How One Picture Crashed A Plane | Colgan Air Flight 9446
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- Опубликовано: 22 июл 2021
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Beechcraft 1900D Image: commons.wikimedia.org/wiki/Us...
Crash Images: NTSB
Drum Images: NTSB
This is the story of colgan air flight 9446. On the 26th of august 2003, a beechcraft 1900d was to fly from barnstable municipal airport to albany international airport in new york. It was 3:20 in the afternoon, but this wasnt a usual flight thought this was a repositioning flight. The plane had just undergone some maintenance and this flight was meant to get the plane to its base in albany. So this plane only had two people onboard the pilots. The pilots worked preparing the plane for takeoff, once they were done with the checklists they started taxing the plane, they talked among themselves about taxi procedures and engine start procedures. In a few minutes they were near runway 24 waiting for another plane to land. At 3:58 pm local time the plane took off from runway 24. As soon as the plane took off things started to go wrong, the pilots complained that they had a runaway trim.
In the cockpits the pilots were struggling to control the plane, The captain said “kill the trim kill the trim” as he wrestled with his plane. But that didnt do the trick, the captain called for a disconnect of the trim system as it was still forcing his plane to nose down. They even tried pulling a circuit breaker to solve the trim issues but the issues persisted. the pilots requested an emergency landing on runway 33, ATC cleared flight 9466 to land on any runway that they wanted, the plane somehow climbed to an altitude of about 1100 feet and it was still in its left turn.
As people watched, the nose of the plane started to drop. It was dropping with each second. As the nose dropped the plane lost altitude and gained speed, the plane crashed nose first into the waters off of yarmouth massachusetts. Both pilots did not make it.
With the plane in shallow waters tit was possible for the investigators to study the wreck and to get to the flight data recorder. There wasn't a whole lot of data since the flight was so short but what was there told them of something that had gone horribly wrong. Before we go any further lets get some terminology out of the way.The elevators are control surfaces at the back of the plane that controls the pitch of the aircraft. On this particular takeoff they noticed that the pilots needed to apply 60 pounds or 27 kilos of force on the control columns to manipulate the elevators, compared to other take offs this was unusually high, once the plane was in the air the data showed that something was forcing the nose of the plane down. To the investigators it looked like the elevator pitch trim was forcing the plane into a dive.
When you trim an airplane the control surfaces are set in such a way that the plane maintains a particular state without the pilot having to do much. For example if you trim the plane up the plane will pitch up even if the pilot doesn't touch the control columns.
To see if something was off with the trim system they started digging into the history of the plane, this plane had been well maintained. The plane was maintained with something known as CAMP or the continuous airworthiness maintenance program. The camp program included a lot of inspections from structural inspections to detail inspections. Lets focus on the detail inspections, the detail inspections were divided into 6 phases and each phase was performed after 220 hours of flight time. 
Наука
The corrected version of Indian Airlines Flight 605 will be up on June 28th 2021, In the mean time enjoy next weeks video!
Ok
Also who edits your videos?
AW Man! I gotta go back in time to watch the fixed version of the video?
*PS Your date is wrong :) Its July right now, not June XD*
Corrected, what was the problem?
There was also the crash of Colganair3407.
Both parties are at fault. The illustration in the manual is confusing, but the maintenance crew clearly did not perform a proper test of the elevator trim system before signing off on it.
Duh .
true but i think the maintenance tech's workplace culture + workload needs to be looked into as well, was the test they used due to laziness/complacency and/or are they encouraged to rush by management
@@babynautilus wouldn't really take that long to pull on the controls or have someone do it for you. Its not dependent on if the engines are working or if the plane is turned on. All they had to do was literally pull on it to see if it works or not.
@@reedman0780 dude the control that went wrong is the trim for trim which isn't connect to the control stick, it is route to the trim wheel which in some plane does need power.
@@arinpoonpinrode1467 isnt that connected using cables? You dont need power for that if its a direct cabling
I would even go beyond the manual, to the design. I may be overreaching, but if it was not mechanically possible to hook it up backwards the mechanics wouldn't have hooked it up backwards.
Agreed. Use different sized pins for the nose-up/nose-down cable ends, then the maintenance guys would need a sledgehammer in order to fit them the wrong way around. Wait, they don't have sledgehammers in their tool kit, do they? lol
It does sound like a good idea. This was definitely a day in which all the Swiss cheese holes lined up.
My thoughts precisely when I saw this. The easiest way to prevent this type of mistakes...
That's a problem I call "the eternal engineer"... The people who design things, especially complicated things, are almost never the ones who are actually going to have to use said things. Any big company that makes any sort of widely used product, from drills to chainsaws to pliers to planes, that actually involves end users, AKA the "dummies in the field" or the "200 pound gorilla" whos actually going to be using the thing all day every day over and over again for years, will inevitably design a much better, more useful product that's less likely to fail. Pilot is a highly skilled job, but just like some goof turning a wrench, even pilots will find new and unheard of ways to break stuff if given enough free time. Like those guys who lost their engines taking that one plane up to its absolute maximum ceiling and otherwise flying it aggressively cause it was empty on a different repositioning flight... In this case here, it was the mechanics.. But they proved the theory correct. An enginerd designed that thing, and made those repair manuals, and a whole team of other enginerds looked at it and thought "wow this is great." and because none of them likely ever once in their lives had to wrench on such an item in the middle of, or at the end of a long stressful, sweaty work shift, maybe it's 100 degrees in the shop, maybe the wife was being angry that morning, maybe you got a flat tire, maybe your uncle Reginald just died.. And aunt Gertrude is having a rough go of it...you know, all the real life stuff that doesn't happen on a drawing board. And so you end up with a major bumblefuckery like this... If they'd just built a prototype, and had a group of mechanics come in and told them "try to fuck this up"... They'd have almost certainly discovered this flaw in the system. Hell, they'd have somehow involved an unapproved forklift in the process within a few hours.
I wonder why nobody mentions RII inspections that has to be performed when working on flight control items. The Required independent Inspection failed. That the drawings in the AMM can be difficult to interpret correctly must be reported. Human factors the dirty dozen was at work here!
Draftsman here. 100% raytheon fault. When I was an apprentice I was always taught: "Draw drawings even an idiot can understand". This doesn't mean that people using the drawings are idiots, this means you should make their work as easy as possible. Raytheon failed this simple rule.
Tell me about the trim tests after the installation please.
Both parties are at fault, a guide wire should have been used, a proper handoff should have been conducted. Tests should have been done. But who in there right minds draws a print from the back and not label it as such. Further, the design is in question. With something as complex as an airplane, it shouldn't be possible to install anything backwards.
@@seanbook9627 Guide wire should be in the manual. If it is not, the responsibility falls to whoever wrote the manual. Same for the tests. About installing backwards... With enough stubbornness , anything could be installed backwards. The designer job in this case is to make very challenging to install something backwards.
Yes, no marked orientation in respect of the front or rear of the aircraft. Put simply an arrow and annotation "Towards front of aircraft" was all that was needed.
@@seanbook9627 "With something as complex as an airplane, it shouldn't be possible to install anything backwards." Even Fischer-Price have managed that one.
A friend of mine was an aircraft mechanic supervisor until he abruptly quit to drive a cement truck. He said there were too many night he woke up at 3am in a cold sweat thinking he had forgotten or neglected something that might bring down a plane.
nah just say the picture is confusing and blame the company.
Amen to that. I even drove back to the shop upon occassion to double check as i had those same thoughts.
Bro same here. I use to inspect helicopters in the navy when I was 18 years old you sign your name on a piece of paper saying you checked everything and it is good. If it crash you are the first person they are coming after. I would come home and couldn’t fall asleep because I kept thinking if I miss something. I hated it
I knew a guy who would always take a picture of the stove and the coffee maker and the bathroom counter before he left on vacation. That way so when his wife freaked out thinking she had forgotten to turn off the stove or coffee maker he could just show her the picture. It seems if you're an aircraft mechanic with that sort of anxiety you could do the exact same thing.
Great point. I am a pharmacist who would get the same cold sweats at 3 AM that I may have brought a patient down. We basically have an error rate of 3%.
When I preflight an aircraft, I always run the trim in either direction to make sure the trim tab moves correctly. Its a 3 min step that might keep you alive.
And just coming out of maintenance I'd be very diligent on a complete pre-flight check. I'm thinking the plane was largely empty. With all those houses below if they were carrying any weight they'd have hit houses, not the water.
Nobody..from the maintenance crew to the pilots, performed that check. The pilots paid with their lives
Seems strange they wouldn’t at least test the trim tab after installing. That’s bad
They may well have done a complete test inspection to ensure the tab was controllable through its full range - but just not checked polarity !
(Some years ago I bought a flat. When the documents came, I found they were for the flat next door. How many times had those flats changed hands and no-one who knew which was which had actually seen the documents before !
@@millomweb yes good point. And shame
I read somewhere else that the pilots skipped that on the preflight. Or skipped the entire preflight. Also that the mechanics tested it but misunderstood (between them) what should happen, because they did an impromptu test instead of following the procedure (which was in a different part of the manual and not referenced by the maintenance procedure).
It took bad documentation, bad maintenance practice, improper testing after maintenance, and bad pilots to bring the plane down.
@@briant7265 If I was a pilot and told to fly a plane from A to B - and there were no passengers, I'd be bloody suspicious !
To hear it was a relocation following maintenance would trigger me like a poofreading error - I'd suspect EVERYTHING !
@@Thiso76 I do question the ability of pilots. If trimming UP made matters worse, why keep doing it ?
Technician test: "does it move?" "Yeah" "Ok, we good!"
lmao
Or like this: "I'm moving down, what do you see?" "Moving down." "Ok, we good."
The control surfaces should move up when you move the trim down, and vice versa. If you have someone perform that test for the first time, or if you have miscommunication between the two technicians, they will get it wrong. It's important that they know what they are seeing and how to communicate.
@@renerpho ??? I think up is up, explain your thinking here. If I trim nose down my elevator and/or elevator trim tab will move down. Up is down only works on aircraft that move the entire stab for trim.
@@brianvosburgh1720 up trim pushes the main control surface it’s mounted on down.
Let’s not forget that it’s a bit confusing: to pitch up, the elevator needs to go down. To trim up, the trim tab needs to go down. To make it worse, the ailerons ant their trim work in opposite, right wing up, right aileron down, trimtab up.
A tired technician could easily make a mistake here.
The control cables should be connected with square and round pegs or something, to avoid this mistake.
We all do mistakes sooner or later, it’s inevitable.
Pleasant surprise to see two videos in one day, even if it is due to an error in the first one.
Definitely the majority of the blame has to go on the manual. It's common sense to have the diagram represent what the maintenance worker will be seeing. The worker themselves can't really be blamed, they can only work within the guidance they receive.
Yes I agree the manual is mainly at fault but maintenance should have thoroughly tested the aircraft and found that something was wrong
Hold on, the piece had two different sides, the diagram was bad, but the technician had obviously not looked carefully enough to check which side goes where. If in doubt, double checking is essential, lives are on the line.
That's the 'get out' clause.
Fortunately, I've NEVER worked like that. One of my bosses once asked "Why do you always question everything ?"
It was the same chap who said that the 'electricians' had tested a piece of equipment we had and found it didn't work. Immediately didn't believe the info - so checked the equipment myself - and found it did work. The one single switch on it was enough to confuse electricians !
What was the error in the first one?
@Andy White But then they didn't perform the proper checks, so there's some contribution from them there. Not following procedures bites you in the ass guaranteed.
Raytheon is absolutely at fault. I studied technical writing in college. I had courses that were about pouring over accident reports where breakdowns in communication were a factor. The Challenger was a big one we covered.
These are trained mechanics who work on these types of systems all the time. They know the parts. But the manual was backwards! They followed the instructions and the instructions were wrong! If they hadn't followed the instructions it would have been their butts on the line. More than one crash happened because of this! The people putting the manual together know how well used they will be! These aren't like the dinky instructions that people throw aside when putting furniture together! This is an airplane! It gets maintaince from different people on a regular basis. If there are issues, the pilots may talk the mechanics. There simply isn't room for this kind of negligence.
