Date: | Wednesday 11 September 1991 |
Time: | 10:03 |
Type: | Embraer EMB-120RT Brasilia |
Owner/operator: | Continental Express |
Registration: | N33701 |
MSN: | 120077 |
Year of manufacture: | 1987 |
Total airframe hrs: | 7229 hours |
Cycles: | 10009 flights |
Engine model: | Pratt & Whitney Canada PW123 |
Fatalities: | Fatalities: 14 / Occupants: 14 |
Aircraft damage: | Destroyed, written off |
Category: | Accident |
Location: | Eagle Lake, TX -
United States of America
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Phase: | En route |
Nature: | Passenger - Scheduled |
Departure airport: | Laredo International Airport, TX (LRD/KLRD) |
Destination airport: | Houston-Intercontinental Airport, TX (IAH/KIAH) |
Investigating agency: | NTSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:Embraer 120 N33701 was pulled into the Continental Express hangar at Houston around 21:30 for scheduled maintenance which included removal and replacement of both left and right hand horizontal stabilizer deice boots. The second shift mechanics started working on the right hand deice boot. Although planned for the third shift, the 47 screws from the top of the left leading edge assembly for the horizontal stabilizer were already removed by the second shift. The third shift mechanics finished the replacement of the right hand deice boot but did not have time to replace the left hand boot as well.
The first flight was a 07:00 scheduled flight from Houston to Laredo.
Flight 2574 departed Laredo for the return leg to Houston at 09:09. The cruise portion of the flight was uneventful and at 10:03 the aircraft was descending through 11800 feet to 9000 feet when the air loads caused the left horizontal stabilizer leading edge to bend downward and separate. A sudden severe nose down pitchover occurred and the wings stalled negatively. A negative g of 3.5 was recorded by the FDR. Eyewitnesses reported a bright flash and saw the aircraft breaking up while descending in a flat left spin until impact.
PROBABLE CAUSE: "The failure of Continental Express maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures for the airplane's horizontal stabilizer deice boots that led to the sudden in-flight loss of the partially secured left horizontal stabilizer leading edge and the immediate severe nose-down pitchover and breakup of the airplane. Contributing to the cause of the accident was the failure of the Continental Express management to ensure compliance with the approved maintenance procedures, and the failure of FAA surveillance to detect and verify compliance with approved procedures."
NTSB board member John K. Lauber filed a dissenting statement on the investigation report, believing the probable cause should read as follows:
"1) The failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures, and 2) the consequent string of failures by Continental Express maintenance and inspection personnel to follow approved procedures for the replacement of the horizontal stabilizer deice boots. Contributing to the accident was the inadequate surveillance by the FAA of the Continental Express maintenance and quality assurance programs."
Accident investigation:
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| |
Investigating agency: | NTSB |
Report number: | NTSB/AAR-92-04 |
Status: | Investigation completed |
Duration: | 10 months |
Download report: | Final report |
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Sources:
NTSB Safety Recommendations A-92-79 and -80
Air Safety Week 4 January 1993 (p. 4)
Flight International 18-24 September 91
ICAO Adrep Summary 1/95
NTSB/AAR-92/04
History of this aircraft
Other occurrences involving this aircraft Location
Images:
photo (c) 32 Bit; 1988
Revision history:
Date/time | Contributor | Updates |