# NTSB NYC04IA010: Beech 1900D, N850CA, Albany, NY, October 16, 2003 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: October 16, 2003, 08:05 local (12:05 UTC) - Place: Albany, NY - Coordinates: 42.748054, -73.80278 - Nearby events: https://openairdocs.org/map.md?lat=42.7481&lon=-73.8028&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report September 1, 2004 - Report: Approved by Office Director - Parties: FAA AAI-100 - NTSB case key (mKey): 58167 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC04IA010 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58167/pdf - Page: https://openairdocs.org/ntsb/NYC04IA010 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, takeoff - roll/run - maintenance - improper, company maintenance personnel (cause) - information insufficient, manufacturer (contributing factor) - flt control syst,elevator trim/tab control - movement restricted - maintenance,inspection - not performed, company maintenance personnel (cause) - aircraft preflight - inadequate, pilot in command (contributing factor) ## 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 (not matched to a registry record) - Reported make and model: Beech 1900D - Category: Airplane - Serial number: UE 403 - Airframe hours: 10883 - Engines: Pratt & Whitney Canada pt6A-67D 1279 horsepower turbo prop; Pratt & Whitney Canada PT6A-67D 1279 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 As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: none; 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 - Co-pilot; age 27; injuries: none; 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 (OpenAirDocs). - [Incident 20031016032229I](https://openairdocs.org/incident/20031016032229I), Oct 16, 2003: Beech 1900D, Albany, NY. (-23) Pilot aborted take off, aircraft would not rotate. Pilot stated flight controls "elevator" would not move above neutral position at take off speed, but… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.