that weigh near 50lbs are considered normal anymore. The large bags of the old days make up 75% of what are checked today. This has become the new way to avoild checking too many bags..just make em as big as possible with 8 wheels. When I worked our MCO flights, we had 175+ bags and none came close to the 25lb average. There should be a dimesional limit as well as weight limits to bags.

 

[drifterreno]

America West has a maximum weight of 50 lbs per bab and only can check in 2--other must be carry on

 

[diogenes]

This thread is provoking several thoughts.

1. There are dimensional and weight limits to checked baggage; exceed them and pay a steep price. The problem is, as soon as you try to collect excess baggage fees, you''re immediately dealing with a hissy fit, then a PSS that overrides your decision, and potentially, a counseling for rude behavior. See it EVERY day. So while corporate POLICY sez collect the cash, corporate ACTION sez let it slide. The intent of the excess baggage fee was to discourage excess baggage, not be a profit center for the airline. The reason has been tragically demonstrated.

2. The 25 lb average baggage weight has been a joke. In 1981 I could routinely load 125 bags forward on a B737-200. In the last year U operated the 200''s, due the the major increase in size of baggage, I could routinely load only 85 bags forward. While the same volume was occupied (and the same ACTUAL weight in that volume); perversely, instead of showing the 1981 figure of 3125 (25 lbs x 125 bags), we arrived at the 1999 figure of 2125 (25 lbs x 85 bags). This not only causes overweight, but out of balance aircraft.

3. The 165 lb passenger weight also includes carry on items. Seen many 165 lb folks lately, sans carry on items? About time these issues were addressed.

4. Prior to 1999, fleet service was responsible for the weight and balance calculations for mainline aircraft. U shifted this responsibility to a central office, claiming more professional and reliable efforts were needed. In reality, this was one more step in dumbing down the job so an orangutang could do it. Unfortunately, the law of unforseen consequences is a law, like gravity. Another poster has eloquently stated how mechanics have stood their ground to field a safe aircraft. I, and many others, have stood our supervisor down, and refused to pencilwhip an overweight aircraft. In the pre-unions days, that took stones. Now, we have agents who don''t even know the aircraft is unsafe, or why. And we have central load planning agents who don''t know the physical constraints of a cargo bin - it''s just a video game on the computer. screen.

5. There are an amazing number of foreign nationals operating the commuter flights. As the pay sucks, they are here for the green card and flying time. Do they have the interpersonal skills, are they acclimated to American culture, and are they prepared to catch the fast-paced nuances where safety hangs in the balance? No racism here, for many of whom I speak are Irish, Middle and Eastern European, etc.

Again, there was a good statement about safety being about redundant systems. That applies to people, too. There used to be several competent people looking at the weight and balance. Now, far to often, the pilot is the ONLY competent person to have a look.

 

[dashflyer]

Bottom line, as sad as it is, safety comes with a price.

 

[FrugalFlyer]

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On 5/21/2003 8:07:47 PM diogenes wrote:

This thread is provoking several thoughts.

1. There are dimensional and weight limits to checked baggage; exceed them and pay a steep price. The problem is, as soon as you try to collect excess baggage fees, you''re immediately dealing with a hissy fit, then a PSS that overrides your decision, and potentially, a counseling for rude behavior. See it EVERY day. So while corporate POLICY sez collect the cash, corporate ACTION sez let it slide. The intent of the excess baggage fee was to discourage excess baggage, not be a profit center for the airline. The reason has been tragically demonstrated.
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You''re right about the excess baggage rules and fees not being enforced. It''s kind of sad. People think that the baggage weight limit is a suggestion, kind of like the speed limit. If you throw enough of a hissy fit, you get away with excess baggage.

Besides a hissy fit, ignorace works as well. Whenever I travel overseas, I see relatives drop off 1 person with at least 5 pieces of (large & expensive)luggage at the check-in counter (plus carry-on luggage). You''d think a family is travelling but it''s only one person, taking back everything but the kitchen sink to the old country. When the agent tries to enforce the excess luggage rules, pretend to not speak/understand a word of English. After repeating him/herself a few times and the people pleading not to understand/speak a word, the check in agent usually gives up. At times I''ve felt like stepping up to the counter and offering to translate.