Chicago O'hare Intl Airport
Aircraft Accident/Incident Report

Lake Michigan, Michigan 49512
Saturday, April 7, 2007 21:23 EDT

NTSB Narrative Summary Released at Completion of Accident

The flight crew received a left thrust reverser unlock indication while holding for takeoff. The captain cycled the reverser, and had decided to return to the gate when the messages cleared. With the issue apparently resolved, he elected to takeoff. The captain reported experiencing a small vibration on climb out and, a short time later, he heard a "loud bang" and the "aircraft pitched and yawed/rolled to [the] left." The autopilot disengaged and the left thrust lever moved to idle during the event. The first officer ran the checklist to stow the reverser. The captain decided to continue to the intended destination because the thrust reverser messages had cleared and the vibrations had stopped. The flight subsequently landed uneventfully. The flight data recorder (FDR) indicated that the left engine vibration levels were elevated during the accident flight. Approximately 3 minutes into the flight, the left engine thrust reverser unlocked parameter changed to "On" for about 1 second. About 11:20 (MM:SS) after takeoff, the left engine vibration level increased momentarily, and both the left and right engine speeds and fuel flows began to decrease. As the decrease in fuel flows was occurring, the airplane rolled right, left, and right again over about a 4-second period. The decrease in engine parameters lasted over 3 minutes before returning to normal. The left engine thrust reverser unlock parameter indicated "On" for about 4 seconds during that time. The left engine vibration levels decreased after the event, below the levels previously recorded during the flight, and approximately to the level of the right engine vibration. The vibration and engine speed variations suggested separation of the left engine translating cowling at that point. The left engine thrust reverser deploy parameter remained in the "Off" state for the entire flight. Additionally, the FDR data revealed that the left engine vibration levels were elevated and left engine thrust reverser did not deploy on the two previous flights. The post accident inspection revealed that the left engine translating cowl had separated from the engine assembly and damaged the empennage. Damage to the thrust reverser components was consistent with prior operation with the reverser out of alignment and jamming of the translating structure. Review of the aircraft's maintenance records revealed a history of anomalies related to the left engine thrust reverser. About one month prior to the accident, the aircraft maintenance log contained the discrepancy, "L Rev Unlock Caution." The entry was deferred in accordance with the minimum equipment list (MEL). The left pneumatic drive unit and the left thrust reverser flex shafts were subsequently replaced; however the discrepancy was not resolved. Eleven days after the initial write-up, a ballscrew actuator and a cascade assembly were replaced. The maintenance record indicated that rigging and operational checks were satisfactory, and the MEL item was closed. There were no further entries related to the left thrust reverser in the aircraft maintenance log. The MEL allowed the airplane to be dispatched with one of the engine thrust reversers inoperative. It required that the inoperative reverser be inspected for structural damage, deactivated, and stowed and locked in the forward thrust position. In the event of an in-flight unlock or deploy indication, the flight manual instructed the crew to manually stow the reverser. There was no guidance in the event of an indication on the ground. Bombardier has initiated a revision to the flight manual to include instructions in the event of a thrust reverser unlock message received during ground operations.

NTSB Probable Cause Narrative

In-flight separation of the left engine thrust reverser translating cowling due to intermittent binding and jamming of the reverser on the accident flight and on previous flights. Contributing factors were the inadequate maintenance action by the operator due to their failure to properly resolve the prior reverser malfunctions, the failure of the pilots of previous flights in not referring earlier reverser deployment failures for maintenance action, and incomplete company/manufacturer's procedures because they did not address anomalous reverser indications during ground operations.

Event Information

Type of Event Accident
Event Date 4/7/2007
Event Day of the Week Saturday
Time of Event 2123
Event Time Zone Eastern Daylight Time
Event City Lake Michigan
Event State MICHIGAN
Event Country --
Zipcode of the event site 49512
Event Date Year 2007
Event Date Month 4
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 425130N
Event Location Longitude 0862130W
Event Location Airport Chicago O'Hare Intl
Event Location Nearest Airport ID ORD
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 2056 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 120
Weather Observation Facility ID GRR
Elevation of weather observation facility 794
Distance of event from weather observation facility (units?) 35
Time Zone of the weather observation EDT
Lighting Conditions Night
Lowest Ceiling Height 5500
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) -3
Dew Point at event time (in degress fahrenheit) -7
Wind Direction (degrees magnetic) 280
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 9
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.93
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 4
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 24111
NTSB Notification Source FAA
NTSB Notification Date Apr 12 2007 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Dec 11 2008 11:19AM
User who most recently changed record lema
Basic weather conditions Visual Meteorological Cond
FAA District Office FAA-AAI 100

Aircraft Involved

Aircraft #1

Aircraft Registration Number N77181
NTSB Number CHI07FA107
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Canadair
Aircraft Model CL-600-2B19
Aircraft Series Identifier --
Aircraft Serial Number 7181
Certified Max Gross Weight 53000
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 54
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Mar 1 2007 12:00AM
Airframe hours since last inspection --
Airframe Hours 24805
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Wells Fargo Bank Northwest
Aircraft Owner Street Address --
Aircraft Owner City Salt Lake City
Aircraft Owner State UT
Aircraft Owner Country USA
Aircraft Owner Zipcode 84111
Operator is an individual? No
Operator Name Mesa Airlines, Inc.
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City Phoenix
Operator State AZ
Operator Country USA
Operator Zip code --
Operator Code MASA
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 LAN
Departure City Lansing
Departure State MI
Departure Country USA
Departure Time 2036
Departure Time Zone EDT
Destination Same as Local Flt --
Destination Airport Code ORD
Destination City Chicago
Destination State IL
Destination Country USA
Specific Phase of Flight Cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Dec 11 2008 10:46AM
User who most recently changed record lema
Since inspection or accident Time of Accident
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --