NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. … · 1978. 2. 10. · The National...

1 . Report No. 2.Governrnent Accession No. NTSB-AAR- 7 8- 15

3 .Rec ip ient 's Catalog No.

National Transportation Safety Board Bureau of Accident Investigation Washington, D.C. 20594

L I

4 . T i t l e and S u b t i t l e Aircraft Accident Report -- Columbia Ppcific Airlines, Beech 99, N19gW?U Richland, Washington, February 10, 1978

7 . Author(s)

9 . Performing Organization Name and Address 2329A

11.Contract o r Grant No. I 13.Type of Report and

5.Report Date

6.Performing Organization .

8. Performing Organization

December 21, 1978

Code

Report No.

10.Work U n i t No.

12.Sponsoring Agency Name and Address

NATIONAL TRANSPORTATION SAFETY BOARD Washington, D. C. 20594

Period Covered

Aircraft Accident Report February 10, 1978

14.Sponsoring Agency Code

17. Key Words Mistrimed horizontal stabilizer; inoperative trim warning systems; stall; inadequate trim warning system check procedures; inadequate flightcrew training; inadequate maintenance procedures; ineffective FAA surveillance.

19.Securi ty C l a s s i f i c a t i o n 20 .Secur i ty C l a s s i f i c a t i o n (of t h i s repor t ) (of t h i s page)

UNCLASSIFIED UNCLASSIFIED

18 .D is t r ibut ion Statement This document is available to the public through the National Technical Informa- tion Service, Springfield, Virginia 22151

21.No. o f Pages 22 .Pr ice

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TABLE OF CONTENTS

Page

Synopsis 1 . . . . . . . . . . . . . . . . . . . . 1 . 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.16.1 1.16.2 1.16.3 1.17 1.17.1

1.17.2 1.17.3

1.17.4 1.18

2 . 3 . 3.1 3.2

4 . 5 .

Factual Information . . . . . . . . . . . . . . . 2 2 History of the Flight . . . . . . . . . . . . . . 3 Injuries to Persons . . . . . . . . . . . . . . . 3 Damage to Aircraft . . . . . . . . . . . . . . .

Other Damage . . . . . . . . . . . . . . . . . . 3 3 Personnel Information . . . . . . . . . . . . . .

Aircraft Information . . . . . . . . . . . . . . 4 6 Meterological Information . . . . . . . . . . . . 7 Aids to Navigation . . . . . . . . . . . . . . . 7 Communications . . . . . . . . . . . . . . . . . 7 Aerodrome Information . . . . . . . . . . . . . . 7 Flight Recorders . . . . . . . . . . . . . . . . 7 Wreckage and Impact Information . . . . . . . . .

Medical and Pathological Information . . . . . . 10 Fire . . . . . . . . . . . . . . . . . . . . . . 11 Survival Aspects . . . . . . . . . . . . . . . . 11 Test and Research . . . . . . . . . . . . . . . . 12 Powerplants . . . . . . . . . . . . . . . . . . . 12 The Horizontal Stabilizer Trim System . . . . . . Aircraft Performance . . . . . . . . . . . . . . 17 Additional Information . . . . . . . . . . . . . 20

Maintenance Practices . . . . . . . . . . . . . 20 Aircraft Minimum Equipment List (MEL) . . . . . . 23

and Surveillance 24 29

12

Columbia Paci€ic Airlines' Operational and

Federal Aviation Administration Certification

Investigator's Observations of a Company Plight . . . . . . . . . . . . . . . . New Investigative Techniques . . . . . . . . . . 29

Analysis . . . . . . . . . . . . . . . . . . . . 30

Conclusions . . . . . . . . . . . . . . . . . . . 35 Findings . . . . . . . . . . . . . . . . . . . . 35 Probable Cause . . . . . . . . . . . . . . . . . 3?

Recommendations . . . . . . . . . . . . . . . . . 37 Appendixes . . . . . . . . . . . . . . . . . . . 41

Appendix A . Investigation and Hearing Appendix B . Personnel Information

Appendix D . Flight Track . . . . . . . . . . . .

. . . . . 41 42 43 44 45

. . . . . . . Appendix C . Aircraft Information . . . . . . . . Appendix E . Wreckage Distribution Chart . . . .

ii

NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

Adopted: December 21, 1978

COLUMBIA PACIFIC AIRLINES BEECH 99, N199EA

RICHLAND, WASHINGTON FEBRUARY 10, 1978

SYNOPSIS

At 1650 P.s.t. on February 10, 1978, Columbia Pacific Airlines, Inc., Flight 23, a Beech 99, crashed in visual flight rules conditions on takeoff from runway 36 at the Richland Airport, Richland, Washington. Flight 23, a regularly scheduled passenger flight to Seattle, had 15 passengers and 2 crewmembers on board. After liftoff, the aircraft climbed steeply to 400 feet above the runway, then stalled and crashed 2,000 feet beyond the end of the runway. impact. All persons on board were killed, and the aircraft was destroyed.

A severe fire erupted after

The National Transportation Safety Board determines that the probable cause of the accident was the failure or inability of the flightcrew to prevent a rapid pitchup and stall by exerting sufficient push force on the control wheel. of a mistrimmed horizontal stabilizer and a center of gravity near the aircraft's aft limit. The mistr-lmmed condition resulted from discrepancies in the aircraft's trim system and the flightcrew's probable preoccupation with making a timely departure. Additionally, a malfunctioning stabilizer trim actuator detracted from the flightcrew's efforts to prevent the stall.

The pitchup was induced by the combination

Contributing to the accident were inadequate flightcrew training, inadequate trim warning system check procedures, inadequate maintenance procedures, and ineffective FAA surveillance.

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1. FACTUAL INFORMATION

1.1 History of t h e F l i g h t

Columbia P a c i f i c A i r l i n e s F l igh t 23, a Beech 99 (N199EA), w a s operated under the provis ions of 1 4 CFR 135 as a r egu la r ly scheduled passenger f l i g h t from Richland t o S e a t t l e , Washington. a t Richland a t 1525 P.s.t. 1! on F l igh t 18 from S e a t t l e . a r r ived , N199EA w a s being inspected t o f u l f i l l the requirements of an Airworthiness Directive. The a i r c r a f t w a s not a v a i l a b l e t o the crew f o r p r e f l i g h t inspect ion u n t i l 1630; F l igh t 23 w a s scheduled t o depart a t 1640.

The crew a r r ived When they

A t 1628, t h e cap ta in w a s b r i e f e d on weather by t h e Walla Walla, Washington, F l i g h t Service S t a t i o n (FSS), and he f i l e d a dispatch release which contained a i r c r a f t weight and balance, rou te of f l i g h t , and weather information. About 1630, t h e aircraft w a s fueled and 600 l b s of baggage w a s loaded. About 1635, t he f i r s t o f f i c e r l e f t t he terminal bui lding and connected t h e a u x i l i a r y power u n i t t o t h e a i r c r a f t . H e then inspected t h e a i rcraf t and boarded; t h e captain boarded s h o r t l y t h e r e a f t e r . When t h e passenger boarding ca l l w a s made, t h e cap ta in l e f t t h e a i r c r a f t t o ob ta in magazines f o r t h e passengers. g e t t i n g i n t o h i s seat when t h e f i r s t passenger boarded.

H e w a s seen

A t 1646, t h e first o f f i c e r contacted the Pasco Airport T r a f f i c Control Tower, using F l i g h t No. 29, and advised that they w e r e t a x i i n g and would request an instrument f l i g h t r u l e s c learance t o S e a t t l e via Yakima, Washington, when airborne. The Pasco Control Tower received no f u r t h e r c a l l s from F l i g h t 23. The f i r s t o f f i c e r informed operat ions on company frequency t h a t they would be depart ing s h o r t l y and would r e l a y t h e i r estimated t i m e of arrival i n S e a t t l e when airborne. There were no f u r t h e r r ad io communications with t h e crew. The a i r c r a f t d a i l y f l i g h t l o g f o r February 1 0 showed t h a t t h e a i r c r a f t l e f t the ramp a t 1645 and took o f f a t 1648.

I n general , witnesses described the a i r c r a f t ' s a t t i t u d e a t l i f t o f f as normal and estimated t h e po in t of l i f t o f f between 1,173 and 1,486 f t ; however, immediately t h e r e a f t e r t he a i rcraf t began a s t e e p climb a t an angle of 20' t o 45" t o an a l t i t u d e of 300 t o 400 f t above t h e runway and then appeared t o dece le ra t e . a t t h e top of t h e climb, and t h e a i r c r a f t turned o r yawed t o the l e f t . The nose dropped and t h e a i r c r a f t descended t o the ground a t a f l i g h t p a t h angle estimated t o have been 45". f i r e a f t e r t h e a i r c r a f t h i t t h e ground. F i r e consumed the a i r c r a f t wi th in 7 minutes.

The wings rocked o r wobbled

Fuel from ruptured f u e l tanks caught

- 1/ A l l t i m e s he re in are P a c i f i c standard, based on t h e 24-hour clock.

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The accident occurred during dayl ight hours a t 1650:12 a t l a t i t u d e 46' 19" and 119" 18'W. 393 f t m . s . 1 .

The e l eva t ion of t he impact s i t e w a s

1 . 2 I n j u r i e s t o Persons

I n j u r i e s - C r e w Passengers Other

F a t a l 2 15 0 Serious 0 0 0 Minor/None 0 0 0

1.3 Damage t o A i r c r a f t

The a i r c r a f t w a s destroyed by impact and f i r e .

1.4 Other Damage

None

1 .5 Personnel Information

The capta in and f i r s t o f f i c e r held A i r l i n e Transport P i l o t c e r t i f i c a t e s , al though not required f o r t he operat ion conducted. (See Appendix B.) checked i n accordance with t h e requirements of 1 4 CFR 135.122, 135.131, and 135.138. during t h e i r employment.

They w e r e t r a ined by the a i r l i n e and cu r ren t ly f l i g h t

T h e i r records d isc losed no unsa t i s f ac to ry performance

The capta in and f i r s t o f f i c e r had flown together f requent ly f o r about 6 months. accident . P i l o t f l i g h t check on February 9 before he f in i shed h i s normal duty s h i f t which ended a t 2200. Both p i l o t s reported f o r duty about 1300 on February 10, and both had flown together 1.3 hours before t h e accident .

The capta in had not flown on the 2 days before t h e The f i r s t o f f i c e r successfu l ly completed h i s A i r l i n e Transport

Five Columbia P a c i f i c A i r l i n e ' s p i l o t s w e r e interviewed regarding t h e work h a b i t s of t h e capta in and f i r s t o f f i c e r . t h e capta in as a good p i l o t who always used t h e check l i s t and would ge t upset i f t he f i r s t o f f i c e r ca l l ed an i t e m out of sequence. They s t a t e d t h a t he w a s a "take-charge" type ind iv idua l who performed those f i r s t o f f i c e r d u t i e s which he f e l t w e r e performed too slowly. with a f u l l y loaded Beech 99, he would t r i m i t nose l i g h t f o r takeoff-- he would pos i t i on t h e t r i m i nd ica to r from 2/3 t o the a f t edge of t he green band. t o the nosedown and noseup extremes while performing the t r i m check. They reported t h a t he w a s concerned about meeting t i m e schedules. p i l o t s t a t e d t h a t i f departure from the ramp occurred a t 1300 and takeoff

These p i l o t s r a t ed

They s a i d t h a t ,

They could not r e c a l l h i s ever pos i t ion ing the s t a b i l i z e r

One

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occurred a t 1305, t h e cap ta in would he l i eve he w a s 5 minutes late. a l s o believed t h a t i n aE emergency s i t u a t i o n , t h e captain would be r e l u c t a n t t o a sk f o r a s s i s t a n c e from h i s f i r s t o f f i c e r .

They

The f i v e p i l o t s r a t e d t h e f i r s t o f f i c e r as a good p i l o t and an easy going'' individual who enjoyed f l y i n g with t h e captain. The f i v e I'

p i l o t s thought t h a t t h e f irst o f f i c e r would not i n i t i a t e a c t i o n i n an emergency bu t would w a i t f o r i n s t r u c t j o n from the captain.

1.6 A i r c r a f t Information

The aircraft w a s c e r t i f i c a t e d under delegat ion opt ion procedures i n accordance with t h e airworthiness requirements of 14 CFR 23 i n May 1968. It w a s t h e f i r s t aircraft with a moveable ho r i zon ta l s t a b i l i z e r c e r t i f i c a t e d under t h i s regulat ion.

N199EA had been operated by t h r e e operators before Columbia

During t h i s period, P a c i f i c A i r l i nes . From October 1968 t o August 1971, f i v e discrepancies were reported concerning trim system components. t h e t r i m a c t u t a t o r w a s replaced t h r e e t i m e s . seven discrepancies concerned t h e t r i m sys'tem, and from May 1975 t o June 1977, e i g h t discrepancies concerned t h e t r i m system. During t h i s l a s t period, t h e standby p i t c h t r i m w a s found t o be unsa t i s f ac to ry , and t h e main and standby motors were replaced after 11,471 t o t a l a i r c ra f t . hours--7,790 hours a f t e r t h e a c t u a t o r had been replaced. (See Appendix C.) The out-of-trim warning system w a s found on four occasions t o be improperly r igged, and on a f i f t h occasion i t w a s found t o be inoperat ive. The trim-in-motion system w a s unsa t i s f ac to ry on two occasions.