No way. Those techs never looked at the actual control surface during their test. It's easy to tell which way the control surface has moved at max command. A simple visual inspection of the tail during the trim test would have shown the error. This was just lazy, shoddy work. The manual wasn't incorrect. Poorly drawn, yes, but that's why airplane techs make the big bucks because they are supposed to be able to read and interpret what they see. A simple transposing of a pulley from front to back in the manual doesn't excuse the failure to visually inspect the control surface during the trim system test.
@@technicholy1299 I can agree that it wasn't done well, but it is still a problem if you are sending out backwards instructions. But it shouldn't have even been a question. Part of technical writing is idiot proofing things. Not just because people are stupid (but boy can they be stupid!) but because you only have a small amount of space to convey your point and print can leave some things to interpretation.
Can we agree that the problem here is multilevels of people not wanting to take the time to check their work properly!
... Pre-flight check...?.?
I don't think the parts should fit together the wrong way either. There's another video I can't remember that I came to the same conclusion.
@@technicholy1299 ditto!
Reminds me a bit of how a driver will be so convinced their foot is on the brake when it’s really on accelerator that they will push down even harder on the pedal whilst charging forward. Never occurred to them that up might be down.
That's something I definitely cannot relate to. My immediate instinctive reaction to something doing the opposite of my intention, is to reverse my own behavior. in that case, let up, and try again. I've never gotten pedals mixed, but I've had accelerators stick and carburetor throttle plates freeze open at WOT.
Imagine driving your car with the steering reversed. You're so used to turning the wheel one way and the car behaving accordingly, that if it does the opposite you just try to steer even harder in the same direction.
@@adotintheshark4848 funny you say that, I have the hardest time backing trailer because yo7 have to turn steering wheel the opposite way and I’m looking through a mirror.
@@ducknorris233 I had the same difficulty a time or two. Your brain is trained to do just the opposite of what you need to do.
Sounds like the poor picture exposed a dysfunctional repair facility: poor handoff procedures between shifts and off-the-cuff testing of repairs. What other potential disasters did they turn out before this?
And also pilots not conducting a detailed preflight check on a plane that was just coming out of maintenance. Sadly for them they paid that shortcut with their lives.
Never cut corners on safety. Especially when this is your own.
I previously worked loading cargo jets for UPS at Portland, this was during when that Air Alaska flight nose dived into the ocean and was later found out was due to to a rotary control screw in the tail of the plane. Air Alaska's maintenance building was our neighbor.
NTSB was all over every Air Alaska maintenance facility. After the accident there was a lot of activity at our neighbor. We heard that the NTSB interviewed every mechanic in maintenance procedures. It cost the airline a lot of money in OT pay. I can just imagine what happened to Colgan Air after this.
@@christianbarnay2499 Bingo. Even beginning Cessna 150 pilots preflight their plane, which includes making sure the control surfaces move correctly.
Raytheon is a major weapons manufacturer- they have deep enough pockets to crush any probes into their own faulty manuals
Yes, and?
I’ve been a professional airline pilot for 30 years. What, specifically, are you alleging? I have no personal interest in the B1900 or the operator, so what are you implying?
Did Raytheon also cover up all the socks that went missing from their Speed Queen dryers?
Seriously, this is baseless speculation. Could does not equal did. Beechcraft, Cessna, Hawker, Learjet, all local products here. I suppose you have proof of this, right? 🙄
We deal with Raytheon I work for a military contractor
They spread covid too?
And why exactly would they want to "crush a probe into a faulty manual"? Do you think any company wants to have a faulty manual? Clearly, the manual was correct in what it was showing, it was simply too easy to misinterpret what you were looking at. I am sure many techs have replaced trim tab cables correctly using this manual AND following the approved test procedure AND having the "good practice" to use a guide wire while removing the old one to insure proper replacement with the new. Besides, what government military contractor wants to have their products malfunction making it less likely they would remain a government military contractor?
When I was in maintenance training in the Air Force we studied an incident in where an F-16 or F-15 used push rods to control elevator deflection. The maintenance crew had reversed them causing a fatal accident. After that the attachments were redesigned so they could not be physically connected in the wrong configuration. It was an engineering fix that was so simple that no one could screw it up. It's sad it sometimes takes a crash or accident to make simple fixes like this.
It was an F-15, the mechanic committed Suicide because he felt so guilty.
@@djmech3871 I worked on E-3 AWACS and we once had one come in for binding on the ailerons in the control column. Come to find out ISO MX had crossed the cables in one wing and they were rubbing for months and were well worn. They figured another 20 flights or so and the cables could have came apart. Doesn't mean they would have lost control, would have been a serious loss of primary flight controls situation though.
Both the maintenance team and the poor manual quality are to blame. Had the first team run a guide wire for the second to follow or hand the manual been more clear and foolproof, the accident likely wouldn't have happened. Like so many crashes, it was the combination of factors that tragically took the lives of the two blameless pilots.
Well done video. 👍
The pilots were not blameless. They knew the plane just went out of repair and they failed to properly verify the direction the control surfaces moved during preflight check. The only difference is that contrary to all other people involved in that mess up they were the only ones who paid their mistake with their lives.
As an A&P mechanic I would always when I did any critical to safe flight components have someone visually check positioning of flight controls as I moved them or tabs. Also would measure in degrees to insure that they had full movement. Did heavy checks on SAAB 340s with full removal of flight controls and cables and did rigging of both. No excuses for the maintenance crews on not doing that plus that should have been an RII item.
Absolutely, but the manual should tell them to do so.
It was RII and there was a functional test in the AMM. It just wasn’t listed in the R&R of the actuators, it was at the end of the rigging procedure.
There is a GLARING difference from the from of the drum to the back of the drum. We all get into a hurry sometimes and cut corners, that being said. Who in the fck is training and supervising those mechanics? They should be very well trained, especially in this business.
apparently they can only do it literally by the book.
One place I worked, it was found that a very important document was not available in electronic format. One of my colleagues ended up with the job of typing it up ! I then got the job of proofreading the typed up version against the original.
I even found a technical error in the original !
this reminds me of xerox printers "sometimes" replacing numbers when scanning a document.
Luckily, according to US media those scanners are mainly used in settings like nuclear power-plants, goverment agencies etc.
