CASE STUDY

CASE STUDYCRASH OF AIR MIDWEST FLT 5481 ON 08 JANUARY 2003

INTROAIMTo study an accident case scenario and bring out lessons for the safe op of Army Avn ac. SCOPE SHORT DESCRIPTION OF THE ACCIDENT

THE INVESTIGATION

INVESTIGATION RESULTS

ERRORS AND CONTRIBUTING FACTORS

LESSONS LEARNT

OPEN FORUM SHORT DESCRIPTION OF THE ACCIDENTVIDEO

SHORT DESCRIPTIONDATE : 08 JAN 2003

TYPE OF AC : BEECHCRAFT 1900D

OPERATOR : AIR MIDWEST, US AIR EXPRESS

LOC OF CRASH : CHARLOTTE/DOUGLAS INTERNATIONAL AIRPORT, NORTH CAROLINA,UNITED STATES

PAX : 19

CREWS :2

INJURIES (NON-FATAL) : 1 (ON GRD)

FATALITIES : 21 (ALL ON BOARD AC)SHORT DESCRIPTIONCAPTAIN : Katie Leslie, age 25Was serving in Air Midwest till March 2000. She held an airline tpt plt cert and a FAA first-class med cert dated Nov 19, 2002, with no limitations.

1,865 hours total flying time, including 1,100 hours as a Beech 1900D PIC.

She had flown approx 134, 32, and 6 hrs in the 90 days, 30 days, and 24 hours.

The check plt stated that the captain had no difficulties during upgrade training and that she demonstrated very good knowledge of the airplane sys and very good judgment

SHORT DESCRIPTIONCO PLT : Jonathan Gibbs, aged 27 Was serving in Air Midwest from May 2001.

He held a commercial pilot license dated November 12, 2000, and an FAA first-class medical certificate dated December 10, 2002, with no limitations. 706 hours total flying time on Beech 1900D airplanes.

He had flown approximately 210, 59, and 6 hours in the 90 days, 30 days, and 24 hours, respectivelyPilots described the first officer as a talented and very precise pilot with good attention to detail and good comm skills. Pilots also stated that the first officerpossessed good situational awareness and good knowledge of the Beech 1900D.

THE INVESTIGATIONTHE INVESTIGATIONProbable Cause as Determined by the Investigators

FOD on Runway

Wake Turbulence from the Preceding Ac

Maint Error

Improper Wt and BalTHE INVESTIGATIONProbable Cause as Determined by the Investigators

FOD on Runway

THE INVESTIGATIONProbable Cause as Determined by the Investigators

Wake Turbulence from the Preceding Ac

THE INVESTIGATIONProbable Cause as Determined by the Investigators

Maint Error

THE INVESTIGATIONProbable Cause as Determined by the Investigators

Improper Wt and Bal

THE INVESTIGATION RESULTSActual Causes/ Reasons to Crash

THE INVESTIGATION RESULTSActual Causes/ Reasons to Crash

THE INVESTIGATION RESULTSTHE INVESTIGATION RESULTSActual Causes/ Reasons to Crash

Faulty Maint

Improper Cal of Weight and BalERRORS AND CONTRIBUTING FACTORSERRORS AND CONTRIBUTING FACTORS Maint

Loader/ Luggage Handler

Op

PltsERRORS AND CONTRIBUTING FACTORSMaint

ERRORS AND CONTRIBUTING FACTORSMaint

The on grd jobs were carr out by the trainee

The supervisor was giving instrs only

No cross checking

9 out of 25 steps were skipped

Deadly Combination of Technicians Sincere but less qual trainee Qual but insincere supervisor

Late hr wkload Fatigue Less no of techs were presentERRORS AND CONTRIBUTING FACTORSLoader/ Luggage Handler

ERRORS AND CONTRIBUTING FACTORSLoader/ Luggage Handler

She had confusion/ doubt but never expressed to the pilots

She saw the aircraft as tail heavy but did not inform to anyone

The environment of information exchange was missingERRORS AND CONTRIBUTING FACTORSOperator

ERRORS AND CONTRIBUTING FACTORSOperator

Exact weight calculation of Pax was not carried out

Average weight of pax calculation was wrong

Exact weight calculation of luggage was not carried out

Average weight of luggage calculation was wrong ERRORS AND CONTRIBUTING FACTORSPlts

Did not check the elevator mov according to con column displacement

Did not check the actual wt of pax and luggage

Did not distribute the wt to keep CG within limit

Did not notice the tail hy attitude of the ac

Was slow to react

Did not op the elevator trimmer

LESSONS LEARNTLESSONS LEARNTPilots

The exact weight of luggage must be calculated thoroughly

The approximate weight of pax should be calculated as close as possible

Weight (Pax and Luggage) must be distributed as per manual to keep the CG well within the limit

All the control surfaces must be checked by the pilots during pre flight inspection

The control surface movements must be checked as far as possible during taxi check

LESSONS LEARNTMaintenance

All the control surfaces including movements as per the control column displacement must be checked during daily inspection inspection

The major inspections should not be carried out at late hour

All the adjustments must be crossed checked

No major adjustments should be carried out by the trainees

A team should not be comprised of only one qualified technician

Error reporting must be a practice for all

LESSONS LEARNTLoader/ Luggage Handler/ Flight Crew/ Ground Crew

Every luggage must be weighed sincerely

Any anomaly in aircraft appearance must be reported

The environment should offer everyone to express his/ her views

LESSONS LEARNTHQs

Periodical checks must be conducted on maintenance procedure

Periodical checks must be conducted on weight and balance procedure OPEN FORUM

CONCL