2 fatalities

2003-08-26: Beechcraft 1900D (N240CJ) — USAir Express - US Airways Express — Hyannis-Barnstable, United States of America

Hyannis-Barnstable, United States of AmericaTakeoff (climb)

On August 26, 2003, a Beechcraft 1900D (registration N240CJ) operated by USAir Express - US Airways Express was involved in an aviation accident near Hyannis-Barnstable, United States of America during takeoff. 2 people were killed. Investigators recorded the probable cause as: The improper replacement of the forward elevator trim cable, and subsequent inadequate functional check of the maintenance performed, which resulted in a reversal of the elevator trim system and a loss of control in-flight. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 8 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781200871Data APIEditorial standards

An accident occurred when maintenance improperly replaced the forward elevator trim cable, leading to a system reversal and loss of control. The flightcrew did not perform required checklists, and the maintenance manual had an erroneous depiction.

Accident Sequence

The accident flight was the first flight after maintenance personnel replaced the forward elevator trim cable. Shortly after takeoff, the flightcrew reported a runway trim and manually selected nose-up trim. However, the elevator trim then traveled to the full nose-down position. Control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane.

Maintenance Actions

During the replacement of the cable, maintenance personnel skipped a step in the manufacturer's airliner maintenance manual (AMM). They did not use a lead wire to assist with cable orientation. Additionally, the AMM incorrectly depicted the elevator trim drum, and the orientation of the cable around the drum was ambiguous. Despite these issues, the maintenance personnel stated that they had completed an operational check of the airplane after maintenance.

Investigation Findings

The Safety Board performed a mis-rigging demonstration on an exemplar airplane, which reversed the elevator trim system. An operational check on that airplane revealed that when the electric trim motor was activated in one direction, the elevator trim tabs moved in the correct direction, but the trim wheel moved opposite of the corresponding correct direction. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction. Additionally, the captain did not address the recent cable change noted on his maintenance release and did not perform a first flight of the day checklist, which included an elevator trim check.

Probable cause

The improper replacement of the forward elevator trim cable, and subsequent inadequate functional check of the maintenance performed, which resulted in a reversal of the elevator trim system and a loss of control in-flight. Factors were the flightcrew's failure to follow the checklist procedures, and the aircraft manufacturer's erroneous depiction of the elevator trim drum in the maintenance manual.