Luckly again, that only happens with "lower quality and resolution settings" like the clearly labeled "normal" setting.
Good luck, that xerox know that - they just forgot to inform their own technical support and customers.
Do not worry that where unable to reach their customers due to a scanned customer list - xerox uses decentralized distribution and customer support, so there never was a thing like a detailed customer list they could use.
I love your videos, slowly going through and watching them. Something about the history of disasters and near disasters, plus the steps to prevent them, is just really intriguing to me!
I live in Barnstable County and remember this well. Was really sad and I'm happy to see a deep dive on it from this channel.
It is interesting to me that everybody faced with this situation ended up crashing the plane. The original pilots clearly believed the trim system to be broken (and were correct about that), to the point of shutting it off and pulling fuses. In all their efforts, and the pilots in the simulator, nobody though to just reset trim to 0 and start over.
I'm not blaming or claiming I would have done better. It's just, with my 20/20 hindsight it seems like the answer was so close, and everybody tested missed it.
The part that gets me was they knew what the failure condition was going to be and still couldn't figure it out.
@@technicholy1299 I doubt they told the pilots on the sim what they were facing. At most they might have known they would face some malfunction.
They disconnected the automatic trim solenoid and trimmed it manually. When that did not work they then disconnected the power to the solenoid. It was not the problem, but they did not know that.
@@trevor311264 couldn't they have just flown without trim? wouldn't they have felt the inverse movements?
@@jhoughjr1 there is no such thing as "without trim".
And no, they didn't have a chance connecting the dots, as faulty trim training revolves around a runaway trim scenario, which is why the pulled the power to the electric trim.
Actually i was surprised why the other video is unable to play.. No issues man .Keep entertaining it
Thanks for uploading this! Keep up the great work!
One suggestion for a future video I would like to see is Midwest Express Flight 105, a DC-9 that crashed near Milwaukee on September 6, 1985.
Looking forward to your new Indian Airlines Flight 605 video!
You are doing a great job. You cover older, more obscure and forgotten accidents. As a professional pilot and CFI your presentation is informative. Thanks
I would say the manual mostly, as the manual is there to remove all doubt in the equation
i think both. but the manual was the major problem.
but after you repaired something you test it, right? The manual was confusing but the maintenance crew did bad work
@@-Tris- they test it with there test. i think the official takes to much time so they do there own shorter one.
@@Eralov It just sounds strange. To me it sounds like a 2 man job, one in the Cockpit and one outside.
"Trim up!"
"OK!"
"Trim down!"
"OK!"
something like this
@@-Tris- the maintenance crew did test it, they moved the trim control fully one way and it moved full, they moved it fully the other way and it moved fully. The controls moved the wrong way but they did not know that, it was not in the training and they are not pilots. Kind of getting an assistant to fully move them when you observe.
amazing video as always!
Former aircraft maintenance technician here:
I have connected controls backwards on three separate occasions.
First was on a Short Skyvan aileron trim system due to the complete removal of cables and a confusing diagram where toy could not tell how the cables “crossed” to give the correct control direction.
Second was on a Cessna 207 aileron system again with cables completely removed and a confusing diagram as to which cables went where after they crossed.
Third was a Navion Rangemaster elevator trim. It uses two sets of two teleflex cables that are identical to move each of the elevator trim tabs.
In each of these cases, I discovered the error before the aircraft was inspected for release by doing my own checks. The Navion was the closest to catching me off guard because I saw the left trim tab from the entry door which was correct, but the right one was reversed and I only noticed it because I’d left it out of a neutral position and it was going the opposite way when I saw it approaching the aircraft later on.
Regardless though, all engine and flight controls require an independent control check. This is by regulation, not according to the maintenance manual. It requires a qualified person _who was not directly involved_ in the job to conduct an independent check of the assembly, locking, sense, and range of travel of the flight or engine controls.
Raytheon was right to put blame on the mechanics. Had they done their checks, found the reversed controls, and correctly fixed it.. then they could have blamed Raytheon for making confusing manuals and more importantly, spared the lives of the pilots.
Very light and old aircraft like a Piper Cub or Aeronca Champ don’t have any diagrams or instructions for control cable replacement. You use what are called standard practices (FAA Advisory Circular 43.13 puts most of them in manual form) and still follow the regulations for an independent control check.
Lots of mechanics aren’t pilots, or they don’t understand how flight controls should move-especially for tabs which are often counterintuitive and can be antiservo tabs as well.
The “sense” is perhaps one of the most important parts of the independent control checks.
For a trim tab, the edge of the trim wheel closest to the tab should always move in the same direction as the trailing edge of the tab.
Elevator trim: move the back of the wheel up, trailing edge of the tab should move up.
Rudder trim. Turn the knob right. Back of the knob goes left. Trailing edge of the tab goes left.
Aileron trim. Turn knob left. Left side of knob goes down. Trailing edge of left aileron trim tab should go down. Right side of knob goes up. Trailing edge of right aileron trim tab should go up (if installed).
It seems to me that this didn't have to happen. The intent of the elevator trim system is to relieve control pressure to allow for "hands off" flight. You should be able to fly without it - providing it is set neutral. These pilots identified this as a pitch trim issue, they tried to disable the trim system. If they had been able to set the trim to a neutral position, they should have been able to land it. Trim reverse issues are very serious and difficult to recognize, but once identified, it should be recoverable. Now I speak in general terms, the 1900 might do something different that made it not possible to get the trim to neutral.
That was my initial armchair quarterback thought too, but if experienced pilots couldn't do it in the simulator 6 TIMES, when they KNEW what the problem was, it's unlikely anybody could figure that out and respond appropriately immediately after takeoff.
the maintenance guys probably had a guy at the back watch as a guy in the cockpit pushed nose down trim and the tab went down and they assumed all was well. wrong, not how it works. the guy watching was probably new and clueless. he heard down, saw down and said fine.
Or the unofficial test the techs did was "Did it move? Yes. Did it move the other way? Yes. All good lets go home".
