Pilot Debrief

Beech 1900D near Charlotte, North Carolina — 2003-01-08

Final reportDCA03MA022
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Date
2003-01-08
Location
Charlotte, North Carolina, USA
Aircraft
Beech 1900D
Registration
N233YV
Category
Airplane

Probable cause

the airplane's loss of pitch control during take-off. The loss of pitch control resulted from the incorrect rigging of the elevator system compounded by the airplane's aft center of gravity, which was substaintially aft of the certified aft limit. Contributing to the cause of the accident were (1) Air Midwest's lack of oversight of the work being performed at the Huntington, West Virginia, maintenance station; (2) Air Midwest's maintenance procedures and documentation; (3) Air Midwest's weight and balance program at the time of the accident; (4) the Raytheon Aerospace quality assurance inspector's failure to detect the incorrect rigging of the elevator control system; (5) the Federal Aviation Administration's (FAA) average weight assumptions in its weight and balance program guidance at the time of the accident; and (6) the FAA's lack of oversight of Air Midwest's maintenance program and its weight and balance program.

Contributing factors

Contributing to the cause of the accident were (1) Air Midwest's lack of oversight of the work being performed at the Huntington, West Virginia, maintenance station; (2) Air Midwest's maintenance procedures and documentation; (3) Air Midwest's weight and balance program at the time of the accident; (4) the Raytheon Aerospace quality assurance inspector's failure to detect the incorrect rigging of the elevator control system; (5) the Federal Aviation Administration's (FAA) average weight assumptions in its weight and balance program guidance at the time of the accident; and (6) the FAA's lack of oversight of Air Midwest's maintenance program and its weight and balance program.

NTSB narrative

On the morning of January 8, 2003, a Beechcraft 1900D operated by Air Midwest as Flight 5481 departed Charlotte, North Carolina, on a routine scheduled flight with 19 passengers and two crew members. During the takeoff and initial climb phase, the aircraft pitched up uncontrollably, stalled at 54 degrees nose high, and crashed just 35 seconds after liftoff. The aircraft was approximately 580 pounds over its maximum allowable takeoff weight with a center of gravity well aft of limits at 45.5% of the mean aerodynamic chord, exceeding the 40% aft limit. Compounding this, improperly rigged elevator control cables limited nose-down elevator authority to just 7 degrees instead of the manufacturer standard of 14 to 15 degrees. In daylight VFR conditions, all 21 people on board were killed and the aircraft was destroyed.

Evidence available

  • CVR
  • FDR / data
  • Photos
  • 186 docket documents
View NTSB final reportView NTSB docket

Docket documentsshowing 50 of 186