Accident Details
Probable Cause and Findings
A loss of reliable airspeed indication due to an accumulation of ice on the air data/pitot sensors. Contributing to the incident was the flight crew's improper response to the erroneous airspeed indications, their lack of coordination during the initial recovery of the airplane to controlled flight, and icing conditions.
Aircraft Information
Analysis
HISTORY OF FLIGHT
On May 12, 2005, about 2316 central daylight time, a Boeing 717-200, N910ME, operated by Midwest Airlines, Inc., as flight 490, experienced a series of pitch oscillations while climbing to cruise altitude over Union Star, Missouri. The flight crew declared an emergency, and diverted to Kirksville Regional Airport (IRK), Kirksville, Missouri. There were no injuries to the 2 certificated airline transport pilots, 2 flight attendants, and 76 passengers. Night instrument meteorological conditions (IMC) prevailed for the flight, which was operating on an instrument flight rules flight plan from Kansas City International Airport (MCI), Kansas City, Missouri, to Ronald Reagan Washington National Airport (DCA), Washington, D.C. The scheduled passenger flight was conducted under 14 Code of Federal Regulations Part 121.
According to flight crew statements, the flight had initially originated in Los Angeles, California, and landed at Omaha, Nebraska, due to weather, before continuing on to Kansas City. Once in Kansas City, the captain was briefed by company dispatch personnel regarding significant weather in the area, and noted the weather on a display screen that was located in the operations area.
As the airplane was taxied for departure at 2231, the captain elected to delay the takeoff, and wait for the weather to pass further to the east. Once the weather passed, and the flight crew received a "ride report" from a departing flight, the incident flight departed from runway 1L.
The captain performed the takeoff, and afterwards engaged the autopilot with a configuration selected, vertical profile guidance was provided by the flight management system. The crew requested a northeasterly departure, and flew a 010-degree heading, taking the airplane away from weather cells that were about 25 miles away. The crew did not observe any weather cells or lightning on the departure path, and as the airplane climbed, the captain observed only green areas on the airborne radar, despite adjusting radar pitch and tilt.
After departure, the airplane entered IMC, but no turbulence was noted. The captain turned to a heading of 060 degrees, and about flight level (FL) 230, the crew was advised to change radio frequencies and was cleared to climb to FL 270. At that point in the flight the airplane was under the control of the autopilot, and was climbing at airspeeds between 280 and 300 knots. The closest weather cell was about 20 to 25 miles away, and the crew felt they did not need to utilize airplane anti-icing because the outside temperature was still too warm to require it.
The first indication of something abnormal was when the captain noticed the master caution light was illuminated. After commenting to the first officer, he looked down at the center pedestal and notice that the CONFIG cue switch was illuminated. He then pushed the CONFIG key, located on the center instrument panel, and noted the "RUDDER LIM FAIL" alert on the engine and alert display unit. He looked at the alert for about 10 seconds, and was about to ask the first officer to retrieve the quick reference handbook (QRH) when the event began.
The airplane initially pitched down, to what the first officer recalled was in excess of 20 degrees. The captain remembered hearing the autopilot disconnect aural signal. When the pitch down occurred, the captain was still the pilot flying, but the first officer then began assisting him on the controls. The airplane continued in a steep dive, which the first officer felt was "almost beyond recovery." Both pilots recalled saying, "up, up, up" during the initial descent, and noted that the airplane did not respond to control inputs at first and that the flight controls felt very heavy. The first officer thought that the airplane lost at least 5,000 feet of altitude during the first descent. The captain recalled that the elevator response was "not normal," and that he was not getting the amount of response he expected from the flight control inputs. At times he would get little response from the elevator control inputs, but then it would quickly change to "a lot" of response, unlike any training scenario or airplane flight characteristics he had previously experienced.
The airplane then pitched up, and the first officer stated that he told the captain to push forward on the control wheel, and assisted him in pushing forward. As the airplane pitched up the airspeed decreased, and slowed to about 190 knots. At that point the autothrottles were not engaged, and the first officer increased the engine power to about 3/4 of the "throttle throw," which equated to about 80 percent N1. The first officer stated that the power levers felt "normal." The captain stated that while he was trying to recover the airplane, he attempted to maintain a level pitch attitude by placing the pitch of the airplane in a fixed position, and tried to level the wings of the airplane, but altitude control was unobtainable.