From August 1971 t o May 1975,

The last operator of N199EA before i t w a s acquired by Columbia P a c i f i c w a s A t l a n t i c Central A i r l i n e s of New Brunswich, Quebec, Canada. It w a s purchased by Maine Aviation of Portland, Maine, on May 17, 1977, who so ld N199EA and another Beech 99 t o Columbia P a c i f i c i n June 1977. I n t h e interim, Maine Aviation performed a Phase-4 inspect ion on N199EA i n accordance with Beech Aircraft Corporation's continuous maintenance in spec t ion procedures and as required by 1 4 CFR 91.217(b),(4). phase-4 inspect ion does no t include t h e s t a b i l i z e r t r i m system. day, t h e l o c a l Federal Aviation Administration's General Aviation Dis t r ic t Off ice (GADO) issued a s tandard airworthiness c e r t i f i c a t e on t h e a i r c r a f t i n accordance wi th 14 CFR 21.183(d).

The On t h a t

When Columbia acquired t h e a i r c r a f t , N199EA had accumulated 12,638 hours, and t h e s t a b i l i z e r t r i m a c t u a t o r had accumulated 1,167 hours s i n c e i t w a s l as t replaced. e i t h e r a i r c r a f t .

Maine Aviation had no t operated

The owner of t h e f a c i l i t y that provided con t r ac t maintenance t o Columbia P a c i f i c A i r l i n e s had accompanied the f i r s t f l i gh tc rew t o Port land, Maine, and had discussed the Beech 99 ' s systems and r e l a t e d

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Airworthiness Directives with Bar Harbor's chief of maintenance. (Bar Harbor i s a subsidary of Maine Aviation which operated nine Beech 99's.) The owner reported t h a t he d i d not perform an acceptance inspec t ion of t h e a i r c r a f t before the A i r l i n e took possession of them. H e s t a t e d t h a t Maine Aviation had conducted a l l t h e necessary maintenance up t o t h a t t i m e , and he had reviewed t h e maintenance records.

Columbia P a c i f i c A i r l i n e s w a s authorized t o use the Beech 99 i n i t s commercial operat ion on Ju ly 15, a f t e r i t s Beech 99 proving test on Ju ly 11; the proving test is required by 14 CFR 135.32. Ju ly 20, Columbia P a c i f i c A i r l i n e s began the FAA-approved continuous maintenance inspec t ion program with i t s cont rac t maintenance f a c i l i t y i n Pasco, Washington--9 m i l e s southeast of Richland.

E f fec t ive

On February 10, 1978, t h e a i r c r a f t had made two f l i g h t s , F l igh t 1 3 and then F l i g h t 10, before being sen t t o maintenance between 0900 and 0930 f o r t h e rou t ine inspec t ion and se rv ic ing of the nose landing gear required by Airworthiness Direc t ive 72-10-4. This work d id not involve t h e t r i m system. The crew who had flown the a i r c r a f t before i t w a s s en t t o maintenance reported t h a t a l l a i r c r a f t systems operated normally. However, one of t h e crewmembers noted t h a t , while s e t t i n g t h e ho r i zon ta l s t a b i l i z e r t o t h e f u l l noseup t r i m pos i t i on before the f i r s t f l i g h t , t he t r i m i nd ica to r on the cont ro l pedes ta l appeared t o be s l i g h t l y forward of t h e normal a f t l i m i t . H e d id not record h i s observation i n t h e d a i l y f l i g h t log.

The mechanic who inspected t h e nose landing gear s t a t e d t h a t

The runup w a s conducted with re ference t o the checkl i s t . t h e a i r c r a f t w a s run up i n i t i a l l y t o determine the opera t iona l s t a t u s of i t s systems. Although he could not remember how many i t e m s of equipment were checked, he s t a t e d t h a t everything checked functioned normally.

A review of N199EA's maintenance records d isc losed t h a t a l l required modif icat ions t o t h e s t a b i l i z e r trim system had been performed. N199EA's d a i l y f l i g h t l o g shee t f o r February 10, 1978, contained a mechanic's s igna tu re au thor iz ing t h e a i r c r a f t ' s release f o r t he f i r s t f l i g h t of t h e day. There were no mechanical discrepancies recorded by t h e crew of F l i g h t s 1 3 and 10. The l o g shee t did not show a s igna ture r e l eas ing t h e a i r c r a f t f o r f l i g h t following the inspec t ion of t he nose landing gear, and the re w e r e no e n t r i e s i n the deferred maintenance po r t ion of t h e log.

The inves t iga t ion d isc losed t h a t t he s t a b i l i z e r t r i m system f a i l e d to operate i n f l i g h t on th ree occasions within the 2 weeks preceding t h e accident . On January 29, t he d a i l y f l i g h t l og showed t h a t t he main t r i m system functioned in t e rmi t t en t ly . The captain, who made the r epor t , s t a t e d t h a t on two occasions t h e main t r i m f a i l e d t o respond when t h e switches on t h e cont ro l wheel w e r e activated--once on the f i r s t o f f i c e r ' s wheel and once on h i s wheel. using the standby t r i m system. The ac tua to r jackscrew, trim-stop l i m i t switch w a s readjusted, and the a i r c r a f t w a s re leased.

The f l i g h t w a s completed by

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During t h e week before t h e accident, t h e ac tua to r f a i l e d t o respond t h e second t i m e during a t r a i n i n g f l i g h t ; however, t he f a i l u r e w a s a t t r i b u t e d t o t h e f i r s t o f f i c e r ' s lack of experience i n the Beech 99. No co r rec t ive a c t i o n w a s taken. The switches on the con t ro l wheel are dual-element, thumb switches and must be pressed simultaneously t o activate t h e t r i m . The cap ta in and mechanic who discussed t h e problem concluded t h a t t h e t r a i n e e had not pressed t h e switches properly. Another cap ta in interviewed s t a t e d t h a t t h e same type inc iden t occurred f o r t he t h i r d t i m e during t h e week before t h e accident and he did not r e p o r t t h e incident .

The d a i l y f l i g h t l ogs a l s o disclosed 12 writeups i n which the trim-in-motion a u r a l system w a s e i t h e r i n t e r m i t t e n t o r inoperat ive. A p a r t had been ordered t o r e p a i r t h e trim-in-motion a u r a l system, bu t i t had not been received. The last r e p o r t , "trim-in-motion audio s t a y s on when CB i s in ," w a s made on October 17, 1977, bu t w a s deferred u n t i l November 11, when maintenance found i t "checked okay." The out-of-trim warning horn w a s reported as inoperat ive on November 9, 1977, bu t w a s de fe r r ed u n t i l November 11, when t h e microswitch w a s readjusted. There were four e n t r i e s i n t h e d a i l y f l i g h t l o g about t h e de i ce r boots being p a r t i a l l y t o f u l l y i n f l a t e d constant ly . The last remark w a s recorded February 6, 1978, and records showed no c o r r e c t i v e ac t ion .

The gross weight of t h e a i r c r a f t before takeoff w a s c lo se t o t h e maximum allowable ramp weight of 10,455 l b s . weight range ca l cu la t ed w a s 10,439 t o 10,491 lb s . weights w a s r e l a t e d t o a f u e l load which ranged from 1,048 l b s t o 1,100 l b s . The cen te r of g rav i ty (c.g.) w a s wi th in l i m i t s a t 193.4 inches; t h e a f t l i m i t w a s 195 inches. Fuel burnoff f o r taxi, runup, and takeoff w a s about 55 l b s .

The most probable The d i f f e rence i n

1.7 Meteorological Information

The captain w a s given t h e weather by t h e Walla Walla FSS a t 1628; i t i s summarized below:

S e a t t l e t ranscr ibed weather en rou te broadcast synopsis-- Freezing level w e s t of Cascades near 2,000 f t and east of Cascades near 4,000 f t , except l o c a l l y a t surface. Clouds w e s t of Cascades 2,000 t o 3,000 f t s ca t t e r ed , v a r i a b l e broken, 25,000 f t broken, tops 10,000 f t . Clouds east of Cascades 8,000 f t s ca t t e r ed , becoming clear by midnight.

Washington area fo recas t : I c ing not s p e c i f i c a l l y fo recas t ; f r eez ing level--2,000 t o 4,000 f t .

The 1500 S e a t t l e terminal fo recas t : 5,000 f t broken, s l i g h t chance of l i g h t r a i n showers; s ca t t e r ed , va r i ab le , and broken by 1700.

Ceiling 2,000 f t broken;

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The 1700 Richland surface weather observation: Estimated ceiling 15,000 ft broken; 25,.000 ft broken; visibility--50 mi; temperature--43" F; dewpoint--34" F; wind--270° at 6 kns; altimeter--29.74 inHg.

1.8 Aids to Navigation

Not applicable

1.9 Communications

There were no reported communications difficulties.

1.10 Aerodrome Information

The Richland Airport was an FAA-designated commuter service airport and was served regularly only by Columbia Pacific Airlines. airport has no traffic control facilities; UNICOM r is available. Richland Airport is owned by the Port of Benton, Benton County, Washington, and is operated by Richland Flying Service. At least 2,500 passengers per year embark from the airport via the commuter airline and air taxi operations.

The

The airport elevation is 393 ft m.s.1. There are two asphalt runways, the longest of which, 18/36, is 4,000 ft.

1.11 Flight Recorders

No flight data recorder or cockpit voice recorder was installed in N199EA, nor was either required.

1.12 Wreckage and Impact Information

The aircraft first hit the ground 1,669 ft beyond the end of runway 36 and 1,031 ft to the left of the runway extended centerline. Examination of the wreckage disclosed that the aircraft struck level ground in a slightly left wing-low, nose-level attitude. The landing gear were fully extended, and the flaps were extended 30 percent. empennage separated from the fuselage and moved down the crash path 30 ft ftom the point of initial impact. The landing gear separated as the aircraft skidded 78 ft along a magnetic heading of 272". came to rest without changing direction. (See figure 1.)

The

The aircraft

Although the forward outboard wing fitting failed on impact, the left wing remained attached to the fuselage. remained attached to the wing. remained attached to the wing, and the propeller blades were bent opposite the direction of normal rotation.

The aileron and flaps The left engine including the propeller,

- 21 A non-government aeronautical advisory station.

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Figure 1. Aerial view of wreckage s i te .

The b o l t on t h e forward outboard r i g h t wing f a i l e d on impact. The a i l e r o n and f l a p s remained attached. from i ts mounts and pivoted outboard p a r a l l e l t o t he wing. blades were a l s o bent opposi te t h e d i r e c t i o n of normal ro t a t ion .

The r i g h t engine separated The p rope l l e r

Control cables remained connected t o t h e i r r e spec t ive con t ro l s The Beech i n t h e f l i g h t compartment and on a l l f l i gh t - con t ro l surfaces .

f l i g h t con t ro l l ock assembly w a s found stowed i n i t s normal loca t ion beneath t h e c a p t a i n ' s seat.

The empennage separated a t fuselage s t a t i o n (FS) 409.50. It had broken c i r cumfe ren t i a l ly because of compressive forces--the lower h a l f w a s deformed more than t h e top h a l f . ho r i zon ta l s t a b i l i z e r , i t s l a r g e s t s t r u c t u r a l member, contained a t r ansve r se f r a c t u r e a t i t s midpoint i n t h e tube-box assembly. Normally the s t a b i l i z e r h a s a 7' d ihedra l angle. allowing t h e s t a b i l i z e r t o droop.

The torque tube i n t h e

The torque tube w a s broken by impact forces , (See f i g u r e 2.)

F i r e destroyed t h e fuselage above the f l o o r level. The inboard po r t ions of t h e wings from t h e fuselage t o t h e engine n a c e l l e s were a l s o destroyed by f i r e . There w a s no evidence of f i r e o r smoke damage t o t h e empennage.

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Figure 2. Front view of separated empennage.

The remains of t h e airstair door t o the cabin, located behind t h e l e f t wing, w a s found inverted on t h e ground adjacent t o the cabin entrance. from i t s fuse lage attachment, and a small mound of s o i l , deposited a t t h e entrance t o t h e cabin, ind ica ted t h e door w a s dragged along t h e ground. N o s i g n i f i c a n t impact marks were formed on the two l a t ch ing s t r i k e r p l a t e s which secure t h e upper door la tches . w a s not la tched. destroyed by f i r e .

The f r o n t support cab le showed evidence of having been pul led

The s a f e t y chain The cargo door adjacent t o the airstair door w a s

The two overwing emergency e x i t s w e r e closed. The cockpit ha tch a t t h e cap ta in ' s s t a t i o n w a s closed. t o t h e nose baggage compartment w a s nea r ly destroyed by f i r e , t he remains showed some evidence of impact d i s t o r t i o n . door a l s o showed evidence of impact d i s t o r t i o n .

Although the l e f t s i d e door

The r i g h t s i d e nose baggage

The f l i g h t compartment w a s mostly destroyed by f i r e . The t h r o t t l e s and p rope l l e r levers w e r e f u l l forward, and t h e f u e l l eve r s w e r e i n t h e high i d l e pos i t ion . The landing gear handle w a s i n t h e down pos i t ion . The f l a p handle and ind ica to r w e r e set a t the 30-percent f l a p pos i t ion . The a i l e r o n t r i m pos i t i on ind ica to r w a s set a t zero, t he rudder trim ind ica to r showed 3" l e f t t r i m , and the electrical hor izonta l s t a b i l i z e r t r i m i nd ica to r w a s i n t he "parked" pos i t i on ( f u l l nosedown t r im) . A por t ion of t h e crew's f l i g h t bag w a s melted over the toggle switches f o r main and standby s t a b i l i z e r t r i m power. power switch w a s "Off," and t h e standby power switch w a s "On." Figure 3.)

The main t r i m (See

- 10 -

Figure 3. Closeup of t r i m switches -- main off and standby on. Note switch imprints i n burned f l i g h t bag.

The c i r c u i t breaker panel was damaged by impact and f i r e . Many of t he c i r c u i t breakers were t r ipped, including those associated wi th t h e main and standby trim systems. The a i r c r a f t b a t t e r y and the engine-driven starters had not malfunctioned e l e c t r i c a l l y .