@@seraphina985 scary
I am a retired airline pilot. I flew the 1900 for many hours. This case reminded me of an incident I had in a B737-200 on takeoff. My copilot was flying and after takeoff he tried to actuate the trim electrically and it didn’t move. We ,followed the checklist, disabled the electric trim, and at that point he tried to use the manual trim wheel. No dice. I declared an emergency and we turned back to the airport, Houston Intercontinental. It took a good amount of force on the control wheel to adjust pitch but it was manageable. We made a safe landing. I learned from maintenance later that the trim jackscrew shattered and jammed the trim. What happened to that 1900 crew was very unfortunate. If the trim had jammed like ours did, they would not have been able to move the trim wheel to what they thought was full up but was really the full down position. They might have been able to save the airplane.
From a former airline pilot who turned down an offer from Colgan
..they had some very good people.
RIP, this accident is on Beechcraft / Raytheon
Manuals need to be written clearly.
Not just a Beechcraft issue.
I had a door pop open after take off at 400AGL while instructing on an Aztec, a Piper product.
A good guy/sharp mechanic read the diagram incorrectly, and installed the door incorrectly.
Trim malfunction can kill you - in any aircraft. Pay special care and attention if you know tech/mechanics made any work on a trim system.
Awesome video! I have to mainly place the fault on the fault manuals though the maintenance people also should have done a full check. I wonder if there was a way that the pilots could’ve caught this during the controls check?😸😸
Did the mechanics have a procedure for checking the control system after this work? Who wrote it, and was it FAA approved?
@@Knirin I believe there was another chapter in the manual (falls back on the poor design of the manual) that told them how to check the systems.
Definitely Rapeon, your manual should have no ambiguity. Poor pilots.....they never had a chance. Great video. Keep the good work up.
Why did I only see my fave channel now , I thought it’s past 4 days , good I look forward to another video tonight ,
I believe that was flying as a US air express flight; around that time, when I was in college and graduate school, I flew on many of these 1900s in the Northeast; including Albany many times. So I remember this
Do you remember Business Express Airlines? We had a lot of 1900s in Albany (including a pilot and maintenance base).
Pepperidge farms remembers
@@rob737700 I don't remember the airlines name, but I know there is a big bass there in Albany. Later the older brother of a college friend of mine was a maintenance supervisor there for a while
in the old days, pilots do a walkaround and test flaps, elevators and see if they are functioning the way its supposed to....
Pilots still do a walk around, but they generally are checking for free unobstructed movement of control surfaces. When it comes to the ailerons, they would have moved in accordance with pilot input on the yoke. The problem here is it was that the actuation of the aileron trim tab had been reversed. A walk around check does not verify the aileron trim tab. As is often the case with an incident like this, there is often a series of missteps that leads to the crash. Had the original crew used a tracer wire to show how the aileron trim tab control cable was wired, there would not have been a crash. If the manual had a more useful picture of the position of the cables - from the mechanic’s perspective, there would not have been a crash. Had the same mechanic who started the cable replacement, completed the replacement, there would not have been a crash. I’ll be a little harsh, but had the pilot concentrated on flying the airplane and returning to base, and not trying to fix the problem, there might not have been a crash. It’s a pretty big ‘might,’ and contrary to what most pilots instinctively do.
Bit hard to manually handle the elevators on a B1900D walk around, you’d need to wheel out a scissor lift every time you did a preflight.
Thanks for a great investigation. These smaller ones get missed but are just as important. What a nightmare.
Your channel doesn't need a maintenance check. You are ready to take off to 100.000 subscribers, then fast climb to level 500!
Broooo, this was my first airline pilot job! Still at the same holding company 10 years now, although its completely different.
Thank you for flying opposite world airlines. Have a nice day.
Great video, very enjoyable watching experience!
As a retired 43 yr Maintenance engineer, all A/C work is carried out, viewing things from the rear. It is an orientation, port to starboard as viewed from the rear. The drum was depicted that way, rear to front.
Hmmm; do I have a bizarre thought pattern or does this not work: when in doubt on the trim, move the trim to the central position as marked on the trim wheel?
No you don't, either that or we are F'd up equally. I fly r/c planes and at some time; what you said would have hit me. In addition (I know hind sight and all) why not try an opposite input on the pitch ctrl. Yer getting the idea as pilot that your already pretty fucked; it time to jump outside the box. If as you said they went neural trim and things improved even slighlty why not carefully keep going the same direction, it would have indicated to the pilots almost excatly what the problem was. The angain I am not a trianed pilot and was sitting in his seat.
@@murdoch817 The question is just how quickly would this hit you in the heat of the moment without the benefit of hindsight. This is the thing the whole sequence of events likely happened faster in reality than it took to explain them in this video. That and both you and I have the benefit of being sat comfortably and safely on our asses and primed by context to think outside the box. I actually do have a PPL myself and I can pretty much guarantee it would have took me longer to diagnose the problem from the clues in the real life situation.
For one thing listening to a narrative after the fact that focuses so exclusively on the trim allows you to think about that system in isolation and ignore everything else. Doing this in a real plane which are more complex than RC ones and have several other systems that could be responsible risks missing potential clues that it is something else. You would thus be losing vital seconds even after first suspecting that was the cause scanning your instruments for anything that might be causing the issue. In fact when your first attempts to fix the issue fail this is usually something you should be doing as being distracted by a missed diagnosis is another major killer. Unfortunately I don't think these guys had enough time to figure this all out, especially in such a high stress situation.
Adrenaline is good for two things fighting and running away but note what is not included there is thinking as adrenaline actually supresses a lot of the brains higher reasoning functions. This makes sense from an evolutionary perspective staying alive from most natural threats that generally require quick spontaneous reactions where overthinking kills as a predator is not going to wait for you to take your time assessing the situation and determine the optimal solution. When the threat depends on your ability to quickly diagnose a problem with a highly complex piece of technology that most pilots let alone most humans will never face your brain going into "Must fight off or run from predator" mode doesn't help. Truth is our tech is well ahead of our evolutionary ability to keep up and as such we in general do get really bad at making sense of it at the worst possible time ie when it goes wrong in a way that makes it a threat to us.
The maintenance manual is absolutely at fault.
well, if you are my age you have seen all sorts of maintenance manuals that don't make obvious sense as this one did. These guys were young. They will learn. The customers will remain dead however.
