Colgan Air 9446

• According to Colgan Air’s maintenance records, on August 23, 2003, aircraft N240CJ underwent a Detail Six (D6) phase check as part of its approved phase maintenance program using guidance from the Beech 1900D Airliner Maintenance Manual. The D6 check was performed at the Hyannis, Massachusetts (HYA) station beginning on August 23 at 1647.
• The Maintenance Program Manual (MPM) states that the emphasis of the D6 check is on the empennage and aft fuselage, which includes visual inspections, lubrications, free play checks, engine borescopes, engine mount torque checks, servicing, operational checks, and cable tension checks.
• The check was interrupted mid-stream (procedures for interrupting checks are contained in the General Maintenance Manual section 3.5.3) and the remaining work was deferred on August 24, 2003 at 0800. Ten revenue flight legs were conducted on Sunday August 24, and the D6 check was continued that night at 2030. The check was completed on Tuesday August 26, 2003 at 1100.
• According to Colgan Air’s maintenance records, on August 24, the maintenance technicians (MTS) performed workcard # 27-30-01 as part of the D6 work package. Section two of this workcard requires a free play check of the elevator trim tab actuators. The MTS accomplished the 19 steps for this check and found both left and right elevator trim tab (ETT) actuators to have failed the check. Failure of the actuators by this check requires replacement before further flight. Two actuators were ordered and four MTS were assigned - two to each actuator - to replace them.
• As per the BE1900D maintenance manual, replacement of the ETT Actuators requires accomplishment of all the manual procedures per the BE1900D maintenance manual (MM), 27-30-06. Interviews were conducted with: a maintenance technician, who replaced the left actuator the first day and the right actuator the second day; the lead technician (LT) on duty; and the Quality Assurance (QA) inspector who performed the required item inspection (RII). Per the interviews, the maintenance manual procedures were followed.

Source: NTSB NYC03MA183 Aircraft Maintenance and Records Group Factual Report, §5.0

• According to the interviews, the MTS chose to omit step (c) of the Elevator Trim Tab Actuator Removal and step (i) of the Elevator Trim Tab Actuator Installation.

Source: NTSB NYC03MA183 Aircraft Maintenance and Records Group Factual Report, §5.0

• Omission of these steps discounts nineteen maintenance steps required by the manufacturer’s MM in the process of accomplishing the ETT actuator replacements. These steps guide the maintenance technician through the removal and installation of the elevator control surface(s) and are the MM procedures 27-30-02.
• According to the interviews with the maintenance technician, the two ETT actuators were replaced and an operational check was conducted. In the process of performing operational checks, the ETT cable system seized. The maintenance technician took the pedestal panels loose to ascertain the problem with the cable system. The maintenance technician documented that the “Elevator trim tab cable fell off drum under pedestal” on Maintenance Work Order # 08477.
• The maintenance technician discovered that the ETT forward cable became kinked and ordered out a replacement cable. The necessary floorboards and access panels were opened to gain entry to the forward cable. The LT stated during an interview that management at Colgan Air had been in discussion with Raytheon Aircraft to determine if the part number of the right hand (R/H) ETT actuator was correct. It was found that the part number was incorrect and the R/H ETT actuator had to be replaced. This part was also ordered out under the correct part number.
• The ETT actuator and forward cable were delivered to the hangar the following afternoon, August 25, 2003. That night two MTS were assigned to replace the recently installed R/H ETT actuator and two MTS were assigned the ETT forward cable change. The forward cable was replaced per MM 27-30-04, while the R/H ETT actuator was replaced per MM 27-30-06. The steps (c) and (i), removal and installation of the right elevator, were omitted.

Source: NTSB NYC03MA183 Aircraft Maintenance and Records Group Factual Report, §5.0

• As per interviews with the two MTS that performed the forward cable replacement, the drum assembly was removed in the cockpit during the dayshift, prior to their assignment to the forward cable change. The turnover from day shift to night shift did not contain written turnover notes of explicit work performed. Non-routine discrepancies on the Detail check were open that indicated that work was not complete.
• Per interviews, the two MTS did not use a lead wire when routing the cable through the forward cable pulley system. Attaching lead lines as part of the cable replacement is addressed in MM 27-30-04. Step (g) states, “attach lead lines to the aft ends of the forward cables and properly identify them to facilitate reinstallation.” One of the maintenance technicians marked the topmost cable pulleys with a letter “T” to facilitate re-assembly. Following the re-assembly both MTS checked the routing of the forward cable by referring to MM 27-30-04, figure 201.

Source: NTSB NYC03MA183 Aircraft Maintenance and Records Group Factual Report, §5.0

• The BE1900D maintenance manual does not contain an Elevator Trim System Operational check. The MTS stated that testing of the system was based on what they determined to be proper tests for properly testing the system components.