The hor izonta l s t a b i l i z e r ' s t r i m ac tua tor jackscrews w e r e extended 6 1/32 inches, which corresponded t o 1.0' noseup t r i m ( s t a b i l i z e r leading edge down 1.0'). (See Figure 4 . )

Examination of t he de i ce r system i n j e c t o r valve disclosed t h a t t h e pressure s i d e of t he valve had a continuous leak causing par t ia l i n f l a t i o n of t h e wing and empennage de icer boots.

1.13 Medical and Pathological Information

Post-mortem and toxico logica l examinations of t he f l igh tcrew d isc losed no evidence of f a c t o r s which would have a f f ec t ed t h e i r a b i l i t y t o operate the a i r c r a f t .

Medical examinations of four passengers and the f l igh tcrew disclosed t h a t they died from impact trauma. on the remaining passengers.

Autopsies were not performed

- 11 -

Figure 4 . I n s t a l l a t i o n of s t a b i l i z e r t r i m ac tua to r i n empennage.

F i r e -- 1.14

Fuel from ruptured f u e l tanks caught f i r e a f t e r ground impact. Local f i r e f i g h t i n g u n i t s responded 3 1 / 2 minutes a f t e r t he crash. extinguished t h e f i r e 4 minutes a f t e r t h e f i r s t u n i t had a r r ived , however, f i r e had already consumed t h e a i r c r a f t .

Firemen

1.15 Survival Aspects

The accident w a s no t survivable because of t he i n t o l e r a b l e impact fo rces and postcrash f i r e .

The crew's seatbacks had bent rearward and had separated from t h e seat s t ruc tu re . The ad jus t ab le seat support frames remained locked and anchored t o t h e f l o o r t rack. All of t h e seat adjustment locking p ins w e r e engaged, and t h e r e w a s no evidence t h a t the seats had s l ipped.

Most of t he passenger seats were f l o o r mounted, and they revealed pronounced compression r a t h e r than lateral deformation. The f l o o r t r acks were separated and displaced downward i n numerous loca t ions . Many of t he sea t l eg , f loor - t rack r e t e n t i o n devices separated from the s e a t l e g s and remained i n the f l o o r t r a c k assemblies. A l l of t he track- mounted seats had s l i d forward. The las t th ree seats i n the cabin w e r e

- 12 -

n o t track-mounted; they a l s o had been dislodged by impact forces . The f i v e passengers i n t h e last t h r e e seats w e r e thrown forward. s e a t b e l t s w e r e burned, and therefore , i t could not be determined i f they had f a i l e d .

Some

1.16 T e s t s and Research

1.16.1 Powerplants

Following t h e on-scene examination of both engines and t h e i r a s soc ia t ed components, t h e Safety Board's powerplant group conducted a d e t a i l e d examination a t t h e Product Support Division of P r a t t & Whitney A i r c r a f t of Canada, Ltd., Longueuil, Quebec, Canada. The group f u r t h e r examined t h e p rope l l e r s a t H a r t z e l l P rope l l e r , Inc., Piqua, Ohio.

Examination disclosed t h a t power tu rb ine s h a f t s from t h e compressors and power tu rb ine assemblies of both engines had been scored and d i s t o r t e d . This evidence suggested t h a t both engines w e r e operat ing when t h e a i r c r a f t crashed. however, could no t b e establ ished. No mechanical discrepancies w e r e found t h a t would have prevented t h e engines from operat ing normally.

The exact power output of t h e engines,

Examination of t h e H a r t z e l l p r o p e l l e r s disclosed t h a t they w e r e operat ing i n t h e low p i t c h (high rpm) regime. Since t h e method by which t h e blade angles w e r e determined w a s not p rec i se , only a blade- angle operat ing range could be establ ished. Except f o r one blade on t h e l e f t p rope l l e r , a l l o t h e r s showed evidence of having absorbed a s u b s t a n t i a l amount of impact energy. No mechanical discrepancies w e r e found t h a t would have prevented t h e p r o p e l l e r s from operat ing normally.

1.16.2 The Horizontal S t a b i l i z e r T r i m System

The ho r i zon ta l s t a b i l i z e r t r i m system i n the Beech 99 c o n s i s t s The t r i m system i s of two electrical systems wi th no mechanical backup.

actuated by two motors which are mounted i n the empennage. (On/Off) power switch f o r each motor is mounted on t h e cen te r con t ro l pedes t a l and is placarded MAIN o r STDBY. The main system i s operated by dual-element t r i m switches on each con t ro l wheel, and the standby system i s operated by dual-element t r i m switches on t h e cen te r con t ro l pedestal . pedes ta l .

A two-position

A t r i m p o s i t i o n i n d i c a t o r i s located on t h e cen te r con t ro l

Normally, t h e system i s a c t i v a t e d with t h e pedestal-mounted "MAIN" power switch and i s operated by pushing the dual-element t r i m switches on t h e con t ro l wheel f o r e and a f t . I f t h e t r i m switches are moved forward, t h e leading edge of t h e s t a b i l i z e r w i l l move up; i f t he t r i m switches are moved a f t , t h e leading edge of t h e s t a b i l i z e r w i l l move down. "STDBY" power switch and i s operated by the. pedestal-mounted, dual- element t r i m switches.

The standby system i s ac t iva t ed with the pedestal-mounted

A l l of t h e t r i m switches are spring-loaded t o a

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cen te r pos i t ion , and s t a b i l i z e r movement s tops when the switches are moved t o t h e center pos i t ion . Each p a i r must be moved together i n order f o r t h e c i r c u i t t o be completed. P a r t of t he pretakeoff check r equ i r e s movement of a l l of t he dual-element switches ind iv idua l ly t o in su re t h a t no one switch w i l l opera te t h e system. The t r i m i nd ica to r must a l s o be monitored while ind iv idua l switches are being operated. Any movement on t h e ind ica to r i nd ica t e s a malfunction i n the system, and takeoff should no t be made.

I f t h e motor f o r t h e main t r i m system continues t o opera te a f t e r t h e t r i m switches on t h e con t ro l wheel are re leased , a but ton on t h e s i d e of t h e con t ro l wheel g r ip , placarded "TRIM REL," should be pushed t o i n t e r r u p t t h e c i r c u i t u n t i l t h e main t r i m power switch can be turned o f f . The standby system does not incorporate t h i s t r i m release f e a t u r e and must be deact ivated by turn ing t h e power switch ''OFF." The t r im-release f e a t u r e i s a l s o required t o be checked before takeoff .

The ho r i zon ta l s t a b i l i z e r t r i m system a l s o includes two a u r a l warning devices: The trim-in-motion system advises t h e p i l o t of s t a b i l i z e r movement. The aural s i g n a l i s i n t e r m i t t e n t tones amplified through a speaker o r head- phone. This system is independent of t h e rad io system.

A trim-in-motion warning and an out-of-trim warning.

The out-of-trim warning system advises the p i l o t of m i s t r i m during takeoff . 90-pemenb. l e f t t h r o t t l e lever pos i t i on w i l l activate the warning horn when t h e t r i m i s set outs ide t h e takeoff range, as shown by the green band of t h e ind ica to r . t h i s f e a t u r e following takeoff t o permit use of the f u l l t r i m range without a c t i v a t i n g t h e horn. warning system i s not included i n t h e Airplane F l igh t Manual (AFM) before-takeoff checkl i s t .

A switch i n s t a l l e d on t h e t h r o t t l e quadrant a t the

A microswitch on t h e landing gear w i l l deac t iva t e

The procedure f o r checking the out-of-trim

To check t h e e n t i r e t r i m system before takeoff , t h e procedures c a l l f o r f i r s t a c t i v a t i n g t h e standby system and then operat ing the pedestal-mounted dua l element switches ind iv idua l ly , while simultaneously monitoring t h e t r i m pos i t i on ind ica to r and l i s t e n i n g f o r t he trim-in-motion a u r a l tone. Next, t h e main system i s checked i n a similar manner, except f o r t he add i t ion of t h e trim-release fea tu re . set i n the green band, t h e check i s complete. Moving the s t a b i l i z e r from t h e f u l l nosedown t o the f u l l noseup pos i t ion , o r v i c e versa , i s only required on t h e f i r s t f l i g h t of t he day.

When the t r i m i s

When t h e main s t a b i l i z e r t r i m power switch is "ON," t h e s t a b i l i z e r moves 0.15 inch per second. The t i m e required t o move the s t a b i l i z e r from f u l l nosedown t o f u l l noseup i s 18.33 seconds. s t a b i l i z e r w i l l move a t one-third t h a t speed, o r 0.05 inch per second, and w i l l take 55 seconds t o travel from one t r i m l i m i t t o t he other .

I n t h e standby mode, t he

- 1 4 - The Safety Board's i nves t iga t ion disclosed t h a t t he re were

several discrepancies within the a i r c r a f t ' s s t a b i l i z e r t r i m system which could not be r e l a t e d t o impact damage.

(1) Actuator c lu t ch

The dual-motor ac tua tor incorporates a twin jackscrew and a c l u t c h mechanism designed t o s l i p i f e l e c t r i c a l power i s appl ied t o e i t h e r of t h e motors a f t e r t h e jackscrew reaches the end of i t s travel. The c lu t ch cons i s t s of two p l a t e s separated by s i x metal b a l l bear ings r e s t r a i n e d i n de t en t s by a spr ing load. Torque i s t ransmit ted through t h e b a l l bear ings during normal operation. imposed on the jackscrew as i t reaches the end of i t s t r ave l , t he jackscrew w i l l react aga ins t t h e spr ing load, separa te t h e p l a t e s , and allow t h e b a l l bearings t o move f r ee ly . Thus, torque i s not t ransmit ted, and the motor i s protected.

I f an excessive load I s

Safety Board inves t iga to r s examined t h e ac tua to r manufactured by the Tal ley Corporation of Newburry Park, Cal i forn ia , a t Tal ley ' s f a c i l i t y . c lu t ch de ten t plate--al l exhibi ted l i t t l e t o no wear. wi th in the de ten t p l a t e were worn t o an oval shape. t i o n s r equ i r e a 0.045-inch clearance between the spacer and t h e c lu t ch output gear . i n s t a l l e d i n t h e c lu tch , t he re w a s no t s u f f i c i e n t c learance t o allow a normal s i z e b a l l bearing t o m i s s t he de ten t p l a t e . through 8.)

jackscrew travel were found properly rigged. t h e c lu t ch s l ipped with appl ica t ions of hydraul ic pressure of 150 p s i . The c lu t ch w a s i n s t a l l e d i n a replacement ac tua tor , and i t s l ipped under loads from 150 t o 650 p s i . below 650 p s i . The c lu t ch i t s e l f normally has a breakout load of 3 t o 4 inch-pounds, but t h e c lu t ch i n quest ion s l ipped a t 14 t o 18 inch-ounces. Manufacturer's f l i g h t test da t a show t h a t i n a takeoff with 30 percent f l a p s and the s t a b i l i z e r i n a f u l l noseup t r i m pos i t ion , the a i r loads measured a t the jackscrew 5 seconds a f t e r l i f t o f f w e r e 380 l b s with a corresponding con t ro l wheel push fo rce of 37 lbs .

Four of t h e b a l l bear ings w e r e loose and were outs ide t h e Two b a l l bear ings

Engineering specif ica-

When t h e clearance w a s measured with four unworn b a l l s

(See f igu res 5

During bench tests of t he ac tua tor , microswitches which l i m i t Under simulated a i r loads

A normal ac tua to r c lu t ch should not s l i p

(2) T r i m p o s i t i o n ind ica to r

The po in te r i n t h e t r i m pos i t i on ind ica to r moves as a funct ion of magnetic f o r c e influenced by d.c. vo l tage from a va r i ab le potentiometer housed i n the hor izonta l s t a b i l i z e r ac tua to r and dr iven by the gearbox. A wiper r o t a t e s from one end of t he potentiometer t o the o ther , receiving an increase o r decrease i n vol tage corresponding t o the pos i t i on of t he s t a b i l i z e r . Ten v o l t s are required t o move the ind ica tor po in te r f u l l d e f l e c t i o n from f u l l nosedown trim t o f u l l noseup trim. The ind ica to r i n N199EA gave an erroneous reading when t e s t ed . When 10 v o l t s were appl ied , t he po in te r stopped halfway within the green band, or takeoff range. This meant t h a t , i n order t o pos i t i on the poin te r i n the green band f o r takeoff , t h e s t a b i l i z e r would have moved t o an adverse noseup trim pos i t ion .

- 15 -

Figure 5 . Clutch assembly i n various stages of disassembly, 1) ,output gear, 2) spring, 3) spacer, 4 ) bal l retainer, 5) detent plate, 6) torque l i m i t gear, 7 ) shaft. A l l photos X2

Figure 6. Balls taken from the clutch assembly. x10

- 16 -

Figure 7. Bearing faces of t he b a l l retainer ( l e f t ) and torque l i m i t gear ( r i g h t ) . Brackets i n d i c a t e r ings of b a l l material deposited on these components. X2

Figure 8. One of t he b a l l depression holes on the torque l i m i t gear showing areas of wear. X10

- 1 7 -

The Safety Board a l s o found t h i s condi t ion on a Beech 99 i t used f o r f l l g h t tests during t h i s inves t iga t ion . During a conformity inspec t ion , Beech A i r c r a f t found t h a t t he t r i m pos i t i on ind ica to r reacted i n a similiar fashion. Inves t iga to r s discovered t h a t , when the ind ica to r w a s tapped o r v ib ra t ed , i t r eg i s t e red a r e l i a b l e reading. o ther Beech 99 opera tors d i sc losed t h a t t h ree reported experiencing.the same d i f f i c u l t y with t h e ind ica to r occasional ly .

