TSB investigation finds lack of flight control lock and gusty winds led to stuck elevator control that caused Beechcraft 1900 airplane to abort take off

DARTMOUTH, NS, Nov. 12, 2013 /CNW/ - The Transportation Safety Board of Canada (TSB) today released its investigation report (A11A0101) into the 10 December 2011 aborted take-off of a Hawker Beechcraft 1900D operated by Exploits Valley Air Services Ltd. at the Gander International Airport in Newfoundland and Labrador.

The 2 crew members were preparing to depart on a flight from Gander to Goose Bay, Newfoundland and Labrador, with 13 passengers on board. After the crew began the take-off roll, they noted that the control column was stuck in the full forward position. The take-off was aborted, and the aircraft was taxied back to the terminal to unload the passengers and then to the operator's hangar for further examination. There were no injuries to the passengers or crew.

It was determined that before the flight, the aircraft had been parked outside in gusty wind conditions without control locks installed. This caused the elevator control to slam down repeatedly and eventually become jammed against a stop bolt designed to limit its downward travel. The stuck control was not detected before take-off, since an elevator control check was not carried out as part of the maintenance daily inspection or the after-engine-start checklist.

The manufacturer issued communiqués to advise readers of similar occurrences; however, the information provided by the manufacturer was not clear or concise, and thus there was a risk that operators may not fully understand the safety and risk-mitigation measures to be taken. Additionally, operators such as Exploits Valley Air Services are not required to have a safety management system (SMS) similar to larger operators. As such, there is an increased risk that hazards will not be identified and mitigated.

Following this occurrence, the operator requires that flight control locks be used any time there isn't a crew member at the controls. The US FAA issued an Emergency Airworthiness Directive, effective immediately upon receipt, that requires operators to examine the elevator control system. Hawker Beechcraft has issued a service bulletin for Model 1900-series aircraft, and provides parts and instructions to install a second stop bolt for the elevator control.

Air safety management systems are a TSB Watchlist issue. Watch the TSB video!

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

SOURCE: Transportation Safety Board of Canada

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