Aircraft Accidents and Communication

I remember in The Empire Strikes Back, Yoda takes Luke to task for not raising his ship out of the bog; Luke is intimidated by the ship’s size, despite all Yoda’s Force teachings.  So, in a film ‘moment’, Yoda demonstrates what it is to believe in one’s abilities; he raises the ship and floats it to dry land.  Luke is stunned; when he says he doesn’t believe what the little Jedi Master had done, Yoda simply replies, “That … is why you fail.”

It appears that I’m upsetting some people with my articles.  I never apologize for hurt feelings; the point of these articles is not to criticize individuals, but to make aviation people and the flying public aware of aviation safety issues … period.  If someone sees themselves doing something unsafe in what I write, then perhaps there should be more inner contemplation and a lot less sleeve wiping.  I’m playing the messenger and the message is simple:


I’ve had the honor of knowing people who have made management an art form; unfortunately, they are few and far between.  I, myself, was mediocre as a manager – not awful, but not great.  I was a better team leader working NTSB or FAA investigations.  While these positions never carried the authority necessary to supervise, a true leader doesn’t need to wave authority or abuse it.  Instead he should know how to guide.

A true leader directs the mission; he is not led around or distracted.  A leader sets the pace; he’s the drummer to which his reports march to.  He knows what and when to delegate; never shunning the weight of responsibility.  Loyalty is acquired by demonstrating loyalty.  He is willing to take a bullet for the team while holding each of his people accountable for their actions: publicly praising or privately reproaching.

But most importantly, he communicates, face-to-face, when possible; he leaves no opening to interpretation.  And when the plan doesn’t work, he’s not above listening to his team while reserving the charge of the final decision for himself.

Both in government and industry, management secures itself by its size, by the fortress it builds.  When issues pile up, it is easier to add layers of management, rather than to confront the situation and solve it.  This creates a top-heavy bureaucracy that increases the distance between Management and ‘the floor’, or Labor.  When Management fills a supervisor slot, the priority is to fill the position with a warm body, not necessarily an experienced individual.  Further turmoil is produced as the new supervisor wastes months establishing his failed leadership.  The consequence is a disgruntled work crew who feels isolated and unheard.  Meanwhile, Upper Management remains ignorant, often by choice, sitting atop the fortress.

In the aviation world, this is often leads to unionization.  As a union is brought in – for good or bad – another layer is added; communication breaks down even further; reconciliation between Management and Labor is no longer available.  This all sounds so dramatic; “Management is the bad guy, causing breakdowns in a company, for sure,” yet Labor has its own stake in the turmoil.

And this is where I usually came in.  The aircraft has crashed; the victims mourned and buried; the fingers are pointing; and the media is screaming for blood.  What I immediately saw upon entering an accident investigation was the breakdown in Management/Labor relations.  What was so very obvious: that communications broke down long before; it was almost non-existent.

Several years ago, I inspected an airline; the airline’s Directors lived and worked in one state; the mechanics, the pilots and the airliners were at an airport in another state 800 miles away.  The Director of Maintenance never made it to where the aircraft were; he never saw the aircraft, his reporting managers or the maintenance performed.  Worse: his disconnection was not limited to geographical distance – that’s workable.  But there was no communication, ever.

This wasn’t a matter of the airline being too big; a worldwide air carrier whose Director can’t be in all places as his employees.  Instead, it was a matter of complacency; time between status meetings with his reporting managers were measured in months, not days or weeks; he never met or tracked any of the mechanics the airline hired.  What became apparent was this communication breakdown was a recipe for disaster.

And that disaster usually comes in the form of an accident.  Air Midwest 5481, Colgan 9446 and ValuJet 592 are all accidents that can be traced back to poor internal communications, not only between Management and Labor within the airline, but to the contractors working to maintain that airline’s fleet.  From what maintenance manual procedures to follow to how to ship hazardous materials, the communication breakdown is the foundation of an airline’s problems.  The manufacturing industry can engineer an airliner that operates practically flawlessly; it cannot fix the ills of the airline it sells it to.

As explained to me, management is usually divided into two levels: Upper and Lower Management.  Upper Management is made up of Presidents, Vice-Presidents and Chief Executive Officers.  Their purpose is to look ahead: to determine where the market is going, where to invest future strategies and to evaluate the company’s potential; their job is future growth and opportunities.

Lower Management, e.g. Directors, Managers and Supervisors are trusted with the company’s resources; they’re responsible for making Upper Management’s long and short-term plans come to fruition.  When these plans are not communicated, e.g. budget cuts, station closings, pay raises, work contracted out; issues that may be trivial to Upper Management, become the foundation for disgruntled Labor employees.  It may take months for the complaints to bubble up to the Upper Management level, but by then the damage is done.  Work stoppages, strikes, poor customer service and heavy employee turnovers result in the plans being put off, the growth being crippled and customers opting for the competition.

The worst casualty of an air carrier’s financial downturn is Training, because it is the easiest thing to cut.  Training and Safety run concurrently; as Training decreases, so does Safety.  And there the air carrier sits, back in the Safety hole.  It is a vicious circle; one can see it play out in history, like the sine waves of the Economy.  And like those hills and valleys of the Economy, they usually end up repeating themselves.  They end up as a disaster.

The only thing that I would say to the air carrier, after seeing how history repeated itself, is, “That … is why you fail.”

Aircraft Accidents and Retirement

I recently got to look at my retirement portfolio and discovered, to my surprise, that I’m doing pretty darn good.  While my first retirement funds continue to mature, I still look at five years (minimum) until full retirement.  If my novels catch on, perhaps my retirement can be more fruitful (shameless plug) – maybe a cruise or two.  I write for the fun of it.  Any other financial benefit is just so much unexpected lasagna.

Man, I love lasagna.  My bride makes it with sweet Italian sausage and …  I’m sorry, I digress.

I still can’t get my mind around the fact that my wife and I are looking at a life of leisure; I’m fifty-seven years old and, the last time I checked, still in good shape; heck, I still have a lot to offer the next generation, from analog aircraft maintenance to accident investigation.  But then, on second glance, I’ve been watching my older coworkers get off the workforce train for over three decades now.  And before the faint voice of my hammock called to me, I’ve seen that what made them so valuable, so inspiring to people like me; it got off the train with them.

As I’ve mentioned before, I’ve been in aviation for over thirty-five years.  A wonderful career; unique, yet dependent on the careers of many others who took the time to bestow on me their experience, wisdom and ‘tribal knowledge’.  I have been truly blest.  However, as these mentors step out of the workforce forever, a voracious hole replaces them, one that cannot be filled.  What’s worse, what’s left amounts to agenda-builders, politicians and bean-counters, whose first reactions to the departing mentors are, “Good riddance to them,” and “we’d thought they’d never leave.”  As we, the mentor’s apprentices, clean up following the retirement parties, the agenda-builders, et al, are tossing out decades full of knowledge by the barrel-full.

That paragraph sounds cynical: agenda-builders, politicians and bean-counters.  Why not just say, “Lions and Tigers and Bears, oh my”?  But there’s logic behind my point, not that politicians or accountants are purposely trying to undermine safety; I truly don’t believe anyone is intentionally trying to make the skies less safe.  But I would never want my Congressman piloting my airplane or have my tax preparer fixing my airliner.  In reality, these folks understand a scintilla of how any airline works, even those accountants who work for an airline.  Safety is not measured in dollars, but in experience.

I used to work for an operator who flew DC-10 and B727 aircraft.  All the flight controls (ailerons, flaps, slats, spoilers, elevators and rudders) and engine controls for those aircraft are run by cables.  With over two hundred aircraft in the fleet, my co-mechanics and I became quite adept at changing and rigging cables.  It wasn’t just that the proper routing was important (re: Aircraft Accidents and Lessons Unlearned IV: Colgan Air 9946) but the conditions necessary to rig the cables properly (re: Aircraft Accidents and Lessons Unlearned I: Air Midwest 5481).

Today’s next generation airliners are digital.  All those flight controls previously mentioned are now operated digitally, which means wires carry signals to hydraulic units at the flight control or engine; this advance has reduced weight by thousands of pounds of cables per aircraft, while improving efficiency and reliability.  This is what makes bean-counters happy: less fuel burned, better on-time departures and reductions in repairs.  Politicians are happy because the aircraft are more ecological.  Everybody is happy.  Indeed, these are win-wins for everyone.

Until we forget everything about how we got to this point.  The longer we go without revisiting the past, the easier it is to forget what’s important.  The more we trust digital technology to cure all our ills, the greater will be our fall.  At a cruise altitude of 37,000 feet, that’s a long way to fall.

What’s that you say?  “The technology is flawless; it’ll never fail?”  Tell that to Captain Sullenberger and First Officer Skiles on US Air flight 1549 when their primary instruments relied on the engine generators.  Maybe Captain Kang-kuk and Captain Jung-min of Asiana Air flight 214 relied too much on the technology when making a routine landing in San Francisco – maybe not.  However, something failed to work right.  Perhaps if Captain Dubois or First Officer Robert were alive, they could testify to the unreliability of technology during the final minutes of Air France flight 447.  I’m not mocking these professionals – never.  Each of these professionals were properly trained, accrued hundreds of flight hours in the accident aircraft types and were qualified in every sense of the word.  But we can’t close our eyes to what is happening here.

Let me revisit the cable issue I spoke of with the B727 and DC-10.  Each new-age airliner is built with a redundant system … you know, just in case the technology fails.  One redundant system is a cable-driven spoiler on each wing; in case of system failure, at least one spoiler is mechanically driven to provide the pilots with limited, yet adequate, control of the airliner.

To give perspective, the older airliners relied on systems that employed about forty cable-driven actuators, fuel controls and release hooks.  Now they have about one or two cable systems.  Does one believe that a cable change/rig will come up enough in the years between scheduled maintenance for the mechanics to become proficient?  Probably not.  And each month, the industry retires qualified mechanics and erasing their experience.

For the last year, I have had the fortune to work with some of these outstanding aviation veterans; they’ve come back to teach a new generation of inspectors and industry professionals where we in aviation came from.  Their approach is patient; the topics can be tedious, yet they are just as important as when the procedures were being actively written so many years ago.

The greatest road block to the dispensing of knowledge comes from the agenda-builders, et al, who decide on what’s important and what can be cancelled as far as training.  You see, it’s the bean-counters who are cutting the budget for training; they task the agenda-builders to clean house and reduce the number of old classes.  The agenda-builders, lacking that experience level, cut training with indiscretion, often replacing that training with stuff that looks cool.

Again, ‘stuff that looks cool’ sounds very cynical; “God, Stephen you’re old.  Yell at kids to get off your lawn much?”  Let me justify my statement: one of the things I teach my students on is about complacency.  A British airline called EasyJet recently went on social media showing a twenty-six-year old Captain and a nineteen-year old First Officer of their A320 Airbus.  This is truly a novelty; the airline: EasyJet, thinks this ‘stuff looks cool’.

Not that it matters, the Captain is female, which is part of the novelty.  Instead, let’s focus on the First Officer, a man, who is unable – because of his age – to be licensed in Great Britain to drive an 18-passenger bus through Piccadilly Circus – I swear, look it up.  However, he can fly a 150-passenger Airbus over Piccadilly Circus.

Does one think the EasyJet crew has the combined experience to fly out of any emergency?  Perhaps they do have the training, but I’m talking about experience, not training.  Both Captain Sullenberger and First Officer Skiles of US Air flight 1549, each have flying careers that span longer than the EasyJet Captain has been alive … period.  I wonder how the EasyJet crew would handle a situation that tapped years of experience of the US Air flight 1549 crew over the Hudson.

