NYC04IA010

NTSB incident investigation · Beech 1900D · Albany, NY · October 16, 2003

Incident · No injuriesIncident investigationFinal report
Date
October 16, 2003, 08:05 local (12:05 UTC)
Place
Albany, NY
Injuries
2 uninjured
Damage
No damage
Phase of flight
Takeoff
Aircraft
N850CABeech 1900D
Weather
Visual (VMC) · Day
Status
Completed · report September 1, 2004
Report
Approved by Office Director
Parties
FAA AAI-100
FAA report
20031016032229I
Case key
58167

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

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Probable cause

The maintenance technician's improper maintenance performed on the airplane, and his failure to perform a functional check, which resulted in a restricted movement of the elevator trim wheel. Factors were the captain's inadequate preflight inspection, and insufficient information in the manufacturer's maintenance manual.

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.

Miscellaneous/otherTakeoff - roll/run
Maintenance - improperCompany maintenance personnelCause
Information insufficientManufacturerFactor
Flt control syst,elevator trim/tab control - movement restricted
Maintenance,inspection - not performedCompany maintenance personnelCause
Aircraft preflight - inadequatePilot in commandFactor

Analysis

During the takeoff roll, the flightcrew was unable to rotate the airplane, and the takeoff was aborted uneventfully. Examination of the airplane revealed that when the elevator trim wheel in the cockpit was positioned to neutral, the elevator trim was actually in the full nose-down position. The elevator trim wheel could not be physically moved lower than 3 units of nose up trim. The incident flight was the first flight after maintenance, in which the elevator trim wheel was removed and reinstalled. The maintenance technician did not index the trim wheel when he removed it, and reinstalled the trim wheel incorrectly. In addition, the maintenance did not contain a procedure to remove and reinstall the elevator trim wheel. Following the maintenance, no functional check of the elevator trim system was performed. When the captain performed a preflight inspection of the airplane, he did not set the elevator trim wheel to the setting prescribed on the preflight checklist, and he failed to detect the error.

Factual narrative

On October 16, 2003, at 0805 eastern daylight time, a Beech 1900D, N850CA, operated by CommutAir as Continental Connection flight 8718, was not damaged during an aborted takeoff at Albany International Airport (ALB), Albany, New York. The certificated airline transport pilot and certificated commercial pilot were not injured. Visual meteorological conditions prevailed for the planned flight to Westchester County Airport (HPN), White Plains, New York. An instrument flight rules flight plan was filed for the positioning flight conducted under 14 CFR Part 91.

According to the Director of Safety at CommutAir, the captain initiated a takeoff roll on runway 1 at ALB. As the airplane accelerated to approximately 115 knots, about V1, the captain noted that the elevator control was jammed. He subsequently aborted the takeoff and taxied back to the ramp uneventfully.

The airplane was examined at CommutAir's maintenance facility after the incident. The examination revealed that when the elevator trim wheel in the cockpit was positioned to neutral, the elevator trim was actually in the full nose-down position.

A maintenance technician performed maintenance on the airplane one day prior to the incident, and the incident flight was the first flight after the maintenance was completed. The maintenance technician stated that part of the work performed on the airplane included removal and replacement of a throttle pin. To accomplish that procedure, the maintenance technician had removed the elevator trim wheel. However, he did not index the elevator trim wheel before removing it, and reinstalled it incorrectly. The maintenance technician further stated that there was no published procedure in the Raytheon Airliner Maintenance Manual (AMM) regarding the removal and reinstallation of the elevator trim wheel. Following the maintenance, neither the maintenance technician nor the quality inspector performed a functional check of the elevator trim system.

CommutAir's Exterior Preflight Inspection checklist instructed pilots to set the elevator trim 1.5 units nose up, prior to performing the exterior check. The captain stated that during his preflight inspection of the airplane, he set the elevator trim wheel to what he believed to be 1.5 units nose up. However, examination of the miss-indexed trim wheel revealed that it could not be physically moved lower than 3 units nose up.

Following the incident, CommutAir expanded the trim check procedure contained in the Exterior Preflight Inspection checklist. In addition, Raytheon Aircraft added a procedure to the AMM for removing and reinstalling the manual elevator trim wheel.

Aircraft

Registration
N850CA
Reported as
Beech 1900D
Category
Airplane
Serial number
UE 403
Airframe hours
10,883
Engines
Pratt & Whitney Canada pt6A-67D, 1,279 horsepower, turbo propPratt & Whitney Canada PT6A-67D, 1,279 horsepower, turbo prop
Damage
No damage
Flight
Positioning · Part 91
Registered owner
Champlain Enterprises Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 29, 2003 · 92 hours before
Departed
ALB · Albany, NY
Destination
HPN · White Plains, NY
Flight plan
IFR
Airport
ALB · Albany International Airport, runway 1, 7,200 × 150 ft, asphalt

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
June 18, 2003
Seat
Left
Flight hours
3,100 total · 2,100 in this make and model · 1,800 as pilot in command
Role
Co-pilot
Age
27
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
March 15, 2003
Seat
Right
Flight hours
2,850 total · 600 in this make and model · 2,250 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 36 °F
Altimeter
29.87 inHg
Observed at
ALB

FAA reports on this event · 1

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