According to the interviews, the MTS chose to omit step (c) of the Elevator Trim Tab Actuator Removal and step (i) of the Elevator Trim Tab Actuator Installation. The passengers on the Lion Air 610 flight were on board one of Boeing's newest, most-advanced planes. pull the power back.". According to data from Federal Aviation Administration (FAA) air traffic control (ATC), the flight departed runway 24 at Hyannis about 1538. Five attempts resulted in crashes shortly after takeoff; in one attempt, the simulator pilot was able to circle for a landing, but impacted terrain while attempting to land. When the flightcrew received the airplane, the captain did not address the recent cable change noted on his maintenance release. ... referencing another flight, the 2003 Colgan Air 9446 … OTD in 2003, Colgan Air Flight 9446 crashes into Nantucket Sound near Yarmouth, Massachusetts killing both crew on board. In the process of performing operational checks, the ETT cable system seized. Colgan Air Services offers a variety of services to new and current pilots. During interviews, the two MTS working the forward ETT cable stated there was no confusion in the handling of the cable drum or how the manual illustration was interpreted. It appears the elevator trim was also set incorrectly for the takeoff, leading one to believe even the shortened checklist was run haphazardly. ", At 1540:39, the CVR recorded, "terrain terrain. The flightcrew subsequently requested to land on runway 33, and ATC cleared the flight to land on any runway. According to interviews with the QA inspector and the LT, the ETT system was re-checked following the cable replacement performed. According to the CVR, the pilot's initial reaction to the elevator trim set too nose down was to use the electric trim, as would be expected. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction. Incredibly, the NTSB did not pursue this. On August 26, 2003 a Beech 1900D on the route hit … Step (c) in MM 27-30-06 simply says "Perform the ELEVATOR REMOVAL procedure" and sends you to the section of the manual that covers that, it is a big job. ", At 1538:53, the captain stated, "I got it... (pull) back ... she's heavy buddy ... roll it back roll my trim Steve. The LT stated during an interview that management at Colgan Air had been in discussion with Raytheon Aircraft to determine if the part number of the right hand (R/H) ETT actuator was correct. Code 7700 LLC. The airplane initiated a left turn and reached an altitude of approximately 1,100 feet. At 1539:36, the first officer stated, "slowly," followed by the CVR recording sounds similar to a decrease in engine/propeller speed. [NTSB NYC03MA183 Group Chairman's Factual Report, §D.]. the two MTS did not use a lead wire when routing the cable through the forward cable pulley system. The NTSB determined that Flight 9446 was the first flight after maintenance personnel replaced the forward elevator trim cable. [NTSB NYC03MA183 Aircraft Maintenance and Records Group Factual Report, §5.0]. At 1539:14, the captain requested that the landing gear be raised, followed by the CVR recording sounds similar to landing gear motor noises. In the days before Colgan Air flight 9446 crashed, a Hyannis-based maintenance crew replaced two elevator trim actuators and a forward elevator trim cable, which help control the pitch of an aircraft. . The turnover from day shift to night shift did not contain written turnover notes of explicit work performed. It seems the NTSB didn't put their best team on this one, the report is poorly written and doesn't teach the lessons that are needed. National Transportation Safety Board. Maintenance caused this crash. However, the elevator trim then traveled to the full nose-down position. コルガン・エア9446便墜落事故は、2003年8月26日に バーンスタブル市営空港 （英語版） 発 オールバニ国際空港 （英語版） 行コルガン・エア9446便（ビーチクラフト 1900D）が離陸直後に ヤーマス （英語版） の海岸から100 ヤード (91 m)沖の海に墜落し、2名のパイロットが共に死亡した事故である:85 After the NTSB's final report was published, Aero News Network observed that Beechcraft 1900D maintenance manuals were considered as accident factors in two previous fatal accidents. The check was interrupted mid-stream (procedures for interrupting checks are contained in the General Maintenance Manual section 3.5.3) and the remaining work was deferred on August 24, 2003 at 0800. Interviews were conducted with: a maintenance technician, who replaced the left actuator the first day and the right actuator the second day; the lead technician (LT) on duty; and the Quality Assurance (QA) inspector who performed the required item inspection (RII). The necessary floorboards and access panels were opened to gain entry to the forward cable. Per the interviews, the maintenance manual procedures were followed. Shortly after takeoff, the flightcrew declared an emergency and reported a "runaway trim." Hardly a challenge and response. Witnesses observed the airplane in a left turn, with a nose-up attitude. ", At 1540:47, the CVR recorded, "woop woop pull up pull-". The forward cable was replaced per MM 27-30-04, while the R/H ETT actuator was replaced per MM 27-30-06. More about this: Functional Check Flights. In my opinion there is no debate and a CDV would have saved this crew. They further stated that the job went normally and that the operational checks were good. Both Colgan flight crews, despite which Regional name they flew under, became fixated at low altitudes. The report here is either in error or there is more to what happened than meets the eye. On August 26, 2003 a Beech 1900D on the