Continental Express Flight 2574: Difference between revisions
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==Role in developing the culture of safety== |
==Role in developing the culture of safety== |
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According to Meshkati (1997), the crash of Continental Express Flight 2574 was the most dramatic turning point for “[[safety culture]]” in the United States. [http://www.aviation.uiuc.edu/UnitsHFD/TechPdf/02-3.pdf] 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, p. 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. |
According to Meshkati (1997), the crash of Continental Express Flight 2574 was the most dramatic turning point for “[[safety culture]]” in the United States. [https://web.archive.org/web/20040213043321/http://www.aviation.uiuc.edu/UnitsHFD/TechPdf/02-3.pdf] 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, p. 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. |
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This movement for air safety continued with the enactment on April 5, 2000, of the [[Wendell H. Ford Aviation Investment and Reform Act for the 21st Century]], which is also called [[Wendell H. Ford Aviation Investment and Reform Act for the 21st Century|AIR 21]]. |
This movement for air safety continued with the enactment on April 5, 2000, of the [[Wendell H. Ford Aviation Investment and Reform Act for the 21st Century]], which is also called [[Wendell H. Ford Aviation Investment and Reform Act for the 21st Century|AIR 21]]. |
Revision as of 16:00, 12 August 2017
![]() Wreckage of Flight 2574 | |
Accident | |
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Date | September 11, 1991 |
Summary | In-flight structural failure due to improper maintenance[1] |
Site | Colorado County, near Eagle Lake, Texas, USA 29°18′35″N 96°13′56″W / 29.3098°N 96.2321°W |
Aircraft type | Embraer EMB 120RT Brasilia |
Operator | Britt Airways, Inc., dba Continental Express |
Registration | N33701 |
Flight origin | Laredo International Airport, Laredo, Texas |
Destination | Houston Intercontinental Airport (now George Bush Intercontinental Airport), Houston, Texas |
Passengers | 11 |
Crew | 3 |
Fatalities | 14 (all) |
Survivors | 0 |
Continental Express Flight 2574 (Jetlink 2574) was a scheduled domestic passenger airline flight operated by Britt Airways[2] from Laredo International Airport in Laredo, Texas, to Houston Intercontinental Airport (IAH) (now called George Bush Intercontinental Airport) in Houston, Texas. On September 11, 1991, the Embraer EMB 120 Brasilia, registered N33701,[3] crashed while the turboprop aircraft was en route to Houston, killing all 14 people on board. The aircraft wreckage hit an area near Eagle Lake, Texas which is located approximately 65 miles (105 km) west-southwest of IAH.
The media stated there was initial speculation that a bomb had destroyed the aircraft; however, the National Transportation Safety Board (NTSB) subsequently discovered that missing screws on the horizontal stabilizer led to the crash.[4]
Aircraft and crew
![](http://upload.wikimedia.org/wikipedia/commons/thumb/1/15/Embraer_EMB-120RT_Brasilia%2C_Continental_Express_AN1897959.jpg/220px-Embraer_EMB-120RT_Brasilia%2C_Continental_Express_AN1897959.jpg)
The Embraer 120 Brasilia, serial number 120077, was built in 1988, three years before the accident, and had accumulated 7,229 flight hours through 10,009 cycles.[1]: 8 The Federal Aviation Administration records stated that the aircraft had been sent to the maintenance hangar 33 times for unscheduled repairs.[5]
The crew consisted of 29-year-old Brad Patridge of Kingwood, Texas (Greater Houston) as captain and 43-year-old Clint Rodosovich of Houston as the first officer.[6] Both were experienced pilots with 4,243 flight hours and 11,543 flight hours, respectively.[1]: 5
Incident
The EMB 120 departed Laredo International Airport at 09:09, operating under Federal Aviation Regulation Part 135 and after a normal takeoff was assigned a cruise altitude of flight level 250 (FL250), then reassigned to FL240. At 09:54 the flightcrew responded to the Houston Air Route Traffic Control Center, and started descending to nine thousand feet. At approximately 10:03 the while descending through 11,500 feet with an indicated airspeed of 260 knots the leading edge of the left horizontal stabilizer separated from the airframe, and the airplane pitched down dramatically, rolling around on an axis as the left wing folded.[1] The escaping fuel from the wings ignited, and the pilots lost consciousness from the severe G-forces due to the major oscillations of the crippled aircraft. The wreckage fell in southeast Colorado County, Texas, exploding on impact, off Farm to Market Road 102, seven miles (11 km) southeast of Eagle Lake, Texas,[7] and 60 miles (97 km) west of Downtown Houston.[8] The Texas Department of Public Safety said rescue units discovered no survivors.[7] The wreckage was spread over a 2- to 4-square-mile (10 km2) area; some pieces fell into the Colorado River.[8] About $500,000 (1991 value; currently $1,100,000[9]) worth of diamonds were discovered in the wreckage; they had no role in the crash.[6]
Investigation
The National Transportation Safety Board (NTSB) investigation revealed that screws had been removed from the horizontal stabilizer during maintenance the night before the accident and, following a shift change, the screws had not been 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.
