Colgan Beech fatal (8/03) final report

[Propblast]

A good call by TWADude. The FAA has a "blood priority". They don't really clamp down until after the fact.

Propblast

 

[Publishers]

negligence

While workmans comp may be involved, I believe that if it ends up that gross negligence was invloved, the pilots can sue and recover damages. If the manual that Raytheon had was improper, they too would be open for legal action as well as the individal maintenance person.

All of these cases are tragic and all are far from simple. You can play the "what if" games until you are blue in the face. As most of us know, there is rarely one single factor in an accident, they are usually the result when a bunch of factors come together in a single moment.

 

[climbhappy]

am i hearing that the visual check done by the captain to move by the electric trim and verify trim wheel movement was not done. second, in the misrigging of it , what would have happened when the captain overrode the fo trim ?

in my recent groundschool, we watched the valujet disaster and saw the test done by the fed with respect to these oxy gens.

it was horrifying. they never had a chance. neither did this crew.

actually, if the aircraft was returned to service improperly without a maintenance flight, then the merits of a huge wrongful death suit get stronger and stronger. if the policies and procedures of colgan management didn't allow for this anomoly to be detected, they'll pay dearly.

 

[chperplt]

am i hearing that the visual check done by the captain to move by the electric trim and verify trim wheel movement was not done. second, in the misrigging of it , what would have happened when the captain overrode the fo trim ?

You are correct.. Neither the Captain nor the FO performed the first flight of the day check on the trim wheel.

When the captain overrode the FO trim wheel, the same thing would have happened that did happen. They commanded a nose up action but inturn, the elevator went nose down. The trim wheel spun in the correct position relative to the trim request. The cable was backwards and commanded the opposite action.

 

[79%N1]

When the captain overrode the FO trim wheel, the same thing would have happened that did happen. They commanded a nose up action but inturn, the elevator went nose down. The trim wheel spun in the correct position relative to the trim request. The cable was backwards and commanded the opposite action.

Thats messed up, man! Scarry thought how little control we may have over what we trust others to ensure is working properly!

 

[WileE]

You know what would have happened?

If they had done a test flight? The pilots would have died on the test flight instead of the ferry flight. Test flights at these companies involve taking off, flying a pattern and if you don't crash, its a successful test. If you crash, I guess they didn't do the tail right.

 

[chperplt]

You know what would have happened? If they had done a test flight? The pilots would have died on the test flight instead of the ferry flight. Test flights at these companies involve taking off, flying a pattern and if you don't crash, its a successful test. If you crash, I guess they didn't do the tail right.

You're missing the bigger picture my friend. IF the crew was doing a test flight, they would have been told what the problem with the airplane was. They then would have had the foresight to perform a functional check on the elevator and it's trim components.

Secondly, IF the company would have brought qualified people in to fix the aircraft properly rather than send the aircraft out to be fixed, the accident would never had occurred.

 

[Publishers]

Questions

As evidenced from above, you would not acutually had to find the problem by flying at all.

It was known what was worked on and a test on the ground would have shown the problem.

Usually a mechanic is given a card to perform a certain maintenance function. It is then often someone else who is responsible for seeing that the work was done and checked for proper function.

The above should hold true no matter who, the company or a contractor, performs the maintenance.

As a pilot, it is always good to see what your aircraft did last. We do not really know whether or not this crew knew that the aircraft had come out of maintenance. The fact that they did not do the first flight check list is indicative that maybe they took this flight more casually than normal as there would be no passengers.

If there is one thing that I have learned over the last 30 years in aviation is that many good people have serious and sometimes fatal accidents. Other times, those that surely should have been killed through their actions end up coming out all right.

 

[chperplt]

As a pilot, it is always good to see what your aircraft did last. We do not really know whether or not this crew knew that the aircraft had come out of maintenance. The fact that they did not do the first flight check list is indicative that maybe they took this flight more casually than normal as there would be no passengers Emphasis added.

How much 121 time do you have? My guess by your profile is zero.

We as pilots in a 121 operation don't have a clue (generally) what heavy maintenance was done on an airplane. Each airplane has two sets of books. One is stored somewhere other than the airplane, and the one in the airplane. The airplane maintenance log will generally only show work done as a result of a pilot write-up.

Yes, we know that this crew knew the aircraft came out of maintenance. What we don't know if what they were told was done to the aircraft. We also know that dispatch told them the airplane was going to ALB to pick up a revenue trip. We know this because that is what the company told the pilot group after the accident. It was shortly after the fact that the truth came out.

The aircraft came out of a maintenance base which is a pilot base as well. Aircraft overnight in the maintenance hanger. It's common practice to pick an airplane up from maintenance.

Are you trying to tell me that you find fault with the crew, because maybe the took the flight more casually than normal? Am I reading that wrong?

 

[DH106]

Not a criticism, but a heads-up to current 1900D drivers:

Our 1900D manual had a specific preflight procedure for checking/preflighting the elevator trim tab, Nearly none of the pilots I flew with were familiar with the procedure (the company wasn't even training it), so I always took the time to show it to my FO's.