A survey of

(3) Out-of-trim warning system

The out-of-trim warning horn w a s reported t o be inopera t ive on November 9, 1977, and t h e microswitch w a s repor ted ly adjusted 2 days later t o co r rec t t h e discrepancy. of t he warning system recorded i n t h e maintenance records. During postaccident examination, t h e microswitch w a s found improperly posi t ioned. It is i n s t a l l e d near t he ac tua to r and r i d e s on a c a m which r o t a t e s as t h e jackscrew i s moved. The pos i t i on of t h e switch w a s such t h a t movement of the s t a b i l i z e r from t h e takeoff range t o i t s extreme limits did not a c t i v a t e t h e switch which would have allowed vol tage through the landing gear microswitch t o sound t h e warning horn. t h e switch had s l ipped from impact forces .

There w e r e no f u r t h e r discrepancies

There w a s no evidence t h a t

The out-of-trim warning system, including t h e ac tua to r , t r i m

P i l o t s are a l s o required t o v i s u a l l y check s t a b i l i z e r trim p o s i t i o n ind ica to r , and trim-in-motion ind ica to r , i s a minimum equipment l i s t i t e m . p o s i t i o n with re ference t o t h e ex te rna l i nd ica to r on the s i d e of t he empennage before takeoff . because t h e poin te r , used t o l i n e up t h e leading edge of t h e s t a b i l i z e r t o t h e zero re ference mark ( r i v e t ) on the fuselage, w a s p a r t i a l l y hidden by t h e de i ce r boot.

The ind ica to r on N199EA w a s not r e a d i l y v i s i b l e

Neither a s s i s t a n t chief p i l o t included the out-of-trim warning system as a check i t e m when asked t o recall t h e i r procedures f o r checking t h e trim system. I n f a c t , one reported t h a t he d id not check the system a t a l l . Also, most c r e w s r e l i e d on the system t o the ex ten t t h a t , i f t h e horn warning d id not sound when f u l l power w a s appl ied f o r takeoff , it meant t h e s t a b i l i z e r t r im w a s c o r r e c t l y set. F ina l ly , trim system check procedures var ied between p i l o t s , and the capta in decided how the check w a s t o be conducted.

1.16.3 A i r c r a f t Performance

Based on t h e weight and balance and c.g. of N199EA and on weather condi t ions a t t h e time of t h e accident , ca l cu la t ions disclosed that, with f l a p s extended 30 percent , a Beech 99 would r equ i r e a ground r o l l of 1,750 f t i n order t o l i f t off a t an airspeed of 94 kns indicated airspeed (KIAS) .

Four witnesses who were loca ted a t several vantage po in t s a t t h e a i r p o r t , estimated t h e l i f t o f f po in t of N199EA. estimates, the average l i f t o f f po in t w a s a f t e r a 1,364-ft ground r o l l which w a s 386 f t , o r 22 percent , sho r t of t h e ca lcu la ted ground r o l l .

Based on t h e i r

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The Safety Board examined the following possibilities to determine what effect they would produce on aircraft pitch control during takeoff: (1) Inadvertent opening of cabidcargo door(s) during takeoff, (2) a jammed elevator, (3) an untimely inflation of deicer boots, ( 4 ) runaway noseup trim, and ( 5 ) takeoff with an extreme noseup trim.

On May 8 to 10, 1978, a Beech 99, owned and operated by Rio Airlines of Killen, Texas, was instrumented and flown at the manufacturer's facility through flight profiles derived from accident data. These flight tests were conducted to determine which of the above factors or combination of factors could have produced the accident takeoff profile, and to identify the handling characteristics of a Beech 99 under the various conditions.

The tests included flight to various aircraft pitch attitudes at different configurations of weight and c.g. and at different stabilizer trim settings. First, these tests were performed at altitude and then on takeoff from a runway. The objectives were to determine: (1) Time, altitude, and control wheel forces required to establish a desired pitch attitude; (2) time and altitude required to decelerate to a stall and reach zero rate of descent, and the airspeed at the apex; (3) time required to return to original altitude; and ( 4 ) techniques and control wheel forces required to avoid a stall. conducted with configurations incorporating: (1) As close as possible, the weight and c.g. of N199EA, (2) a "worst case" c.g. position, and (3 ) a c.g. position that permitted a comparison of the sensitivities of performance parameters and control wheel forces to changes in the vertical distribution of the load in the aircraft. These tests also made it possible to study the effect of various mass moments of inertia on the aircraft's longitudinal handling characteristics.

Three series of tests were

The flight profile of N199EA based on witnesses' observations and confirmed by the flight tests follows:

STALL 0 200-250 FT AGL 350-400 FTAGL

72 KN NWLO LIFTOFF 78 KN 84 KN

IMPACT

I 5-6 SEC 1 4 3 S E C L

rAKE RELEASE

13 SEC

Figure 9. Flight profile of N199EA.

- 1 9 - The tests d isc losed that t h e nosewheel l i f t e d off a t 78 KIAS

and t h e aircraft l i f t e d of f a t 84 KIAS with the s t a b i l i z e r i n the f u l l noseup t r i m pos i t ion . The aircraft f l i g h t manual r equ i r e s a l i f t o f f speed of 94 KIAS f o r a maximum gross weight takeoff . from brake release t o l i f t o f f w a s 1,350 ft--nearly the same d i s t ance averaged from witness statements. Control wheel push fo rces d id not become s i g n i f i c a n t u n t i l a f t e r l i f t o f f .

Ground r o l l d i s t ance

The tests a l s o d isc losed t h a t a i r speed would increase when the

When no r e s t r a i n i n g con t ro l wheel f o r c e w a s pitchup a t t i t u d e w a s less than 15'. a t t i t u d e s of more than 15'. appl ied , p i t c h would reach 30" i n about 1 .5 seconds. w a s permitted t o increase t o a p i t c h a t t i t u d e of 30" and i f t h i s s teep a t t i t u d e w a s no t cor rec ted wi th in 5 t o 6 seconds of i n i t i a l pitchup, wing s t a l l w a s c e r t a i n , and recovery before descent t o the i n i t i a t i n g a l t i t u d e w a s unl ikely. A t p i t c h a t t i t u d e s of about 30" s u f f i c i e n t e l eva to r a u t h o r i t y w a s a v a i l a b l e t o avoid a s t a l l i f immediate and p o s i t i v e con t ro l f o r c e s w e r e appl ied before t h e a i r c r a f t decelerated t o stall speed. Although s u f f i c i e n t e l eva to r au tho r i ty ex is ted t o prevent r o t a t i o n t o high noseup p i t c h a t t i t u d e s a f t e r takeoff , a t t i t u d e awareness had t o be maintained t o r e s t r a i n t h e rap id pitchup tendency of t he Beech 99 i n the test conf igura t ion a f t e r l i f t o f f . I f t he main t r i m system w a s inopera t ive , t he long i tud ina l con t ro l wheel fo rces required could reach 50 t o 65 pounds of push f o r c e before t h e standby t r i m system could be se l ec t ed and the out-of-trim condi t ions corrected.

Airspeed would decrease a t p i t c h

I f t he a i r c r a f t

I n summary, t he Safety Board's performance eva lua t ion revealed the following:

(1) Inadvertent door opening during takeoff w a s e l iminated

Also, witnesses d id not see an a f t e r ca l cu la t ions ind ica ted an open door would not cause t h e a i r c r a f t t o p i t c h up on takeoff as N199M did. open door.

(2) A jammed e l eva to r w a s considered improbable, because the fl-lght tests s imulat ing a takeoff with the con t ro l column lock p in i n s t a l l e d d id not produce a reasonable approximation of t he accident p r o f i l e . The s tandard con t ro l locking device w a s stowed, and the re w a s no evidence t h a t fore ign objec ts had obstructed t h e con t ro l system.

(3) An untimely i n f l a t i o n of t h e de icer boots w a s dupl icated i n f l i g h t and w a s found t o produce neg l ig ib l e pitchup a t a i r speeds less than 100 kns.

(4) Although not impossible, runaway noseup t r i m w a s considered improbable. For t h e s t a b i l i z e r t r i m t o have run from a takeoff s e t t i n g t o an extreme noseup t r i m would r equ i r e e i t h e r 9 o r 27 seconds, depending on whether t he main o r standby motor w a s i n operation. l i f t o f f when t r i m co r rec t ions are most l i k e l y t o be f i r s t appl ied, i t i s un l ike ly t h a t pi tchup a f t e r l i f t o f f would have been as abrupt as t h a t

I f i t began a t

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reported by witnesses. switch to disengage the system in the event of runaway. Also, the stabilizer was not found in an extreme noseup position. Fault analyses of the electrical and mechanical design of the trim system performed by the manufacturer and the FAA indicated that the likelihood of a runaway trim was remote.

The main trim system incorporates a trim release

(5) Takeoff with an extreme noseup trim was determined to be the most probable condition which, combined with a center of gravity near the aft limit, would have caused the flight profile of N199EA. aircraft was rotated and lifted off about 10 kns earlier than normally expected; however, pilot technique could vary the point at which rotation would begin. generated before liftoff to warn a pilot of mistrim. Flight tests indicated that the Beech 99 is controllable on takeoff with full noseup trim and with the center of gravity near or at the aft limit. Although the control forces are high, they are manageable and within the limits specified by Federal Aviation Regulation Part 23.143. If, through inattention or for some other reason, the pilot permits the Beech 99 to rotate to a.pitch attitude of 30' or greater during a climb after takeoff and if he then does not promptly correct the aircraft attitude, a stall will occur from which recovery is essentially impossibze.

The

There were no abnormally high control wheel push forces

1.17 - Additional Information

1.17.1 Columbia Pacific Airlines' Operational and Maintenance Practices

Operations

The Airlines' original corporate entity was Execuair, Inc., which flew its first scheduled flight between Richland and Seattle on December 21, 1971, with a six-passenger Piper Navajo (PA-31). Execuair, Inc., was purchased by Columbia Pacific Resources in March 1974.

In early 1977, Columbia reported that the Navajo's seating capacity was not adequate to handle the increasing traffic growth. that time, it operated four Navajos. Because of its greater seat capacity and its favorable cost considerations, the Beech 99 was chosen to augment the operation.

At

From May 23 through 27, 1977, the Airlines' Director of Operations, who was also its chief pilot, and a line captain attended Beech 99 ground school at the Beech Aircraft Training Center at Wichita, Kansas. According to the chief pilot, the training consisted of 30 hours of audio-visual instruction with little classroom instruction because instructors were not available. Since the Beech 99 was no longer being manufactured, flight training was not available from Beech Aircraft Corporation.

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From June 12 through 15, 1977, Columbia's chief p i l o t and another l i n e capta in v i s i t e d B a r Harbor Ai r l ines t o obta in f l i g h t i n s t r u c t i o n and t o take de l ivery of a r ecen t ly purchased Beech 99 (N1034S). They received some informal ground i n s t r u c t i o n and 6 hours of f l i g h t t r a i n i n g covering normal and emergency procedures. Richland on June 159 t r a i n i n g from Bar Harbor and returned t o Richland along with t h e chief p i l o t i n N199EA.

N1034S w a s flown t o On July 6, two o ther l i n e capta ins received f l i g h t

The chief p i l o t w a s given check p i l o t approval by the FAA J u l y 11, 1977, and he w a s t h e only check p i l o t i n t h e company. A s of J u l y 1977, t h e company employed 33 p i l o t s .

Since acqui r ing t h e Beech 99, t h e A i r l i n e conducted 125 hours About 8 hours out of t he 25 hours of proving test of p i l o t t r a in ing .

f l i g h t s w e r e observed by an FAA inspec tor along scheduled routes . According to the proving test r epor t of the 13 simulated emergency procedures observed on those f l i g h t s , none concerned the t r i m system.

On August 24, 1977, t h e Chief of t h e Spokane GADO sen t a le t ter t o t h e Pres ident of Columbia P a c i f i c A i r l i n e s s t a t i n g h i s concern t h a t t h e A i r l i n e may not be s u f f i c i e n t l y s t a f f e d with supervisory personnel t o meet i t s rap id growth i n s i z e and complexity. inc ident ind ica ted t h a t b e t t e r management of a i r c r a f t maintenance w a s needed and t h a t i t s chief p i l o t ' s d u t i e s i n both operat ions and maintenance f a r exceeded t h e c a p a b i l i t i e s of one man. He w a s encouraged by t h e changes being made i n maintenance recordkeeping and assignment of r e s p o n s i b i l i t y i n t h i s area, the planned development of its own maintenance f a c i l i t y a t Richland, and t h e proposed add i t ion of two a s s i s t a n t operat ions supervisors t o reduce t h e burden on i t s chief p i l o t .

He s t a t e d t h a t a p a s t

On September 20 and 22, t h e Spokane GADO approved two Columbia cap ta ins as check p i l o t s . On January 1, 1978, Columbia began operat ing i t s own maintenance f a c i l i t y a t t h e Richland Airport and had h i red t h e ind iv idua l who had provided cont rac t maintenance as i ts Director of Maintenance; he a l s o continued t o opera te h i s own f a c i l i t y at Pasco, Washington.

According t o the A i r l i n e ' s Operations Manual, a l l p i l o t s were given i n i t i a l and recur ren t ground and f l i g h t t ra in ing . The t r a i n i n g w a s t o be accomplished i n accordance with t h e s tandards of 14 CFR 135.138 and FAA Advisory Ci rcu lar Multi-Engine F l i g h t T e s t Guide. a l s o a provis ion f o r t r a i n i n g i n new equipment. The manual ou t l ined t h e t r a i n i n g subjec t matter but d id not spec i fy required numbers of hours. An o r a l o r w r i t t e n test w a s required.