Source: NTSB NYC03MA183 Aircraft Maintenance and Records Group Factual Report, §5.0

• According to interviews with the QA inspector and the LT, the ETT system was re-checked following the cable replacement performed. The system had been run full up and down travel several times, both electrically and manually. The QA inspector performed the Required Item Inspection (RII) function and was present at both the tail and the cockpit pedestal during all phases of the operational checks. The QA inspector was satisfied with the performance of the ETT cable system and the two ETT actuators and complied with the RII functions of the job.

Source: NTSB NYC03MA183 Aircraft Maintenance and Records Group Factual Report, §5.0

• During interviews, the two MTS working the forward ETT cable stated there was no confusion in the handling of the cable drum or how the manual illustration was interpreted. The MTS admitted to winding the cable and installing the drum to agree with the depiction in the manual. They further stated that the job went normally and that the operational checks were good.

Source: NTSB NYC03MA183 Aircraft Maintenance and Records Group Factual Report, §5.0

• According to a representative of Colgan Air Inc., after scheduled maintenance, the flightcrew was dispatched to fly the accident airplane on a positioning flight. The flightcrew was aware that maintenance was performed on the airplane; however, it was unknown if the flightcrew was aware of the type of maintenance.
• According to data from Federal Aviation Administration (FAA) air traffic control (ATC), the flight departed runway 24 at Hyannis about 1538. Shortly after takeoff, the flightcrew declared an emergency and reported a "runaway trim." The airplane initiated a left turn and reached an altitude of approximately 1,100 feet. The flightcrew subsequently requested to land on runway 33, and ATC cleared the flight to land on any runway. No further transmissions were received from the flightcrew.
• Witnesses observed the airplane in a left turn, with a nose-up attitude. The airplane then pitched nose-down, and impacted the water at an approximate 30-degree angle.
• According to data from the flight data recorder (FDR), the airplane began the flight at a pitch trim control position of approximately 2 degrees negative (nose down). Shortly after takeoff, the pitch trim control moved to approximately 3 degrees negative, where it remained for a period of about 10 seconds. The pitch trim control then moved to an approximate 7 degree negative position, where it remained for the duration of the flight. The data also revealed that after takeoff, the airspeed continued to increase to approximately 250 knots.
• The accident flight was the first flight after maintenance had been performed on the airplane; which included replacement of both elevator trim actuators and the forward elevator trim cable.
• Excerpts of the cockpit voice recorder (CVR) transcript revealed the following:
• At 1538:40, the first officer stated, "V1... rotate." About 6 seconds later, the captain stated, "we got a hot trim, Steve ... roll back Steve roll back roll back roll back roll back."
• At 1538:53, the captain stated, "I got it... (pull) back ... she's heavy buddy ... roll it back roll my trim Steve."
• At 1539:00, the captain stated, "do the electric trim disconnect... hold... all right, Steve ... hold back Steve"
• At 1539:04, the captain stated, "no go on the controls with me Steve." The first officer replied, "I got it."
• At 1539:14, the captain requested that the landing gear be raised, followed by the CVR recording sounds similar to landing gear motor noises.
• At 1539:18, the captain requested that the flaps be raised, which the first officer conformed that they were "up."
• At 1539:21, the captain radioed the HYA tower controller, requesting an emergency return to the airport, which the tower controller approved.
• At 1539:33, the first officer queried the captain, "you want the power back?" The captain replied, "pull the power back. pull the power back."
• At 1539:36, the first officer stated, "slowly," followed by the CVR recording sounds similar to a decrease in engine/propeller speed.
• At 1539:40, the captain stated, "all right, were gonna need both of us on this Steve."
• At 1539:48, the first officer stated, "(could) I pull the breaker?"
• At 1539:49, the CVR recorded a sound similar to an altitude alerter.
• At 1539:49, the captain stated, "pull the breaker Steve ... pull the breaker ... I got it if you've got the trim baby."
• At 1539:54, the first officer stated, "where is it?" The captain replied, "find it... look left of the silver thing, Steve. look left of the silver thing."
• At 1540:02, the first officer stated, "left of the silver thing?" The captain replied, "left of the silver thing Steve ... don't let go of the st- control Steve, just stay with me ... you pull back for all your worth, baby ... just keep (pulling/holding) back for all your worth .... Steve (pull/hold) back."
• At 1540:39, the CVR recorded, "terrain terrain. * pull up."
• At 1540:47, the CVR recorded, "woop woop pull up pull-"
• The recording ended at 1540:47

Source: NTSB NYC03MA183 Group Chairman's Factual Report, §D.

• 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.

Source: NTSB Statement of Probable Cause

• The captain also did not perform a first flight of the day checklist, which included an elevator trim check.

Source: NTSB Statement of Probable Cause

• 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.

Source: NTSB Statement of Probable Cause

The improper replacement of the forward elevator trim cable, and subsequent inadequate functional check of the maintenance performed, which resulted in a reversal of the elevator trim system and a loss of control in-flight. Factors were the flightcrew's failure to follow the checklist procedures, and the aircraft manufacturer's erroneous depiction of the elevator trim drum in the maintenance manual.

Source: NTSB Statement of Probable Cause