If you have ever done any mechanic or maintenance work you're piss poor at your job if a bad picture makes you fail. They should have tested the trim and noticed it was backwards
@@bodhi-pickahfilecoinlurker5964 nope, the root cause analysis would show that the fault lay in the illustration in the manual. Everything else is incidental to that. If the picture had shown the orientation of the pully in relation to the front and rear of the aircraft then the fitters would have put the cables the correct way.
nope. a backwards from your ideal diagram doesn't replace the fact ur supposed to know wtf u are doing, and how to test it.
@@trevor311264 So as good maintenance ENGINEERS, they ASSUMED the orientation of the illustration. They didn't think about what they were actually doing, nor did they test it properly. Some root cause analysis.
Maintenance tech fellows were the guilty party. I worked as an engineer for decades, and have seen so many mistakes like this one, but we were NOT maintaining aircraft. As a pilot once said, "mostly, we have problems AFTER maintenance""
The *reason* for the crash and for 6 out of 6 simulations 8:02 crashing was the sentence AFTER the sentence you highlighted 7:10 and read aloud. Manually returning trim to neutral in the time alloted (in at least one of the 6 simulations) would have normalized flight but when the pilot moved the elevator in the desired direction the trim motor moved the trim tabs in the opposite direction - negating even a neutral trim setting. That would have repeated for every elevator input and would take conscious awareness of the issue and brief control inputs followed by (opposite) manual trim to manage a landing.
Blame the manuals. No reasonable person would expect the (unlabled) image would be from the BACK.
Once in a classroom, a particularly astute prof. added 'facing the window' to the locator, 'to the left' because that direction is 'to the right' to anyone with their back to the window. D.u.h.
As an extra note to my comments earlier, I believe some trims work by disrupting the lift of the ail; this means that the trim flap moves up to get the tail to loose lift and down to add lift.
If this was the case here, then this MUST be clearly stated in the check procedure, so the technicians can verify their work.
If should also be in the pre-flight control surface movement checks, especially for checks post maintenance.
GOOD JOB AS ALWAYS
Definitely the onus is/was on the creator of the manual, and the company knew it. However, they followed the golden rule in litigation: "Deny until proven otherwise." So very sad.
Okay so explain how thousands of flights and maintenance checks had zero issues reading the same manual?
You can’t have lazy idiots working on aircraft, people need to look at the rigging and understand how it actually functions before saying all is good.
My only problem with this channel is that he takes NTSB reports and dumbs them down into ways that seem INCONCEIVABLE for a company to publish such a manual, or a person to take such an action, etc.
The manual was simply a contributing factor - that’s it. You have to take into account other items like the fact that this hasn’t been a previous issue with said manual BUT maybe it could be. Instead he basically says it was backwards and have people commenting “omg how could they!” 🤣
"I got this information from court documents, not the investigation report."
So yeah. Raytheon got sued.
@@EstorilEm The truth is, some people fake their way through things and appear to know what they're doing. Then you have those who actually have a brain and know when something isn't right -- those are the peeps you want, not the former... BUT, we need "idiots" because they're those ones who find the flaws, sometimes with sad serendipity.
The first rule in writing safety/maintenance docs is to assume the tech reading it is an idiot, and to assume that something will be done incorrectly when given a chance. Therefore, you, as a tech author, MUST write at the most basic level possible (most docs are written at an 8th grade level, and some even down to the 5th grade level). If you are to include pictures or figures, they should be from the most common perspective encountered (with a secondary perspective, ideally), and the perspective must be label (e.g., view from the rear looking in to the front, etc.).
Sadly, some of those writing requirements have arisen and evolved from litigation resulting from loss of life or limb. Companies are in it for the money, and rarely make corrections unless forced to through the courts.
You can't litigate away stupidity, but you can provide instruction that even "idiots" can follow. This is what Raytheon should have done before the lawsuit that forced them to make this simple change, but they didn't, and two people lost their lives in this instance over Raytheon's greed.
LOL no literally the onus was on the people certified and responsible to affect the repair. Not some tech writer who can read minds on what way would the pulley be depicted.
@@briant7265 So? You can sue a ham sandwich. Doesn't mean anything for liability or the truth of the matter. They literally screwed up a simple machine. Thats on them.
All the parts involved in the maintenance of this aircraft were at fault: faulty manual, because of its double interpretation for lack of orientation cues; faulty technicians, for deviating from protocol; faulty maintenance firm, for allowing lack of communication between shifts on unfinished jobs and deviations from protocol. Now it is up to the appropriate investigation agency to determine what is the percentage of blame to be assigned each part in any accident, for insurance companies are charged accordingly - and it may also affect what amounts could be claimed by victims or their relatives.
Only need one origination cue, the proper way so it functions.
Im glad planes are maintained by guys just winging it with their best guess from a book and completely lost without it.
Great video as always. Was this demonstration in FSX? If so, where did you find the Beech 1900 model used in the video? Thanks.
Yay, keep em coming!
Maybe engineers should perform a test flight after making repairs on control surfaces. So if they goof it, the goof only themselves.
My dad was (WWII) in charge of maintenance on B36's. He was also a pilot and required to test fly all aircraft that had been worked on by his organization.
@@boraborabob1 Maybe if they did a test flight, they might have caught it early on. Cos they would have known to use the trim in reverse.
I hold the mechanics most culpable for the crash. Always, a check test should be made to ensure that a repair or replacement functions properly.
There is one SIMPLE fix for this. The mechanics deliver the plane back to its base or wherever it's needed. Then there'd be no real loss - other than the aircraft.
This was not the only crash where confusing instructions caused a near catastrophe. Air Astana 1388 had a "roller coaster ride from hell." as stated in the episode of Air Crash Investigation. The problem was in the "reverse zone". It is a 6 foot section of cable where the orientation changes from horizontal to vertical, but the mechanics had no supervision, and the controls were reversed. (i.e. turn the yoke right = left turn and vice versa). Fortunately, the crew landed the plane with no fatalities.
Having one crew taking a thing apart and a totally separate crew putting it back together sounds like a recipe for disaster
up and down should've been painted in different colors on the cables.
True. Or even unique fixing methodology, or some way that there isn't any confusion.