There w a s

Regarding the Beech 99, t h e A i r l i n e made no determination on t h e minimum number of hours of t r a i n i n g necessary t o qua l i fy i ts p i l o t s . The Director of Operations reported that, a s i d e from h i s t r a i n i n g a t

- 22 -

Beech Ai rc ra f t , he d id not have s u f f i c i e n t information from which t o e s t a b l i s h a minimum hour requirement. H e s t a t e d t h a t t he number of hours given each p i l o t depended on t h e p i l o t ' s background. information on t h e a i r c r a f t w a s obtained from Bar Harbor Air l ines . Training consis ted of ground and f l i g h t i n s t ruc t ion on subjec t areas out l ined i n t h e Operations Manual and the audio-visual course obtained from Beech Ai rc ra f t . The Ai r l ine could not provide the Safety Board with a sy l labus showing t h e d e t a i l s of t h e t r a in ing out l ined i n i t s manual.

Operational

The t r a i n i n g record of t h e capta in involved i n the accident d id not show c l e a r l y the kind of i n i t i a l t r a i n i n g he received i n the Beech 99. No da te s were recorded on the th ree wr i t t en tests i n h i s record; none of t h e tests r e l a t e d t o t h e Beech 99. t r a i n i n g accomplishments and da te s had been recorded on a form, h i s f l ight- t ime record indicated t h a t he w a s f l y i n g scheduled f l i g h t s on those dates . According t o records, he had received 2 . 3 hours of i n i t i a l f l i g h t t r a in ing before h i s check f l i g h t . The f i r s t o f f i c e r ' s record showed he obtained 1.8 hours of f l i g h t t r a i n i n g before receiving h i s check f l i g h t . Neither record showed they had received the audio-visual presentat ion. The records d id not d i sc lose whether e i t h e r p i l o t had previous turboprop a i r c r a f t experience.

Although a number of

A review of a l l t h e Air l ines ' p i l o t t r a i n i n g records showed t h a t t he A i r l i n e genera l ly m e t t he recordkeeping requirements of 14 CFR 135.43; however, t h e records d id not contain the p i l o t s ' duty assignments and f l i g h t t i m e as required by t h e regulat ion. Testimony a t the Safety Board's publ ic hearing on t h e acc ident d i sc losed t h a t t h e Ai r l ine maintained f l i g h t t i m e i n a separa te f i l e . The records d id not contain information from which t o assess a p i l o t ' s t r a i n i n g progress, and such information i s not s p e c i f i c a l l y required by regula t ion . Although a l l p i l o t s had successfu l ly passed t h e o r a l o r wr i t t en tests and f l i g h t checks, a comparison could not be made t o assess a p i l o t ' s l e v e l of prof ic iency.

On January 28, 1978, Columbia's f l i g h t operat ions department issued a le t ter t o a l l personnel s t a t i n g t h a t the Ai r l ine w a s again experiencing numerous la te f l i g h t s and c i t e d some reasons f o r t he delays. The le t te r s t a t e d , "An on t i m e departure is a key t o on t i m e arrivals," and t h a t t h e p o t e n t i a l is g rea t e r f o r reducing the l o s t t i m e during ground turnarounds r a t h e r than i n f l i g h t . The let ter required t h a t f l igh tcrews be i n t h e i r a i r c r a f t a t least 5 minutes before depar ture t i m e . i n obtaining weather information and i n completing weight and balance forms. The let ter a l s o cautioned crews not t o a l low themselves t o become rushed i n the cockpit -- t h a t once i n the a i rp l ane they should r e l a x and opera te a t t h e i r des i red pace.

The le t te r urged teamwork i n terms of one crew a s s i s t i n g another

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Maintenance

A s of January 1, 1978, Columbia P a c i f i c had seven persons, including t h e Direc tor of Maintenance and a sec re t a ry , assigned t o i ts maintenance department. powerplant r a t ings . course; one had at tended t h e Beech 99 course before he w a s employed by Columbia, and t h e o ther had at tended a Beech 90 course before he w a s employed by t h e Air l ine . personnel nor w a s one required.

The f i v e mechanics held cur ren t a i r f rame and Two mechanics had at tended a Beech A i r c r a f t maintenance

There w a s no t r a i n i n g program f o r maintenance

The continuous maintenance inspec t ion program consis ted of f i v e 100-hour inspec t ions i n accordance with the A i r l i n e ' s approved program and 1 4 CFR 91.217(b) (5). maintenance, t h e A i r l i n e used a i r c r a f t d a i l y f l i g h t logs , an inspec t ion form f o r each of t h e f i v e inspect ions, and an intermediate inspec t ion worksheet.

To con t ro l discrepancies and t o schedule

The d a i l y f l i g h t l og contained th ree color-coded sheets . One shee t w a s a permanent p a r t of t h e log, one w a s removed f o r t he maintenance department, and t h e o the r w a s removed f o r adminis t ra t ive purposes. The back of t h e log w a s designed f o r recording deferred maintenance i t e m s , bu t t h i s po r t ion w a s not used by t h e mechanics. t r ans fe r r ed t o t h e intermediate inspec t ion worksheet which w a s maintained i n t h e maintenance o f f i c e . a s c e r t a i n t h e a i rwor th iness of an a i r c r a f t . system f o r placarding var ious inopera t ive equipment nor had they es tab l i shed procedures t o be followed i n t h e event c e r t a i n equipment became inoperat ive.

A l l deferred i t e m s w e r e

A s a r e s u l t , a f l igh tcrew could not r ead i ly Also, t h e Ai r l ine had no

1.17.2 A i r c r a f t Minimum Equipment L i s t

FAA permits c e r t a i n a i r c r a f t equipment t o be inopera t ive t o a l low f o r uninterrupted operat ion of t h e a i r c r a f t i n revenue serv ice . The minimum equipment l ist w a s approved during t h e type c e r t i f i c a t i o n of t h e Beech 99 and is a p a r t of t h e FAA-approved a i r c r a f t f l i g h t manual designed t o provide ope ra to r s -wi th t h i s au tho r i ty and t o in su re an acceptab le level of sa fe ty .

Regarding the ho r i zon ta l s t a b i l i z e r t r i m system, the Beech 99 minimum equipment l ist provides t h e following:

"2. S t a b i l i z e r Pos i t ion Indica tor - may be inopera t ive provided visual check i s made p r i o r t o each T/O ( takeoff ) and both a u r a l i nd ica to r s are funct ioning.

"3. Trim-in-motion Aural Ind ica to r - may be inopera t ive provided pos i t i on ind ica to r i s funct ioning and maximum operat ing speed (Vmo) is r e s t r i c t e d to. 200 kns.

- 24 -

"4. Out-of-trim Aural Warning Indica tor - may be inoperative provided n e u t r a l pos i t i on is v i s u a l l y checked p r i o r t o each takeoff and s t a b i l i z e r pos i t i on indica to r i s funct ional .

"5. S t a b i l i z e r Actuator Motor - one t r i m system motor may be inopera t ive f o r f l i g h t l imi ted t o e s s e n t i a l crew only, Vmo r e s t r i c t e d t o 200 kns."

Inopera t ive items covered by t h e minimum equipment list are required t o be brought t o the a t t e n t i o n of t he f l ightcrew, e i t h e r by placarding o r by f l i g h t logsheet en t ry , and appropr ia te procedures are requi red t o be es tab l i shed and followed by t h e operator i f a f l i g h t i s made with i t e m s inoperat ive.

The preamble t o t h e minimum equipment list states:

... The operator is responsible f o r exerc is ing t h e necessary opera t iona l cont ro l t o assure t h a t no a i r c r a f t is dispatched with mul t ip le MEL i t e m s inopera t ive without f i r s t determining t h a t any i n t e r f a c e o r i n t e r r e l a t i o n s h i p between inoperative systems o r components w i l l not r e s u l t i n a degradation i n t h e level of s a f e t y and/or undue increase i n crew workload.

11

"...The exposure t o add i t iona l f a i l u r e s during continued operat ion with inoperat ive systems o r components must a l s o be considered i n determining that an acceptable level of s a f e t y i s being maintained. The MEL w a s never intended t o provide f o r continued operat ion of t h e a i r c r a f t f o r an indef- i n i t e period with airworthiness items inoperat ive.

The m i m i m u m equipment l ist does not spec i fy t i m e l i m i t s .

1.17.3 Federal Aviation Administration C e r t i f i c a t i o n and Survei l lance

On June 30, 1969, a FAA mul t ip l e expert opinion team w a s formed t o eva lua te t h e f l i g h t c h a r a c t e r i s t i c s of the Beech Models 99 and 100. had ind ica ted that t h e one-hand c o n t r o l l a b i l i t y forces required by 1 4 CFR 23.145 w e r e except ional ly high. FAA found t h a t both models were no t i n compliance wi th 1 4 CFR 21.21, 23.143 with regard t o a mistrimmed takeoff , o r 23.145(b).

F l i g h t tests conducted t o eva lua te reported longi tudina l o s c i l l a t i o n

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A s a result of the flight test evaluations on July 1 and 2, the FAA team of experts found:,

"1. The possibility of takeoff with stabilizer trim at extremes of travel creates an unsafe condition in accordance with FAR 23.143 and FAR 21.21. This is applicable to both the Model 99 and 100.

"2. me longitudinal controllability forces observed during the flight evaluation were considered excessive for aircraft of this type and prevented making a smooth transition from one flight condition to another. FAR 23.145(b). In particular, on the Model 99 at forward gross, conditions 23.145(b) (3), (4), (5) and (6) were in noncompliance. On the Model 100 at most forward regardless, conditions 23.145(b) (4) and (6) were in noncompliance. Other required conditions having similar forces would be considered in noncompliance. were found to be accurate."

This is not considered in compliance with FAR 23.143 and

The forces noted and checked in the TIR

These flight tests, however, were concentrated primarily on nosedown trim.

Of the eight recommendations submitted, all team members agreed on two --

"1. That mistrim forces on takeoff be reduced or alternatively that a takeoff warning system be installed to warn the pilot that trim is beyond safe limits for takeoff.

"2. That the longitudinal control forces be lowered or alternatively that FAA require a letter of competency for each pilot-in- command of these aircraft.

On June 20, 1969, a Beech 99 crashed at Pasco, Washington, after a short takeoff roll and an abnormally steep climb, followed by a loss of control. The two crewmembers, the only occupants on board, were killed and the aircraft was destroyed by impact and postcrash fire. Investigation disclosed that the horizontal stabilizer actuator jackscrews were in the full aircraft noseup trim position. functionally tested and was found to be within manufacturer's tolerances. Examination of the aircraft showed that the flaps were extended 30 percent and the landing gear were retracted. about 8,300 lbs and the c.g. was about 179 in. It was not determined if an unscheduled trim condition was involved. of probable cause was the flightcrew's failure to maintain flying speed, improper operation of flight controls, and inadequate preflight preparation.

The actuator

The aircraft's gross weight was

The Safety Board's determination

On July 6, 1969, a Beech 99 crashed at Monroe, Georgia, killing the 12 passengers and 2 crewmembers on board. the en route phase of flight; the aircraft descended and struck the

The plane crashed during

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ground i n a near ver t ical dive. ho r i zon ta l s t a b i l i z e r ac tua to r jackscrews w e r e i n t he f u l l nosedown t r i m pos i t i on . and t h e landing gear were re t r ac t ed .

Inves t iga t ion disclosed t h a t t h e

The f l a p s w e r e between t h e approach and r e t r a c t e d pos i t i on ,

The Safety Board's determination of t h e probable cause w a s :

... an unwanted change i n long i tud ina l t r i m which r e s u l t e d i n I 1

a nosedown high-speed f l i g h t condi t ion t h a t w a s beyond the physical c a p a b i l i t y of t h e p i l o t s t o overcome. accident sequence could n o t be s p e c i f i c a l l y determined. However, t h e design of t h e a i r c r a f t f l i g h t con t ro l system w a s conducive t o malfunctions which, i f undetected by t h e crew, could l ead t o a l o s s of control."

The i n i t i a t i n g element i n t h e

On J u l y 9, 1969, a n FAA s p e c i a l i nves t iga t ion team w a s organized as a r e s u l t of t h e foregoing acc iden t s and t h e s p e c i a l f l i g h t tests t h a t had been conducted on J u l y 1 and 2, 1969. Two areas about t h e a i r c r a f t concerned FAA: "The powerful f o r c e s a s soc ia t ed with the s t a b i l i z e r m i s t r i m , and t h e general c o n t r o l l a b i l i t y during configurat ion changes." The ob jec t ive of t h e s p e c i a l i nves t iga t ion team w a s "...to make an o v e r a l l review of t h e problem with t h e i n t e n t of exploring means t o provide a n acceptable level of safety." w i t h 1 4 CFR 21.21(a)l. The t e a m examined t h e problem of a takeoff with t h e s t a b i l i z e r i n a n extreme noseup t r i m p o s i t i o n with t h e c.g. near t h e forward l i m i t and found ".,..there w a s very l i t t l e c o n t r o l problem and a r e l a t i v e l y l i g h t push f o r c e (20-25#) t o maintain normal climb speeds.

This a c t i o n w a s i n accordance

The s p e c i a l i nves t iga t ion team concluded i n p a r t :

" . . . that with s p e c i f i c modifications and procedures spec i f i ed under t h e recommendations of t h i s r epor t , t h e Model 99 is a s a t i s f a c t o r y a i r p l a n e f o r t h e purposes approved.

... t h a t t h e complexities and individual c h a r a c t e r i s t i c s of I 1

t h e a i r p l a n e r e q u i r e that t h e p i l o t i n command demonstrate h i s knowledge and s k i l l t o a competent a u t h o r i t y on these f ea tu res . p re sen t i n command, i t be assured that they receive appropriate r e f r e she r t r a i n i n g through formal t r a i n i n g programs and f u t u r e commanders be required t o demonstrate competence.

