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NTSB: Maintenance error preceded Colgan Air crash
EMILY C. DOOLEY
STAFF WRITER
HYANNIS - Mechanics on the Cape skipped a maintenance step and installed a piece of equipment backward before clearing a Colgan Air plane that later crashed in Nantucket Sound last year, killing the two pilots aboard.
The mechanics also did not perform an operational check to make sure the components they installed were working properly, according to the National Transportation Safety Board.
The Beechcraft 1900D crashed Aug. 26, 2003, as pilot Scott Knabe and co-pilot Steven Dean wrestled to right a control problem they reported moments after takeoff. They were flying the empty plane on a repositioning flight from Barnstable Municipal Airport to Albany, N.Y.
Both men died on impact, according to investigators.
It was the first flight after a four-person maintenance crew installed two elevator trim actuators and a forward elevator trim cable, which help control the pitch of the aircraft.
The work, which took three days and was completed the day before the crash, was performed at the Colgan maintenance hangar at the airport.
"It just reinforces that these two guys died for no reason," brother Robert Dean said. "It was unnecessary."
Months before a final report and probable cause will be issued, these details were revealed in a letter sent by the NTSB to the Federal Aviation Administration.
The letter was sent after the board closed an investigation into the crash of another Beechcraft 1900D in Charlotte, N.C., in January 2003. The planes are the same model and had both recently undergone maintenance.
The final report on the Charlotte crash lists faulty maintenance and an overloaded plane as the cause of the crash, which killed 21 people.
The safety recommendation letter states that the mechanic in the Charlotte crash skipped nine steps listed in the maintenance manual. If followed, some of those may have indicated a part had been misrigged, perhaps preventing the accident, according to the letter.
That letter also mentions the Colgan Air accident as an example of crashes occurring after mechanics missed a step. It says that when the mechanics were replacing the actuators, they did not remove the elevators, which is a step listed in the manual.
While listing errors, the letter does not state a cause for the Colgan Air crash. The NTSB has also declined name a specific cause, saying more investigation is necessary.
"(The maintenance crew) did admit skipping that step but we're still looking into whether or not that had anything to do with the accident," NTSB air safety investigator Robert Gretz said. "Just because they skip a step doesn't mean the plane will crash."
The letter also mentions that a cable drum was installed backward, which could cause the plane to move in the opposite direction intended by the pilot.
During the investigation, the NTSB revealed that while written instructions for installing the trim drum were correct, the accompanying illustration was in backward.
"The illustration was backward, but the mechanics followed the illustration and therefore they installed it backwards," NTSB spokesman Ted Lopatkiewicz said.
"Functional check"
The letter also mentions that checks to be sure items are working are also important in detecting problems. In both the Charlotte and Yarmouth crashes, that move never happened, according to the letter.
"The mechanics stated that after they were done with everything, they did perform a functional check, but we're still investigating to see if that that's true," Gretz said.
Colgan Air is a U.S. Airways Express carrier and ferries about 200 passengers daily between the Cape, islands, Boston and New York.
Colgan spokeswoman Mary Finnigan would not say if Colgan has changed maintenance procedures since the crash. "I can't comment on anything that has to do with the investigation," she said.
Following the crashes, Beechcraft manufacturer Raytheon Aircraft Company made one change to the manual and seven corrections.
The changes and facts stated by the NTSB will help bolster an investigation and lawsuit filed by the families of two people killed aboard the Charlotte plane, said attorney John Greaves, of the Los Angeles firm Baum Hedlund.
Damages sought
Raytheon and seven others are named in the wrongful death suit that seeks unspecified punitive damages.
"The question is going to be are they culpable for defective procedures that the mechanics are using," Greaves said. "If we can show a pattern here that these things are happening, that's going to help the jury determine if this is a one time fluke or a pattern caused by defective information."
The firm of Baum and Hedlund, which has litigated more than 60 commercial aviation crashes, has not been retained by the families of either pilot. Greaves said that since both pilots were employees the families will only be entitled to Workers' Compensation.
The safety letter sent to the FAA includes 20 recommendations the federal agency should consider to make flying safer.
Adopting a program detect maintenance oversights, requiring functional checks after critical flight maintenance is performed and developing a job training program for mechanics are among the recommendations.
The FAA has 90 days to respond to the recommendations," FAA spokesman Les Dorr said. Recommendations are typically accepted by the FAA, said Susan Coughlin, former NTSB chairwoman and current President and CEO of Aviation Safety Alliance. "The NTSB looks at recommendations purely from the standpoint of safety," she said. "The FAA has to look at them in an operational context."
(Published: April 16, 2004)
Copyright © Cape Cod Times. All rights reserved.
