Crash of a Beechcraft 1900D in Ghardaïa: 1 killed

Date & Time: Jan 28, 2004 at 2101 LT
Type of aircraft:
Operator:
Registration:
7T-VIN
Survivors:
Yes
Schedule:
Hassi R’Mel – Ghardaïa
MSN:
UE-365
YOM:
1999
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
1742
Circumstances:
The aircraft departed Hassi R'Mel-Tilrhempt Airport at 2030LT on a 15-minutes charter flight to Ghardaïa, carrying three crew members and two employees of the Sonatrach (Société Nationale pour le Transport et la Commercialisation d’Hydrocarbures). At 2044LT, the crew was cleared for a right hand circuit in preparation for an approach to runway 30. At that moment a Boeing 727 inbound from Djanet was on long finals. The copilot stated that he intended to carry out an NDB/ILS approach to runway 30. The captain however preferred a visual approach. The copilot carried out the captain's course and descent instructions with hesitation. At 2057LT, the EGPWS alarm sounded. Power was added and a climb was initiated from a lowest altitude of 240 feet above ground level. The captain then took over control and assumed the role of Pilot Flying. The airplane manoeuvred south of the airport until 2101LT when the copilot saw the runway. The captain rolled left to -57° and pitched down to -18.9° in order to steer the airplane towards the runway. Again the EGPWS sounded but the descent continued until the airplane impacted the ground and broke up. All five occupants were injured and the aircraft was destroyed. A day later, the copilot died from his injuries.
Probable cause:
The Commission believes that the accident can be explained by a series of several causes which, taken separately, would not lead to an accident.
The causes are related to:
1 - the lack of rigor in the approach and landing phase evidenced by a failure to follow standard operating procedures, including the arrival checklist.
2 - the failure to strictly comply with the holding, approach and landing procedures in force for the aerodrome of Ghardaïa.
3 - the fact that the captain seemed occupied by the visual search maneuvers that put him temporarily out of the control loop. He was so focused on the visual search for the runway and abandoned the monitoring of parameters that are critical for the safety of the flight. This concentration completely disoriented him.
4 - the fact that the crew did not respond appropriately to different alarms that occurred, indicating a lack of control in the operation of the aircraft in that kind of situation. Lack of control was apparently due to his lack of training on this aircraft type.
5 - The activities in the southern part of Algeria may cause a certain routine that can promote the tendency to conduct visual approaches. It seems, indeed, that the crew is more experienced in visual flights.
6 - A lack of coordination and communication between the crew members flying together for the first time.

Crash of a Beechcraft 1900D off Hyannis: 2 killed

Date & Time: Aug 26, 2003 at 1540 LT
Type of aircraft:
Operator:
Registration:
N240CJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Hyannis - Albany
MSN:
UE-40
YOM:
1993
Flight number:
US9446
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2891
Captain / Total hours on type:
1364.00
Copilot / Total flying hours:
2489
Copilot / Total hours on type:
689
Aircraft flight hours:
16503
Aircraft flight cycles:
24637
Circumstances:
The accident flight was the first flight after maintenance personnel replaced the forward elevator trim cable. When the flightcrew received the airplane, the captain did not address the recent cable change noted on his maintenance release. The captain also did not perform a first flight of the day checklist, which included an elevator trim check. Shortly after takeoff, the flightcrew reported a runway trim, and manually selected nose-up trim. However, the elevator trim then traveled to the full nose-down position. The control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane. During the replacement of the cable, the maintenance personnel skipped a step in the manufacturer's airliner maintenance manual (AMM). They did not use a lead wire to assist with cable orientation. In addition, the AMM incorrectly depicted the elevator trim drum, and the depiction of the orientation of the cable around the drum was ambiguous. The maintenance personnel stated that they had completed an operational check of the airplane after maintenance. The Safety Board performed a mis-rigging demonstration on an exemplar airplane, which reversed the elevator trim system. An operational check on that airplane revealed that when the electric trim motor was activated in one direction, the elevator trim tabs moved in the correct direction, but the trim wheel moved opposite of the corresponding correct direction. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction.
Probable cause:
The improper replacement of the forward elevator trim cable, and subsequent inadequate functional check of the maintenance performed, which resulted in a reversal of the elevator trim system and a loss of control in-flight. Factors were the flightcrew's failure to follow the checklist procedures, and the aircraft manufacturer's erroneous depiction of the elevator trim drum in the maintenance manual.
Final Report:

Crash of a Beechcraft 1900D in Charlotte: 21 killed

Date & Time: Jan 8, 2003 at 0849 LT
Type of aircraft:
Operator:
Registration:
N233YV
Flight Phase:
Survivors:
No
Schedule:
Charlotte - Greenville
MSN:
UE-233
YOM:
1996
Flight number:
US5481
Crew on board:
2
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
21
Captain / Total flying hours:
2790
Captain / Total hours on type:
1100.00
Copilot / Total flying hours:
706
Copilot / Total hours on type:
706
Aircraft flight hours:
15003
Aircraft flight cycles:
21332
Circumstances:
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 post crash 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 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 was:
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 system,
5) the FAA’s 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.
Final Report: