16 Feb 2012: Embraer EMB120 FC — Arctic One Llc

16 Feb 2012: Embraer EMB120 FC (N1110J) — Arctic One Llc

No fatalities • Iliamna, AK, United States

Probable cause

the maintenance personnel's failure to install the cotter pins that secured castellated nuts on the left elevator vertical hinge bolts, which resulted in the left elevator partially detaching in flight. Contributing to the accident was the failure of maintenance personnel to document the non-routine maintenance procedure that was used to remove and reinstall the elevator during maintenance.

— NTSB Determination

Accident narrative

On February 16, 2012, at about 1308 local time, Everts Air Cargo flight 1291, an Embraer EMB-120, N1110J, experienced an uncommanded pitch down while descending into Iliamna Airport (KILI), Iliamna, Alaska. There were no injuries to the 2 crewmembers onboard but the airplane sustained substantial damage. The flight was operating under 14 CFR Part 121 Supplemental as a cargo only flight from Anchorage, Alaska (KANC) to KILI.

The Captain reported that the flight from KANC had been uneventful. The Captain reported that during the descent, while at about 250 knots airspeed with his hands on the controls and the autopilot engaged, the airplane pitched to about 20 degrees nose down. The captain reported he then disconnected the autopilot and adjusted the pitch trim while pulling back on the column to recover from the pitch excursion. The flight crew declared an emergency and slowed the airplane to about 200 knots. Approximately 5-10 miles from the airport, while in a slow left turn at 3000 feet msl altitude, the airplane pitched down a second time while the captain was hand flying. As he recovered from the pitch down, he was lined up for a 5 mile final approach for runway 35. The captain elected to make a high speed, flaps up landing and landed uneventfully on runway 35. Post-flight inspection revealed that the left elevator was bent at the mid span trim tab, had partially detached from the aircraft, and was missing two attachment bolts.

A review of the airplane maintenance history showed that while in "A" check maintenance, a dent was noted in the left elevator and the elevator was removed. The maintenance team did not follow the EMB 120 maintenance manual procedure for removal of the left elevator. During the non-routine maintenance procedures used by the maintenance team, cotter pin safeties that were removed from castellated nuts on the 2 outboard vertical hinge bolts on the left elevator were not reinstalled. The removal of these two bolts is not part of the EMB 120 maintenance manual procedure for removal of the left elevator. The maintenance team did not document the non-routine procedure they used to remove and reinstall the left elevator.

The Require Inspection Items (RII) inspector had inspected the elevator installation for the procedures in the manual and was not aware of the undocumented non-routine maintenance procedures used, and hence did not examine the nuts that did not have the required cotter pins, which were not to be removed as part of the approved procedure. The FAA found that the maintenance teams that removed and reinstalled the elevator were inexperienced in EMB 120 elevator removal and reinstallation procedures.

Contributing factors

  • factor Maintenance personnel
  • factor Maintenance personnel
  • cause Maintenance personnel

Conditions

Weather
VMC

Loading the flight search…

What you can do on Flight Finder

  • Search flights between any two airports with live fares.
  • By aircraft — pick a plane model (e.g. Boeing 787, Airbus A350) and see every route it flies from your origin.
  • Route map — click any airport worldwide to explore its destinations, or draw a radius to find nearby airports.
  • Global aviation safety — aviation accident database, 5,200+ records since 1980, with map and rankings by aircraft and operator.
  • NTSB safety feed — recent U.S. aviation accidents and incidents from the official NTSB CAROL database, updated daily.

Frequently asked questions

How do I search flights by aircraft type on FlightFinder?

Pick an aircraft model — Boeing 737, Airbus A320, A380, Boeing 787 Dreamliner and more — enter your origin airport, and FlightFinder shows every route that plane flies from there with live fares.

Which aircraft types can I filter by?

We support Boeing 737/747/757/767/777/787, the full Airbus A220/A319/A320/A321/A330/A340/A350/A380 family, Embraer E170/E175/E190/E195, Bombardier CRJ and Dash 8, and the ATR 42/72 turboprops.

Is FlightFinder free to use?

Search and schedules are free. Pro ($4.99/month, $39/year, or $99 one-time lifetime) unlocks the enriched flight card — on-time stats, CO₂ per passenger, amenities, live gate & weather — plus My Trips with push alerts.

Where does the route data come from?

Live schedules come from Amadeus, AeroDataBox and Travelpayouts. Observed routes (which aircraft actually flew a given city pair) are crowdsourced from adsb.lol ADS-B data under the Open Database License.