Hyannis - Albany

The accident flight was the first flight after maintenance personnel replaced the forward elevator trim cable. When the flightcrew received the airplane, the captain did not address the recent cable change noted on his maintenance release. The captain also did not perform a first flight of the day checklist, which included an elevator trim check. Shortly after takeoff, the flightcrew reported a runway trim, and manually selected nose-up trim. However, the elevator trim then traveled to the full nose-down position. The control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane. During the replacement of the cable, the maintenance personnel skipped a step in the manufacturer's airliner maintenance manual (AMM). They did not use a lead wire to assist with cable orientation. In addition, the AMM incorrectly depicted the elevator trim drum, and the depiction of the orientation of the cable around the drum was ambiguous. The maintenance personnel stated that they had completed an operational check of the airplane after maintenance. The Safety Board performed a mis-rigging demonstration on an exemplar airplane, which reversed the elevator trim system. An operational check on that airplane revealed that when the electric trim motor was activated in one direction, the elevator trim tabs moved in the correct direction, but the trim wheel moved opposite of the corresponding correct direction. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction.

Flight / Schedule

Hyannis - Albany

Registration

N240CJ

MSN

UE-40

Year of Manufacture

1993

Date

August 26, 2003 at 03:40 PM

Type

CRASH

Flight Type

Positioning

Flight Phase

Takeoff (climb)

Crash Site

Lake, Sea, Ocean, River

Crash Location

Hyannis-Barnstable Massachusetts

Region

North America • United States of America

Coordinates

41.6535°, -70.2823°

Crash Cause

Human factor

Narrative Report

On August 26, 2003 at 03:40 PM, Hyannis - Albany experienced a crash involving Beechcraft 1900D, operated by USAir Express - US Airways Express, with the event recorded near Hyannis-Barnstable Massachusetts.

The flight was categorized as positioning and the reported phase was takeoff (climb) at a lake, sea, ocean, river crash site.

2 people were known to be on board, 2 fatalities were recorded, 0 survivors were identified or estimated. This corresponds to an estimated fatality rate of 100.0%.

Crew on board: 2, crew fatalities: 2, passengers on board: 0, passenger fatalities: 0, other fatalities: 0.

The listed crash cause is human factor. The accident flight was the first flight after maintenance personnel replaced the forward elevator trim cable. When the flightcrew received the airplane, the captain did not address the recent cable change noted on his maintenance release. The captain also did not perform a first flight of the day checklist, which included an elevator trim check. Shortly after takeoff, the flightcrew reported a runway trim, and manually selected nose-up trim. However, the elevator trim then traveled to the full nose-down position. The control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane. During the replacement of the cable, the maintenance personnel skipped a step in the manufacturer's airliner maintenance manual (AMM). They did not use a lead wire to assist with cable orientation. In addition, the AMM incorrectly depicted the elevator trim drum, and the depiction of the orientation of the cable around the drum was ambiguous. The maintenance personnel stated that they had completed an operational check of the airplane after maintenance. The Safety Board performed a mis-rigging demonstration on an exemplar airplane, which reversed the elevator trim system. An operational check on that airplane revealed that when the electric trim motor was activated in one direction, the elevator trim tabs moved in the correct direction, but the trim wheel moved opposite of the corresponding correct direction. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction.

Aircraft reference details include registration N240CJ, MSN UE-40, year of manufacture 1993.

Geospatial coordinates for this crash are approximately 41.6535°, -70.2823°.

Fatalities

Total

2

Crew

2

Passengers

0

Other

0

Crash Summary

The accident flight was the first flight after maintenance personnel replaced the forward elevator trim cable. When the flightcrew received the airplane, the captain did not address the recent cable change noted on his maintenance release. The captain also did not perform a first flight of the day checklist, which included an elevator trim check. Shortly after takeoff, the flightcrew reported a runway trim, and manually selected nose-up trim. However, the elevator trim then traveled to the full nose-down position. The control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane. During the replacement of the cable, the maintenance personnel skipped a step in the manufacturer's airliner maintenance manual (AMM). They did not use a lead wire to assist with cable orientation. In addition, the AMM incorrectly depicted the elevator trim drum, and the depiction of the orientation of the cable around the drum was ambiguous. The maintenance personnel stated that they had completed an operational check of the airplane after maintenance. The Safety Board performed a mis-rigging demonstration on an exemplar airplane, which reversed the elevator trim system. An operational check on that airplane revealed that when the electric trim motor was activated in one direction, the elevator trim tabs moved in the correct direction, but the trim wheel moved opposite of the corresponding correct direction. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction.

Cause: Human factor

Occupants & Outcome

Crew On Board

2

Passengers On Board

0

Estimated Survivors

0

Fatality Rate

100.0%

Known people on board: 2

Operational Details

Schedule / Flight

Hyannis - Albany

Flight Type

Positioning

Flight Phase

Takeoff (climb)

Crash Site

Lake, Sea, Ocean, River

Region / Country

North America • United States of America

Aircraft Details

Registration

N240CJ

MSN

UE-40

Year of Manufacture

1993