Continental Express Flight 2574
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| Summary | |
|---|---|
| Date | September 11, 1991 |
| Type | Maintenance error |
| Site | Eagle Lake, Texas, USA |
| Fatalities | 14 |
| Injuries | 0 |
| Aircraft | |
| Aircraft type | Embraer EMB 120 Brasilia |
| Operator | Britt Airways, Inc., dba Continental Express |
| Tail number | N33701 |
| Survivors | 0 |
Continental Express Flight 2574 was a scheduled domestic passenger airline flight from Laredo International Airport in Laredo, Texas to Intercontinental Airport in Houston, Texas.
On September 11, 1991, the Embraer EMB 120 Brasilia, registered N33701, carrying 14 people, crashed as it was approaching the runway for landing, killing all 14 people on board.
Contents |
[edit] Investigation
The National Transportation Safety Board (NTSB) investigation revealed that bolts had been removed from the horizontal stabilizer during maintenance the night before the accident and, following a shift change, the screws were not replaced. The plane crashed on its second flight of the day.
NTSB cited the failure of airline maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures. The failure of Federal Aviation Administration (FAA) surveillance to detect and verify compliance with approved procedures was cited as a contributing factor. Following the accident, the FAA conducted a National Aviation Safety Inspection Program (NASIP) of Continental Express' maintenance program. It found very few safety deficiencies, and complimented the airline on its internal evaluation system. NTSB expressed concern that the NASIP did not find deficiencies in shift turnover procedures and other matters relevant to the accident, and recommended that the agency improve its NASIP procedures.
Some months after Eagle Lake, the same airline had a similar incident when a plane was forced to return to the airport after bolts had been removed from a wing panel. NTSB decried that even a fatal accident and an FAA NASIP inspection weren't enough to overcome what appears to have been corporate culture.
[edit] Probable Cause
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
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 CONTINENTAL EXPRESS MANAGEMENT TO ENSURE COMPLIANCE WITH THE APPROVED MAINTENANCE PROCEDURES, AND THE FAILURE OF THE FAA SURVEILLANCE TO DETECT AND VERIFY COMPLIANCE WITH APPROVED PROCEDURES. (NTSB REPORT AAR-92/04)
[edit] Role in developing the culture of safety
According to Meshkati (1997), the crash of Continental Express Flight 2574 was the most dramatic turning point for “safety culture” in the United States.[1] As a member of the National Transportation Safety Board (NTSB) at that time, Dr. John Lauber suggested that the probable cause of this accident included “The failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures” (NTSB/AAR-92/04, 1992, pg. 54, as cited in Meshkati, 1997). As a result of this and other similar aviation accidents, safety culture came to the forefront as the exclusive topic at the U.S. National Summit on Transportation Safety, hosted by the NTSB in 1997.
[edit] External links
[edit] Reference
Meshkati, N. (1997, April). Human performance, organizational factors and safety culture. Paper presented on National Summit by NTSB on transportation safety. Washington, D.C.
