NTSB Factual Report

The Safety Board's full report is avialable at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-04/01.

On January 8, 2003, about 0847:28 eastern standard time, Air Midwest (doing business as US Airways Express) flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport (CLT), Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and the airplane was destroyed by impact forces and a postcrash fire. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport (GSP), Greer, South Carolina, and was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

The accident airplane had been flown from the Tri-State/Milton J. Ferguson Field, Huntington, West Virginia (HTS), to CLT on January 7, 2003 (the day before the accident). Air Midwest records indicated that the accident pilots flew the accident airplane on six flight legs that day. The first officer (the nonflying pilot) of the flight from HTS to CLT told the accident first officer, when handing off the airplane, that "everything was normal" and "it was a good flying airplane."

The accident pilots began their trip sequence about 1340 and ended their trip sequence at CLT about 2045. Another flight crew met the accident airplane for a trip that night from CLT to Lynchburg Regional Airport/Preston Glenn Field, Lynchburg, Virginia. That flight crew flew the accident airplane back to CLT the next morning (January 8th), arriving at 0715. According to postaccident interviews, neither the captain nor the first officer of those two flight legs noticed anything unusual about the airplane.

On January 8, 2003, the accident flight crew was scheduled to fly two flight legs on a 1-day trip sequence-CLT to GSP and GSP to Raleigh-Durham International Airport (RDU), Raleigh-Durham, North Carolina-and then to travel on duty as passengers from RDU to CLT. An Air Midwest pilot saw the captain in the gate area about 0745 and the first officer about 0800.

The dispatch release for flight 5481 showed that a maximum of 32 bags was allowed on the flight. One of the two ramp agents working flight 5481 stated, in a postaccident interview, that 23 bags had been checked and that 8 bags were carried on the airplane. The ramp agent stated that two of the checked bags were heavy, with an estimated weight of between 70 and 80 pounds. The ramp agent also stated that he told the captain that some of the bags were heavy, although they were not marked as such. According to the ramp agent, the captain indicated that the bags were fine because a child would be on board, which would allow for the extra baggage weight. The ramp agent estimated that the forward cargo compartment was about 98 percent full by volume.

Cockpit voice recorder (CVR) information early in the recording indicated that the flight crew was completing the preflight paperwork regarding the airplane's weight and balance. Air Midwest records indicated that flight 5481 departed the gate on time about 0830. The captain was the flying pilot, and the first officer was the nonflying pilot.

Flight data recorder (FDR) data indicated that, beginning about 0835:16, the flight crew performed a control check of the elevators. The pitch control position parameter, which measures the position of the control column, recorded values from 15º airplane nose up (ANU) to 16.5º airplane nose down (AND). These values corresponded to elevator positions from full ANU to 7º AND. About 0837:20, the CVR recorded the first officer contacting the CLT Air Traffic Control Tower (ATCT) ground controller and informing him that flight 5481 was ready to taxi. The ground controller instructed the flight crew to taxi to runway 18R.

About 0846:18, the tower (local) controller cleared flight 5481 for takeoff and instructed the flight crew to turn right to a heading of 230º after takeoff. About 0846:35, the captain asked the first officer to set the takeoff power, and the first officer stated that the power had been set.

About 0846:48, the airplane's airspeed was above 102 knots, and the elevator position was 7º AND. About 3 seconds later, the elevator position was 1º AND, and the pitch attitude of the airplane began to increase. After 0846:53, the pitch trim started moving AND, and, about 3 seconds later, the captain called for the landing gear to be retracted. About 0846:57, the elevator position returned to 7º AND, and, about 2 seconds later, the CVR recorded the sound of the landing gear retracting.

About 0847:02, the first officer stated, "wuh," and the captain stated, "oh." About 0847:03, the captain stated, "help me." At that point, the airplane was about 90 feet above ground level, and FDR data showed that the airplane's pitch attitude was 20º ANU and airspeed was 139 knots. About 0847:04, the CVR recorded the captain asking, "you got it?" and FDR data indicated that the flight crew was forcefully commanding AND. During the next 8 seconds, the CVR recorded multiple statements and sounds from both flight crewmembers associated with their efforts to push the airplane's nose down. Also, about 0847:09, the CVR recorded a change in engine/propeller noise and, about 1 second later, the beginning of a sound similar to the stall warning horn.

About 0847:13, the FDR recorded a maximum pitch attitude of 54º ANU. About 0847:16, the captain radioed the ATCT and stated, "we have an emergency for Air [Midwest] fifty four eighty one," and the CVR recorded the end of the sound similar to the stall warning horn. About 0847:18, the airplane's pitch attitude decreased through 0º, and the elevator position began to move ANU. By 0847:19, the airplane was about 1,150 feet above ground level, and the FDR recorded a maximum left roll of 127º and a minimum airspeed of 31 knots. About 1 second later, the FDR recorded a pitch attitude of 42º AND.

About 0847:21, the captain stated, "pull the power back," the elevator position reached full ANU, and the airplane's pitch attitude was 39º AND. At 0847:21.7, the CVR recorded the beginning of a sound similar to the stall warning horn, which continued to the end of the recording. About 0847:22, the airplane's roll attitude stabilized at about 20º left wing down; the pitch attitude began to increase; and the elevator position moved in the AND direction, reaching about 8º ANU. About 1 second later, the elevator position began moving in the ANU direction. About 0847:24 the airplane rolled right through wings level, and the pitch attitude increased to about 5º AND.

About 0847:26, the FDR recorded a maximum right roll of 68º and a maximum vertical acceleration of 1.9 Gs. About the same time, the captain stated, "oh my god ahh," and the first officer stated something similar to, "uh uh god ahh [expletive]." The CVR recording ended at 0847:28.1. The FDR's last recorded pitch attitude was 47º AND; roll attitude was 66º to the right; and pitch control position was 19.2º ANU, which corresponded to an elevator position of full ANU.

The airplane struck a US Airways maintenance hangar on CLT property and came to rest about 1,650 feet east of the runway 18R centerline and about 7,600 feet beyond the runway 18R threshold. ATCT controllers heard an emergency locator transmitter signal beginning about 0847:29. The accident occurred at 35º 12' 25" north latitude and 80º 56' 46.85" west longitude during daylight hours.

NTSB Probable Cause

the airplane's loss of pitch control during take-off. The loss of pitch control resulted from the incorrect rigging of the elevator system compounded by the airplane's aft center of gravity, which was substaintially aft of the certified aft limit.

Contributing to the cause of the accident were (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 control system; (5) the Federal Aviation Administration's (FAA) 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.