The airplane entered another dive, and the first officer stated to the captain, "I have the airplane," and said that the captain responded, "Okay." The first officer continued manipulating the flight controls with inputs from the captain, and was able to bring the airplane under control with his help. The captain, however, stated that he heard the first officer state, "I'm flying," and the captain took that to mean, "He was with me on the flight controls." The captain continued operating the flight controls until he later began to communicate with ATC, and it was at that point that he relinquished control of the airplane to the first officer. He did not recall "formally" transferring control of the airplane to the first officer, but stated that it was "understood."
During the event, the airplane went through a series of climbs and descents before the flight crew was able to recover. The first officer stated that during the recovery he was trying to keep the airspeed away from the stall speed and away from the overspeed red zone. The captain stated that the airspeed changed instantaneously from low to high, at points becoming greater than 400 knots with an overspeed warning in literally seconds. The airspeed went from the bottom of the airspeed tape to the top so quickly, that the captain could not visualize the airplane doing this. When the airspeed was indicating over 400 knots on his Primary Flight Display (PFD), the captain stated that he glanced at the integrated standby instrument system (ISIS), and noted that there was a difference in the two displayed speeds. He could not recall the difference in the two speeds.
The captain did not report any fluctuations in the instruments prior to the event, but that during the event there was a "blinking" or flashing on and off of the PFD. He would notice a very high airspeed during a pitch down, and then would see a "flicker" or "flash," and when the display came back, it would indicate a reversal of information, with the airspeed low and the pitch high. He only recalled seeing the PFD flash, and was not sure if the navigation display (ND) did so as well. He was not using the flight director bars during the recovery, nor did he recall seeing them.
As the flight crew began to recover from the event, the captain felt that they needed to get the airplane on the ground, and elected to divert to IRK. As there were many tasks to be accomplished, the captain began making arrangements with ATC and briefed the passengers, while the first officer continued to fly the airplane. The first officer had the captain re-engage the autopilot, and they continued using the autopilot until they were on the approach to IRK. Following the recovery, the crew noted a "COLUMN DISC" alert on the engine and alert display. The entire event and recovery occurred in IMC.
During the descent the captain performed the in-range checklist silently. The flight crew then performed the before landing procedures and entered a right traffic pattern for runway 18 at IRK. The first officer flew the airplane during the landing, while the captain operated the speedbrakes and the throttles. The crew did not re-engage the autothrottles. The first officer stated that while on approach, the elevator response seemed "normal." The airplane subsequently landed uneventfully.
PERSONNEL INFORMATION
The captain held an airline transport pilot certificate with ratings for airplane single and multiengine land, which was issued on December 7, 1988, as well as a type rating for DC-9 aircraft. His most recent Federal Aviation Administration (FAA) first-class medical certificate was issued on January 17, 2005, with the limitation, "Holder shall wear lenses that correct for distant vision and possess glasses that correct for near vision." According to company records, and interviews, the captain had accumulated 18,000 total hours of flight experience, including 203 hours in the Boeing 717 (B-717). A review of FAA records found no accident, incident, or enforcement actions pertaining to the captain.
The captain was hired by Midwest Airlines in January 1987, and subsequently upgraded to captain in December 1988. While working at Midwest Airlines he had flown as captain on DC-9, MD-80, and B-717 airplanes. He worked in the Flight Standards and Training department at the airline for about 12 years in various positions, including check captain, ground instructor, simulator instructor, proficiency check airman, and aircraft instructor. He returned to line flying in 2001, and at the time of the event he was no longer a check airman. He transitioned to captain in the B-717 on February 11, 2005, and the requirements for his most recent proficiency check were also completed on that date.
The first officer held an airline transport pilot certificate with a rating for airplane single and multiengine land, which was issued on September 14, 2004, as well as a type rating for BA-3100 aircraft. His most recent FAA first-class medical cert...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# NYC05MA083