Individually Owned: 150,657
Corporate Owned: 137,281
Barnstable Municipal Airport
Aircraft Accident/Incident Report
Yarmouth, Massachusetts 02675
Tuesady, August 26, 2003 15:40 EDT
NTSB Narrative Summary Released at Completion of Accident
The accident flight was the first flight after maintenance personnel replaced the forward elevator trim cable. When the flightcrew received the airplane, the captain did not address the recent cable change noted on his maintenance release. The captain also did not perform a first flight of the day checklist, which included an elevator trim check. Shortly after takeoff, the flightcrew reported a runway trim, and manually selected nose-up trim. However, the elevator trim then traveled to the full nose-down position. The control column forces subsequently increased to 250 pounds, and the flightcrew was unable to maintain control of the airplane. During the replacement of the cable, the maintenance personnel skipped a step in the manufacturer's airliner maintenance manual (AMM). They did not use a lead wire to assist with cable orientation. In addition, the AMM incorrectly depicted the elevator trim drum, and the depiction of the orientation of the cable around the drum was ambiguous. The maintenance personnel stated that they had completed an operational check of the airplane after maintenance. The Safety Board performed a mis-rigging demonstration on an exemplar airplane, which reversed the elevator trim system. An operational check on that airplane revealed that when the electric trim motor was activated in one direction, the elevator trim tabs moved in the correct direction, but the trim wheel moved opposite of the corresponding correct direction. When the manual trim wheel was moved in one direction, the elevator trim tabs moved opposite of the corresponding correct direction.
NTSB Probable Cause Narrative
The improper replacement of the forward elevator trim cable, and subsequent inadequate functional check of the maintenance performed, which resulted in a reversal of the elevator trim system and a loss of control in-flight. Factors were the flightcrew's failure to follow the checklist procedures, and the aircraft manufacturer's erroneous depiction of the elevator trim drum in the maintenance manual.
Event Information
| Type of Event | Accident |
| Event Date | 8/26/2003 |
| Event Day of the Week | Tuesday |
| Time of Event | 1540 |
| Event Time Zone | Eastern Daylight Time |
| Event City | Yarmouth |
| Event State | MASSACHUSETTS |
| Event Country | -- |
| Zipcode of the event site | 02675 |
| Event Date Year | 2003 |
| Event Date Month | 8 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 413635N |
| Event Location Longitude | 0701520W |
| Event Location Airport | Barnstable Municipal Airport |
| Event Location Nearest Airport ID | HYA |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 4 |
| Degrees magnetic from airport | 180 |
| Airport Elevation | 55 |
| Weather Briefing Completeness | Not pertinent |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1556 Eastern Daylight Time |
| Direction of event from weather observation facility (degrees) | 180 |
| Weather Observation Facility ID | HYA |
| Elevation of weather observation facility | 55 |
| Distance of event from weather observation facility (units?) | 4 |
| Time Zone of the weather observation | EDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 23 |
| Dew Point at event time (in degress fahrenheit) | 20 |
| Wind Direction (degrees magnetic) | -- |
| Variable Wind Indicator | Variable |
| Wind Speed (knots) | 6 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.86 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 2 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 16160 |
| NTSB Notification Source | AS-2R |
| NTSB Notification Date | Aug 26 2003 12:00AM |
| NTSB Notification Time | 1630 |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Aug 31 2004 9:41AM |
| User who most recently changed record | NTSB\JOHB |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | Washington, DC |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N240CJ |
| NTSB Number | NYC03MA183 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | Yes |
| Damage | Destroyed |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Beech |
| Aircraft Model | 1900D |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | UE-40 |
| Certified Max Gross Weight | 17060 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 21 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | Aug 26 2003 12:00AM |
| Airframe hours since last inspection | 0 |
| Airframe Hours | 16503 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | Raytheon Aircraft Credit Corporation |
| Aircraft Owner Street Address | 9709 East Central |
| Aircraft Owner City | Wichita |
| Aircraft Owner State | KS |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 67206 |
| Operator is an individual? | No |
| Operator Name | Colgan Air Inc. |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | 10677 Aviation Lane |
| Operator City | Manassas |
| Operator State | VA |
| Operator Country | USA |
| Operator Zip code | 20110 |
| Operator Code | NSVA |
| Owner has at least one certificate | -- |
| Other Operator of large aircraft? | -- |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | -- |
| Indicates Domestic or International Flight | -- |
| Operator carrying Pax/Cargo/Mail | -- |
| Type of Flying (Per_Bus / Primary) | Positioning |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | HYA |
| Departure City | Hyannis |
| Departure State | MA |
| Departure Country | USA |
| Departure Time | 1538 |
| Departure Time Zone | EDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | ALB |
| Destination City | Albany |
| Destination State | NY |
| Destination Country | USA |
| Specific Phase of Flight | Emergency landing after takeoff |
| Report sent to ICAO? | No |
| Evacuation occurred | No |
| Date of most recent change to record | Jun 17 2004 10:20AM |
| User who most recently changed record | PEAR |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | 33 |
| Runway Length | 5252 |
| Runway Width | 150 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |