Charlotte crash inquiry puts focus on manual

Ted Reed
Ames Alexander
Staff Writers Posted on Fri, Sep. 19, 2003

Investigators are focused on whether flaws in a maintenance manual contributed to two fatal Beech 1900D crashes this year, one in Charlotte and one in Cape Cod, Mass., sources say.

In both cases, mechanics worked on the planes’ flight control systems shortly before the crashes, using a manual that is increasingly coming under scrutiny.

There are several circumstantial similarities between the Jan. 8 Charlotte crash, which killed 21 people, and the Aug. 26 Cape Cod crash, which killed two. But flaws in the maintenance manual could be the first indication that a similar problem may have contributed to both crashes.

In a conference call last week, officials from the Federal Aviation Administration and Raytheon Aircraft discussed FAA concerns about an illustration in Raytheon’s Beech 1900D manual, according to investigator Bob Gretz, who heads the National Transportation Safety Board investigation of the Cape Cod crash.

The illustration – of a component that helps control the plane’s elevator trim – was backwards, sources familiar with the investigation told The Observer. It’s unclear whether mechanics did improper maintenance as a result of the faulty illustration. It’s also unclear whether the mistake was in other manuals.

Pilots in the Cape Cod crash complained about “runaway trim” shortly after takeoff. The elevator trim tab is a small tail flap that helps control a plane’s pitch. The flight data recorder indicates the plane took off with its trim control system in a position that would tend to point the nose downward, when it should have pointed up, investigators have found.

Gretz said the illustration shows the elevator trim drum, where cables from the elevator trim are connected.

The FAA is considering action to ensure mechanics working on Beech 1900s have proper maintenance instructions, agency officials say.

A spokesman for Wichita, Kan.-based Raytheon, which produces the manual, declined to comment, citing the ongoing investigation. A spokesperson for Colgan Air, which operated the Cape Cod plane, also declined to comment.

Two days before the Jan. 8 Charlotte crash, which killed 21 people, a mechanic improperly adjusted the elevator control cables, investigator believe. He’d never before done the job on a Beech 1900, and failed to follow some steps in the manual, investigators say.

 The manual lacked explicit instructions, according to testimony at an NTSB hearing in May. In a February letter to the NTSB, Air Midwest vice president of maintenance Joe Machalek wrote that more explicit instructions “could have avoided the elevator mis-rigging.”

The manual is supposed to be regularly updated by Raytheon Aircraft, which manufactured the Beech 1900D between 1991 and 2002; airlines are responsible for ensuring that those updates are inserted into their manuals.

The FAA says ultimate responsibility for manuals rests with the airlines. Air Midwest operated the Charlotte flight, while Colgan Air operated the Cape Cod flight.

Before the Cape Cod crash, Colgan mechanics in Hyannis, Mass., used the manual while changing a cable that helped move the elevator trim tab, but “the manual was difficult to follow,” said a source familiar with the investigation.

As a result, “The board has increased its focus on the maintenance manual, on the clarity, on how descriptive the instructions are and whether or not it provides sufficient instructions for maintenance to be at a high standard,” the source said.

Two pilots were killed when the plane crashed three minutes after takeoff from Barnstable Municipal Airport. The plane carried no passengers because it was flying to Albany, N.Y., to be positioned for a future US Airways Express passenger flight.

The fatal flight was the first one following maintenance.

The Jan. 8 crash killed 19 passengers and two pilots when the plane crashed 37 seconds after takeoff from Charlotte/Douglas International Airport. The Air Midwest plane was operating as a US Airways Express flight.

The pilots could not control the aircraft, and could not counter the effect of a heavy load of passengers and baggage, because of an incorrect cable adjustment at a Huntington, W.Va., hangar operated by a third party contractor, NTSB investigators have indicated.

The NTSB is likely to include a discussion of the maintenance manual in its final report on both the Charlotte and Cape Cod crashes, sources said.

Crash investigators have found vague maintenance instructions were partially to blame in other accidents, including a fire that broke out in an engine of a Continental Express plane as it was landing in Newark, N.J., on Jan. 21, 1998. A flight attendant suffered a minor injury.

 In that case, the NTSB found that a lug used to hold a fuel filter in place came out, allowing fuel to spill onto hot engine surfaces. A Kansas repair station had drilled too large a lug hole while overhauling the fuel heater six months earlier, but the NTSB found that a lack of direction in the overhaul manual was also a factor.

One source said the focus on maintenance in the Charlotte crash has put considerable personal pressure on the mechanics who were involved.

To an extent, a knowledge of the shortcomings in the maintenance manual could limit any perception that they may have acted carelessly, he said.

“These are working stiffs who don’t deserve to have the kind of mental anguish they’ve gotten,” the source said. “These guys did the best they could with the manual they had.”

Ted Reed: (704) 358-5170; treed@charlotteobserver.com
Ames Alexander: (704)358-5060; aalexander@charlotteobserver.com