N139ZV

Substantial
Minor

Beech 1900D S/N: UE-139

Accident Details

Date
Friday, January 10, 1997
NTSB Number
NYC97FA045
Location
BANGOR, ME
Event ID
20001208X07345
Aircraft Damage
Substantial
Highest Injury
Minor
Fatalities
0
Serious Injuries
0
Minor Injuries
2
Uninjured
9
Total Aboard
11

Probable Cause and Findings

The inadequate flight and winter operations training provided by the operator, and the pilot's improper decision to abort the takeoff while airborne above V1, due to a false stall warning horn. Also casual was the airport operations improper decision to discontinue plowing, and their failure to remove a snow pile on the runway. Factors relating to the accident were an easterly crosswind, the narrow icy runway conditions, inadequate FAA oversight in allowing the operator to continue operations with an inadequate training program that continued over several years, and the manufacturer's checklist which delayed the activation of the stall vane heat until just prior to takeoff.

Aircraft Information

Registration
N139ZV
Make
BEECH
Serial Number
UE-139
Engine Type
Turbo-shaft
Year Built
1931
Model / ICAO
1900D B190
Aircraft Type
Fixed Wing Multi Engine
No. of Engines
2

Registered Owner (Historical)

Name
ALPINE AVIATION INC
Address
1177 ALPINE AIR WAY
Status
Deregistered
City
PROVO
State / Zip Code
UT 84601-8270
Country
United States

Analysis

HISTORY OF FLIGHT

On January 10, 1997, at 0923 eastern standard time, a Beech 1900D, N139ZV, operated by Mesa Airlines, Inc., doing business as USAir Express Flight 5326, was substantially damaged during an aborted climb after takeoff at the Bangor International Airport, Bangor, Maine. The certificated airline transport captain, first officer, and seven passengers were not injured. Two passengers received minor injuries. Instrument meteorological conditions prevailed for the scheduled passenger flight, destined for Boston, Massachusetts. An instrument flight rules flight plan had been filed for the flight conducted under 14 CFR Part 135.

The airplane had been flown by the flight crew from Boston, to Bangor International (BGR), and arrived, at 0856. The airplane was fueled, passengers were boarded, and the flightcrew started the engines and taxied to the de-icing area. While in the de-icing area, the engines were shut down and airplane de-icing was initiated at 0912, and completed at 0917. The engines were restarted, and the airplane was taxied to runway 33 for takeoff. At 0921, Flight 5326 was cleared for takeoff by the BGR tower controller.

The first officer (FO) stated that she was the flying pilot. The FO briefed the captain that this was to be a zero degree flap takeoff, and repeated the takeoff speeds to be used. After taxing onto the runway, the FO applied power, began the takeoff roll, and requested that the captain set the final takeoff power.

The cockpit voice recorder (CVR) transcript revealed the following: the flight crew called out the "takeoff final items," at 0921:10; which included ice protection items, at 0921:21; the propeller RPM was heard to increase, at 0921:59; and the FO called out "set takeoff power," at 0922:09. The captain then made the following callouts: "eighty knots cross checked," at 0922:12; "the wind is from the right," at 0922:17; and "V one rotate," at 0922:19.

The CVR revealed the sound of a horn, at 0922:21, which was similar to the stall warning horn. At 0922:26, the captain called out, "abort abort." The sound of the horn ceased, at 0922:28, and the captain called out, "abort Doris Doris," at 0922:29. The CVR recorded the sounds of impact and the recording ended, at 0922:31.

The FO stated that at Vr, she pulled the yoke back with both hands, raised the pitch of the airplane into the command bars, and heard the stall warning horn sound as the airplane rotated. She stated that she released "a little back pressure," observed the airspeed indicator at 120 knots, and applied more back pressure. The airplane then left the ground, but it felt sluggish. She estimated that the airplane was about 20 feet above the runway when the captain commanded, "Abort! Abort!" The FO closed the throttles and the airplane contacted the ground approximately on the centerline of the runway. She stated that, "visibility went to zero because of the flying snow." She then brought the "throttles to Ground Fine," and felt the captain's hand on top of hers as she moved the throttles into reverse.

According to one passenger, the airplane lifted from the runway and the engines were "whining as we started to climb."

The passenger also stated:

"...Very shortly we seemed to level off and then it appeared to me that the pilot was aborting the takeoff...I heard a loud snap and suddenly the fuselage was ripped open..."

Another passenger stated:

"...Rolled onto runway, turned right and proceeded with takeoff. (noted: that there was not spool up to full power with brakes applied before takeoff.) Plane took off and gained 10 - 20 feet altitude. Heard the stall alarm and pilot aborted take-off putting back down on runway, landing about 15 [degree] angle to the right of center line. Nose gear gave way. Right engine propellers broke-off and came through cabin..."

After touch down, the airplane veered left into the snow bank on the runway. The airplane pivoted 90 degrees nose right as it traveled through the snow bank while still on the runway, and exited the snow about 819 feet from the point of entry. The crew and passengers exited through the overwing exits and the main cabin door.

