Aircraft Accident/Incident Report

Union Star, Missouri 64494
Thursday, May 12, 2005 23:16 CDT

NTSB Narrative Summary Released at Completion of Accident

After departure, the incident airplane was climbing toward its cruising altitude in a stratified region of precipitation within a convective system, and in conditions which were favorable for the accumulation of structural icing. At some point, the pitot/static system began accumulating ice because the air data heat system had not been activated or was not functioning. The condition first manifested itself as a "RUDDER LIMIT FAULT" warning due to icing of the rudder limiting system pitot tube. The icing continued to accumulate on the other probes of the air data system, degrading its ability to reliably determine the airplane's airspeed. About 19,000 feet, the flight crew disengaged the autopilot and pushed the pitch control column forward, and the airplane entered a descent. The flight crew initially applied uncoordinated control inputs, in the process reaching nearly 100 pounds of differential force on the pitch control column, while attempting to recover the airplane. During this period, airplane's pitch continued to oscillate through 5 cycles, for duration of 8 minutes, reaching altitudes as low as 10,600 feet and as high as 23,300 feet. During the oscillations the airplane's indicated airspeed varied greatly, between 54 and 460 knots; however, the airplane systems tests and aircraft performance data show that the recorded, as well as the displayed, airspeed indications were adversely affected by the icing conditions. Once regaining control of the airplane, the crew diverted and made an uneventful landing. Post-incident testing of the airplane's mechanical and electronic systems revealed no abnormalities that would have accounted for the unreliable airspeed indications or the loss of control reported by the flight crew. Post-incident computer modeling also confirmed that the airplane performed in a manner consistent with all deviations from normal flight having been initiated or exacerbated by the control inputs of the flight crew. Review of flight data recorder, cockpit voice recorder, and flight crew interviews revealed that the flight crew's actions during the event were in part contradictory with operator's training and operational procedures. Specifically, the crew initially failed to properly identify and respond to the erroneous airspeed indications that were presented and failed to coordinate their recovery of the airplane to controlled flight.

NTSB Probable Cause Narrative

A loss of reliable airspeed indication due to an accumulation of ice on the air data/pitot sensors. Contributing to the incident was the flight crew's improper response to the erroneous airspeed indications, their lack of coordination during the initial recovery of the airplane to controlled flight, and icing conditions.

Event Information

Type of Event Incident
Event Date 5/12/2005
Event Day of the Week Thursday
Time of Event 2316
Event Time Zone Central Daylight Time
Event City Union Star
Event State MISSOURI
Event Country --
Zipcode of the event site 64494
Event Date Year 2005
Event Date Month 5
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 395800N
Event Location Longitude 0943500W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 2317 Central Daylight Time
Direction of event from weather observation facility (degrees) 190
Weather Observation Facility ID MCI
Elevation of weather observation facility 1026
Distance of event from weather observation facility (units?) 46
Time Zone of the weather observation CDT
Lighting Conditions Night
Lowest Ceiling Height 3900
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 8
Air Temperature at event time (in degrees celsius) 18
Dew Point at event time (in degress fahrenheit) 18
Wind Direction (degrees magnetic) 130
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 7
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.99
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 80
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 24838
NTSB Notification Source FAA ROC
NTSB Notification Date May 12 2005 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jan 8 2009 1:48PM
User who most recently changed record broda
Basic weather conditions Instrument Meteorological Cond
FAA District Office AAI-100

Aircraft Involved

Aircraft #1

Aircraft Registration Number N910ME
NTSB Number NYC05MA083
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage None
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name BOEING
Aircraft Model 717-200
Aircraft Series Identifier --
Aircraft Serial Number 55174
Certified Max Gross Weight 115000
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 2
Cabin Crew Seats 4
Passenger Seats 88
Total number of seats on the aircraft 94
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Nov 24 2004 12:00AM
Airframe hours since last inspection 894
Airframe Hours 4806
ELT Installed No
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name U S BANK NA TRUSTEE
Aircraft Owner Street Address 1420 5TH AVE
Aircraft Owner City Seattle
Aircraft Owner State WA
Aircraft Owner Country USA
Aircraft Owner Zipcode 98101
Operator is an individual? No
Operator Name Midwest Airlines
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 6744 South Howell Ave.
Operator City Oak Creek
Operator State WI
Operator Country USA
Operator Zip code 53154
Operator Code MWEA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code MCI
Departure City Kansas City
Departure State MO
Departure Country USA
Departure Time 2308
Departure Time Zone CDT
Destination Same as Local Flt --
Destination Airport Code DCA
Destination City Washington
Destination State DC
Destination Country USA
Specific Phase of Flight Climb - to cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Dec 28 2008 5:00PM
User who most recently changed record muzd
Since inspection or accident Last Inspection
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --