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Last updated: 3 August 2020
Status:Final
Date:Wednesday 8 January 2003
Time:08:49
Type:Silhouette image of generic B190 model; specific model in this crash may look slightly different
Beechcraft 1900D
Operated by:Air Midwest
On behalf of:US Airways Express
Registration: N233YV
C/n / msn: UE-233
First flight: 1996
Total airframe hrs:15003
Cycles:21332
Engines: 2 Pratt & Whitney Canada PT6A-67D
Crew:Fatalities: 2 / Occupants: 2
Passengers:Fatalities: 19 / Occupants: 19
Total:Fatalities: 21 / Occupants: 21
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location:Charlotte-Douglas International Airport, NC (CLT) (   United States of America)
Crash site elevation: 228 m (748 feet) amsl
Phase: Takeoff (TOF)
Nature:Domestic Scheduled Passenger
Departure airport:Charlotte-Douglas International Airport, NC (CLT/KCLT), United States of America
Destination airport:Greenville-Spartanburg Airport, SC (GSP/KGSP), United States of America
Flightnumber:5481
Narrative:
Air Midwest flight 5481, a Beechcraft 1900D, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport (CLT, North Carolina, USA. The 21 occupants aboard the
airplane were killed.
The accident airplane had undergone a detail six (D6) maintenance check between the night of January 6 and the morning of January 7, 2003. During this check the elevator cable tension was adjusted.
In the process the elevator control system was incorrectly rigged, restricted the airplane’s elevator travel to 7º airplane nose down, or about one-half of the normal downward travel. This error was not detected prior to release to service.
The airplane returned to service on the morning of January 7 and flew a total of nine flight legs before the accident flight.
At 08:37 the aircraft was ready for taxi for a flight to Greenville-Spartanburg Airport, South Carolina, USA. At 08:46 the flight was cleared for takeoff from runway 18R. One minute later, immediately after the landing gear had been retracted, the nose pitched up to 20°. Both crew members reacted with surprise and the captain asked the first officer to help him.
Both flight crew then attempted forcefully push the nose down. The nose continued to pitch up to 54° and the stall warning horn sounded. The aircraft's nose dropped and it rolled 127° to the left.
The airplane’s roll attitude then stabilized at about 20º left wing down; the pitch attitude began to increase. About 08:47:24 the airplane rolled right through wings level, and the pitch attitude increased to about -5º. The nose dropped again and the airplane struck a US Airways maintenance hangar and came to rest about 1650 feet east of the runway 18R centerline and about 7600 feet beyond the runway 18R threshold.

It appeared that, aside from the limit nose down elevator travel, the aircraft had an excessive aft center of gravity due to substantially inaccurate weight and balance calculations.

Probable Cause:

PROBABLE CAUSE: "The airplane’s loss of pitch control during takeoff. The loss of pitch control resulted from the incorrect rigging of the elevator control system compounded by the airplane’s aft center of gravity, which was substantially aft of the certified aft limit. Contributing to the cause of the accident was: (1) Air Midwest’s lack of oversight of the work being performed at the Huntington, West Virginia, maintenance station; (2) Air Midwest’s maintenance procedures and documentation; (3) Air Midwest’s weight and balance program at the time of the accident; (4) the Raytheon Aerospace quality assurance inspector’s failure to detect the incorrect rigging of the elevator system; (5) the FAA’s average weight assumptions in its weight and balance program guidance at the time of the accident; and (6) the FAA’s lack of oversight of Air Midwest’s maintenance program and its weight and balance program."

Accident investigation:
cover
Investigating agency: NTSB
Status: Investigation completed
Duration: 1 year and 2 months
Accident number: NTSB AAR-04-01
Download report: Final report

Classification:
Elevator issue
Loss of control

Sources:
» SKYbrary 
» NTSB
» ALPA Submission to the NTSB on Air Midwest Flight 5481

METAR Weather report:
12:51 UTC / 07:51 local time:
KCLT 081251Z 22006KT 10SM SCT140 BKN250 03/M07 A2975 RMK AO2 SLP075 T00331072=

13:51 UTC / 08:51 local time:
KCLT 081351Z 23007KT 10SM SCT140 BKN250 04/M06 A2976 RMK AO2 SLP079 T00391061=

14:51 UTC / 09:51 local time:
KCLT 081451Z 24008KT 210V290 10SM FEW140 BKN250 07/M04 A2977 RMK AO2 SLP083 T00671044 53008=


Follow-up / safety actions
On January 27, 2003 the FAA issued Notice N8400.40 requiring a number of operators of 10 to 19 passenger seat aircraft to validate the Weight and Balance Control Program to sample passenger weights, carry-on baggage weights, and checked baggage weights for part of their flights.
The survey showed that the average passenger weight was higher than the estimates by 20.63 pounds, carry-on bags were higher by 5.72 pounds and domestic checked bags by 3.81 pounds. Consequently, on May 12, the FAA reported it is adding 10 pounds to its estimate for passengers and five pounds to luggage (Notice 8300.112). This notice was cancelled by the publication of AC 120-27D August 11, 2004.

NTSB issued 24 Safety Recommendations

Show all...

Photos

photo of Beechcraft-1900D-N233YV
accident date: 08-01-2003
type: Beechcraft 1900D
registration: N233YV
photo of Beechcraft-1900D-N233YV
accident date: 08-01-2003
type: Beechcraft 1900D
registration: N233YV
photo of -
photo of Beechcraft-1900D-N233YV
N233YV
 

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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Charlotte-Douglas International Airport, NC to Greenville-Spartanburg Airport, SC as the crow flies is 121 km (75 miles).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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