Pilots of Colganair Flight 900446 fight
for their lives as their plane dives
towards the ground. You pull for all your
worth. Just keep pulling for all your
worth. Picture trying to do your day job
while deadlifting 250 pounds. Oh no.
Both pilots are killed.
The wreckage reveals very little.
That is a rat's nest. The cockpit voice
recording got a runaway trip. Provides a
key insight. Listen how exhausted they
are. Trying to keep the nose up but
analysis of flight data turns the case on
its head. This doesn't look right. Well,
that was the huge ah ha moment for me.
How'that possible? Everybody missed what
was just such a simple mistake.
A Colgan Air crew prepares for the last
flight of the day in a recently serviced
aircraft. Weather looks
good. Should be an easy ride. Captain
Scott Knnabbe has been with Colganair for
more than two years. Six months ago he was
promoted to Captain Scott Kanabe
was among the most careful and meticulous
pilots. He was a very
successful and very good accountant.
But he had the aviation bug. How's the
paperwork? Weight and balance is checked
and filed. First officer Stephen Dean has
been with the airline for less than a
year. Did you put in for that
upgrade? Actually no I didn't. I put in my
notice. I can't afford to do this anymore.
I understood. Being a young pilot
moving his way up the ladder in the
regionals, the first officer quickly
discovered that his pay could not his wife
and daughter. So a week before
this flight he gave notice.
Don't mind these reposition flights.
Yeah, no passengers, no problems.
Knair has a small fleet of BEEC 1900s
the aircraft oper as part of USAir's
regional arm. The Beechcraft is a
smaller plane popular for commuter
flights.
They fly short distances. They fly into
places that the big name carriers wouldn't
be able to fill up or make a lot of money.
Maintenance log checked and aircraft is
released. After four days of routine
maintenance in Hyanis, the plane is being
returned to service. Colgan 9446
will fly empty to upstate New York.
Sometimes we have to resort to these non
revenue flights to reposition the plane
from one location to another.
Occasionally that could also happen when
you have to bring the plane to a specified
maintenance facility. Today's flight from
Hyanis, Massachusetts west to Albany, New
York should take 50 minutes.
Circuit breakers checked. Checked. The
pilots perform their final checks.
All right. I'm not getting any radios
here. Have you get anything in your heads,
sir? Check, check, check.
What a cluster. When an airplane is
let's return back to service. Pilots will
expect that all subsistence are working.
So you will show up to the airplane and
expect that everything has been service
accordingly and it's safe to return back
to flying after
a short delay because of a Minor radio
problem. Flight 900446 taxis for takeoff.
The afterions are set. Cabin PA not
required. Tower cold.
9446 we're good to go. 24 Colgan
9004 and 46 Runway 24 cleared for
takeoff. Clear for takeoff.
24 Kgan 9446 set
the power.
Power set. The beach 1900
being as such a stable aircraft as soon as
it accelerates on the takeoff roll it will
reach fliable speeds in a distance as
short as 4,000ft 80 knots and
it will basically fly itself off the
ramway with very minimal pilot input.
V1 rotate.
At 3:38pm Flight 9446 lifts
off the Runway but it's barely gaining
altitude. We have a hot elevator trim.
The captain suspects there's an issue with
the trim system which is preventing the
plane from climbing normally.
Trim tabs on the elevator adjust the
plane's pitch during takeoff. They're
powered by a switch on the control column
but the captain's trim switch isn't
working. If you have a trim issue on
takeoff it is very difficult to overcome.
You have seconds not minutes because you
don't have any altitude. Just 50ft
off the ground the plane's nose is
dropping. Roll back. Roll back.
Roll it back. I got it.
Kanaabbe instructs the first officer to
adjust the trim manually.
The manual trim is a wheel located on the
left side of the throttle quadrant that
allows you to trim it into a nose up
addite. But that
doesn't help pull back an
airplane that is nose heavy will
continuously require back pressure on the
control yoke.
It's everybody. Using brute force the
pilots manage to raise the plane's nose
and climb away from the Runway. Despite
the plane's determination to pitch down do
the electric trim disconnect. The captain
wants to cut the power to the trim
altogether.
But before the co pilot can even find the
right circuit breaker back
Steve no, stay the controls with me. The
nose drops again.
Put up our gear.
Selecting the gear up in an airplane will
reduce the amount of starac being exposed
to the airstriam improving your climb
performance. This would have make the
pilots gain altitude at a faster rate.
45 seconds into the flight the pilots
still can't get the plane to climb
normally.
9446 is requesting emergency back sir.
Got a runaway Trim, the captain wants to
return to Hyanis Airport.
Colgan9446, Roger. Right a left downwind.
Your choice. Report midf field.
Okay, roger. We will do. Using all of
their physical strength, the pilots
managed to level off at,200ft and start
the turn back to Hyanis.
Allgh, we have
a beach. 1900 aircraft that just took off
reporting control problems. We need fire
and rescue to Runway three three with
brief respite from the struggle. Can I
pull the breaker? Yeah, pull the breaker.
See? Pull the breaker. The ye. The pilots
return to troubleshooting the trim issue.
Where is it? Find it. In the confusion,
the first officer can't locate the breaker
for the automatic trim. Look. Left of the
silver thing, Steve. Left of the silver
thing. Left of the silver thing. Left of
the silver thing. This dick seeve.
Stay with me. The second attempt to
disconnect the trim system also fails.
Less than two minutes after taking off,
Colga 9446 is losing altitude.
You pull for all your worth. Just keep
pulling for all your worth. Really what he
was saying is pull for your life. Because
that was the only hope they had at that
time.
Five miles from the airport, the pilots
struggle to return to Hyanis.
9446 is requesting 33, sir.
9446 roger. Runway 33 cleared
the land. You're gonna need both of us on
this, Steve.
The pilots use all their strength to keep
their plane airborne. Steve. Ke I'm
pulling but it's still not enough.
We have a beach. 1900 aircraft down east
of Point Gamon. Two pilots, no passengers.
Two minutes after takeoff, KGAN 9004 and
46 crashes three and a half miles from the
airport in Hayanis, Massachusetts.
The Coast Guard was there almost
immediately, but they were not able to
save the pilot and the co pilot. Hitting
the water at a very high rate of speed is
like hitting cement. The pilot's
bodies are recovered from the wreckage
within four hours.
A team from the National Transportation
Safety Board, the NTSB arrives in Cape Cod
to begin the investigation can be posted
on under recovery process. This is the
second beach 1900 to crash in six months.
There was the Air Midwest accident down in
Charlotte. The big question was, you know,
is there anything related? Was there a
fleet wide problem?
NTSB investigators consider why Colgan Air
Flight 9446 crashed so soon after takeoff,
killing both pilots. It's similar to
an Air Midwest crash in Charlotte, North
Carolina which took the lives of 21
people. Witnesses reported that the
aircraft climbed for a
Few seconds and then the nose pitched up
high in the air. It edged over and then
literally tumbled towards the ground into
a building.
With hundreds of American built beach
1900s in service, investigators need
to find out if there's a design fault with
the aircraft that could put even more
lives at risk.
Steve. Hey, great. You can set up over
there. Thanks, boss. The NTSB calls
in Steve Carbone, an investigator who has
been working for months on the beach 1900
accident in Charlotte.
What do we know so far about the cause of
that other BE 1900 crash, the one in
Charlotte? We think the plane was loaded
wrong and the pilots lost control of it.
A witness reported that Colgan Air 1900
seemed to struggle to hold altitude before
descending into the water south of the
airport. Pilots understand that altitude
is their best friend. And taking off from
the airport and then pretty much flying
right into the ocean is a sure sign that
something was wrong. Could be
controlled problems after takeoff in both
accidents, the similarities
between Kogan and Air Midwest wasn't just
the fact that Both were beach 1900. In
both instances, the attitude of the
aircraft was uncontrollable.
Charlotte. They lost control of the pitch.
Was it outside its center? Gravity?
The balancing point of an airplane is
called its center of gravity. Passengers
and luggage must be carefully distributed
from front to back to keep the plane
stable in flight.
In Charlotte, investigators believe the
beach 1900 may have been tail heavy,
which caused it to pitch up after takeoff.
The Colgan flight was empty. So without
any passengers. Maybe the center of
gravity was too far forward. You could
have an empty airplane and still be out of
your center of gravity. Crew weight 454
pounds. They calculate Flight
9446's center of gravity based on the
distribution of the weight on board. And
then the fuel weight was 3,271 pounds.
That should do it.
Look how far from it that is.
Yeah, but it's within limits.
The team is now certain that whatever
brought down Colgan 9446, it was not
related to its center of gravity.
With Kogan, center of gravity didn't turn
out to be an issue, even though it did
have to be eliminated as a possibility.
Thank you for meeting with me.
Investigators turned to the air traffic
controller for insight into why the pilots
of Colgan 9446 lost control after takeoff.
Tell me about the flight. It'a normal
takeoff. About a minute after they wanted
to return to the airport.
9446 is requesting emergency back. Sir.
We have a runaway trim. He told
you a runaway Trim? Yeah.
Pilot reported a runaway trim to air
traffic control, which is a control issue.
And so that information was very helpful.
It helped us work smarter, not harder.
Runaway trim occurs when the motorized
trim tabs on the elevator malfunction,
causing the plane to pitch nose up or nose
down. Aroundeight trim close to the
ground will be specifically challenging
because pilots will have very limited time
to perform the required actions to safely
control that aircraft. Now, he came off a
Runway 24 and reported his
emergency here.
Turned back toward the airport,
and the plane never got above 1200ft on my
radar and he hit the water
here.
If the pilot feels that he's having a trim
runaway, there's something in the pitch
system that is clearly a problem.
This is very helpful. Thank you. And we're
certainly going to investigate that. Will
the wreckage confirm what the pilots
reported and help explain what brought
down a widely used commuter aircraft in
just over two minutes?
Good. You got them. The flight data
recorder and cockpit voice Recorder of
Colganair Flight 9446 are recovered from
the sea floor. They are in good shape.
Ship them to the lab. Mean we'get some
answers from these. We were lucky in
some areas where we had the flight data
recorder and we had the cockpit force
recorder. If we didn't have flight
recorders on this one, boy, I don't know.
That is a rat's nest.
Investigators turn their attention to what
remains of the control systems. So there's
a lot of cables that go to the tail,
cables that control the elevator, the trim
and the rudder as well. I see some of the
trim cable in there. Let's find as many
pieces of it as we can. The trim cables
are smaller and head fractured, and so
it's a big puzzle to be able to track the
cables from one end to the other. Could
take a while.
While one team looks for the cables
connecting the trim system, another
focuses on the maintenance history of
Colgan9004.46,
I'm going to look into work done on the
flight controls.
The aircraft was brought into has four
days before the accident for regular phase
inspection. Could a faulty repair
be connected to the pilot's report of
runaway trim? Check out which inspection
they were in. At Colnair,
monthly routine inspections are divided
into phases, focusing on different areas
of the plane.
They were working on the tail. Exactly.
Which means they might have done work on
the trim system. They flew in with no
problems, and then on the first flight
out, they couldn't control it. Something
happened that was detrimental to safety of
the aircraft. They spent at least four
separate days on the inspection ###n take
them so long?
It doesn't say a phase check.
In this case, what they call a detail
check, you can do it within an eight hour
period, especially on a 1900, because it's
a very simple aircraft. But the fact that
it took four days led us to understand
that there was something else that
occurred. Mind if I record this?
Sure.
I was wondering why did it take you so
long to do your face checks? No, we
definitely found a lot of stuff that we
need to replace.
I got the flashlight.
Just bring the light a up to my left.
Yeah. The trim actuator is worn out.
Cables from the cockpit connect to the
trim actuators. Mechanical rods
in the tail that move the trim tabs up or
down. What did you do when you found the
problem with the actuators? We removed the
old ones, ordered new ones and installed
them. And the new ones went in
easily and it worked fine. U well,
not exactly.
Okay, Bob, run the trim system, please.
Did the actuators move? No.
Neither did the trim cable. The test
revealed problems with the actuator
replacement. When we replaced the
actuator, we bent and kinked the cable
that connects it to the cockpit controls.
It was just a dumb mistake. If he's an
experienced, competent mechanic, why would
he do that? And the answer was he was not.
He was. A new hire, had never done this
job before. And their training program
allowed him to do this without any
supervision. I ordered a new cable and
installed it. That's why it took four
days. And you tested it?
Yeah. Yep. After the
new cable was installed, maintenance
workers performed a visual check.
Okay, let's give it a try. When examining
the paperwork after the accident,
everything looked in order. That's it.
It's working. Thanks, man. Yet we still
had an issue because it didn't explain
what actually happened. With no credible
leads to explain why the pilots thought
they had a trim issue, investigators must
rely on what they learn from the cvr. The
cockpit voice recorder. Okay. Hear it.
The recording runs about 17 minutes from
the moment the pilots powered up on the
ground.
Could the pilot's communications reveal
why Colganair Flight 9446 failed to
maintain altitude?
Hi, its maintenance. This is Colan 9004
46. Hey, I was told to stay in contact
with you for the whole trip. Yeah, they
might call you and turn you back. Because
they did find a problem. I don't know for
sure. Why would maintenance
want to turn them around? Maybe there was
something wrong with the plane. Somebody
had doubts about the work. They did.
I, as a mechanic could not ever
release an aircraft that there was a
question of its airwortthhiness. You
cannot say. Well, you know, the wings aret
pretty strong on there. We're 90% positive
they're not going to fall off. You can't
do that. I d prefer not to fly something
if it's broken. I'd rather you do it
because you are the pilot in command. All
right. Broken airplane. I wouldn't
want to screw it up.
Okay. It'll be a standard Coolan takeoff.
If things get spooky on the Runway, we'll
abort it. Did you
just say spooky? As investigators continue
to review, the CVR flight crew should
not be that nervous. They're surprised by
the pilots's concern about the condition
of their aircraft.
Sadly, the aircraft manuals went down with
the aircraft. So exactly what
the maintenance personnel put in those log
books for the pilots to review we will
never know.
When did they first realize there was a
serious issue with their aircraft?
Looks like merely seconds after takeoff.
V1 rotate.
We have a hot elevator trim. They
identified a trim issue seconds after
takeoff, long before contacting the
controller. So what do they do about it?
Kill the trim. Kill the trim. The captain
tries to disconnect the trim system on his
yoke, but his attempts fail.
Roll back. Roll back. Roll it back. I got
it.
Their commanding nos up trim inputs, but
it doesn't seem to help.
9446 is requesting emergency back, sir.
Got a runaway trim. Okay, there it
is. Runaway trip, just like the controller
said.
Did they try pulling the breaker? Looks
like it.
Pull the br ste. Pull the breaker at the
yoke. Listen how exhausted
they are. Trying to keep the nose up.
Where is it? Find it. The pilot was
calling for the co pilot to pull the
circuit breaker so they can stop these
electrical signals that are commanding the
runaway tram. But you have to have time to
pull the circuit breakers. Look. Left of
the silver things, Steve. Left of the
silver. Left of the silver thing. Left to
the silver thing. O this dick. See?
Stay with me. The coal pilot had to
abandon pull in the breaker in order to
help the captain. Steve, keep pulling.
Oh, no.
Two minutes from takeo the impact.
Those guys fought the trim right until
they hit the water. We need to find
out what's going on with that trim system.
Was there a mechanical issue with the trim
that the pilots could not overcome?
Okay, let's have a look. We were lucky we
had a solid state flight data recorder.
Some of the old, old flight recorders
might only have 16 parameters. This one
had a lot more. Investigators examined the
fdr, the flight data recorder to determine
why the pilots reported a runaway trim.
This doesn't look right. What do you mean?
This trimmed. That is way out of
calibration. It either wasn't
maintained properly or it was damaged in
the accident and so on. This one we didn't
have exact treosition.
If the FDR wasn't calibrated, those
readings are worthless. It's a
major setback. Without the FDR data,
the investigators may not be able to
confirm the pilot's report of a runaway
trim. But we have all those other
parameters. Pitch elevator.
Let's ask the lab to try and calculate
what the trim position would be.
Performance case study. It's a great idea.
A case study like this would help us to
define whether the elevator trim tape of
cables had anything to do with the
accident. It was one other thing that we
could check into to verify the results we
were finding. Will the team be able to get
accurate trim data? Steve KE I'm pulling.
And explain why two experienced pilots
were unable to keep their plane in the
air. Oh no.
So the lab took the control column
positions and extrapolated for trim. I
see. Excellent. A performance
study using the FDR data gives the NTSB
a new look at the trim inputs on Flight
9446.
So they adjust the trim to take off right
here? Yepah. It's part of the before taxi
checklist.
Before taxi checklists. Before taxi
Weather radar on standby. Trim set.5
Takeo trim set.
The takeoff trim was set to 0.5 nose down
instead of.5 nose up.
That's odd. When's the next input?
Right after takeoff. That's right after
he said. We've got a hot elevator
trim. Plane is pitching down instead of
up. How's that possible?
Investigators discover the plane wasn't
responding to the pilots's nose up trim
inputs. And it happens again here, one
last time a few seconds later. Roll back.
Roll back. Roll it back. I got it.
The more the first officer tries to
manually trim the nose up, the more the
nose drops. It's like the trim is
reversed. A good analogy is
learning to drive. Imagine how weird it
would be if you turned your steering wheel
right and the car went left. Talk about
confusing and exhausting.
You pull for all your worth. Just keep
pulling for all your wor. They were
dealing with the backwards trim, which I
don't know how anyone would have ever
fathomed that. Investigators calculate
that within a minute of takeoff the pilots
would have required £250 of force to hold
the nose up.
I'm. Hold on,
Steve.
How on earth can they have wired a trim
system backwards?
The team retrieved this from the wreckage.
O great. In an
effort to prove the trim cables on Flight
9446 were reversed,
investigators study a key piece of the
trim system found in the wreckage.
Okay. The trim cable is threaded and
wrapped around this drum and then runs in
a loop from the cockpit to the tail.
Maybe they fed the cable incorrectly
around the drum. Let's check the
installation manual.
Looks like maintenance threaded the drum
correctly.
Yeah, but how did they install it?
The cable drum is one piece of the story
that was telling us that it might have
been incorrectly rigged, but we needed to
dig deeper. Okay,
let's give this a try. The NTSB
considers how the maintenance crew
installed the drum. It's good.
We. Yep. It's.
Well, that doesn't fit.
Yeah. The only way to install this thing
like this. Investigators discover that in
order for the drum to fit the pin, it had
to be flipped, thereby crossing the wires.
Well, that was the huge aha moment for me.
The manual, the way it was depicted at
that time, it could mislead somebody.
In this case, it did.
We have a hot elevator trim.
Because the wires were crossed, the trim
tab operated in reverse.
Give a trim, kill the trim,
pull back. They knew they had a
malfunction. They just couldn't figure out
what it was. There's only one explanation.
The maintenance manual must be wrong.
I'll check with the manufacturer. But even
if the manual is wrong, why didn't anyone
notice the trim cables were crossed?
I'll check to see if the maintenance team
got inspector to sign off on the work.
They are a second set of eyes. They have
to be the one who is making sure that the
job is done right. That is what an
inspector does. After you installed
the drum, did an inspector sign off on the
work? Yes, he did. In fact, he assisted
with it. He assisted?
Yep. The inspector cannot get in there
with wrenches. He cannot get in there and
tell you, okay, you got to put this bolt
here or anything like that. Thanks for
your help tonight. The thing is, with an
inspector being part of the job, he's
making the same mistakes that the people
that he's supposed to be overlooking are
making. So he becomes part of the problem.
The inspector who helped with the
installation didn't notice the crossed
wires and signed off on the work.
The last time we spoke, you said you
tested it. That's right.
After the new cable was installed. Okay,
let's give it a try. Maintenance workers
performed a visual check. That's it. It's
working. Yeah. Thanks, man.
Yeah, that's coming in now.
Thanks.
Hey. Hey. What did
d you find out? The inspector helped with
the installation. So not exactly an
objective inspection. What about you?
Well, it's just like we thought. No
drawing in the manuals. Rm this is
how the drum should have been oriented
when they threaded the cable. The manual
shows the slots on the drum are facing
out. But the correct way to
thread the cable is with the flat side
facing out. Here's what I don't get. They
tested the trim system when the
installation was complete and said it was
working fine. How's that possible?
Long night? Yeah. Found a recording
of the trim check test. You're kidding.
It's on the cvr. Recorded well before
their flight. In order for the mechanics
to do an operational check correctly,
they had to power the airplane up. Okay,
Bob, run the trim system, please. So the
power was on. The CVR was on. It worked to
our advantage. I think I know how the trim
tabs pass the visual ground tests even
though they were running in reverse.
Arey you good in the cockpit?
Yeah. Okay, let's give it a try.
Trim nose up. Trimming thosese upe.
Moving up. Looks good. That trim
Nose down. Trimming down.
Okay, that's it. That's working.
Thanks, man.
Sounds like a normal test. No, they got it
backwards. We hear the cockpit
call trim up and the maintenance worker
says he sees the trim tab move up. That is
reversed. If you trim nose up,
the trailing edge moves down in the
opposite direction. The same is true for
trimming the nose down.
It is counterintuitive, but you're right.
It is an easy mistake to make. Checking a
trim system can be a little confusing.
You have to make sure you're on the same
page with the other person. Are you
talking tab up or nose up? Because tab up
is nose down. The ground guys missed it.
Okay. Why didn't the pilots?
Trim test is definitely a pre takeo
checklist item. But then they run it
according to the transcript. They ran the
checklist.
All the four start checks.
Parking brake. It's set. Pre flight
complete before taxi. Checklists before
taxi. Weather radar.
They skipped the trim check.
I'm biased because I have a pilot
background. I feel like that first flight
of the day checklist is crucial. That's
where you can catch it.
Even if they had checked it, would they
have known whether the trim system was
reversed just by looking at the direction
the trim wheel was spinning?
Good. Point pilots test the trim
by pressing the trim switch and monitoring
the direction in which the manual trim
wheel spins. To trim nose up,
the wheel would turn backwards.
Investigators recreate the reverse trim
system on the same model of Beach 1900
that crashed to determine whether the
pilots could have detected that the trim
was reversed. Let's give this a try.
Investigators trim the plane nose up.
The wheel is moving backwards the
way the pilots expected it to turn. Even
though the trim cable was reversed, the
wheel still moves backwards as it should.
What is in error is the fact that the drum
is upside down. It is now running the
cables in the wrong direction. So
everything in the cockpit is correct.
The test reveals the pilots of Kgan Air
Flight 9446B1 rotate wouldn't have
realized the cables were reversed even if
they had checked them prior to takeoff.
We have a hot elevator trim.
In their final report, the NTSB concludes
the cause of the accident was the improper
installation of the trim cable system and
Beechcraft's erroneous depiction of the
elevator trim drum in their maintenance
manual. The stick.
Stay with me. These factors ended up
sealing the pilots's fate'n
take both of us on under Steve.
Steve. Keith. I'm pulling.
The pilot's grueling efforts kept the
plane in the air for more than two
minutes. P But in the end,
the extreme stick pressures were too much
for the pilots to overcome. Picture trying
to do your day job while deadlifting £250.
It's just too much.
Hold on, Steve.
No.
This accident was 100% preventable. First
and foremost is your plane has to be
flyable. And it's only flyable if the
manuals and maintenance is and pilot
instructions make sense. The Colganair
9446 report echoed similar findings to
the other Beach 1900 crash months earlier
in Charlotte, North Carolina.
Improperly installed control cables were
also a factor in the Air Midwest accident
that killed 21 people. If you looked
up the term maintenance accident and
dictionary, those two accents would be
there. Colgan and Air Midwest were poster
childs for maintenance accidents.
If Colgan properly followed the
maintenance program as dictated by the
regulations, this accident never would
have happened. After the accident,
Beechcraft'maintenance manuals were
amended and airlines adopted stricter
procedures for airplane checks. After
undergoing routine maintenance, the person
in the cockpit missed it. The people on
the elevators missed it. The inspector
missed it. Everybody missed what was just
such a simple mistake.