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Loss of Pitch Control During Takeoff Air Midwest Flight 5481 Raytheon (Beechcraft) 1900D, N233YV Charlotte, North Carolina January 8, 2003

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Loss of Pitch Control During Takeoff Air Midwest Flight 5481 Raytheon (Beechcraft) 1900D, N233YV Charlotte, North Carolina January 8, 2003 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 PB2004-910401 Notation 7545B National Transportation Safety Board Washington, D.C. Aircraft Accident Report Loss of Pitch Control During Takeoff Air Midwest Flight 5481 Raytheon (Beechcraft) 1900D, N233YV Charlotte, North Carolina January 8, 2003 RAN S P T O L R A T LUR IBUS A N P UNUM E O T I I O T A N N S A D FE R NTSB/AAR-04/01 T Y B OA PB2004-910401 National Transportation Safety Board Notation 7545B 490 L’Enfant Plaza, S.W. Adopted February 26, 2004 Washington, D.C. 20594 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-51 490 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. iii Aircraft Accident Report Contents Abbreviations . viii Executive Summary . x 1. Factual Information . 1 1.1 History of Flight . 1 1.1.1 Maintenance Events Preceding the Accident Flight . 4 1.2 Injuries to Persons. 8 1.3 Damage to Airplane . 8 1.4 Other Damage. 8 1.5 Personnel Information. 9 1.5.1 The Captain . 9 1.5.2 The First Officer. 10 1.5.3 The Maintenance Personnel . 11 1.5.3.1 The Quality Assurance Inspector. 11 1.5.3.2 The Foreman . 12 1.5.3.3 The Mechanic. 12 1.5.3.4 The Raytheon Aerospace Site Manager. 13 1.5.3.5 The Air Midwest Regional Site Manager . 14 1.6 Airplane Information . 14 1.6.1 Pitch Control System . 15 1.6.1.1 Pitch Trim Control System . 19 1.6.2 Maintenance Program . 19 1.6.3 Elevator Control System Rigging Procedure . 20 1.6.3.1 Rigging Procedure at the Time of the Accident. 20 1.6.3.2 Applicable Steps That Were Skipped During Maintenance . 22 1.6.3.3 Revised Rigging Procedure . 23 1.6.4 Weight and Balance . 26 1.7 Meteorological Information. 28 1.8 Aids to Navigation . 28 1.9 Communications . 28 1.10 Airport Information. 28 1.10.1 Aircraft Rescue and Firefighting . 29 1.10.2 Air Traffic Control . 30 1.11 Flight Recorders . 31 1.11.1 Cockpit Voice Recorder. 31 1.11.1.1 Safety Recommendations A-97-36 and A-02-25. 32 1.11.2 Flight Data Recorder . 32 1.11.2.1 Flight Data Recorder Study . 33 1.12 Wreckage and Impact Information . 34 1.12.1 General Wreckage Description . 34 1.12.2 Fuselage . 35 1.12.3 Engines. 36 1.12.4 Pitch Control System . 37 Contents iv Aircraft Accident Report 1.12.4.1 Pitch Trim Control System . 39 1.13 Medical and Pathological Information . 39 1.14 Fire . 39 1.15 Survival Aspects . 40 1.15.1 Emergency Response . 40 1.16 Tests and Research . 42 1.16.1 Ground Tests . 42 1.16.1.1 Baseline Configuration . 42 1.16.1.2 Turnbuckle Length Adjustments . 42 1.16.1.3 Cable Tension Adjustment Procedural Errors . 43 1.16.1.4 Cable Stretch . 43 1.16.2 Airplane Performance Study . 43 1.16.2.1 Flight 5481 Weight and Balance Study . 44 1.16.2.1.1 Air Midwest Weight and Balance Program . 44 1.16.2.1.2 Airplane Component Buildup Method . 44 1.16.2.1.3 Takeoff Ground Roll Weight Analysis . 46 1.16.2.2 Load Manifest Study . 47 1.16.2.3 Elevator Control Authority Study . 48 1.16.2.3.1 Relationship Between Pitch Control Position and Actual Elevator Position . 48 1.16.2.3.2 Available Elevator Travel . 50 1.16.2.4 Beech 1900D Simulation Studies . 50 1.16.2.4.1 Elevator Required to Match Accident Flight Data . 51 1.16.2.4.2 Elevator Required to Establish Controlled Flight . ..
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