Accident at Homer, Alaska, 23 Nov 1987

Accident narrative

On November 23, 1987, about 1825 Alaska standard time, a Beech Aircraft Corporation 1900C operated by Ryan Air Service, Inc. as Flight 103 crashed short of runway 3 at the Homer Airport in Homer, Alaska. The airplane was operating as a scheduled passenger flight from Kodiak to Anchorage, with intermediate stops in Homer and Kenai. Both flightcrew members and 16 passengers were fatally injured; three passengers were seriously injured. The airplane was destroyed.

### The flight

Flight 103 arrived in Kodiak at 1709, where it was emptied of cargo. No fuel was added. Nineteen passengers boarded the airplane. The captain, 26, had 7,087 total flight hours, with 4,420 hours in the Beech 1900 and 714 hours as pilot-in-command in the type. The first officer, 40, had 10,532 total flight hours, with 300 hours in the Beech 1900, all as first officer.

At Kodiak, the first officer asked the station agent that the airplane be loaded "with 1,500 pounds of cargo." The agent thought this request was unusual, as previous pilots operating with a full passenger load had asked for 1,100 or 1,200 pounds of cargo. The agent stated the first officer told her, "Before we could get the 1,500 pounds on board, it would bulk out."

The baggage loader, assisted by the flightcrew, loaded suitcases, gun cases, frozen crabs, two dogs in kennels, and approximately 13 to 14 pieces of packaged venison weighing 795 pounds. The loader stated that after loading, the airplane's tailstand was about one inch from the ground, the lowest he had ever seen it. Typically, the tailstand came to within three to four inches of the ground.

The flightcrew's incomplete weight and balance manifest indicated a takeoff weight of 15,700 pounds. The aircraft flight log indicated 1,450 pounds of cargo and a calculated center of gravity (CG) location of 299.5 inches aft of reference. The aft CG limit for the Beech 1900 is 299.9 inches.

### Sequence of events

At 1737, Flight 103 contacted Kodiak tower for its instrument flight rules clearance to Homer. The flight was cleared via V-438. At 1742, the tower cleared the flight for takeoff from runway 7. The local weather was clear with 15 miles visibility.

A passenger stated that he thought the airplane would "never become airborne." He described the main gear lifting off the runway, the airplane falling back, and accelerating for about another 15 knots before becoming airborne and climbing steeply.

The flightcrew retracted the landing gear and the 10 degrees of takeoff flaps. At 1744, climbing through 1,900 feet, the flight requested a visual flight rules climb and was cleared to 12,000 feet. At 1810, Anchorage Air Route Traffic Control Center cleared Flight 103 to descend and to expect a delay at Homer due to a preceding airplane.

At 1818, the flightcrew requested the Homer weather, which was reported as 1,500 scattered, 3,500 broken, 4,500 overcast, visibility 12 miles, temperature 31 degrees Fahrenheit, and wind 340 degrees at 9 knots. At 1819, the flight was cleared for the localizer/DME approach to runway 3. Flight 103 reported a two-mile final at 1824.

Ground witnesses described the airplane on short final approach. Its wings began to rock back and forth, and it dropped steeply to the ground in a flat attitude. The airplane struck the airport perimeter fence and slid to a stop on its belly. At 1828, the Homer Flight Service Station reported receiving an emergency locator transmitter signal. There was no fire.

### What the investigation found

The wreckage was distributed along 150 feet. The landing gear actuators indicated the gear was down and locked at impact. The flap handle was found in the up position. The left flap actuator brackets were broken, and the right flap actuator was in an intermediate position between 7 and 12 degrees. Company procedure was to select full 35-degree flaps when landing was assured. The cockpit manual stabilizer trim wheel was in the full nose-down position. Both engines and propellers showed no evidence of preexisting malfunction, and evidence indicated each powerplant was at a relatively high power setting at impact.

Investigators observed up to 3/8 inch of rime ice on the leading edges of the wings and tail surfaces. The Board concluded that this ice accumulation did not cause the accident, noting that certification tests showed no significant decrease in controllability with up to 1.5 inches of ice.

The Safety Board weighed all cargo and baggage, which totaled 2,283 pounds. Based on actual passenger and cargo weights, the Board calculated that the airplane departed Kodiak between 397 and 513 pounds over its maximum gross takeoff weight, with a CG between 8.43 and 10.66 inches aft of the aft limit. As fuel was consumed en route, the CG moved further aft. At Homer, the landing weight was between 69 and 184 pounds over the maximum allowable landing weight, with a CG between 8.64 and 11.20 inches aft of the limit.

The Board observed flight tests on a Beech 1900 to examine characteristics with an aft CG. The tests showed that static stability deteriorated rapidly as the CG moved aft, and extending flaps caused it to deteriorate further. With the CG 7 inches aft of the limit and flaps up, static stability was essentially neutral. With flaps down, the static stability became negative, resulting in an unstable airplane. Test pilots and engineers believed that if flaps were extended 35 degrees with the CG 11 inches aft of the limit, it would not have been possible to control the airplane during landing.

The Board believed that because of the extreme aft CG, the airplane pitched up when the pilot initially selected full flaps. The full nose-down trim, intermediate flap position, and high engine power indicated the pilot may have attempted to regain control by adding power and raising the flaps. The Board believed the airplane stalled as the pilot raised the flaps.

The investigation reviewed Ryan Air's operations and FAA surveillance. Company policy at Kodiak restricted cargo to 1,100 pounds with a full passenger load. The Board noted that the flightcrew disregarded company procedures by failing to accurately determine the cargo load and failing to properly complete the weight and balance card. The Board concluded that despite certain weaknesses in company management, these weaknesses did not contribute to the cause of the accident. The Board also found that communication between FAA flight standards inspectors and the regional counsel was inadequate, which contributed to a breakdown in the effectiveness of the FAA's oversight of Ryan.

Regarding survival aspects, rescue personnel found the left front cabin door open but the rear cargo door jammed. Attempts to cut into the fuselage were hampered because the skin kept springing back. Rescuers were also unable to locate the master switch to shut off electrical power for 45 minutes. Movement in the cockpit caused electrical arcing, which delayed the extrication of the first officer. The Board calculated that vertical decelerations during the crash were between 19.8 and 35.76 Gs. All passenger seats separated from their floor and wall tracks. The Board noted these forces exceeded the design standards of the airplane's seats.

### Probable cause

The National Transportation Safety Board determined that the probable cause of this accident was "the failure of the flightcrew to properly supervise the loading of the airplane which resulted in the center of gravity being displaced to such an aft location that airplane control was lost when the flaps were lowered for landing."