During an interview, the Captain stated that he checked the stall warning vane prior to his leaving the accident site, and found ice had frozen the stall warning vane in position. He said he wiggled the vane and broke it free of ice holding it in place.

The accident occurred during the hours of daylight approximately 44 degrees, 48 minutes north latitude, and 68 degrees, 49 minutes west longitude.

FLIGHT CREW INFORMATION

Captain

The Captain held an Airline Transport Pilot Certificate with a rating for airplane multiengine land, and was type rated in the Beech 1900, with the limitation that a second in command was required. He also held a Commercial Pilot Certificate for airplane single engine land. His most recent Federal Aviation Administration (FAA) First Class Medical Certificate was issued on December 6, 1996.

The Captain was hired by Mesa Airlines on October 10, 1994, and flew as a First Officer (FO) on the Embraer 120. He was upgraded to Captain in the Beech 1900, and took his type rating check ride in July, 1996. Since the check ride, the Captain estimated that he had flown about 350 to 400 hours in the Beech 1900, all of which was pilot-in-command (PIC). He reported that his total flying experience was about 5,800 hours.

During an interview with the Captain, he stated that he had received no crew resource management (CRM) training. He recalled that he did receive "some" winter operations training during his initial hire training in October, 1994. He also stated that he was unfamiliar with operations in snow conditions, and that this was only his third takeoff and landing in snow. The Captain's base of operation with Mesa was Boston.

First Officer

The First Officer (FO) held an Airline Transport Pilot Certificate with a rating for airplane multiengine land, and was type rated in the Cessna 650. She also held a Commercial Pilot Certificate with ratings for airplane single engine land and glider. The FO held a Flight Instructor Certificate with ratings for airplane single engine land, glider, and instrument airplane. Her most recent FAA First Class Medical Certificate was issued on August 8, 1996.

The FO was hired by Mesa Airlines in September, 1995. She received her initial training in the Beech 1900, and had accumulated about 1,100 hours of second-in-command experience in make and model. The FO reported that her total flying experience was approximately 4,100 hours.

During an interview with the FO, she stated the she had received "a good 1 1/2 hours of CRM," during her recurrent training in August, 1996. The FO did not recall any winter operation or de-icing training, but did state that winter operations were "mentioned" in the Company Flight Manual and General Operations Manual.

She also stated that she had experienced the stall warning horn activation twice before during takeoff. Each of these resulted in continued flight.

The FO's base of operation with Mesa was Boston.

AIRCRAFT INFORMATION

The airplane was equipped with two Pratt & Whitney Canada Inc., PT6A-67D, engines. Each engine was equipped with propellers manufactured by the Hartzell Propeller Inc., Piqua, Ohio. Each propeller assembly consisted of 4 composite material propeller blades, and both the left and right hub and blade assemblies had accumulated about 3,564 hours.

A review of the airplane's maintenance records did not reveal any repetitive discrepancies related to the engines, propellers, anti-icing, flight controls or stall warning systems.

AERODROME CONDITIONS

The Bangor International Airport (BGR) had a concrete runway, 15-33, which was 11,439 feet long, 300 feet wide, and was grooved. According to the BGR airfield maintenance supervisor on duty at the time of the accident, the BGR snow removal crews had been plowing runway 15-33, from east to west. At 0815, the FAA BGR air traffic control tower (ATCT) advised the plow crews to clear the runway, due to a Boeing 727 that was to depart in 5 minutes. The plow crews were clear of the runway, at 0855. The maintenance supervisor stated that at that time, runway 15-33 had been plowed 150 feet east, and 75 feet west of the centerline. The supervisor reported that the plowed area was covered with a light dusting of snow less than 1/4 inch high, and braking action was "fair." He also reported that the piles of snow, which were the result of wind drifts and snow plowing, were about 1 foot high and 10 feet wide.

A Notice to Airmen (NOTAM) was issued by the FAA, at 0830, which described runway 15-33 as "patchy thin layer of loose snow, braking action - fair." At 0840, BGR issued a field condition report which stated, " RWY 15/33 - plowed 150 feet east of centerline and 75 feet west of centerline full length. Light dusting of snow. Braking fair. Snow removal in progress." According to the BGR Operations Manager, the 0840 field condition report was not relayed to the FAA Flight Service Station because the airfield maintenance supervisor was waiting to finish plowing the runway. Winds were reported to be from 050 degrees at 10 knots.

Prior to the arrival of the Safety Board, the first 8,000 feet of runway 33 was plowed to its full width of 300 feet, from the approach end toward the accident site. The airport management reported that they received approval to perform the plowing from an unidentified Federal Aviation Administration person after the accident.

The airport authority reported that measurements were taken before the snow plowing continued. The airplane's landing gear tracks indicated that the airplane touched down 7,200 feet from the approach end of runway 33. They also measured the right ma...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# NYC97FA045