1978 — Feb 10, Columbia Pacific Airlines Flight 23 takeoff crash/fire, Richland, WA — 17

–17 Kimura. World Commercial Aircraft Accidents 3rd Ed., 1946-1993, V.1. 4-11-1994, p. 3-25.
–17 NTSB. AAR. Columbia Pacific Airlines…Richland, Washington, Feb 10, 1978. 1978.

Narrative Information

National Transportation Safety Board: “At 1650 P.s.t. on February 10, 1978, Columbia Pacific Airlines, Inc., Flight 23, a Beech 99, crashed in visual flight rules conditions on takeoff from runway 36 at the Richland Airport, Richland, Washington. Flight 23, a regularly scheduled passenger flight to Seattle, had 15 passengers and 2 crewmembers on board. After liftoff, the aircraft climbed steeply to 400 feet above the runway, then stalled and crashed 2,000 feet beyond the end of the runway. A severe fire erupted after impact. All persons on board were killed, and the aircraft was destroyed.

“The National Transportation Safety Board determines that the probable cause of the accident was the failure or inability of the flightcrew to prevent a rapid pitchup and stall by exerting sufficient push force on the control wheel. The pitchup was induced by the combination of a mis-trimmed horizontal stabilizer and a center of gravity near the aircraft’s aft limit. The mis-trimmed condition resulted from discrepancies in the aircraft’s trim system and the flightcrew’s probable preoccupation with making a timely departure. Additionally, a malfunctioning stabilizer trim actuator detracted from the flightcrew’s efforts to prevent the stall.

“Contributing to the accident were inadequate flightcrew training, inadequate trim warning system check procedures, inadequate maintenance procedures, and ineffective FAA surveillance.” (NTSB 1978, 1)

“Columbia Pacific Airlines Flight 23, a Beech 99 (N199EA), was… a regularly scheduled passenger flight from Richland to Seattle, Washington. The crew arrived at Richland at 1525 P.s.t. on Flight 18 from Seattle. When they arrived, N199EA was being inspected to fulfill the requirements of an Airworthiness Directive. The aircraft was not available to the crew for preflight inspection until 1630; Flight 23 was scheduled to depart at 1640….

“In general, witnesses described the aircraft’s attitude at liftoff as normal and estimated the point of liftoff between 1,173 and 1,486 ft; however, immediately thereafter the aircraft began a steep climb at an angle of 20″ to 45″ to an altitude of 300 to 400 ft above the runway and then appeared to decelerate. The wings rocked or wobbled at the top of the climb, and the aircraft turned or yawed to the left. The nose dropped and the aircraft descended to the ground at a flightpath angle estimated to have been 45″. Fuel from ruptured fuel tanks caught fire after the aircraft hit the ground. Fire consumed the aircraft within 7 minutes.” (NTSB 1978, 2)

“N199EA had been operated by three operators before Columbia Pacific Airlines. From October 1968 to August 1971, five discrepancies were reported concerning trim system components. During this period, the trim actuator was replaced three times. From August 1971 to May 1975, seven discrepancies concerned the trim system, and from May 1975 to June 1977, eight discrepancies concerned the trim system. During this last period, the standby pitch trim was found to be unsatisfactory, and the main and standby motors were replaced after 11,471 total aircraft hours–7,790 hours after the actuator had been replaced…The out-of-trim warning system was found on four occasions to be improperly rigged, and on a fifth occasion it was found to be inoperative. The trim-in-motion system was unsatisfactory on two occasions.” (NTSB 1978, 4)

“The investigation disclosed that the stabilizer trim system failed to operate in flight on three occasions within the 2 weeks preceding the accident. On January 29, the daily flight log showed that the main trim system functioned intermittently. The captain, who made the report, stated that on two occasions the main trim failed to respond when the switches on the control wheel were activated–once on the first officer’s wheel and once on his wheel. The flight was completed by using the standby trim system. The actuator jackscrew, trim-stop limit switch was readjusted, and the aircraft was released.” (NTSB 1978, 5)

“During the week before the accident, the actuator failed to respond the second time during a training flight; however, the failure was attributed to the first officer’ s lack of experience in the Beech 99. No corrective action was taken. The switches on the control wheel are dual-element, thumb switches and must be pressed simultaneously to activate the trim. The captain and mechanic who discussed the problem concluded that the trainee had not pressed the switches properly. Another captain interviewed stated that the same type incident occurred for the third time during the week before the accident and he did not report the incident.