I recall that you had to set the trim to a certain setting... then, you'd go outside, and look at the elevator --- the trim tab trailing edge should be lined up with the elevator trailing edge, at the specified trim setting. If the two trailing edges weren't lined up, it was a sign of mis-rigging.

I believe it was a Raytheon-published procedure, put out around 1999 (?).

Current 1900D drivers: check your manuals about this, and correct me if I'm wrong?

 

[Mungusaurus]

Lesson Time

Okay boys n gals, the trim check as described would have given no indication to the crew. To have discovered this problem one crewmember would have had to stand outside the aircraft while the other actuated the trim and informed the watching crewmember in which direction they were moving it. The watching crewmember would then verify the direction of travel.NOT IN THE MANUAL This was not a case of elevator trim mis rigging but from the sound of it the cables to the actuator being installed backwards, you can do this and from the outside the rigging would look correct.
Had they done the normal fist flight of the day checks all would have indicated normal from the cockpit. This does not excuse the fact they did not do it but it is a moot point. Lets wait for the official report before we rush to any judgements. And to one and all please be careful, thanx, Mung.

 

[climbhappy]

question

there is a position in the maint dept at 121 carriers called the RII.
The Required Item Inspector. essentially the quality assurance guy and the 121 version of an IA. he is someone that scrutinizes the work of hourly A&Ps. Did this guy pencil whip the work?

 

[chperplt]

Did this guy pencil whip the work?

It's funny you should ask that... I don't know the RII events in the accident, but do you remember when LVBs left engine wouldn't shut down in Boston? The condition lever was pulled to cutoff and nothing.. the firewall fuel valve was pulled and nothing...

Those poor Augusta old folks had to exit over the right wing while they ran the left side out of fuel.

Interestingly enough, the aircraft had just come out of HYA maintenance. The cable from the condition lever to the fuel control unit was installed backwards and without a safety pin. A couple pulls and the cable fell off. The even funnier thing was that the rag that was in the fuel tank and prevented the firewall valve from closing had been there a while.. It would have sucked to have a real fire and not be able to get the full off.

Hey Sammy... You on these boards? Any comments? How's Florida treating you?

 

[Publishers]

chperplt

I was not condeming the crew and I have more Part 121 experience than I ever needed.

What I was pointing out was that it never hurts to be inquisitive as to what and where the aircraft your flying came from.

After the incident in CLT, if I am a 1900 driver and the aircraft has come out of this type of maintenance and I know it, I might have spent more time looking at or attempting to check it.

Obviously the maintenance supervisor or QC did not confirm the work was done correctly.

My remark about the preflight was only that they thought this was no big deal. We have an obligation to our families to check this to the best of our abilities every time we fly aircraft. Most of the time, the mechanic that does work is not on the aircraft he worked on, you are. Even back when I owned my first airplane with some partners, I noticed they always wanted me to do the first flight after we had anything done to the airplane.

Now I will admit to some blast offs without much preflight, especially on the second and third trips of the day, but, you can rest assured, even back with that Piper Arrow, that first flight from maintenance was thoroughly looked and run before I went to take off.

 

[chperplt]

Publishers


Thanks for your clarification. Your points are quite valid.

 

[WhiteCloud]

Heard a BIG rumor in Manassas that Colgan is now considering the retirement of the entire 1900 fleet by year's end and going all Saabs thanks in part to this and the Fuel truck incident in BDL.

How is that supposed to solve their problems? A mechanic can screw up the rigging on a Saab too and it just presents a larger target to the fuel truck drivers.

 

[Hawker rider]

This tragic accident is not because of a bad airplane, or a bad crew...

This is just one mechanic making a mistake and nobody catching it. Everybody is always under a lot of pressure, and last time I checked we were also all humans, and that means we make mistakes.

Fact is that the procedures were not followed or neglected by the maintenance base, THAT was the only way this might have been detected before flight.



P.s> is there no way the crew would have been able to know that there was work done on the elevator? What about a discrepancy log? I know you don't get to seea sign off, but surely for this to be a grounding issue it had to have been written up in the discrepancy log and couldn't be deferred with MEL, therefore grounding the airplane.

 

[Crizz]

What grave flight control characteristics would this 1900 have exhibited that would cause it to go down as a result of reversed trim? Couldnt they have recognized the fact that their trim wheel was working in reverse soon after takeoff and a climb trim attempt?

What am I missing?

 

[chperplt]

Couldnt they have recognized the fact that their trim wheel was working in reverse soon after takeoff and a climb trim attempt?

I don't know... I wasn't there so I can't answer that question. I would like to think that a malfunction like that would be recognizable and controllable.

We don't know what else they were dealing with and won't for another month until the full report is made public.

What am I missing?

An awful lot of information and maybe an awful lot of experience. A trim problem in a high performance airplane is a lot different from a trim problem in what you're CFIing in.

 

[Crizz]

Fair enough guys... admittedly I am inexperienced and was hoping to gain some insight from those with more experience. I hope my comments didnt come off in a negative way - they certainly werent meant to be.