route hit … Colgan Air Inc., d/b/a US Airways Express Flight 9446 Aircraft: Raytheon/Beechcraft 1900D Location: Near Hyannis, MA Date: August 26, 2003. Continental Connection flight 3407, crashed during an instrument approach to runway 23 at the Buffalo-Niagara International Airport, Buffalo, New York. The QA inspector was satisfied with the performance of the ETT cable system and the two ETT actuators and complied with the RII functions of the job. As per interviews with the two MTS that performed the forward cable replacement, the drum assembly was removed in the cockpit during the dayshift, prior to their assignment to the forward cable change. However, Raytheon (owner of Beechcraft) denied blame for the crash of Flight 9446, and a company spokesman said the accident would not have happened without the Colgan Air maintenance crew's mistakes. The pilots did not accomplish their checklists following engine start using a challenge and response and appear to have skipped the step requiring they set and check the elevator trim. Always remember that Eddie, when you get right down to it, is just a pilot. Is the movement of an elevator trim tab intuitively obvious? The first officer replied, "I got it.". On February 12, 2009, about 2217 EST, a Colgan Air Inc., Bombardier Dash 8-Q400, N200WQ, d.b.a. August 26, 2003 – Colgan Air Flight 9446, a Beech 1900D operated for US Airways Express as a non-revenue "ferry flight" hit the water off the coast of Yarmouth, Massachusetts shortly after taking off from Barnstable Municipal Airport in Hyannis, MA. If the NTSB compared these two Colgan (Regional) accidents, they would have found more than coincidence. The accident flight was the first flight after maintenance had been performed on the airplane; which included replacement of both elevator trim actuators and the forward elevator trim cable. These steps guide the maintenance technician through the removal and installation of the elevator control surface(s) and are the MM procedures 27-30-02. A Designated FAA Examiner is available on site so you can take your checkride at the same airport you train at. Colgan Air Flight 9446（N240CJ） wreckage.jpg 919 × 641; 117 KB Convair 440-62 Metropolitan, Trans Continental AN0252971.jpg 1,024 × 679; 327 KB DAL1288b.jpg 633 × 417; 40 KB The aircraft had just finished receiving maintenance in Yarmouth, Massachusetts, and was being repositioned to Albany, New York to return to revenue service. Colgan Air Flight 9446 was a repositioning flight operated by Colgan Air for US Airways Express. I think they got this backwards. During the takeoff roll, the pitch trim system began to move in the downward direction. 9446’s flight crew didn’t fly out of the situation; instead they fought the aircraft all the way to the scene of the accident. Non-routine discrepancies on the Detail check were open that indicated that work was not complete. The MM requires lead lines and that these be properly identified. (adsbygoogle = window.adsbygoogle || []).push({}); Flight 9446 was an unscheduled deadhead flight of a Beechcraft 1900D N240CJ. ", At 1540:02, the first officer stated, "left of the silver thing?" The problem was the short cut the MTS took in leaving the elevator installed and failing to use the lead wires to route the cables. The maintenance personnel had skipped a step in the maintenance process. He tries to give you the facts from the source materials but maybe he got it wrong, maybe he is out of date. The control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane. The maintenance technician documented that the “Elevator trim tab cable fell off drum under pedestal” on Maintenance Work Order # 08477. The pitch trim control then moved to an approximate 7 degree negative position, where it remained for the duration of the flight. At 1539:21, the captain radioed the HYA tower controller, requesting an emergency return to the airport, which the tower controller approved. before listening to Eddie. Cockpit Voice Recorder Database, visit us at www.tailstrike.com. The MTS accomplished the 19 steps for this check and found both left and right elevator trim tab (ETT) actuators to have failed the check. According to a representative of Colgan Air Inc., after scheduled maintenance, the flightcrew was dispatched to fly the accident airplane on a positioning flight. Step (i) says "Remove the mounting bolts and remove the actuator through the access opening." The maintenance technician discovered that the ETT forward cable became kinked and ordered out a replacement cable. According to data from the flight data recorder (FDR), the airplane began the flight at a pitch trim control position of approximately 2 degrees negative (nose down). Figure: Colgan Air 9446 elevator trim cable, from NTSB NYC03MA183 Group Chairman's Factual Report, Figure 1. The airline may have a designated functional check flight crew and line crews can simply assume everything is okay. Both pilots died in the crash. flight time/duty time regulations. His reaction would be to command nose up. The maintenance procedure required removal of the elevator, perhaps to gain free access to the cable pulley, but the mechanics skipped this step. The MTS stated that testing of the system was based on what they determined to be proper tests for properly testing the system components. NTSB Probable Cause. As per the BE1900D maintenance manual, replacement of the ETT Actuators requires accomplishment of all the manual procedures per the BE1900D maintenance manual (MM), 27-30-06.