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