@@dnomyarnostaw Yup this is after all why even something as simple as the USB ports on your computer are designed to mechanically not work the wrong way around. Well for the old USB-A and USB-B anyway, USB-C doesn't rely on hard pin assignment instead assigning the pins to the controller in software after performing autodetection of the cable orientation. But still the point stands if the device is not going to work correctly if inserted any other way design it to be impossible to do so preventing such mistakes occurring. It is just good design if nothing else making the design intuitively convey as much information as possible about it's intended usage is going to make for a better user experience, and in safety critical systems like this can even save lives.
The manual is to blame. Technicians are not loose cannons. They are supposed to follow the manual.
They failed to perform a definitive test of the system. . Did they set trim up and confirm trim was in fact up? Did they set trim down and confirm trim was down? No, to both. Gross negligence.
@@davidwebb4904 it's beyond me how they could have tested the work in a meaningful way without confirming the correct operation.
Part of the post maintenance checks is to check on the grond that when one guy command the trim to go up and down that the trim tabs go in the right direction at the tail by another guy at the elevators. Will also be picked up by the rigging check. Fault is with maintenance.
Such a sad story. Aircraft maintenance requires the whole team to be on their "A game". The aircraft manufacturer needs to publish accurate and clear maintenance information, and mechanics must always be "thinking mechanics", as we were taught in school. It only takes one broken link in the chain for a tragedy such as this to occur. Thanks for your great work on these videos.
How can the cable lock pin still be in the same position when you look at it from behind or from the front? Shouldn’t the lock pin be reversed and sit in the right side of the item?
Look at that drawing though it's the same
Although probably not, I wonder if I'd try the counter-intuitive action of trimming down...
I'm the kind of person who does counter-intuitive actions when the intuitive one doesn't work.
However, I have no idea how I'd behave in terms of counter-intuitiveness when under stress like those pilots were...
I just randomly clicked this video and then I heard barnstable municipal airport... i sit and watch the planes there all the time!
At the glider field, we have 1 glider with an elevator trim tab. In the daily preflight, I always have a pilot move the trim while I verify the tab is moving in the correct direction. Flight controls free and correct! Years ago I had the elevator trim tab freeze on a Cherokee. Luckily it froze during climb out while the airplane was in a nose up attitude, otherwise I would have had to strong-arm the landing.
The technician's fault, and the pilots. There has to be a reference or datum somewhere. If not this drum than something else would have looked backwards. Mechanics have to know what they are looking at. Also, pilots should have fully tested the trim system before the flight.
Pilots' fault??? Seriously? How exactly should the pilots have "fully tested" the trim system? The main fault lies with diagram in the manual and the secondary fault is with the technicians who did the work. The pilots were innocent victims who paid with their lives for other people's mistakes.
@@davebarclay4429 Every transport category aircraft gets a full trim test at least once per day.
Scapegoating on any one source is definitely the wrong way to go here. Well, unless your wanting it to happen again.
THE MOST DANGEROUS PART IN FLYING IS MANAGEMENT.
@@ronniewall1481 lol
@@lucidmoses THAT'S NO JOKE IF YOU LOOK HOW MANY TIMES MANAGEMENT HAS CAUSED AN ISSUE.
@@ronniewall1481 People case issues. All people. Now if that wasn't just a tasteless joke then I'm not interested in what you have to say. Prejudice need to die out and for sure, I'll not be a part of it.
@@lucidmoses DO WHAT?
I DON'T THINK YOU COMPREHEND WHAT I AM SAYING.
A LOT OF ACCIDENTS HAVE BEEN CAUSED BY MANAGEMENT MAKING CHANGES THEY SHOULDN'T HAVE. CHANGES NOT IN JUST AIRLINES. I'VE SEEN THOUSAND OF CASES WHERE THE WRONG PERSON MAKES DECISION THAT RESULTED IN CATASTROPHIC EVENTS.
Your flight sims are amazing ! Wales UK.
The pitch trim system on the B1900D gives the current trim setting by using a reference strip on a wheel that is geared to the manual trim wheel, next to a fixed arrow on the captain’s side of the throttle quadrant. If the system had been reverse rigged, the take off trim setting (as dictated by the centre of gravity) may have been set to the complete opposite to what it should have. Being an empty aircraft, the trim would probably have be set in a ‘nose up’ setting to counter the probably-forward CoG. So if that were set the nose down instead, the induced pitch down during/after take off would’ve been a surprise, and trimming nose up, but getting more and more nose down, would’ve been totally disorientating, and looking down to the trim wheel and seeing the opposite of what you’re feeling would add to that. Realistically, unless you’re a test pilot and are expecting that that may happen, no one would’ve stood a chance of recovering that situation so close to the ground. I’m guessing the skipper tried to pull the pitch trim fuse to counteract what he thought might be a trim runaway, but the electrical side of the pitch trim system is limited to a motor to assist the aforementioned manual wheel so that wouldn’t have helped this particular situation.
This was BeachCrafts fault, unfortunately they are not held accountable when they cause deaths like this, people should be going to prison for this.
has the manual at least been improved since?
Plane looks like a mail truck with wings.
I mean you’re not wrong lol
Beech 1900D's are hideous. Even worse in real life. The
Shorts Sherpa is another ugly plane.
@@lisamurphy2314
Ugly Beetches.
interesting, never thought about it. Pilots check for controls (aileron, rudders) in each pre-flight to have free movement and in small planes you even look at the wing to see if the aileron goes the way it supposed to go (i.e. up on the inside of the turn) but have never seen anybody check if the trim is going the right direction (larger airplanes is not even practical).
Ambiguity is anathema to aircraft maintenance! Good job MACI.
So sad they skipped the real test
lol both of them. make diagrams crystal clear and train maintenance people to not do their own thing to test it out, follow the book, write the book better. 2 sides same coin. unfortunately, this killed people (again) and Raytheon/Beech does not wanna fix it
Regarding the test procedure, the manual apparently didn't call for one. So maintenance did less that they could have, but more than required. (Yes. That sounds very stupid.)
I dfidn't know pitch settings were so powerful, I assumed they'd be overidden by the pilots push-pulling the yoke.
Hi there,
Thank you for this video and this important discussion.
I've worked in maintenance and continuing airworthiness for many years but I'm not familiar with this aircraft type, so I will have to double check things.
