MAINTENANCE FAILURE CITED IN CRASH OF DC-8 AIRPLANE NEAR SACRAMENTO

Washington, D.C. - The National Transportation Safety Board today determined that the probable cause of the crash of an Emery Worldwide Airlines DC-8 aircraft near Sacramento, CA, was "a loss of pitch control resulting from the disconnection of the right elevator control tab." The disconnection, the Board said after reviewing the investigative team's report, was "caused by a failure to properly secure and inspect" the bolt attaching the right elevator control tab crank fitting to the pushrod.

"This event was a tragedy," said NTSB Chairman Ellen G. Engleman. "It illustrates the interdependence and critical roles and responsibilities of each member of the aviation safety chain. Safety requires 100 percent performance by everyone."

Emery Worldwide flight 17 crashed into an auto salvage yard on February 16, 2000, while attempting to return for landing shortly after departing Sacramento Mather Airport. The DC-8 was on a scheduled cargo flight to Dayton, OH. The three crewmembers aboard the flight were killed; the aircraft was destroyed by impact forces and post-crash fire.

The Board found that:

• At some time after the previous takeoff (from Reno, NV) and before the accident takeoff roll, the bolt connecting the right elevator control tab crank fitting to the pushrod migrated out of the fitting, allowing the control tab to disengage from its pushrod and shift to a trailing edge down position;
• As the aircraft accelerated during the takeoff roll, the right control tab crank fitting contacted the disconnected pushrod, thereby restricting the upward movement of the control tab's trailing edge and leaving it in an extreme downward deflection;
• As a result, the aircraft's elevator surfaces were driven to command an extreme nose-up pitch attitude that the pilots were unable to overcome despite large nose-down forces applied to the control columns.

The Board judged that the maintenance errors that eventually resulted in the DC-8 crash occurred either during the most recent heavy maintenance "D" check (November 1999) or during subsequent maintenance of the aircraft. However, the Board was not able to determine precisely when the improper maintenance work was done.

As a result of this investigation, the Board issued 15 recommendations to the Federal Aviation Administration, including provisions for revised maintenance procedures, improved training for flight crews, the redesign of DC-8 elevator control tab installations, and replacement of DC-8 aluminum elevator geared tab crank arms.

A synopsis of the Emery Worldwide accident investigation report, including the findings, probable cause, and safety recommendations, can be found on the Publications page of the Board's web site, http://www.ntsb.gov. The complete report will be available in about six weeks.

NTSB Media Contact: Paul Schlamm, (202) 314-6100