NTSB: Maintenance error preceded Colgan Air crash
EMILY C. DOOLEY
STAFF WRITER
HYANNIS - Mechanics on the Cape skipped a maintenance step and installed a piece of equipment backward before clearing a Colgan Air plane that later crashed in Nantucket Sound last year, killing the two pilots aboard.
The mechanics also did not perform an operational check to make sure the components they installed were working properly, according to the National Transportation Safety Board.
The Beechcraft 1900D crashed Aug. 26, 2003, as pilot Scott Knabe and co-pilot Steven Dean wrestled to right a control problem they reported moments after takeoff. They were flying the empty plane on a repositioning flight from Barnstable Municipal Airport to Albany, N.Y.
Both men died on impact, according to investigators.
It was the first flight after a four-person maintenance crew installed two elevator trim actuators and a forward elevator trim cable, which help control the pitch of the aircraft.
The work, which took three days and was completed the day before the crash, was performed at the Colgan maintenance hangar at the airport.
"It just reinforces that these two guys died for no reason," brother Robert Dean said. "It was unnecessary."
Months before a final report and probable cause will be issued, these details were revealed in a letter sent by the NTSB to the Federal Aviation Administration.
The letter was sent after the board closed an investigation into the crash of another Beechcraft 1900D in Charlotte, N.C., in January 2003. The planes are the same model and had both recently undergone maintenance.
The final report on the Charlotte crash lists faulty maintenance and an overloaded plane as the cause of the crash, which killed 21 people.
The safety recommendation letter states that the mechanic in the Charlotte crash skipped nine steps listed in the maintenance manual. If followed, some of those may have indicated a part had been misrigged, perhaps preventing the accident, according to the letter.
That letter also mentions the Colgan Air accident as an example of crashes occurring after mechanics missed a step. It says that when the mechanics were replacing the actuators, they did not remove the elevators, which is a step listed in the manual.
While listing errors, the letter does not state a cause for the Colgan Air crash. The NTSB has also declined name a specific cause, saying more investigation is necessary.
"(The maintenance crew) did admit skipping that step but we're still looking into whether or not that had anything to do with the accident," NTSB air safety investigator Robert Gretz said. "Just because they skip a step doesn't mean the plane will crash."
The letter also mentions that a cable drum was installed backward, which could cause the plane to move in the opposite direction intended by the pilot.
During the investigation, the NTSB revealed that while written instructions for installing the trim drum were correct, the accompanying illustration was in backward.
"The illustration was backward, but the mechanics followed the illustration and therefore they installed it backwards," NTSB spokesman Ted Lopatkiewicz said.
"Functional check"
The letter also mentions that checks to be sure items are working are also important in detecting problems. In both the Charlotte and Yarmouth crashes, that move never happened, according to the letter.
"The mechanics stated that after they were done with everything, they did perform a functional check, but we're still investigating to see if that that's true," Gretz said.
Colgan Air is a U.S. Airways Express carrier and ferries about 200 passengers daily between the Cape, islands, Boston and New York.
Colgan spokeswoman Mary Finnigan would not say if Colgan has changed maintenance procedures since the crash. "I can't comment on anything that has to do with the investigation," she said.
Following the crashes, Beechcraft manufacturer Raytheon Aircraft Company made one change to the manual and seven corrections.
The changes and facts stated by the NTSB will help bolster an investigation and lawsuit filed by the families of two people killed aboard the Charlotte plane, said attorney John Greaves, of the Los Angeles firm Baum Hedlund.
Damages sought
Raytheon and seven others are named in the wrongful death suit that seeks unspecified punitive damages.
"The question is going to be are they culpable for defective procedures that the mechanics are using," Greaves said. "If we can show a pattern here that these things are happening, that's going to help the jury determine if this is a one time fluke or a pattern caused by defective information."
The firm of Baum and Hedlund, which has litigated more than 60 commercial aviation crashes, has not been retained by the families of either pilot. Greaves said that since both pilots were employees the families will only be entitled to Workers' Compensation.
The safety letter sent to the FAA includes 20 recommendations the federal agency should consider to make flying safer.
Adopting a program detect maintenance oversights, requiring functional checks after critical flight maintenance is performed and developing a job training program for mechanics are among the recommendations.
The FAA has 90 days to respond to the recommendations," FAA spokesman Les Dorr said. Recommendations are typically accepted by the FAA, said Susan Coughlin, former NTSB chairwoman and current President and CEO of Aviation Safety Alliance. "The NTSB looks at recommendations purely from the standpoint of safety," she said. "The FAA has to look at them in an operational context."
(Published: April 16, 2004)
Copyright © Cape Cod Times. All rights reserved.
