- Date
- January 10, 1997, 09:23 local (14:23 UTC)
- Place
- Bangor, ME
- Injuries
- 2 minor, 9 uninjured
- Damage
- Substantial damage
- Phase of flight
- Initial climb
- Aircraft
- N139ZVBeech 1900D
- Weather
- Instrument (IMC) · Day
- Status
- Completed · report April 30, 1998
- Report
- Approved by Office Director
- FAA report
- 19970110000309A
- Case key
- 39267
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The inadequate flight and winter operations training provided by the operator, and the pilot's improper decision to abort the takeoff while airborne above V1, due to a false stall warning horn. Also casual was the airport operations improper decision to discontinue plowing, and their failure to remove a snow pile on the runway. Factors relating to the accident were an easterly crosswind, the narrow icy runway conditions, inadequate FAA oversight in allowing the operator to continue operations with an inadequate training program that continued over several years, and the manufacturer's checklist which delayed the activation of the stall vane heat until just prior to takeoff.
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.
Analysis
During takeoff roll, as the FO rotated the airplane, the stall warning horn activated. The airplane lifted from the runway with the stall horn on, and above V1 speed the PIC called out to abort. The FO aborted the takeoff and landed the airplane on the runway. The airplane then entered a snow bank on the left side of the runway. Service Difficulty Reports revealed other stall horn activation's had occurred on takeoff; several occurred after deicing and were attributed to frozen stall vanes on the wing. The accident airplane had been deiced prior to the takeoff. The BE1900 check list called for the stall vane heat to be turned on just before takeoff. Stall training provided by the operator did not include BE1900 simulators, and all recoveries were initiated at the stall horn. The FAA practical test standard for type ratings required the recognition of the stall buffet, stick shaker, or decay of control effectiveness. The flight crew had not received winter operations training, and this was the Boston based PIC's third takeoff in snow. Multiple FAA inspections over several years revealed the Operator was not in compliance with regulations, which included their training program; however, they continued to operate unrestricted. Airport operations had ceased snow plowing the 300 foot wide runway to accommodate airline operations, and reported the runway had been plowed 75 feet west and 150 feet east of runway center. The runway was measured to be plowed 55 feet left of center, with a 1 foot high, and 10 foot wide pile of snow on the west side of the runway. The plowed portion had an icy covering.
Factual narrative
History of flight
On January 10, 1997, at 0923 eastern standard time, a Beech 1900D, N139ZV, operated by Mesa Airlines, Inc., doing business as USAir Express Flight 5326, was substantially damaged during an aborted climb after takeoff at the Bangor International Airport, Bangor, Maine. The certificated airline transport captain, first officer, and seven passengers were not injured. Two passengers received minor injuries. Instrument meteorological conditions prevailed for the scheduled passenger flight, destined for Boston, Massachusetts. An instrument flight rules flight plan had been filed for the flight conducted under 14 CFR Part 135.
The airplane had been flown by the flight crew from Boston, to Bangor International (BGR), and arrived, at 0856. The airplane was fueled, passengers were boarded, and the flightcrew started the engines and taxied to the de-icing area. While in the de-icing area, the engines were shut down and airplane de-icing was initiated at 0912, and completed at 0917. The engines were restarted, and the airplane was taxied to runway 33 for takeoff. At 0921, Flight 5326 was cleared for takeoff by the BGR tower controller.
The first officer (FO) stated that she was the flying pilot. The FO briefed the captain that this was to be a zero degree flap takeoff, and repeated the takeoff speeds to be used. After taxing onto the runway, the FO applied power, began the takeoff roll, and requested that the captain set the final takeoff power.
The cockpit voice recorder (CVR) transcript revealed the following: the flight crew called out the "takeoff final items," at 0921:10; which included ice protection items, at 0921:21; the propeller RPM was heard to increase, at 0921:59; and the FO called out "set takeoff power," at 0922:09. The captain then made the following callouts: "eighty knots cross checked," at 0922:12; "the wind is from the right," at 0922:17; and "V one rotate," at 0922:19.
The CVR revealed the sound of a horn, at 0922:21, which was similar to the stall warning horn. At 0922:26, the captain called out, "abort abort." The sound of the horn ceased, at 0922:28, and the captain called out, "abort Doris Doris," at 0922:29. The CVR recorded the sounds of impact and the recording ended, at 0922:31.
The FO stated that at Vr, she pulled the yoke back with both hands, raised the pitch of the airplane into the command bars, and heard the stall warning horn sound as the airplane rotated. She stated that she released "a little back pressure," observed the airspeed indicator at 120 knots, and applied more back pressure. The airplane then left the ground, but it felt sluggish. She estimated that the airplane was about 20 feet above the runway when the captain commanded, "Abort! Abort!" The FO closed the throttles and the airplane contacted the ground approximately on the centerline of the runway. She stated that, "visibility went to zero because of the flying snow." She then brought the "throttles to Ground Fine," and felt the captain's hand on top of hers as she moved the throttles into reverse.
According to one passenger, the airplane lifted from the runway and the engines were "whining as we started to climb."
