Air Midwest Flight 5481
Flight details
Location: Charlotte, North Carolina
Date: January 8, 2003
Aircraft Type: Beechcraft 1900D
POB: 19
Crew: 2
Fatalities: 21
Survivors: 0
Location: Charlotte, North Carolina
Synopsis
Air crash in North Carolina at Charlotte - Douglas International Airport, A Beechcraft 1900D loses pitch control and is over weight, causing it to stall and crash into the corner of a us airways hangar. The Aircraft is destroyed by the impact and fire, No survivors.
This crash is the milestone for updated weights for passengers and baggage, and the drive for proper maintanence.
Aviation crash videos
Part 1 of 5
Video embedded from YouTube on 29 April 2009 (see Cineflix, undated-a1)
Part 2 of 5
Video embedded from YouTube on 29 April 2009 (see Cineflix, undated-b2)
Part 3 of 5
Video embedded from YouTube on 29 April 2009 (see Cineflix, undated-c3)
Part 4 of 5
Video embedded from YouTube on 29 April 2009 (see Cineflix, undated-d4)
Part 5 of 5
Video embedded from YouTube on 29 April 2009 (see Cineflix, undated-e5)
Investigation Findings [6]
NTSB’s investigations revealed that the probable cause of the accident was due to loss of pitch control by the aircraft during take off.
This was because there was incorrect rigging of the elevator control system and coupled with the improper aircraft weight and balance causing the center of gravity of the plane to be shifted back due to overloading made the pilots unable to recover the aircraft from the high nose up position upon take off (causing a stall) as the elevator control system could not pitch down to the desired effect and made the aircraft uncontrollable in the pitch axis.
Dirty Dozen Contributory Factors
- Complacency
Complacency occurs when technicians who inspect the same aircraft numerous times take these inspections for granted and begin to skip steps in the maintenance procedures due to familiarity.
In this accident, the technician with concurrence from the inspector skipped several steps in the maintenace procedure for the rigging of the elevator. The reason for skipping the steps was because the inspector had done this many times before and did not think the manufacturer intended for mechanics to follow the entire rigging procedure. Also he had performed the entire procedure in the past without following the proper procedures for past adjustments without any adverse consequences. [6]
Hence, the inspector had long been lulled into a sense of complacency and in this case without the proper rigging of the elevator control system contributed to a failure to control the aircraft in the pitch axis when trying to recover from the fatal stall.
- Fatigue
Fatigue causes slower reaction times, reduced vigilance and slower processing of information whilst performing one’s tasks.
In this case, The technician working on the elevator system had worked in a three day period, 17.5 , 8 and 14 hours days respectively which was more than the acceptable duration of 10 – 12 hours working day.[7]
Hence, fatigued, the technician was in no position to perform the tasks properly of for that matter question the wisdom of the inspector skipping pertinent steps as his body was telling him to get the job as quick as he could so that he could rest sooner.
Want to know more?
- AviationKnowledge - The Dirty Dozen (human factors issues) in aviation maintenance
- This article provides a comprehensive feature on the Dirty Dozen human factors in aviation maintenance.
