Case Study 2

UNIVERSITI KUALA LUMPUR
Malaysian Institute of Aviation

Technology
Case Study 2
Air crash Investigation (Dead Weight)
PREPARED FOR
AZIZIHADI YAAKOP
STUDENT NAME & I/D: MUSABBIR ISLAM (53211220115)

GROUP: 2BMe3
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CASE STUDY 2 (DEAD WEIGHT)
SUBJECT: AAB40102-HUMAN FACTOR

DATE: 22/04/2020
1) SUMMARIZE WHAT IS ACTUALLY HAPPENING IN THIS ACCIDENT?
It was disaster that took lives of nineteen passengers and two pilots. Also a person
received minor injury on the ground. On January 8 th, 2003 Air Midwest Flight 5481 was
about to take off from Charlotte Douglas International Airport in Charlotte, North
Carolina, US. And scheduled to departure in Greenville-Spartanburg International
Airport. But after 37 seconds of lift off it turned into a flame. Pilot struggled hard but
could not control the aircraft and it crushed into the corner of US Airways hangar in the
airport.
After investigation NTSB1 reported that because of the overweight the aircraft lost its
pitch control which causes this catastrophe. Even though the pilots calculate that the
aircraft was not overweight, it actually was. Instead of actual weighing of individual
baggage and people, Air Midwest used average weight. They used averages of 175lbs
for every passenger and 20lbs for every baggage. As a result the aircraft was 580lbs
above its maximum takeoff weight. The aircraft’s central of gravity was aft-biased and
making it tail heavy And when landing gear was retracted the CG 2 become more aft-
biased, forcing the plane to pitch up further.
It was also found maintenance personnel set the turnbuckle 3 incorrectly while working
on elevator cable. Also post adjustment control test would be conducted but mechanic
skipped that procedure. And it turned out the turnbuckle tightened. Because of this,
elevator deflection was limited to 7 degree down instead of the normal limit of 14
degree. This mitigate the pilot’s ability to pitch the aircraft downwards to maintain
airspeed in the accident.
1 National Transportation Safety Board

2 Center of gravity
3 Control tension
1
The NTCB report concludes that combination of faulty maintenance job and out of limits
weight played a role as being a probable cause of this fatal disaster. However, this
crash is the milestone for updated weights for passengers and baggage.
2) WHAT IS THE HUMAN FACTOR ELEMENT INVOLVE IN THIS CASE?

DISCUSS IT.
Aviation safety relies heavily on maintenance. Most aviation accidents are not even the
result of vehicle malfunction, but of human error. Human error is defined as a human
action with unintended consequences. Some factors that effect this action is called
Human factors.
Loss of Pitch Control Caused Fatal Airliner Crash in Charlotte, North Carolina. Though
overweight resulted the accident also some Human factors worked behind this. In the
accident technician skipped some in maintenance procedure and install the turnbuckle
incorrectly. And in this reason pilot was unable to hold the pitch control.
 Complacency
People tend to become overconfident after becoming proficient in a certain task, which
can mask the awareness of danger. As a technician gains knowledge and experience,
a sense of self satisfaction and false confidence may occur.
2
In this case, by skipping some maintenance procedure technician didn’t test the system.
So the turnbuckle was tightened than usual and the he didn’t realize. The technician
had done this maintenance many times and that’s the reason he skipped post
adjustment control test. Technician was over confident and didn’t think it would be
needed for him.
Hence, the inspector had long been lulled into a sense of complacency and in this case
without the proper rigging of the elevator control system contributed to a failure to
control the aircraft in the pitch axis when trying to recover from the fatal stall.
 Fatigue
Fatigue is a major human factor that has contributed to many maintenance errors
resulting in accident. Occupation that require an individual to work long hours or stay up
overnight can lead to fatigue. Fatigue can cause a slower reaction times, reduced
vigilance and slower processing of information, decrease of attention and decreased
level of consciousness, which can be very dangerous when conducting maintenance.
In this accident, the technician had worked in a three day period on the elevator system,
and about 15 hours per day which was more than the acceptable duration of 10 – 12
hours working day.
He was fatigued and his body was telling him to done his work as soon as possible so
that he could take rest sooner. Also he was over confidence he used to do it and these
factor drove him to perform task properly as well as skip procedures.
3
3) WHAT CORRECTIVE ACTION SHOULD BE TAKEN TO AVOID ERROR IN

THIS VIDEO? EXPLAIN
A Beechcraft 1900D 4in this video lost pitch control during takeoff and was overweight.
Investigators founded that it had been used the average weight of passengers and
luggage instead of its actual weight which was much more than maximum takeoff
weight.
Moreover, Technician skipped some maintenance procedure that resulted incorrect

installation of turnbuckle in elevator system. Thus he didn’t test the system.
Error can be happened in anyway. But we can prevent or reduce the result same as this
case also. Some corrective action should be taken. Such as
 They should calculate the real weight of passenger and luggage for this small
aircraft.
 Human weight is not constant so the average weight should be updated every
after few years.
 Technician could complete his work properly without skipping.
 He should expect to find something wrong
 Technician should not sign off without test whether it’s needed double check.
4 Aircraft Model
4
 Working overtime made him fatigued. So he needed to be aware of the

symptoms.
 He could forfeit the task or handover to another one.
 He had to treat all of the inspection items equal importance.
 It must never be assumed that an item is acceptable when it has not been
inspected.
Thus they could prevent the accident and save the lives of innocents. Safety is first
priority in aviation sector and we should never ignore this in any situation.
3) YOU ARE A SHIFT LEADER CARRYING OUT A MAJOR AIRFRAME

REPAIR THAT WILL NOT BE COMPLETED DURING YOUR SHIFT.HOW
ARE YOU GOING TO COMMUNICATE THIS TO THE INCOMING SHIFT
WITH REGARDS TO OUTSTANDING WORK, DATA AND SPARES?
Some maintenance task could not be completed within a shift. Also a number of
task take 2 or more days to be completed. In such cases work need to be handed
over from one shift to next shift. Shiftwork is used extensively in commercial air
transport maintenance operations. So we need proper shift turnover that helps
ensure an aircraft’s airworthiness and the safety of technicians. As a shift leader in
turnover time I must need to make effective communication to the incoming shift.
5
The primary objective of handovers is to ensure that all necessary information is

communicated between the out-going and in-coming personnel. Formality relates
to the level of recognition for shift turnover procedures and exists when shift
turnover procedures are part of written operating rules and managers and
supervisors are committed to ensuring that cross-shift information is effectively
delivered.
Firstly, I must have to make written statement or annotation on a work stage sheet.
And handover written reports of tasks to incoming shift manager.
It is also necessary to keep the record of work up-to-date for handover the job.
Secondly, it should be backed up by verbal communication process. So I need to

meet with the incoming and outgoing workers as a group to summarize the progress
of the outgoing shift as a supervisor.
And also I must have to mark by warning flags or placard 5the task that are in
progress as well as Completed one should be clearly mention in maintenance cards
or in logs. It make the incoming shift easy to find and understand
Moreover, I should also summarize any significant problems encountered and

whether
solution is founded. Beside this there are lots of procedure I have to fill to handover
the task to next team. Effective communication is the key to an effective turnover. A
common and serious mistake is an incoming worker assuming that the outgoing
worker has completed a job when, in fact, he or she has not. Communication during
turnover6 is very sensitive issue and I have to make it clear and easy as much as
possible.
5 Printed or handwritten notice

6 Changing shift
6
References
1) NTSB (2004). Aircraft Accident Incident Report. Loss of Pitch Control during Takeoff Air
Midwest Flight 5481 Raytheon (Beechcraft) 1900D, N233YV Charlotte, North Carolina
January 8, 2003. Washington, DC: National Transportation Safety Board.
2) ATEC Journal (2005). Incorporating Air Transport Association Codes into Maintenance
Curriculum.Volume 26. Issue 2
3) https://medium.com/@admiralcloudberg/tipping-the-scales-the-crash-of-air-midwest-
flight-5481-caa032313df6
4) SAFE COMMUNICATION AT SHIFT HANDOVER: SETTING AND IMPLEMENTING

STANDARDS
https://www.hse.gov.uk/humanfactors/topics/standards.pdf
7
8
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UNIVERSITI KUALA LUMPUR

Malaysian Institute of Aviation

Air crash Investigation (Dead Weight)

STUDENT NAME & I/D: MUSABBIR ISLAM (53211220115)

SUBJECT: AAB40102-HUMAN FACTOR

1) SUMMARIZE WHAT IS ACTUALLY HAPPENING IN THIS ACCIDENT?

1 National Transportation Safety Board

2) WHAT IS THE HUMAN FACTOR ELEMENT INVOLVE IN THIS CASE?

3) WHAT CORRECTIVE ACTION SHOULD BE TAKEN TO AVOID ERROR IN

Moreover, Technician skipped some maintenance procedure that resulted incorrect

 Technician could complete his work properly without skipping.

 He should expect to find something wrong

 Working overtime made him fatigued. So he needed to be aware of the

 He could forfeit the task or handover to another one.

 He had to treat all of the inspection items equal importance.

3) YOU ARE A SHIFT LEADER CARRYING OUT A MAJOR AIRFRAME

The primary objective of handovers is to ensure that all necessary information is

Secondly, it should be backed up by verbal communication process. So I need to

Moreover, I should also summarize any significant problems encountered and

5 Printed or handwritten notice

4) SAFE COMMUNICATION AT SHIFT HANDOVER: SETTING AND IMPLEMENTING

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