For those a t

... t h a t t h e trim changes with configurat ion change r e su l t ed i n higher than d e s i r a b l e fo rces but could be r e a d i l y a l l e v i a t e d by t h e p i l o t due t o t h e t r im con t ro l being on t h e con t ro l wheel. Though not meeting t h e i n t e n t of FAR 23.145(b) i n t h e est imat ion of t h e evaluators , t h e a i r p l a n e can be s a f e l y control led and has compensating features ."

I1

The s p e c i a l team recommended, i n p a r t :

" A l l p i l o t s p re sen t ly operat ing t h e model 99 be subjected t o a n o r a l examination t o a s su re t h e i r competence and knowledge on a l l

- 27 -

essential systems and procedures for safe operation of the airplane. All new pilots be examined as to competence to command the airplane, prior to assuming command, by a representative of the Administrator or appropriately designated authority."

"The manufacturer to engage in a long range program to redesign the longitudinal control system so as to substantially reduce the forces required to maintain attitude and velocity without retrimming during configuration changes.

On August 1, 1969, the Safety Board recommended that the Administrator, FAA, establish emergency recovery procedures from unwanted or adverse longitudinal trim conditions and publish them in the FAA- approved flight manual. stabilizer "in-transit" warning system be installed in Beech 99 aircraft and that the horizontal stabilizer trim range be restricted to prevent excessive aircraft nosedown trim while in flight.

The Board also recommended that a horizontal

The Administrator replied on August 6, 1969, that he had taken action to carry out the Board's recommendations.

The FAA also undertook a number which related to the longitudinal control those recommendations provided by the two manufacturer reduced the nosedown control the stabilizer leading edge upward travel restricting the trim range when the flaps

N199EA was equipped with all of

of other corrective actions system. These actions incorporated flight test evaluations. The wheel forces by (1) limiting to 3.5" from 5.5" and (2) are up.

the necessary recommended ~ ~~

changes. However, no long-range redesign plans to reduce the noseup longitudinal control forces had been incorporated in N199EA, nor in any other Beech 99 manufactured.

On June 19, 1978, as a result of the Columbia Pacific Airlines accident, the Safety Board requested of FAA, the objective and the action taken to implement the letter of competency recommended by the team of experts. On August 15,FAA responded that the objective of the letter of competency was ''...to increase the awareness of the BE-99 flightcrews to certain aircraft handling characteristics."

FAA established a requirement for the letter and it was outlined in FAA Order 8430.111, Chapter 9, paragraph 222, March 3, 1975. According to FAA, "This requirement provides evidence that the pilot has satisfactorily demonstrated competency to conduct specific maneuvers and procedures in a particular type, class, and category of aircraft."

A review of FAA Order 8430.1A showed that paragraph 222 provides inspectors with general guidance in enforcing the requirements

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of 1 4 CFR 135, sec t ions 122, 131, and 138. T h i s paragraph does not include s p e c i f i c procedures t o be incorporated during those required f l i g h t checks.

The June 1977 e d i t i o n of FAA Order 8430.111, Chapter 7 , P i l o t and F l i g h t Attendant Crewmember Training Programs, paragraph 153, states t h a t inspec tors shall determine that each t r a i n i n g program is adequate t o prepare crewmembers t o m e e t t h e t e s t i n g requirements of 1 4 CFR 135.122, 135.131, 135.138, and 135.139. The Order encourages inspec tors t o

t r i m , on those a i r c r a f t having t r imable s t a b i l i z e r s , which can cause reduced e l eva to r e f fec t iveness and uncontrol lable s t i c k forces." The Order s p e c i f i c a l l y uses t h e Beech 99 as an example i n areas t o be covered f o r ground and f l i g h t t r a in ing . con t ro l of t he a i r c r a f t with t h e use of t he t r i m system as w e l l as with var ious f l i g h t con t ro l s and engine power s e t t i n g s . The order s t a t e d t h a t t he procedures t o be followed by inspec tors t o accomplish t h i s t r a i n i n g w a s contained i n the referenced Ju ly 19, 1969, Airworthiness Direct ive, which rev ised t h e Beech 99 Ai rc ra f t F l igh t Manual.

emphasize t h e p o t e n t i a l problem areas induced through misuse of s t a b i l i z e r 11

These areas concern longi tudina l

Review of t h e Beech Airworthiness Directives d isc losed t h a t AD-69-16-3 and 69-18-6 had been rescinded by AD-71-12-2, dated June 3, 1971, because the objec t ives of these A D ' s and those s i x r e l a t e d AD's had been accomplished. p i t c h trim procedures. The revised trim check procedures i n AD-69-16-3 had been incorporated i n t o the f l i g h t manual. not descr ibe how t o cope with a mistrimmed s t a b i l i z e r on takeoff , and t h i s information had not been incorporated i n the f l i g h t manual.

The two AD'S d e a l t with trim check and unscheduled

However, AD-69-18-6 did

The FAA GAD0 a t Spokane, Washington, assigned one p r inc ipa l operat ions inspector , one p r inc ipa l maintenance inspec tor , and one maintenance inspec tor t o the Air l ine . Program inspec t ion of Columbia P a c i f i c A i r l i nes w a s conducted September 15 through 1 7 , 1975; i t disclosed no major discrepancies i n the A i r l i n e ' s opera t ion .

A System Worthiness Analysis

Since August 8, 1977, t he p r inc ipa l operat ions inspector conducted th ree base inspect ions; t h e last w a s performed January 25, 1978. On August 2, 3, and 4, su rve i l l ance inspect ions w e r e conducted as a r e s u l t of a company p i l o t ' s complaint of a def ic iency i n communications between f l igh tcrews and maintenance personnel which had r e su l t ed i n maintenance being disregarded. A s a r e s u l t of t h a t complaint, FAA a s s i s t e d the company i n e s t ab l i sh ing a new maintenance discrepancy record system. The second base inspec t ion disclosed t h a t a l l records were i n proper order. The t h i r d base inspect ion disclosed t h a t one Piper Navajo and one Beech 99 (N1034S) were found i n good condi t ion, t h a t a l l p i l o t s ' records w e r e i n good order , and t h a t t he company manual w a s complete except f o r two r ev i s ions on hazardous materials.

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The Safety Board's publ ic hearing on the accident d i sc losed t h a t t h e p r i n c i p a l operat ions inspec tor had never been given a f l i g h t check i n t h e Beech 99. he w a s checked i n the Beech Klng A i r (Model 90) and North American Aero Commander--the model 90 i s not t h e same type a i r c r a f t and does not have a moveable ho r i zon ta l s t a b i l i z e r t h a t can be trimmed. When asked how many hours he thought would be required t o qua l i fy a p i l o t as capta in i n t h e Beech 99, he s t a t e d 6 t o 1 0 hours depending on whether t h e p i l o t had any previous turbine-powered aircraft experience. Testimony a t the pub l i c hearing concerning s t a b i l i z e r m i s t r i m d i sc losed t h a t Columbia P a c i f i c p i l o t s had received only unscheduled (runaway) trim emergency t r a in ing .

However, he had at tended the FAA Academy where

On September 16 and December 15, 1977, and on January 25, 1978, maintenance in spec to r s performed base inspec t ions , t he last of which revealed t h a t t he A i r l i n e ' s maintenance f a c i l i t y w a s i n operat ion, a d i r e c t o r of maintenance had been assigned, two maintenance s h i f t s had been es tab l i shed , t h e maintenance manual had been updated, and a new a i rwor th iness recordkeeping system had been developed.

From August 4, 1977, t o January 31, 1978, s ix su rve i l l ance inspec t ions were performed, four of which w e r e ramp inspec t ions of a i r c r a f t . During t h e var ious inspect ions, a l l four of t he Piper Navajo a i r c r a f t had been examined--one t w i c e and another th ree t i m e s . Beech 99, N1034S, had been examined, and it had been examined on th ree d i f f e r e n t occasions; N199EA had not been examined. According t o the p r i n c i p a l maintenance inspec tor , they are not required t o inspec t a l l a i r c r a f t . The records of t h e var ious inspec t ions d id not d i s c l o s e t h a t t h e A i r l i n e w a s no t recording a i r c r a f t discrepancies i n the deferred s e c t i o n of t he d a i l y f l i g h t log.

Only one

1.17.4 Inves t iga to r ' s Observations of a Company F l igh t

On February 23, 1978, a Safety Board inves t iga to r boarded Columbia P a c i f i c F l i g h t 11 (N1034S) a t Richland t o f l y t o Sea t t l e . During t h e f l i g h t , t h e inves t iga to r noted that the c r e w had posi t ioned t h e i r f l i g h t bag between t h e i r seats ad jacent t o the con t ro l pedestal . This i s a normal procedure. The f r o n t l e f t corner of the bag w a s aga ins t t h e hor izonta l s t a b i l i z e r main and standby t r im power switches. The seams of the f r o n t l e f t and r i g h t rear corners of t he bag w e r e t o rn severe ly from plac ing o r removing i t e m s such as the f l i g h t manual and d a i l y f l i g h t log. guarded, a crewmember can inadver ten t ly t u r n the main power switch of f by placing a f l i g h t l og i n t o t h e bag. opera tors , i n v e s t i g a t o r s learned of e igh t reported ins tances of t h i s ; t hese p i l o t s , however, immediately not iced t h e mistake.

(See f i g u r e 10.) Since the switches are only p a r t i a l l y

During a survey of Beech 99

1.18 New Inves t iga t ive Techniques

None

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Figure 10. Closeup of f l i g h t bag with f r o n t l e f t corner aga ins t = in and standby t r i m switches. Note t h e t o r n seams of t h e bag.

2. ANAT.IYSIS

The f l i gh tc rew w a s c e r t i f i c a t e d , and each had received the off-duty time prescr ibed by regulat ions. There w a s no evidence of physiological problems that might have a f f ec t ed t h e i r performance.

Based on a v a i l a b l e evidence, t h e Safety Board concludes t h a t a n adverse noseup p o s i t i o n of t h e ho r i zon ta l s t a b i l i z e r most probably produced the pitchup and s t e e p climb a f t e r takeoff . during which t h i s configurat ion of t he ho r i zon ta l s t a b i l i z e r w a s repro- duced, confirmed t h a t an adverse p o s i t i o n w i l l produce the accident p r o f i l e i f t h e p i t c h a t t i t u d e is allowed t o increase t o about 30" and is not immediately reduced. t o r e s t r a i n t h e pitchup were high, they were manageable and were within t h e l i m i t s spec i f i ed by regulat ions.

F l i g h t tests,

Although t h e c o n t r o l wheel push fo rces required

P i l o t Technique

It w a s a p i l o t technique among some of t he A i r l i n e ' s p i l o t s t o ease back on t h e c o n t r o l wheel a t 78 KIAS (Vmc) t o ob ta in con t ro l "feel" f o r t h e a i r c r a f t before l i f t o f f . Standard c a l l o u t s are made a t 80 and 90 K'IAS, a t which t i m e r o t a t i o n would begin followed by l i f t o f f a t 94

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RIAS. technique a t 78 KIAS. Reportedly, he trimmed a f u l l y loaded Beech 99 "nose l i gh t . " This would provide f o r low p u l l fo rces during r o t a t i o n and a smoother l i f t o f f ; however, depending on the amount of trim used, push fo rces might be required. According t o f l i g h t tests, con t ro l push fo rces would not have become not iceably high u n t i l a f t e r l i f t o f f . Therefore, the capta in may not have had an ind ica t ion of a m i s t r i m condi t ion through con t ro l wheel pressures before l i f t o f f because of the manner i n which he trimmed t h e a i r c r a f t . a i r c r a f t nose l i g h t , combined with a s t a b i l i z e r i n an adverse noseup trim pos i t ion , probably contr ibuted t o t h e e a r l y l i f t o f f .

The Safety Board could not determine i f t he capta in used a similar

H i s p r a c t i c e of trimming the

The abrupt pitchup of 30' wi th in 1.5 seconds a f t e r l i f t o f f required f l igh tcrew a c t i o n within 5 t o 6 seconds t o reduce t h e s teep a t t i t u d e before s ta l l . F l i g h t tests showed t h a t s u f f i c i e n t e l eva to r au tho r i ty ex i s t ed t o reduce the p i t c h a t t i t u d e had the f l igh tcrew countered with 50 t o 65 l b s of push forces .

The postcrash pos i t i on of t h e s t a b i l i z e r a t a pos i t i on near t h a t of t he co r rec t takeoff t r im s e t t i n g ind ica t e s t h a t t he t r im apparent ly had been corrected from an adverse noseup pos i t ion ; t he t i m e required t o make the co r rec t ion (20 seconds) using t h e secondary trim system alone exceeded t h e t i m e (5 t o 6 seconds) from l i f t o f f t o s t a l l at a p i t c h a t t i t u d e of 30'. However, t h e t i m e from l i f t o f f t o the top of t h e climb would have been about 20 seconds, and i t i s reasonable t h a t t he capta in continued trimming a t least t o t h a t point . Once i n the s ta l l , t he a i r l o a d s on the s t a b i l i z e r would have decreased and c lu t ch s l ippage would have been reduced. I n view of t he sho r t t i m e i n t e r v a l , t h e c r e w probably responded immediately t o co r rec t the extreme pitchup by using t h e trim system ins tead of concentrat ing on applying t h e required push f o r c e s on the con t ro l wheel.

The abrupt climb probably prompted the capta in to : (1) Attempt co r rec t ion of t he p i t c h a t t i t u d e with the main p i t c h t r i m system (dual element switches on t h e con t ro l wheel) and then switch t o the standby system when t h e main system w a s found t o be i n e f f e c t i v e because of t he s l i pp ing ac tua to r c lu tch ; o r , (2) s e l e c t t h e standby system immediately a f t e r t he pitchup, because he suspected a problem with the main system.

Another f a c t o r might have delayed the crew's attempt t o reduce the pi tchup with t h e t r im system. The p a r t i a l l y guarded main p i t c h t r im switch could have been turned of f inadver ten t ly when the f i r s t o f f i c e r placed t h e d a i l y f l i g h t l o g i n t o the f l i g h t case a f t e r he logged takeoff t i m e . and he probably would have turned the main switch ON a f t e r discovering t h e dual element switches on the con t ro l wheel w e r e i n e f f e c t i v e i n reducing the con t ro l forces . he would then have switched t h e main t r im OFF and t h e standby ON. These a c t i o n s probably involved a t least 6 t o 7 seconds.

The capta in then would have found both switches i n the OFF pos i t ion ,

Af te r f ind ing the main trim t o be ine f f ec t ive ,

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The f l i gh tc rew ' s r e l i a n c e on the trim system to c o r r e c t t he pitchup probably diver ted t h e i r a t t e n t i o n from the ou t s ide v i s u a l references, which f l i g h t tests disclosed w e r e e s s e n t i a l i n r e s t r a i n i n g t h e pitchup. he selects and operates t h e standby system while applying, with one hand, t h e forward con t ro l pressures required t o prevent t h e s t a l l . Based on the foregoing, t h e Safety Board bel ieves t h e cap ta in allowed t h e a i r c r a f t t o r o t a t e t o t h e reported 30" p i t c h a t t i t u d e while he attempted t o so lve t h e t r im problem. Under these circumstances, t he standby system would no t have had a b e n e f i c i a l e f f e c t on the out-of-trim conditions, because of i t s r e l a t i v e l y slow rate of operat ion and because of the s l i p p i n g c lu tch .

A p i l o t ' s a t t i t u d e awareness i s p a r t i c u l a r l y c r i t i ca l when

C r e w Training

The Safety Board be l i eves t h a t t h e f l i gh tc rew f a i l e d t o take t h e proper a c t i o n t o reduce t h e pitchup because t h e i r t r a i n i n g d i d not make them aware of t h e need f o r immediate and high opposing con t ro l fo rces of more than 60 lb s . They had no t been t r a ined t o recover from t h e unusual a t t i t u d e i n t h e takeoff configurat ion produced by the mistrimmed s t a b i l i z e r a t takeoff a i rspeeds, a t t i t u d e s , and power s e t t i n g s and w e r e n o t aware of t he urgency and forcefulness of t h e c o r r e c t i v e a c t i o n required t o avoid t h e s t a l l . Also, they were probably not aware of t h e s h o r t time (about 1 second) a v a i l a b l e from the onset of p r e s t a l l b u f f e t t o s t a l l i n t h e takeoff configurat ion a t a high p i t c h a t t i t u d e . lateral c o n t r o l began t o d e t e r i o r a t e i n t h e s ta l l , recovery i n t h e remaining a l t i t u d e w a s e s s e n t i a l l y impossible. t h e a i r c r a f t ' s s t rong tendency t o yaw and bank t o t h e l e f t which provided r e l i a b l e evidence of t h e onset of l o s s of la teral control . A similar yaw and l e f t bank w a s reported by witnesses and w a s probably responsible f o r t he a i r c r a f t ' s dev ia t ion t o t h e l e f t of t h e extended c e n t e r l i n e of t h e runway.

Once

F l i g h t tests es t ab l i shed

A i r c r a f t Airworthiness

The a i r c r a f t noseup trim p o s i t i o n of t he s t a b i l i z e r could have been inadve r t en t ly set because of t h e f a u l t y t r i m p o s i t i o n ind ica to r , o r t h e s t a b i l i z e r could have been mispositioned during maintenance. The reasons f o r t h e f a u l t s i n t h e i n d i c a t o r could not be determined. The s t a b i l i z e r ' s p o s i t i o n i s required t o be noted during p r e f l i g h t inspect ion of t h e a i r c r a f t and co r re l a t ed with t h e t r i m p o s i t i o n ind ica to r i n the f l i g h t compartment during t h e before-takeoff check l i s t . conducted t h i s check, they probably would have discovered t h e inaccuracy i n the t r i m p o s i t i o n ind ica to r . Also, i ts inaccuracy would have been discovered during a f u l l travel t r i m check. According t o t h e A i r c r a f t F l i g h t Manual, t hese checks may be omitted during a turnaround a t the cap ta in ' s d i s c r e t i o n ; a f u l l t ravel t r i m check is required only on t h e f i r s t f l i g h t of t h e day. Since the a i r c r a f t had been flown earlier t h a t day and s i n c e t h e f l i gh tc rew had only about 10 minutes t o conduct a p r e f l i g h t and depa r t on schedule, they evident ly t r e a t e d the f l i g h t as a

Had the f l i gh tc rew

- 33 -

turnaround. s t a b i l i z e r during h i s p r e f l i g h t inspect ion, because he may have been preoccupied with making a t imely depar ture and because the ex te rna l i nd ica to r w a s not c l e a r l y v i s i b l e . t h i s f l i g h t a turnaround, because a new c r e w had been assigned t o the a i r c r a f t and because i t had j u s t been re leased from maintenance. f o r e , the Safety Board concludes t h a t a f u l l travel t r i m check w a s required.

The f i r s t o f f i c e r could have overlooked the mispositioned

The Safety Board does not consider

There-

The f l i gh tc rew w a s not warned of t he mistrimmed condi t ion, because the out-of-trim warning system w a s inoperat ive. probably not aware of t h i s discrepancy, because a check of t he out-of- t r im warning is not required by t h e A i r c r a f t F l igh t Manual o r A i r l i ne check l i s t s . The f l igh tcrew apparent ly d id not conduct a check of the system o r t h e i r check w a s not s u f f i c i e n t . The Safety Board be l ieves the out-of-trim warning system t o be an e s s e n t i a l i t e m , and it should be thoroughly checked p r i o r t o each f l i g h t . Had the system been opera t iona l , t h e accident would have been prevented, because the warning horn would have provided an unmistakable ind ica t ion of t he adverse pos i t i on of the s t a b i l i z e r and of t he inaccura te t r i m pos i t i on ind ica tor .

They were

The trim-in-motion a u r a l warning system w a s determined t o be un re l i ab le . concerning t h i s system, because they were not entered i n the deferred sec t ion of t h e d a i l y f l i g h t log. de tec ted its s t a t u s during a f u l l travel t r i m check.

The f l i gh tc rew w a s not aware of t he series of discrepancies

The f l igh tcrew could have e a s i l y

The f l i gh tc rew should have been aware of t he malfunctioning d e i c e r boots, s ince t h e pressure gage would have shown continuous, p a r t i a l i n f l a t i o n ; therefore , t he de i ce r boots would not have functioned properly. According t o t h e minimum equipment list, t h i s system may be inopera t ive provided t h e a i r c r a f t i s not operated i n i c ing condi t ions. Inves t iga t ion d isc losed t h a t p o t e n t i a l i c i n g condi t ions prevai led along t h e rou te F l i g h t 23 would have taken.

Other opera tors of N199EA had a l s o experienced the same d i f f i c u l t i e s with t h e s t a b i l i z e r trim system. had been repaired o r replaced several t i m e s . It w a s an "on-condition" i t e m t o be repaired o r replaced as necessary. overhaul period required, and the re i s no procedure i n Beech A i r c r a f t Corporation's s e rv i ce i n s t r u c t i o n s f o r inspect ing the airworthiness of t h e ac tua to r c lu tch . A malfunction of t h e ac tua to r required t h a t it be removed and f ac to ry inspected. f ac to ry inspec t ion i f he has t h e necessary technica l l i t e r a t u r e and t o o l s ava i l ab le and has been c e r t i f i e d f o r such by FAA. no t have t h i s c e r t i f i c a t i o n . an airworthy condi t ion res ted heavi ly on p i l o t s accura te ly documenting t h e i r t r i m system discrepancies and on mechanics accura te ly troubleshooting and replacing t h e assembly before o the r complications developed.

The t r i m ac tua to r assembly

There is no s p e c i f i c

An a i r c r a f t operator may conduct a

Columbia d id The success of maintaining the ac tua to r i n

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The Safety Board could not determine why the metal b a l l bearings w e r e loose i n the c lu t ch nor the length of time the c lu t ch w a s i n t h i s condition. The b a l l s were probably misplaced during r epa i r . It is un l ike ly t h a t excessive wear of t he two remaining b a l l s w a s caused e n t i r e l y by a i r l o a d s on the s t a b i l i z e r . consequence of t h e ac tua tor jackscrew having run aga ins t the s tops because of misrigging of t h e l i m i t microswitches. be expected under these circumstances, because four of t he b a l l s w e r e no t present t o absorb the loads placed on the clutch.

The wear was more l i k e l y the

Excessive wear would

The Safety Board be l ieves t h a t the previous in t e rmi t t en t operat ion of t he s t a b i l i z e r ac tua to r experienced by Columbia's o ther f l igh tcrews w a s caused by t h e s l i pp ing c lu tch and that t h i s condi t ion ex i s t ed during t h e accident f l i g h t . Slippage would have caused the ac tua to r t o s t a l l o r ac tua t e a t a slower-than-normal rate when the s t a b i l i z e r w a s subjected t o a i r loads during pitchup. have s l ipped i n both main and standby modes of operation. p i l o t ' s a b i l i t y t o retrim t h e a i rp l ane would have been af fec ted adversely.

The c lu t ch would Thus, the

Maintenance personnel d id not properly diagnose the def ic iency i n the ac tua to r c lu t ch mechanism, and, again, the f l igh tcrew would not have been aware of t h e def ic iency, because the reported discrepancies had not been recorded i n t h e deferred maintenance por t ion of the d a i l y f l i g h t log and t h e s t a b i l i z e r could have operated normally during ground checks.

Therefore, t he Safety Board concludes t h a t i n view of the na ture of t h e mechanical discrepancies , t he a i r c r a f t w a s not airworthy.

FAA Survei l lance

The Safety Board be l ieves that the FAA had not e f f e c t i v e l y performed i t s regula tory func t ions r e l a t e d t o a i r c r a f t and p i l o t c e r t i f i c a t i o n . The team of exper t s ' r epor t attempted t o descr ibe the p o t e n t i a l longi tudina l con t ro l problem with the Beech 99. The team had recommended t h a t t h e con t ro l fo rces be reduced by a i r c r a f t modification o r t h a t a le t te r of competency be required f o r each pilot-in-command. The Safety Board d id not f i nd during i t s f l i g h t tests that the con t ro l fo rces experienced i n a takeoff with f u l l noseup t r i m w e r e subs t an t i a l ly reduced by the modifications made by the Beech Ai rc ra f t Corporation.

The Safety Board agrees wi th the team's al ternat ive-- that a l e t te r of competency be required. p i l o t i s knowledgeable of those f l i g h t condi t ions judged t o be most detr imental t o the s a f e operat ion of t he a i r c r a f t and had demonstrated h i s s k i l l i n con t ro l l i ng t h e a i r c r a f t under those conditions. However, t he manner i n which t h i s c e r t i f i c a t i o n w a s t o be achieved w a s d e f i c i e n t , because the i n s t r u c t i o n s i n FAA Order 8430.1A, paragraph 153, w e r e genera l and d id not state how the f l i g h t s w e r e t o be conducted. i t d id not c l e a r l y state t h e problem t h a t may be encountered with a mistrimmed s t a b i l i z e r on takeoff , and t h i s information w a s not l i s t e d i n t h e A i r c r a f t F l i g h t Manual.

The letter would c e r t i f y t h a t t he

Also,

- 35 -

The tests conducted by the s p e c i a l i nves t iga t ion team were conducted with t h e a i r c r a f t ' s c.g. near the forward l i m i t r a t h e r than the a f t l i m i t . Consequently, t h e low con t ro l fo rces of 20 t o 25 l b s of push f o r c e i d e n t i f i e d might have influenced the t e a m of exper t s ' conclusions and recommendations. Therefore, t he FAA evident ly concluded t h a t t he condi t ion w a s no t p o t e n t i a l l y dangerous and t h a t t he a i r c r a f t w a s equipped wi th f ea tu res that would prevent unsafe operation. Therefore, only runaway p i t c h trim emergency t r a i n l n g w a s emphasized.

The FAA evaluated, bu t d id not adequately document, t he problem of a takeoff with extreme noseup t r i m a t a f t c.g. Addit ional ly , the FAA did not implement t h e letter-of-competency recommendation assoc ia ted wi th t h e test evaluat ions and d i d not i n su re t h a t i ts inspec tor w a s aware of t h i s problem i n t h e Beech 99. Also, t he p r i n c i p a l operat ions in spec to r had not been t ra ined i n e i t h e r t he Beech 99 o r a i r c r a f t of similar type. Therefore, t h e Safety Board concludes t h a t t he FAA's p r i n c i p a l operat ions inspec tor assigned t o Columbia P a c i f i c A i r l i nes w a s no t adequately prepared t o in su re t h a t t he Air l ines ' p i l o t s were thoroughly t r a ined i n the p o t e n t i a l hazards of extreme trim pos i t i ons with an a f t c.g. condition.

The Safety Board be l ieves t h a t t he FAA had not e f f e c t i v e l y performed i t s regula tory func t ions r e l a t e d t o maintenance p r a c t i c e s conducted by the Air l ine . defer red maintenance recordkeeping def ic iency, the A i r l i n e continued using an unacceptable procedure. been corrected during subsequent inspect ions. Further , t h e evidence shows that t h e FAA should have placed more emphasis on the Beech 99 i n t h e i r maintenance su rve i l l ance activit ies.

Although the GAD0 attempted t o co r rec t t he

The unacceptable procedure should have

3. CONCLUSIONS

3.1 Findings

1.

2 .

3.

4 .

5.

The f l i gh tc rew w a s c e r t i f i c a t e d and cu r ren t ly f l i g h t checked f o r t h e intended operation.

The a i r c r a f t w a s c e r t i f i c a t e d and wi th in weight and balance limits a t the time of the accident .

The ho r i zon ta l s t a b i l i z e r trim p o s i t i o n ind ica to r w a s unre l iab le .

The hor izonta l s t a b i l i z e r trim-in-motion system w a s unre l iab le .

The hor izonta l s t a b i l i z e r out-of-trim warning system w a s inoperat ive.

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6.

7.

8.

9.

10.

11.

12 .

13.

14.

15.

16.

1 7 .

18.

The hor izonta l s t a b i l i z e r ac tua tor c lu t ch slipped.

The a i r c r a f t w a s not airworthy.

The f l igh tcrew w a s probably preoccupied with making a t imely departure and d id not c o r r e l a t e t he s t a b i l i z e r ' s pos i t i on with the ind ica to r i n the f l i g h t compartment.

The f l igh tcrew probably mispositioned the s t a b i l i z e r t o an adverse leading edge down pos i t i on by re ly ing on an inaccurate trim pos i t i on ind ica to r and did not v i s u a l l y in su re i t w a s trimmed wi th in the takeoff range.

The f l igh tcrew w a s not aware of the inoperat ive out-of- trim warning system and therefore w a s not a l e r t e d t o t h e adverse a i r c r a f t noseup t r i m condition.

According t o the A i r c r a f t F l igh t Manual and Ai r l ine checkl i s t s , an out-of-trim warning system check w a s not required.

The a i r c r a f t became airborne ea r ly and ro t a t ed rap id ly t o a s teep noseup p i t c h a t t i t u d e .

The f l igh tcrew d id not immediately apply s u f f i c i e n t forward e l eva to r cont ro l fo rce t o prevent the a i r c r a f t from enter ing an excessively high p i t c h a t t i t u d e and s ta l l .

The f l igh tcrew may have r e l i e d i n i t i a l l y on the main t r im system t o reduce e leva tor con t ro l forces , but t h e system w a s not e f f ec t ive .

The f l igh tcrew probably attempted t o reduce the high p i t c h a t t i t u d e and high con t ro l forces with the standby trim system, but t he system w a s not e f f ec t ive .

The f l igh tcrew w a s not adequately t ra ined t o recognize and recover from an extreme noseup p i t c h a t t i t u d e a f t e r takeoff with the c.g. near t h e a f t l i m i t .

The f l igh tcrew w a s no t ab le t o prevent t he a i r c r a f t from s t a l l i n g a f t e r which recovery w a s impossible i n the a l t i t u d e remaining.

The accident w a s not survivable.

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19. The airline's maintenance procedures involving the trim system in the aircraft was deficient and flightcrew training did not emphasize the hazard of a mistrimmed stabilizer on takeoff.

20. The FAA's certification and surveillance of the airline's maintenance procedures were ineffect.ive and, as a result, did not insure that maintenance personnel had sufficient knowledge of the trim system and were capable of maintaining it in an airworthy condition, and certification and surveillance of flightcrew training in the aircraft were deficient because they did not emphasize the potential problems, other than runaway trim, induced through a mistrimed stabilizer.

3 . 2 Probable Cause

The National Transportation Safety Board determines that the probable cause of the accident was the failure or inability of the flightcrew to prevent a rapid pitchup and stall by exerting sufficient push force on the control wheel. combination of a mistrimmed horizontal stabilizer and a center of gravity near the aircraft's aft limit. The mistrimed condition resulted from discrepancies in the aircraft's trim system and the flightcrew's probable preoccupation with making a timely departure. Additionally, a malfunctioning stabilizer trim actuator detracted from the flightcrew's efforts to prevent the stall.

The pitchup was induced by the

Contributing to the accident were inadequate flightcrew training, inadequate trim warning system check procedures, inadequate maintenance procedures, and ineffective FAA surveillance.

4 . RECOMMEmATIONS

As a result of this accident, on August 11, 1978, the Safety Board recommended that the Federal Aviation Administration:

"Issue an Airworthiness Directive applicable to all Beech 99, 99A, A99, A99A, and B99 model aircraft to require an immediate one-time inspection of the horizontal stabilizer trim system to ascertain that all components of the system and its associated position-indicating and -warning circuits are operational within specified tolerances. (Class I, TJrgent Action) (A-78-53)

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Require an inspection to insure that the primary and secondary mode of the horizontal stabilizer actuator are capable of deflecting the stabilizer under specified airloads. exact instructions should be furnished by the Beech Aircraft Corporation. The inspection should be made as soon as the Beech instructions are available and repeated at 2,000-hour intervals (Class 11, Priority Action) (A-78-54)

I 1

The

"Change the minimum equipment list to make the out-of-trim warning system a mandatory requirement for flight. Priority Action) (A-78-55)''

(Class 11,

The investigation of this accident was difficult and time- consuming because of the lack of definitive information on the aircraft's performance and on the flightcrew's reaction to the emergency situation which arose immediately after takeoff. recorder and a cockpit voice recorder would have provided invaluable information in both of these areas, would have significantly reduced the investigative effort, and would have provided more direct evidence of causality. virtually a prequisite to improvements in safety in commuter air carrier and corporatelexecutive operations involving complex multiengine aircraft. and -29, dated April 13, 1978, and we urge the Federal Aviation Administration's early action on these recommendations:

Information from a flight data

The Safety Board believes that these recorders are

Therefore, we reiterate Safety Recommendations A-78-27, -28,

Develop, in cooperation with industry, flight recorder I 1

standards (FDR/CVR) for complex aircraft which are predicated upon intended aircraft usage. (Class 11, Priority Action) (A-78-27)

"Draft specifications and fund research and development for a low cost FDR, CVR, and composite recorder which can be used on complex general aviation aircraft. for these recorders, such as maximum cost, compatible with the cost of the airplane on which they will be installed and with the use for which the airplane is intended. Action) (A-78-28)

Establish guidelines

(Class 11, Priority

In the interim, amend 14 CFR to require that no operation I 1

(except for maintenance ferry €lights) may be conducted with turbine-powered aircraft certificated to carry six passengers or more, which require two pilots by their certificate, without an operable CVR capable of retaining at least 10 minutes of intracockpit conversation when power is interrupted. Such requirements can be met with avaflahle equipment to facilitate rapid implementation of this requirement. (Class 11, Priority Act ion) (A-7 8-29) I'

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BY THE NATIONAL TRANSPORTATION SAFETY BOARD

/s/ JAMES B. KING Chairman

/s / ELWOOD T. DRIVER Vice Chairman

/s/ FRANCIS H. McADAMS Member

/s/ P H I L I P A. HOGUE Member

December 21, 1978

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5'. APPENDIXES

APPENDIX A

INVESTIGATION AND HEARING

1. Investigation

The Safety Board was notified of the acciLznt at about 700, February 10, 1978. The investigation team went immediately to the scene. Working groups were established for operations, human factors, structureslsystems, powerplants, maintenance records, and aircraft performance.

Participants in the on-scene investigation included representatives of the Federal Aviation Administration, Columbia Pacific Airlines, Inc., Beech Aircraft Corporation, Pratt & Whitney Aircraft, Ltd., and Hartzell Propeller, Inc.

2. Public Hearing

A 3-day public hearing at Seattle, Washington, began May 23, 1978. Parties represented at the hearing were the Federal Aviation Administration, Columbia Pacific Airlines, Inc., Beech Aircraft Corporation, and The Talley Corporation.

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APPENDIX B

PERSONNEL INFORMATION

Captain David C. Branford

Captain David C. Branford, 28, w a s employed by Columbia P a c i f i c A i r l i n e s as a first o f f i c e r on Apr i l 12, 1976. cap ta in on March 24, 1977. C e r t i f i c a t e No. 544609600. engine land, and glider-type aircraft. c e r t i f i c a t e . H i s f i r s t - c l a s s medical c e r t i f i c a t e w a s dated September 17, 1977, with no l imi t a t ions .

H e w a s upgraded t o The cap ta in held Ai r l ine Transport P i l o t H e w a s r a t e d i n a i r p l a n e s ingle- and multi-

H e a l s o held a f l i g h t i n s t r u c t o r ' s

Captain Branford had a t o t a l of 3,250 hours, of which 2,000 hours were i n multi-engine a i r p l a n e s and 800 hours were i n single-engine a i rp l anes . Four hundred and f i f t y hours had been logged i n g l i d e r s . He had accumulated 300 hours i n t h e Beech 99. He had recorded 66 hours of f l i g h t t i m e f o r December, 83 hours f o r January, and 21 hours f o r February. The cap ta in had no t flown t h e 2 days before the accident and had flown 1.5 hours on t h e day of t h e accident.

F i r s t Of f i ce r Michael D. Stanley

F i r s t Of f i ce r Michael D. Stanley, 23, w a s employed by Columbia P a c i f i c A i r l i n e s as a f i r s t o f f i c e r on May 9, 1977. H e held an A i r l i n e Transport P i l o t C e r t i f i c a t e No. 531660255, dated February 9, 1978, with r a t i n g s f o r a i r p l a n e s ingle- and multi-engine land. H e a l s o held a f l i g h t i n s t r u c t o r ' s c e r t i f i c a t e . w a s dated November 28, 1977, with no l imi t a t ions .

H i s f i r s t - c l a s s medical c e r t i f i c a t e

F i r s t Of f i ce r Stanley had a t o t a l of 1,800 hours, 1,061 hours of which were i n multi-engine a i r p l a n e s and 739 hours were i n s ingle- engine a i rp l anes . H e had logged 199 hours i n the Beech 99. 65 hours of f l i g h t t i m e f o r January and 30 hours f o r February. before t h e accident h e had flown 3.6 hours and w a s on duty 6 hours. a l s o logged 1.5 hours on t h e day of t h e accident.

H e recorded The day

H e

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APPENDIX C

AIRCRAFT INFORMATION

Beech A i r c r a f t Model 99, serial No. U-37, N199EA, w a s owned by Columbia P a c i f i c Leasing, Inc. , of Richland, Washington, and operated by Columbia P a c i f i c A i r l i nes , Inc., under a lease back arrangement. It w a s approved f o r c e r t i f i c a t i o n i n the normal category on May 2, 1968, i n accordance with t h e a i rwor th iness requirements of 14 CFR 23, with amendments, equivalent s a f e t y f ind ings , and s p e c i a l condi t ions with respec t t o P a r t 135 operat ions.

Previous opera tors of t h e a i r c r a f t w e r e : T i m e A i r l i nes , Benton Harbor, Michigan, which purchased the a i r c r a f t i n October 1968 with 34.9 airf rame hours; Midwest Commuter Ai r l ines , Indianapol is , Indiana, from August 1971 t o May 1975; A t l an t i c Cent ra l A i r l i nes , New Brunswich, Quebec, Canada, from May 1975 t o May 1977; and Columbia P a c i f i c A i r l i nes , from June 1977 u n t i l February 10, 1978.

A t t h e time of t h e accident , t h e a i r c r a f t had accumulated 13,701 f l i g h t hours; 37 hours s ince i t s last continuous inspect ion.

Engines: Two P r a t t & Whitney PT-6-A-20's

S e r i a l No. Tota l T i m e

No. 1 PC-E-21196 No. 2 PC-E- 21 95 8

2254.0 h r s 2733.0 h r s

Propel le rs : Two Hartze l HCB-3-TN-3B's

Tota l Time

No. 1 No. 2

3696.6 h r s 3696.6 h r s

The maintenance records showed t h a t t he ho r i zon ta l s t a b i l i z e r t r i m ac tua to r w a s replaced on t h e following da te s and airframes t i m e s :

December 17, 1969 November 6, 1970 August 4, 1971 Apr i l 11, 1976

1605.8 hours 2744.7 hours 3681.0 hours

11,470.6 hours (motors replaced)

There w e r e no e n t r i e s i n t h e a i r c r a f t log showing t h a t e i t h e r engine had ever l o s t power o r w a s shut down i n f l i g h t .

There were no entries t o show t h a t e i t h e r propel le r experienced an in - f l i gh t malfunction which r e su l t ed i n shut down o r l o s s of t h r u s t .

.START OF TAKEOFF ROU

WITNESSES

0. BENNEl 0 B. REA

NOTE: DISTANCES MEASURED moM END OF RUNWAY

APPENDIX D NATIONAL TRANSPO#TATW)N SAFETY BOARD

WASHIGTOW. D L

COLUMBIA PACIFIC AIRLINES BEACH 99, N 19gA

WCHLAHD AIRPORT, AND, WA. FEBRUARY 10,1978

I

-Fc fc

I

- 45 -

N 25l9" FROM FRONT SPAR

__t

354"M MEASURED

ALONG WING SPAN

I

FUSELAGE C/L

DOOR STEP

GOUGED OUT AREA

LF. MAIN GEAR \

78' 4" I REFERENCE POINT

FOR MEASUREMENTS

/-

RT. MAIN GEAR

@- - - - 25' 5" I 8' 6"

WING TIP

FROM THIS HOLE TO @HOLE

306O~ APPENDIX E NATIONAL TRANSPORTATION SAFETY BOARD

Washington, D.C. 20594 WRECKAGE OlSTRlBUTlON CHART

COLUMBIA PACIFIC AIRLINES BEECH MODEL 99, N 199 EA Richland Washington Airport

Richland, Washington I February 11, 1978

Z U. S. GOVERNMENT PRINTING OFFICE : 1979-623-231/709

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