NTSB blames maintenance in Calif. crash
Emery Worldwide cargo jet also dropped shortly after takeoffWed, Aug. 06, 2003
TIM FUNK, TED REED AMES ALEXANDER Staff Writers
WASHINGTON - Federal accident investigators called Tuesday for improved airline maintenance after concluding that faulty repair work was likely to blame for the February 2000 crash of an Emery Worldwide Airlines cargo jet.
The Emery DC-8 crashed just after takeoff near Sacramento, Calif., killing the three pilots aboard, because maintenance flaws kept them from gaining control of the plane, the National Transportation Safety Board ruled. On Jan. 8, a similar sequence of events led to a crash in Charlotte that killed all 21 aboard a commuter plane, investigators have found. The NTSB is expected to issue a final ruling on the cause of the Charlotte crash by year's end.
At Tuesday's hearing, the NTSB concluded that the Emery crash was caused by a missing bolt, which fell out because it was improperly installed during maintenance. "We need to have every person in the maintenance and safety loop to be fully performing in their jobs ...," said NTSB chair Ellen Engleman following the hearing. "This did not occur and there was a tragedy because of that."
Maintenance mistakes are increasingly the cause of fatal aviation incidents, said NTSB member John Goglia after the hearing. Referring to the 1996 ValuJet crash near Miami, in which 110 people were killed, Goglia said: "Emery was like ValuJet, and some
other crashes that have occurred recently, that have their origins in the
hangar."
There are a number of similarities between the Charlotte and Emery
crashes. In Sacramento, the Emery cargo jet crashed two minutes after
takeoff. In Charlotte, an Air Midwest turboprop operating as US Airways
Express Flight 5481, crashed 37 seconds after takeoff. In both cases, pilots
declared an emergency seconds into the flight. They struggled to force the
noses of their planes down, but flight control systems failed them because of
the faulty maintenance, investigators have found.
Two days before the Charlotte crash, a mechanic made adjustments to the cables that control the elevator, the device that enables pilots to change a plane's pitch. He had
never done the job on a Beech 1900 before and skipped steps in the
maintenance manual.
In the Emery crash, part of the cable system that controls the right elevator was not connected. That's because the bolt connecting them had been improperly installed and fell out, the board concluded. The board stopped short of ascribing blame for that error, saying it could not determine who was responsible.
"We've reviewed the records, we've interviewed the maintenance folks, we've done the best to determine what we could," Engleman said.
The DC-8's elevator assembly was replaced during a heavy maintenance check by third-party contractor Tennessee Technical Services in Smyrna, Tenn., in November 1999. About nine days later, Emery mechanics found the left and right hand elevator dampers were reversed.
In correcting the problem, Emery mechanics worked on the elevator assembly. Goglia said it appears written maintenance instructions weren't always
followed closely. "I believe the majority of people in the maintenance
community will realize the activities were not in accordance with the
maintenance manuals," he said.
To prevent a recurrence of the problems that led to the Emery crash, the NTSB made 15 recommendations to the Federal Aviation Administration on Tuesday. Among them, the board said airlines should revise the instructions they give mechanics to more explicitly
describe steps in maintenance tasks. The board also recommended requiring
airlines to provide mechanics up-to-date drawings and illustrations to help
them properly install and assemble aircraft components.
Maintenance instructions also are an issue in the Charlotte crash. Air Midwest officials
complained to the NTSB that the maintenance manual lacked explicit
instructions for adjusting the Beech 1900's elevator cables.
Tuesday, the NTSB also recommended safeguards to ensure pilots can control DC- 8s and other older-model jets even if parts of the elevator assembly become
disconnected.
Historically, the FAA has agreed to follow most of the NTSB's recommendations. The NTSB examines the causes of crashes in hopes of preventing similar accidents. The agency's investigations often take more than a year. "We don't disagree with the findings," Nancy Colvert, a spokesperson for CNF Inc., the parent company of now-defunct Emery, said Tuesday.
In August 2002, Emery agreed to stop flying after the FAA threatened
to revoke its operating certificate. The agency said it had found more than
100 safety violations during 18 months of heightened inspection following the
crash.
Fred Chesbro, brother-in-law of Kevin Stables, one of the pilots
killed in crash, said he regrets that the NTSB recommendations did not
include increased oversight of third-party maintenance -- which is also an
issue in the Charlotte crash. "Given that we have a number of crashes that
seem to be related to contract maintenance, it seems to me that government
and industry oversight issues ought to be heavy, heavy focuses," he said.
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Ted Reed: (704) 358-5170. treed@charlotteobserver.com