FTW96IA080

NTSB incident investigation · Beech 1900C · Denver, CO · December 25, 1995

Incident · No injuriesIncident investigationFinal report
Date
December 25, 1995, 14:19 local (21:19 UTC)
Place
Denver, CO
Injuries
21 uninjured
Damage
No damage
Phase of flight
Landing
Aircraft
N39019Beech 1900C
Weather
Visual (VMC) · Day
Status
Completed · report June 6, 1996
Report
Approved by Office Director
FAA report
19951225046489I
Case key
19669

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

failure by the outside contractor to perform adequate maintenance, and failure by the operator to perform an adequate inspection.

Analysis

During landing flare, the elevator jammed. The pilot continued the landing using elevator trim to adjust nose attitude. Investigation revealed that an elevator counterweight bolt had backed out and jammed the elevators. The aircraft was on its first trip after being painted by an outside contractor and undergoing a return-to-service inspection by the operator.

Factual narrative

On December 25, 1995, at 1419 mountain standard time, a Beech 1900C, N39019, owned by Beech Acceptance Corporation and operating as Continental Express Flight 2116 from Grand Island, Nebraska, to Denver, Colorado, with an en route stop at McCook, Nebraska, had the elevator jam during landing flare at Denver International Airport. There were no injuries to the 19 passengers or 2 crewmembers and no damage to the aircraft. The flight was operating under Title 14 CFR Part 135 when the incident occurred and a company VFR flight plan was filed. The flight departed McCook, Nebraska, at 1510.

The aircraft was on the second leg of its first flight after being painted and undergoing RII inspection. N39019 was picked up from Jet Center, in Hondo, Texas, at night, and flown to the company maintenance facility at Grand Island where the inspection was conducted prior to return to service.

According to the pilot, during the landing flare, the elevator jammed, limiting travel to about three inches. The pilot continued the landing using the elevator trim. Inspection revealed that an elevator counter balance weight cover plate bolt had backed out limiting the travel of the elevators.

According to the personnel at Jet Center in Hondo, Texas, they were assigned to scuff/sand the existing paint, apply a new top coat, and to balance according to the service manual. They were furnished with Beechcraft Maintenance Manual sections 55-20 and 55-00. According to Jet Center, no one remembers removing any counter weight, but they did add weight to the rudder. There was no record of work on the elevator counter balance weights. It was also stated that the aircraft was never reweighed.

Of the material reviewed by the NTSB, sections 27-30-00 and 55-0-00 of the Beechcraft Maintenance Manual, only section 27-30-00 states to rebalance the elevator after painting or other work.

Jet Center was furnished with the instructions on procedures to rebalance the elevators after painting. Though the section of the manual that requires rebalancing the elevator after painting (and other maintenance) was not furnished to Jet Center, the instructions to rebalance were included in the contract. However, the contract only stated to paint and rebalance. No description of what to rebalance was indicated.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionLanding - flare/touchdown
Flight control,elevator attachment - loose part/bolt/nut/clamp/etcCause
Maintenance - inadequateOther maintenance personnelCause
Maintenance,inspection - inadequateCompany maintenance personnelCause
Flight control,elevator - jammed

Aircraft

Registration
N39019
Reported as
Beech 1900C
Category
Airplane
Serial number
UC-39
Airframe hours
15,906
Engine
P&W PT6-A65B, 715 horsepower, turbo prop
Damage
No damage
Flight
Part 135
Operator
G. P. Express, doing business as Continental Express
Registered owner
Beech Acceptance Corportation
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · December 15, 1995 · 7 hours before
Departed
MCK · Mccook, NE
Destination
DIA
Flight plan
Company VFR
Airport
DEN · Denver International, runway 16, 12,000 × 150 ft, concrete

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
6,500 total · 2,500 in this make and model · 6,000 as pilot in command · 225 in the last 90 days · 7 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 14 °F
Altimeter
30.00 inHg
Observed at
DIA, 1 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.