– Knight Ridder Newspapers

WASHINGTON – Sloppy maintenance, poor federal oversight and excessive weight in the back of US Airways Express Flight 5481 doomed the 21 people aboard, the National Transportation Safety Board concluded Thursday.

The board blamed the Jan. 8, 2003, crash in Charlotte, N.C., chiefly on two parties: Air Midwest, the airline that operated the commuter plane and was responsible for its maintenance and loading; and the Federal Aviation Administration, which oversees maintenance and sets weight and balance guidelines.

The board also faulted an inspector who worked for maintenance contractor Raytheon Aerospace.

“I think the entire system here was broken down,” said NTSB Chairman Ellen Engleman Conners. “There were errors at every level.”

Board member John Goglia compared the accident to the 1996 ValuJet crash, which resulted largely from mistakes by a maintenance contractor.

“I thought ValuJet would be the low-water mark of my career as far as maintenance deficiencies go,” he said of the crash that killed 110 people in the Florida Everglades. “Yet I find myself, with this accident, looking at a new low.”

The board gave the FAA 21 safety recommendations, many aimed at improving procedures for maintaining commercial planes and calculating the weight of passengers and their bags.

Carol Todd, who lost her 72-year-old mother, Ima Rae Pearson, in the crash, said she wants to see those recommendations followed.

“I’d like to know how these things are going to be truly enforced so this doesn’t happen again,” said Todd, who traveled from her home in California to attend the hearing.

The problems began Jan. 6, 2003, when a contract mechanic at a Huntington, W.Va., maintenance hangar was asked to adjust cables that helped control the pitch of a Beech 1900D. The mechanic had never done the job on that type of plane before. And with his trainer’s approval, he skipped key steps in the maintenance manual – steps that NTSB investigators now say would likely have helped mechanics catch mistakes he’d made.

The mechanic’s trainer also inspected the work. That arrangement troubled NTSB investigators, who said trainers can become too involved in maintenance work to objectively evaluate its quality.

Two days later, the plane – heavily loaded with passengers and bags -took off from Charlotte/Douglas International Airport at an unusually sharp angle. Pilots were unable to push the plane’s nose down. The elevator, a tail flap which helps control the plane’s pitch, could move downward only half the usual amount because of the mistakes made in Huntington, NTSB investigators found.

The plane stalled at 1,100 feet, then plunged downward toward a US Airways maintenance hangar. In the cabin, a child cried out “Daddy.”

All aboard died instantly in the fiery crash.

The misrigged elevator, combined with excessive weight in the back of the 19-passenger aircraft, “resulted in a virtually uncontrollable airplane,” said Lorenda Ward, the investigator in charge of the NTSB probe.

Air Midwest operated the plane for US Airways, but hired a contractor, Raytheon Aerospace, to do the maintenance. Raytheon, now called Vertex Aerospace, relied on a Florida labor contractor for mechanics. The only Air Midwest manager in Huntington usually worked days, while most of the maintenance work went on overnight.

The NTSB found Air Midwest didn’t properly oversee the work performed by Raytheon and the contract mechanics it had hired. The board also found that the airline failed to adequately identify problems in its maintenance program.

Air Midwest attorney Brian Gillman said the airline is reviewing the board’s findings and “can’t comment substantively at this time.”

Gillman said, “We hope that with all the work done by all the parties that something positive can come out of this most unfortunate accident.”

Investigators also found that because mechanics didn’t diligently follow the maintenance manual, they missed a crucial step that likely would have allowed them to catch their mistake and prevent the crash.

“You shouldn’t have to tell people to do their jobs,” said Todd, who lost her mother in the crash. “There’s a reason these maintenance manuals are written. You don’t pick and choose your steps.”


It was at least the third U.S. airline crash since 2000 caused largely by maintenance problems, the NTSB has concluded.

All 88 people aboard Alaska Airlines Flight 261 died when the plane plunged into the Pacific Ocean on Jan. 31, 2000. Crash investigators found that insufficient lubrication led to the failure of the jackscrew, a component that helps set the angle of flight.

The following month, three people aboard Emery Worldwide Airlines Flight 17 were killed when an improperly installed bolt fell out, causing the plane to crash in Rancho Cordova, Calif.

A fourth crash, involving another Beech 1900D that crashed off Cape Cod, Mass., in August, 2003, also appears to be related to maintenance. NTSB investigators say mechanics on that plane also failed to follow all steps in the maintenance manual. That crash, which killed two pilots, is still under investigation.


Investigators examining the Charlotte crash found that the inspector in Huntington didn’t properly train the mechanic who was adjusting the plane’s elevator cables for the first time. The inspector was busy training another mechanic, and doing other jobs, and didn’t see the mechanic perform much of the work, investigators said.

And the board faulted the FAA for failing to aggressively pursue serious, previously identified problems with Air Midwest’s maintenance training program.


A few years ago, NTSB investigators said, the FAA had considered delaying its approval for Air Midwest to fly new routes until training problems were addressed. But the FAA decided not to delay its approval. FAA spokeswoman Laura Brown said the agency identified practices that could be improved, beyond what regulations required, and the airline agreed to make those improvements.


The FAA is studying the NTSB’s maintenance recommendations and plans detailed responses to each. Some may involve new rules, while others may involve updating guidance material, Brown said.


An FAA rule-making committee has also been examining passenger and baggage weight issues since June and expects to make recommendations next month.

The FAA “is confident we can address the safety intent of the board’s recommendations,” Brown said.

The NTSB found that the plane’s center of gravity was about 3 inches farther back than it should have been. While that was dangerous, the NTSB said Flight 5481 could have flown without crashing if its elevator had been properly rigged.

The plane was far less tail heavy than the Beech 1900 that crashed on approach in Homer, Alaska, in 1987, killing 18 people. In that case, the NTSB concluded the chief cause was the flight crew’s failure to properly load the plane, which pulled the center of gravity 8 to 11 inches past acceptable limits.


In its investigation of Air Midwest, the safety board found that the airline’s weight and balance program was flawed, resulting in incorrect weight and balance calculations for Flight 5481.

Although Air Midwest revised its weight and balance program after the accident, the NTSB found its program remains unacceptable because it could still result in incorrect calculations of a plane’s center of gravity.

Several NTSB members said they saw a pattern of sloppiness.

Said board member Mark Rosenker: “There were a lot of mistakes here – a host of mistakes.”

—

(c) 2004, The Charlotte Observer (Charlotte, N.C.).

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Distributed by Knight Ridder/Tribune Information Services.

AP-NY-02-26-04 2227EST