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 de-ice 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."
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, p. 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.
This movement for air safety continued with the enactment on April 5, 2000, of the Wendell H. Ford Aviation Investment and Reform Act for the 21st Century, which is also called AIR 21.
Dramatization
Mayday (also known as Air Crash Investigation in the UK, Australia and Asia, and Air Emergency or Air Disasters in the United States) produced a one-hour docudrama about the crash. The episode was entitled "Breakup Over Texas" [2].
References
- ^ a b c d "BRITT AIRWAYS, INC., d/b/a CONTINENTAL EXPRESS FLIGHT 2574, IN-FLIGHT STRUCTURAL BREAKUP, EMB-120RT, N33701, EAGLE LAKE, TEXAS, SEPTEMBER 11,1991" (PDF). National Transportation Safety Board. July 21, 1992. NTSB/AAR-92/04. Retrieved September 9, 2016.
- ^ In-Flight Structural Breakup, Britt Airways, Inc. dba Continental Express Flight 2574, EMB-120RT, N33701, Eagle Lake, Texas, September 11, 1991," fss.aero
- ^ Aircraft accident Embraer 120RT Brasilia N33701 Eagle Lake, TX
- ^ Muck, Patti. "Crash searchers find stabilizer/Discovery points to maintenance mix-up, not bomb." Houston Chronicle. Monday September 16, 1991. A1. Retrieved on August 23, 2009.
- ^ Gill, Dee and David Ivanovich. "Crash in Colorado County/Plane sent for repairs 33 times, records show." Houston Chronicle. Thursday September 12, 1991. A13. Retrieved on August 23, 2009.
- ^ a b Horswell, Cindy, T. J. Milling, and Rad Sallee. "Crash in Colorado County/Attendant on doomed aircraft had resigned to take a new job." Houston Chronicle. Saturday September 14, 1991. A27. Retrieved on August 23, 2009.
- ^ a b Staff. "12 killed in commuter jet crash/Laredo-to-Houston flight goes down near Eagle Lake." Houston Chronicle. Wednesday September 11, 1991. A1. Retrieved on August 23, 2009.
- ^ a b Muck, Patti, John Toth, Jennifer Liebrum, and Dee Gill. "14 die in commuter air crash/Charred site is 60 miles west of city." Houston Chronicle. Thursday September 12, 1991. A1. Retrieved on August 23, 2009.
- ^ 1634–1699: McCusker, J. J. (1997). How Much Is That in Real Money? A Historical Price Index for Use as a Deflator of Money Values in the Economy of the United States: Addenda et Corrigenda (PDF). American Antiquarian Society. 1700–1799: McCusker, J. J. (1992). How Much Is That in Real Money? A Historical Price Index for Use as a Deflator of Money Values in the Economy of the United States (PDF). American Antiquarian Society. 1800–present: Federal Reserve Bank of Minneapolis. "Consumer Price Index (estimate) 1800–". Retrieved February 29, 2024.
- Meshkati, N. (April 1997). Human performance, organizational factors and safety culture. Paper presented on National Summit by NTSB on transportation safety. Washington, D.C.
External links
- NTSB abstract
- NTSB letter
- Aircraft One data
- Horswell, Cindy, T. J. Milling, Rad Sallee. "Crash in Colorado County/Attendant on doomed aircraft had resigned to take a new job." Houston Chronicle. Saturday September 14, 1991. A27.
- 1991 in Texas
- Airliner accidents and incidents in Texas
- Airliner accidents and incidents caused by maintenance errors
- Colorado County, Texas
- Continental Airlines accidents and incidents
- Accidents and incidents involving the Embraer EMB 120 Brasilia
- Aviation accidents and incidents in the United States in 1991
- September 1991 events