Aviation Accident Summaries

Aviation Accident Summary NYC04IA010

Albany, NY, USA

Aircraft #1

N850CA

Beech 1900D

Analysis

During the takeoff roll, the flightcrew was unable to rotate the airplane, and the takeoff was aborted uneventfully. Examination of the airplane revealed that when the elevator trim wheel in the cockpit was positioned to neutral, the elevator trim was actually in the full nose-down position. The elevator trim wheel could not be physically moved lower than 3 units of nose up trim. The incident flight was the first flight after maintenance, in which the elevator trim wheel was removed and reinstalled. The maintenance technician did not index the trim wheel when he removed it, and reinstalled the trim wheel incorrectly. In addition, the maintenance did not contain a procedure to remove and reinstall the elevator trim wheel. Following the maintenance, no functional check of the elevator trim system was performed. When the captain performed a preflight inspection of the airplane, he did not set the elevator trim wheel to the setting prescribed on the preflight checklist, and he failed to detect the error.

Factual Information

On October 16, 2003, at 0805 eastern daylight time, a Beech 1900D, N850CA, operated by CommutAir as Continental Connection flight 8718, was not damaged during an aborted takeoff at Albany International Airport (ALB), Albany, New York. The certificated airline transport pilot and certificated commercial pilot were not injured. Visual meteorological conditions prevailed for the planned flight to Westchester County Airport (HPN), White Plains, New York. An instrument flight rules flight plan was filed for the positioning flight conducted under 14 CFR Part 91. According to the Director of Safety at CommutAir, the captain initiated a takeoff roll on runway 1 at ALB. As the airplane accelerated to approximately 115 knots, about V1, the captain noted that the elevator control was jammed. He subsequently aborted the takeoff and taxied back to the ramp uneventfully. The airplane was examined at CommutAir's maintenance facility after the incident. The examination revealed that when the elevator trim wheel in the cockpit was positioned to neutral, the elevator trim was actually in the full nose-down position. A maintenance technician performed maintenance on the airplane one day prior to the incident, and the incident flight was the first flight after the maintenance was completed. The maintenance technician stated that part of the work performed on the airplane included removal and replacement of a throttle pin. To accomplish that procedure, the maintenance technician had removed the elevator trim wheel. However, he did not index the elevator trim wheel before removing it, and reinstalled it incorrectly. The maintenance technician further stated that there was no published procedure in the Raytheon Airliner Maintenance Manual (AMM) regarding the removal and reinstallation of the elevator trim wheel. Following the maintenance, neither the maintenance technician nor the quality inspector performed a functional check of the elevator trim system. CommutAir's Exterior Preflight Inspection checklist instructed pilots to set the elevator trim 1.5 units nose up, prior to performing the exterior check. The captain stated that during his preflight inspection of the airplane, he set the elevator trim wheel to what he believed to be 1.5 units nose up. However, examination of the miss-indexed trim wheel revealed that it could not be physically moved lower than 3 units nose up. Following the incident, CommutAir expanded the trim check procedure contained in the Exterior Preflight Inspection checklist. In addition, Raytheon Aircraft added a procedure to the AMM for removing and reinstalling the manual elevator trim wheel.

Probable Cause and Findings

The maintenance technician's improper maintenance performed on the airplane, and his failure to perform a functional check, which resulted in a restricted movement of the elevator trim wheel. Factors were the captain's inadequate preflight inspection, and insufficient information in the manufacturer's maintenance manual.

 

Source: NTSB Aviation Accident Database

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