Colgan Crash Probable Cause

[Jetmech41]

I deleted these links because I foresee many stupid reply's coming out of this as usual when all the so called experts enlighten us with their all knowing wisdon.

 

[Dizel8]

Elevator misrigging now accounts for two 1900 crashes, the other being USAir express.

Hopefully someone sees the light now!

 

[chperplt]

The captain noted to the first officer that the DFDR was an open item on the MEL; however, there is no record of the captain mentioning the replacement of the forward elevator trim cable.

I sure hope the above quote isn't indicative of the quality of investigation. The logbook (maintenance can) placed in the airplane, which would be the only thing the crew would see, would not have the elevator trim cable replacement in it. That write up would be in the master aircraft logbook kept with maintenance.

 

[pilotyip]

Improper checklist use

Sounds like the flight crew used improper checklist procedures, not using "First Flight of the Day" checklist and not calling for Takeoff Final Items or Line up checks, it was not clear in the report. it might have saved the day.

 

[chperplt]

it might have saved the day.

How might it have saved the day?

Go back and read the section in the report that details the required preflight checks. Also, do you know what they mean by "first flight of the day" items? There was no first flight of the day checklist.

I'm not saying the crew didn't skip something, but I am saying that what they skipped didn't cost them their lives.

 

[flx757]

it might have saved the day.

In ANY accident sequence, there are numerous opportunities to "save the day". This may have been the last one, but it is overly simplistic to make such a blanket statement. Of course, Monday morning quarterbacking is the most simplistic form of all. And is exceedingly easy.

 

[LearLove]

I'm not saying the crew didn't skip something, but I am saying that what they skipped didn't cost them their lives.

I agree, from what I know,read and have been told there was nothing the crew did that would have caused the accident. A properly repaired aircraft would have flown just fine even with the "skipped items/checklists". The same goes for the CLT accident. The 1900 being slightly overgross in this case had nothing to do with the unflyable condition the 1900 was in given how it was loaded.

In both cases had the MX done to the aircraft been accomplished properly neither accident would have occured. Period, dot, end of discussion.

 

[FarginDooshbahg]

I'm not saying the crew didn't skip something, but I am saying that what they skipped didn't cost them their lives.

I agree, from what I know,read and have been told there was nothing the crew did that would have caused the accident.

In both cases had the MX done to the aircraft been accomplished properly neither accident would have occured. Period, dot, end of discussion.

It's NOT the end of the discussion. Period. Dot. Sure, nothing they did "caused" the accident and a properly repaired aircraft would not have crashed. But omitting a trim check that could have detected a trim system that was operating in reverse could have prevented them from ever taking off in the first place. THAT would have also prevented the accident. Like someone else said, it is never one thing that causes accidents and this one is no exception.

 

[chperplt]

But omitting a trim check that could have detected a trim system that was operating in reverse could have prevented them from ever taking off in the first place.

Where does it say they skipped a trim check?

A trim check on the Beech 1900 would not have caught the problem they had.

 

[FarginDooshbahg]

Where does it say they skipped a trim check?

.

It says so right here in the NTSB report disclosing the probable cause.

NTSB Identification: NYC03MA183
14 CFR Part 91: General Aviation
Accident occurred Tuesday, August 26, 2003 in Yarmouth, MA
Aircraft: Beech 1900D, registration: N240CJ
Injuries: 2 Fatal.

"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. "

Now, I understand that it actually says they did not perform a first flight of the day checklist, which included the trim check, but evidently the NTSB concluded that since they didn't perform the checklist, they didn't perform the check, either.

I don't intend to get into a p!ssing contest over the semantics of the report. Nor to I intend to debate the merits of their conclusion. I am only pointing out what the report says and the conclusion at which the NTSB arrived.

 

[350DRIVER]

Sounds like the flight crew used improper checklist procedures, not using "First Flight of the Day" checklist and not calling for Takeoff Final Items or Line up checks, it was not clear in the report. it might have saved the day.

Sad but I thought the exact same when I read the report.

One can do no wrong in one's eyes though I guess...

3 5 0

 

[BSkin]

If you followed the Colgan expanded checklists in its entirety, at the time of the accident, they would not have been able to detect a problem unless one was outside while the other was running the trim.

 

[FlightTraker]

I've got the checklist right in front of me (Revision 4, 30 April 2002). There is no "First Flight of the day Checklist." Just after the "After Start Checklist," it says in itallics(and I quote)

If First Flight of the Day

First Flight of Day Checks
.............COMPLETED CR



That is all that was on the checklist

 

[TheBigH]

like every accident in aviation there was a chain of events leading up to this one, from the misrigging, to the perhaps overlooked maintenance release, laxed procedures and overlooked checks ...

but in the end when the $#it hit the fan the captain called for everything by the books .... it seems that almost all parties added something to the mix, from Beech to the pilots and everyone in between ...

Hopefully this will serve to prevent such accidents in the future, after all what we need to take away from the investigation, not just to find out who's at fault ...

 

[Lear70]

Like the Japanese say:

Fix the problem, not the blame

.
My condolences to those who lost friends or family, I'm sure we can do better here than to cast blame on their actions. Read the report and take the lessons you glean from it to heart.

 

[~~~^~~~]

Does the Beech 1900 have a trim position indicator? Is the indicator independent of the cockpit trim wheel, or does it have a position sensor back on the elevator somewhere?

 

[John_W_Thompson]

MTOW question

What is the MTOW of the 1900c and d?

 

[chperplt]

Does the Beech 1900 have a trim position indicator? Is the indicator independent of the cockpit trim wheel, or does it have a position sensor back on the elevator somewhere?

The 1900 has a very advanced trim position indicator. One side of the trim wheel has numbers. The trim wheel itself has an arrow... Line things up and there you go.

 

[CitationLover]

What is the MTOW of the 1900c and d?

d is 17120# (c is slightly lower).

the preflight trim check is basically having one check the trim at position 3 and visually looking at the tail then resetting it to 0 and checking it again for "flushness".

one thing i have learned from the two "misrig" accidents and experiences with maintenance is anytime a flight control surface (primary or secondary) has been "adjusted" by maintenance is spend the extra 10min on the ground and thoroughly check the "adjusted" surface with two flight crew members.

sad to have happened both times.

 

[chperplt]

the preflight trim check is basically having one check the trim at position 3 and visually looking at the tail then resetting it to 0 and checking it again for "flushness".

What company do you fly for? That certanly was NOT the trim check at Colgan at the time of this accident.