The passenger also stated:
"...Very shortly we seemed to level off and then it appeared to me that the pilot was aborting the takeoff...I heard a loud snap and suddenly the fuselage was ripped open..."
Another passenger stated:
"...Rolled onto runway, turned right and proceeded with takeoff. (noted: that there was not spool up to full power with brakes applied before takeoff.) Plane took off and gained 10 - 20 feet altitude. Heard the stall alarm and pilot aborted take-off putting back down on runway, landing about 15 [degree] angle to the right of center line. Nose gear gave way. Right engine propellers broke-off and came through cabin..."
After touch down, the airplane veered left into the snow bank on the runway. The airplane pivoted 90 degrees nose right as it traveled through the snow bank while still on the runway, and exited the snow about 819 feet from the point of entry. The crew and passengers exited through the overwing exits and the main cabin door.
During an interview, the Captain stated that he checked the stall warning vane prior to his leaving the accident site, and found ice had frozen the stall warning vane in position. He said he wiggled the vane and broke it free of ice holding it in place.
The accident occurred during the hours of daylight approximately 44 degrees, 48 minutes north latitude, and 68 degrees, 49 minutes west longitude.
Flight crew information
Captain
The Captain held an Airline Transport Pilot Certificate with a rating for airplane multiengine land, and was type rated in the Beech 1900, with the limitation that a second in command was required. He also held a Commercial Pilot Certificate for airplane single engine land. His most recent Federal Aviation Administration (FAA) First Class Medical Certificate was issued on December 6, 1996.
The Captain was hired by Mesa Airlines on October 10, 1994, and flew as a First Officer (FO) on the Embraer 120. He was upgraded to Captain in the Beech 1900, and took his type rating check ride in July, 1996. Since the check ride, the Captain estimated that he had flown about 350 to 400 hours in the Beech 1900, all of which was pilot-in-command (PIC). He reported that his total flying experience was about 5,800 hours.
During an interview with the Captain, he stated that he had received no crew resource management (CRM) training. He recalled that he did receive "some" winter operations training during his initial hire training in October, 1994. He also stated that he was unfamiliar with operations in snow conditions, and that this was only his third takeoff and landing in snow. The Captain's base of operation with Mesa was Boston.
First Officer
The First Officer (FO) held an Airline Transport Pilot Certificate with a rating for airplane multiengine land, and was type rated in the Cessna 650. She also held a Commercial Pilot Certificate with ratings for airplane single engine land and glider. The FO held a Flight Instructor Certificate with ratings for airplane single engine land, glider, and instrument airplane. Her most recent FAA First Class Medical Certificate was issued on August 8, 1996.
The FO was hired by Mesa Airlines in September, 1995. She received her initial training in the Beech 1900, and had accumulated about 1,100 hours of second-in-command experience in make and model. The FO reported that her total flying experience was approximately 4,100 hours.
During an interview with the FO, she stated the she had received "a good 1 1/2 hours of CRM," during her recurrent training in August, 1996. The FO did not recall any winter operation or de-icing training, but did state that winter operations were "mentioned" in the Company Flight Manual and General Operations Manual.
She also stated that she had experienced the stall warning horn activation twice before during takeoff. Each of these resulted in continued flight.
The FO's base of operation with Mesa was Boston.
Aircraft information
The airplane was equipped with two Pratt & Whitney Canada Inc., PT6A-67D, engines. Each engine was equipped with propellers manufactured by the Hartzell Propeller Inc., Piqua, Ohio. Each propeller assembly consisted of 4 composite material propeller blades, and both the left and right hub and blade assemblies had accumulated about 3,564 hours.
A review of the airplane's maintenance records did not reveal any repetitive discrepancies related to the engines, propellers, anti-icing, flight controls or stall warning systems.
Aerodrome conditions
The Bangor International Airport (BGR) had a concrete runway, 15-33, which was 11,439 fe
Aircraft
- Registration
- N139ZV
- Reported as
- Beech 1900D
- Category
- Airplane
- Serial number
- UE-139
- Airframe hours
- 3,565
- Engine
- P&W PT6A-67D, 1,279 horsepower, turbo prop
- Damage
- Substantial damage
- Flight
- Part 135
- Operator
- Mesa Airlines Inc., doing business as Usair Express
- Registered owner
- Mesa Air Group, Inc.
- Airworthiness certificate
- Standard, Normal
- Departed
- BGR
- Destination
- BOS · Boston, MA
- Flight plan
- IFR
- Airport
- BGR · Bangor Intl, runway 33, 11,439 × 300 ft, concrete
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 32
- Certificates
- Airline transport, Commercial
- Airplane ratings
- Single-engine land, Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, Valid Medical--no waivers/lim.
- Seat
- Left
- Toxicology
- Performed
- Flight hours
- 5,800 total · 350 in this make and model · 3,800 as pilot in command · 207 in the last 90 days
Weather
- Conditions
- Instrument (IMC) · Day
- Wind
- 50° at 10 knots
- Visibility
- 1 statute miles
- Lowest ceiling
- 300 ft
- Temperature
- 68 °F, dew point 68 °F
- Altimeter
- 29.00 inHg
- Observed at
- BGR
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.