“The daily flight logs also disclosed 12 writeups in which the trim-in-motion aural system was either intermittent or inoperative. A part had been ordered to repair the trim-in-motion aural system, but it had not been received. The last report, “trim-in-motion audio stays on when CB is in,” was made on October 17, 1977, but was-deferred until November 11, when maintenance found it “checked okay.” The out-of-trim warning horn was reported as inoperative on November 9, 1977, but was deferred until November 11, when the micro-switch was readjusted. There were four entries in the daily flight log about the deicer boots being partially to fully inflated constantly. The last remark was recorded February 6, 1978, and records showed no corrective action.” (NTSB 1978, 6)

“The aircraft first hit the ground 1,669 ft beyond the end of runway 36 and 1,031 ft to the left of the runway extended centerline. Examination of the wreckage disclosed that the aircraft struck level ground in a slightly left wing-low, nose-level attitude. The landing gear were fully extended, and the flaps were extended 30 percent. The empennage separated from the fuselage and moved down the crash path 30 ft from the point of initial impact. The landing gear separated as the aircraft skidded 78 ft along a magnetic heading of 272O. The aircraft. came to rest without changing direction….” (NTSB 1978, 7)

“The accident was not survivable because of the intolerable impact forces and postcrash fire.” (NTSB 1978, 11)

“…the Safety Board concludes that in view of the nature of the mechanical discrepancies, the aircraft was not airworthy.” (NTSB 1978, 34)

“The Safety Board believes that the FAA had not effectively performed its regulatory functions related to maintenance practices conducted by the Airline.” (NTSB 1978, 35)

“As a result of this accident, on August 11, 1978, the Safety Board recommended that the Federal Aviation Administration:

“Issue an Airworthiness Directive applicable to all Beech 99, 99A. A99, A99A, and B99 model aircraft to require an immediate one-time inspection of the horizontal stabilizer trim system to ascertain that all components of the system and its associated position-indicating and -warning circuits are operational within specified tolerances. (Class I, Urgent Action) (A -78-53)

“Require an inspection to insure that the primary and secondary mode of the horizontal stabilizer actuator are capable of deflecting the stabilizer under specified airloads. The exact instructions should be furnished by the Beech Aircraft Corporation. The inspection should be made as soon as the Beech instructions are available and repeated at 2,000-hour intervals (Class 11, Priority Action) (A-78-54)

“Change the minimum equipment list to make the out-of-trim warning system a mandatory requirement for flight. (Class 11, Priority Action) (A-78-55)”

“The investigation of this accident was difficult and time-consuming because of the lack of definitive information on the aircraft’s performance and on the flightcrew’s reaction to the emergency situation which arose immediately after takeoff.. Information from a flight data recorder and a cockpit voice recorder would have provided invaluable information in both of these areas, would have significantly reduced investigative effort, and would have provided more direct evidence causality. The Safety Board believes that these recorders are virtually a perquisite to improvements in safety in commuter air carrier and /operations involving complex multiengine aircraft. Therefore, we reiterate Safety Recommendations A-78-27, -28, -29, dated April 13, 1978, and we urge the Federal Aviation Administration’s early action on these recommendations:

“Develop, in cooperation with industry, flight recorder standards (FDR/CVR) for complex aircraft which are predicated upon intended aircraft usage. (Class 11, Priority Action) (A -78-27)

“Draft specifications and fund research and development for a low cost FDR, CVR, and composite recorder which can be used on complex general aviation aircraft. Establish guidelines for these recorders, such as maximum cost, compatible with the cost of the airplane on which they will be installed and with the use for which the airplane is intended. (Class 11, Priority Action) (A -78-28)

“In the interim, amend 14 CPR to require that no operation (except for maintenance ferry flights) may be conducted with turbine-powered aircraft certificated to carry six passengers or more, which require two pilots by their certificate, without an operable CVR capable of retaining at least 10 minutes of intracockpit conversation when power is interrupted. Such requirements can be met with available equipment to facilitate rapid implementation of this requirement. (Class 11, Priority Action) (A -78-29)”.” (NTSB 1978, 37-38)

Sources

Kimura, Chris Y. World Commercial Aircraft Accidents 3rd Edition, 1946-1993, Volume 1: Jet and Turboprop Aircrafts. Livermore, CA: Lawrence Livermore National Laboratory, Risk Assessment and Nuclear Engineering Group. 4-11-1994.

National Transportation Safety Board. Aircraft Accident Report. Columbia Pacific Airlines Beech 99, N199EA, Richland, Washington, February 10, 1978 (NTSB-AAR-78-15). Washington, DC: NTSB, adopted December 21, 1978, 47 pages. Accessed at: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR78-15.pdf