CASE STUDY MIDWEST 5481.pptx
Transcript of CASE STUDY MIDWEST 5481.pptx
CASE STUDY
CASE STUDYCRASH OF AIR MIDWEST FLT 5481 ON 08 JANUARY 2003
INTROAIMTo study an accident case scenario and bring out lessons for the safe op of Army Avn ac. SCOPE SHORT DESCRIPTION OF THE ACCIDENT
THE INVESTIGATION
INVESTIGATION RESULTS
ERRORS AND CONTRIBUTING FACTORS
LESSONS LEARNT
OPEN FORUM SHORT DESCRIPTION OF THE ACCIDENTVIDEO
SHORT DESCRIPTIONDATE : 08 JAN 2003
TYPE OF AC : BEECHCRAFT 1900D
OPERATOR : AIR MIDWEST, US AIR EXPRESS
LOC OF CRASH : CHARLOTTE/DOUGLAS INTERNATIONAL AIRPORT, NORTH CAROLINA,UNITED STATES
PAX : 19
CREWS :2
INJURIES (NON-FATAL) : 1 (ON GRD)
FATALITIES : 21 (ALL ON BOARD AC)SHORT DESCRIPTIONCAPTAIN : Katie Leslie, age 25Was serving in Air Midwest till March 2000. She held an airline tpt plt cert and a FAA first-class med cert dated Nov 19, 2002, with no limitations.
1,865 hours total flying time, including 1,100 hours as a Beech 1900D PIC.
She had flown approx 134, 32, and 6 hrs in the 90 days, 30 days, and 24 hours.
The check plt stated that the captain had no difficulties during upgrade training and that she demonstrated very good knowledge of the airplane sys and very good judgment
SHORT DESCRIPTIONCO PLT : Jonathan Gibbs, aged 27 Was serving in Air Midwest from May 2001.
He held a commercial pilot license dated November 12, 2000, and an FAA first-class medical certificate dated December 10, 2002, with no limitations. 706 hours total flying time on Beech 1900D airplanes.
He had flown approximately 210, 59, and 6 hours in the 90 days, 30 days, and 24 hours, respectivelyPilots described the first officer as a talented and very precise pilot with good attention to detail and good comm skills. Pilots also stated that the first officerpossessed good situational awareness and good knowledge of the Beech 1900D.
THE INVESTIGATIONTHE INVESTIGATIONProbable Cause as Determined by the Investigators
FOD on Runway
Wake Turbulence from the Preceding Ac
Maint Error
Improper Wt and BalTHE INVESTIGATIONProbable Cause as Determined by the Investigators
FOD on Runway
THE INVESTIGATIONProbable Cause as Determined by the Investigators
Wake Turbulence from the Preceding Ac
THE INVESTIGATIONProbable Cause as Determined by the Investigators
Maint Error
THE INVESTIGATIONProbable Cause as Determined by the Investigators
Improper Wt and Bal
THE INVESTIGATION RESULTSActual Causes/ Reasons to Crash
THE INVESTIGATION RESULTSActual Causes/ Reasons to Crash
THE INVESTIGATION RESULTSTHE INVESTIGATION RESULTSActual Causes/ Reasons to Crash
Faulty Maint
Improper Cal of Weight and BalERRORS AND CONTRIBUTING FACTORSERRORS AND CONTRIBUTING FACTORS Maint
Loader/ Luggage Handler
Op
PltsERRORS AND CONTRIBUTING FACTORSMaint
ERRORS AND CONTRIBUTING FACTORSMaint
The on grd jobs were carr out by the trainee
The supervisor was giving instrs only
No cross checking
9 out of 25 steps were skipped
Deadly Combination of Technicians Sincere but less qual trainee Qual but insincere supervisor
Late hr wkload Fatigue Less no of techs were presentERRORS AND CONTRIBUTING FACTORSLoader/ Luggage Handler
ERRORS AND CONTRIBUTING FACTORSLoader/ Luggage Handler
She had confusion/ doubt but never expressed to the pilots
She saw the aircraft as tail heavy but did not inform to anyone
The environment of information exchange was missingERRORS AND CONTRIBUTING FACTORSOperator
ERRORS AND CONTRIBUTING FACTORSOperator
Exact weight calculation of Pax was not carried out
Average weight of pax calculation was wrong
Exact weight calculation of luggage was not carried out
Average weight of luggage calculation was wrong ERRORS AND CONTRIBUTING FACTORSPlts
Did not check the elevator mov according to con column displacement
Did not check the actual wt of pax and luggage
Did not distribute the wt to keep CG within limit
Did not notice the tail hy attitude of the ac
Was slow to react
Did not op the elevator trimmer
LESSONS LEARNTLESSONS LEARNTPilots
The exact weight of luggage must be calculated thoroughly
The approximate weight of pax should be calculated as close as possible
Weight (Pax and Luggage) must be distributed as per manual to keep the CG well within the limit
All the control surfaces must be checked by the pilots during pre flight inspection
The control surface movements must be checked as far as possible during taxi check
LESSONS LEARNTMaintenance
All the control surfaces including movements as per the control column displacement must be checked during daily inspection inspection
The major inspections should not be carried out at late hour
All the adjustments must be crossed checked
No major adjustments should be carried out by the trainees
A team should not be comprised of only one qualified technician
Error reporting must be a practice for all
LESSONS LEARNTLoader/ Luggage Handler/ Flight Crew/ Ground Crew
Every luggage must be weighed sincerely
Any anomaly in aircraft appearance must be reported
The environment should offer everyone to express his/ her views
LESSONS LEARNTHQs
Periodical checks must be conducted on maintenance procedure
Periodical checks must be conducted on weight and balance procedure OPEN FORUM
CONCL