I feel that there are many factors here. Many of these are analyzed often and at length during human factors training.
The Swiss Cheese model fits really well here.
I'm not sure if I missed something from your narrative, but was there no independent (aka duplicate) Inspection performed? I witnessed the very same problem on an E195 ailerons system and it was caught with the independent inspection, which in Europe is mandatory (critical tasks).
Also, apart from the technicians perhaps not agreeing on what 'up' (human factors again), isn't this aircraft equipped with trim indicator in the cockpit? If it is, then a full up and full down test would be required.
When the trim system is completely disturbed, a trim runaway test should be performed this is another opportunity to discover the problem.
Finally, unless I missed something, it seems that no maintenance check flight was performed. Thos would explicitly ask the pilots to verify the correct function of the trim and elevator systems, giving the crew a chance to figure out the possible relationship of the problem with the maintenance and perhaps act differently.
The attitude of the manufacturer is not correct, of course. One would wonder: did anyone ever write to the Beechcraft to point out the manual misleading picture? Manuals normally include a form to be used to inform the manufacturer of problems with the maintenance data.
Every slice of Swiss cheese can help stop the accident from occurring. I listen to your videos to keep my brain tickled and to compare with my experience where maybe something very small came between a good day and a really bad one.
I will definitely look up thos report and include it in the examples that I use to train my staff.
Again, thank you for your service.
Cheers
Mark
Yeah, while I don't know much about aviation, Beechcraft should have known better to make the manual more understandable. Also, what they could have done is make the trim cable connectors a different size, or color to prevent backwards installation. So the Swiss cheese model starts with a flawed design, then a faulty manual, maintenance not performing a standard check, and finally the pilots using the reversed trim settings, and crashing. Sad, and preventable.
It’s not a “flawed maintenance manual” if tens of thousands of other flights and maintenance work in these areas had zero issues. It’s just your typical lazy mechanics waiting to end their shift and not double-checking critical rigging components.
Period, end of story.
Tens of thousands of other maintenance crews just didn't use the manual. Instead, they used common sense.
As a technician I would like to blame the manuals, but I know better. many of the manuals I deal with require"interpretation" as to how a component is situated in the equipment. How it goes together is not as relevant as how it must operate. many is the time I had components reversed and had to go back in and reverse hoses or cables to get my directionals corrected. testing is the cornerstone of a correct repair. My equipment is mostly terrestrial but does put men and machinery well into the air where a gravity fall can cause injury or death or damage to the structures or equipment they are repairing. You had better believe you have the right test results before putting the machinery back into service. Thanks mini
I’m a corporate pilot who flies a Beechcraft aircraft (King Air 200). They have very similar systems. I can easily see how the MX guys could have screwed up putting it back together. But, a simple systems check with one guy in the cockpit and one outside observing the expected changes to the control surfaces would have caught this. Additionally, a simple little line in the MX manual stating that the image was from the “FRONT VIEW” would have prevented this. In either case, it took both parties to screw this up since it took both failures to cause it. In aviation we always talk about every accident is a chain of events. A break in that chain at any point will stop an accident. It started with Raytheon and it ended with MX. They are both responsible. There is an old unwritten law in aviation “safety rules are written in blood”.
During a preflight inspection pilots normally check correct operation of elevator is and ailerons, so the pilots could have switched back to neutral trim and recovered. Over reliance on trim is another probable cause..
It’s sad that this happened to the crew. The mechanics should have caught this for sure. I’ve been working on planes for 9 years and often times get called out for being slow. I read the entire task twice then before I perform a step I read it 2-3 times to make sure I’m doing it right. Then after the work is done I triple check and even have other techs scrutinize my work down to the safety wire. I rather take an additional hour to do a talk just to make sure i did it correctly.
So much for the "CAMP" system! I'm guessing the maintenance crews never worked on this type plane before!!
Great video thank you
Your videos are incredible. I know I say this each time I watch one. Thank you!
As a tech writer there should be no unanswered questions about what the techs are looking at and every effort should be made to eliminate any mistakes at this point.
This belongs in the list of Murphy's Law examples: Anything that can be installed backwards eventually will be.
Another common factor in disasters is shift changes.
This had both.
Maintenance manual definitely contributed. Of course a proper test of the trim system would have revealed their error, and I would have thought that would be SOP after working on the trim cable system.
Isn't this the exact same or a very similar issue that happened with that Embraer jet on a previous video that you did?
But with that one, they were able to save the plane and successfully land it.
I spent 27 Yrs in Military Aviation (18 in Helicopters and 6 on KC-135), I'm glad the Manuals we had weren't Poorly Written like those in this Video, the Main Blame is with the Manufacturer, and some to the Maintenance Crew for not insuring proper test and checks before signing the Aircraft Off for "Safe for Flight"
Excellent as always 👌 thanks for continuing to share!
How this plane took off with wrong trim settings?
IDK if I was troubleshooting a problem and turning it one way made the problem worse, I would try turning it the other way. Trim is what sets the angle of the tail, If as they are adding more up trim they are having compensate with more elevator movement, they could have set it back to the original setting and been able to control it. Especially if they noted maintenance had be performed on the trim system.
i am enjoying your video,s so much
this reminds me of something 74Gear said: 'if the plane isn't doing what you want it to do, try something else.' This may have saved these pilots.
It feels like trim is something that is helpful but leads to many different accidents. Just the fact that there are usually s3everal trim run away procedures, indicates that it's a delicate system.I'm not a pilot, but watching this episode, reading 373 MAX stories, I have a feeling that if pitch becomes uncontrollable, then there should be a step when pilots return trim to neutral and try to fly the plane manually.
A MIF (Maintenance-Induced Failure) caused by documentation and shop practices. This is far from the only case of transposed control cables. Every pre-take-off check should include a "Full and free movement of the controls, IN THE CORRECT SENSE" , where possible. It's a good idea to do that as part of a pre-start check, (so you don't waste fuel taxiing to a holding point and then back) If the aircraft's been in for maintenance, when it's handed over, a thorough walk-around check of everything accessible or visible is essential. (On a single-seat homebuilt, everything's visible from the cockpit, and you can probably over-ride any trim manually anyway, but on anything much bigger, walk-around is vital.)