I imagine that as I walk out the door on my last day, the lock won’t even click behind me before my memory will be, not unlike a wisp of steam dispersing in a hurricane.  My hope is that something … anything, I’ve passed on, will stick.  Perhaps, but not likely; there’s too much pressure for the aviation veterans to be forgotten.  As Pogo once said, “We have met the enemy and he is us.”  So be it; the fight will no longer be mine.  Instead, I’ll just go in and work on dinner with my bride.

Maybe she’s making lasagna.

Aircraft Accidents and Misguided Fans

In the late seventies, my good friend Rose and I used to drive twenty minutes out to JFK airport; we’d park in long term and make our way to the Pan Am Terminal’s Observation deck.  There we’d watch the new DC-10s, L-1011s and 747s land and take-off.  I always loved aviation; I couldn’t get enough, going through rolls of 110 film for my Kodak Pocket camera, trying to get that perfect shot, spending my paycheck to develop the pictures.

Aviation does that; it gets under your skin.  Much like a Roadie following his/her favorite band or a surfer catching the perfect curl, one can’t escape being a fan.  When I started fixing airliners, it still made me catch my breath, realizing I got to work on this aeronautical behemoth.  Each night in Omaha’s Eppley Airfield airport, when the ramp crew retired inside the cargo building, I’d wait outside to watch the B727 take off and turn toward Memphis.  There are thousands of aviation fans like myself; some are fortunate to fly, repair or control airplanes, while others must settle for pictures or stories; I see their captivating pictures all the time on social media.

But then there are those who take the ‘love’ too far.  They don’t intentionally cross the line; they just want to share something, e.g. pictures or information that they feel makes them look accessible to important aviation stuff.  However, ignorance is not an excuse for being a misguided fan.

Last week on Twitter, I saw a commercial pilot (of all people who should know better) posted a snapshot of an airliner’s maintenance logbook.  He wanted to give his followers something to connect with him on; an understandable, but foolish thought.  I was more surprised that people who should also know better, retweeted the image and shared it with everyone.  In today’s highly visual media, it is hard to control what ends up on Facebook or Twitter, but sharing this type of maintenance (MX) document is so very wrong.

First off, maintenance logbooks are proprietary; they belong to the operator of that aircraft, whether it’s an airline or someone’s personal Cessna 150.  The information is important only to that operator.  Think of it as sharing someone else’s electric bill or mechanic’s repair estimate with the world.  Some information on the MX page can tell, e.g. engine or airframe vital information, repairs made and how they were referenced, again: proprietary.  Then there’s some personal information that it contains.

For several years, airframe and powerplant (A&P) certificate numbers (used with the mechanic’s signature to release an aircraft) were the mechanic’s social security number (SSN); mine was one; they were used in the days before digital technology turned SSNs into identity theft problems.  When the FAA changed the system, I was given a new A&P number, but only when I requested it; some people have never swapped over.  Even those who don’t have their SSN as an A&P number are susceptible to hacking or identity theft.  Government branches, e.g. the FAA can (and have been) hacked; China did just that kind of hacking a few years ago.  Personal information can be traced backwards through government records, using either a pilot’s or mechanic’s certificate information to acquire their SSNs.  So, posting this information on Twitter opens several innocent people up to identity theft.

Also, the logbook holds information that can be misunderstood.  In 1995, I worked on B727 aircraft in Omaha’s Eppley Airfield (OMA).  In the ‘old days’, the same B727 engine was used on DC-9s and earlier B737 models; they had a habit of ‘bleeding’ oil all over the lower engine cowl; it looked like caramel spattered on the white lower cowl; it was normal; indeed, it was expected.  One day, a new FAA Operations General Aviation Inspector doing ramp surveillance was aghast at the oil stains; she was unfamiliar with the B727’s quirks.  She went to write up our aircraft for repair … that is until her co-inspector talked her down again and led her to understand the nature of the ‘bleeding’ engine.

Mechanics and pilots often make entries in logbooks; the language is normal, innocuous, using aviation terms either party wouldn’t think twice about.  A passenger reading these entries, however, would be confused, if not scared, unless they realized how harmless the entries are.    Terms like ‘hot brakes’, ‘hung starts’ or even items deactivated per the Minimum Equipment List (MEL) paint a different kind of picture to the inexperienced, just like the previously mentioned new FAA inspector’s obsession with ‘bleeding’ oil.  Even items deferred per the MEL can be confusing, e.g. an airliner can fly revenue flights while mechanics troubleshoot a broken system over a matter of days; this is normal.  For instance, an entry: “Inboard anti-skid system, replaced #3 brake anti-skid transducer – no help.  Item remains deferred on MEL 32-##.”  The average passenger might think, “Hey, don’t we need that anti-skid transducer-ee-thingy?  What if we slide off the runway and explode like in those super realistic Die Hard movies?”

Truthfully, yes, it’s good to have all your anti-skid transducer-ee-thingies.  But, the aircraft manufacturer has provided maintenance procedures that allow systems, like anti-skid, to be deactivated while operating the aircraft safely, without threat to anyone’s health or well-being.

However, the average person reading this line in a MX log on a Twitter post will have a different view: that planes are being flown while broken.  “Oh my!”  “Warning Will Robinson!”  The truth is, the aircraft is just as safe; the pilots have received ample training and the mechanics are on top of the deferral.  Yet, I’ve watched people witness normal maintenance, e.g. strut servicing, from the terminal window, then refuse to fly on that ‘unsafe aircraft’.  Countless times inexperienced people have reported unsafe activities by airlines that amount to nothing beyond a misperception.

So, what do these scared social media people do?  They forward Twitter or Facebook postings to the local news station or their Congressman, two entities with less aviation knowledge than even the Twitter follower has.  The local news station has their ‘aviation experts’, alias travel reporters or uncertificated airline people; those who know just enough to be dangerous; then they go on the news station to give their ‘expert hearsay advice’.  If you don’t think this happens, let me refer you to Germanwings 9525 and Malaysian Air MH370, two disasters that were played out on every major news station around the world for months, with contradictory ‘expert input’ from people who knew next to nothing about human behavior or aviation, and even less about accident investigation.  This, however, didn’t stop them from filling the travel industry with fear while inflating their egos and wallets.

So, we discussed proprietary information, personal information and misinterpretation, but let’s look at why posting airline log pages on social media is so very wrong.  When an aircraft accident occurs, the first thing the airline must do is lock up all information pertaining to that aircraft; they have no choice in this; nobody, even within the airline, is given access to those records without the NTSB’s or FAA’s consent.  This is done to prevent important information – such as MX log pages – from getting into the hands of media outlets and the inexperienced, e.g. Twitter and Facebook followers, those who can (and will) muddy the accident investigation.  If accident investigations are corrupted, the findings and fixes will be ineffective, even if the MX log page was posted days or weeks before. This results in the accident happening again because the problem wasn’t discovered the first time.

On November 2001, just two months after 9/11, American Airlines 587, an Airbus A300, crashed in Belle Harbor, New York.  When the investigation focused on a device called the yaw damper actuator, a device that assists the pilot during cruise, it was noted that the flight was delayed from the gate after a mechanic was called out to look at a yaw damper indication light.

Let me be unquestionably clear: this yaw damper light had absolutely nothing to do with the accident; it was a coincidence.  However, if the log page had been made public knowledge in those first few days, the direction of the investigation would have been misdirected for days, possibly weeks, while investigators chased phantom problems.  Fortunately, the Systems Investigation group put an end to the misdirection right away, with no more than a whisper and the investigation proceeded undisturbed.  This is one example of how conspiracy theories can begin, from misinformation that would play out in the media.  Many other accident investigations have not been as successful stemming the tide.

TWA flight 800 was mired in missile theories or structural inconsistencies; that investigation played out for years in the media as theory after theory was debunked; all the while, attention towards the true cause was put off for months.  Malaysian Air MH370 played out in the media for months with ‘aviation expert’ terrorist theories, all the while the trail got colder and colder, finally disappearing beneath the waves.  I don’t need to go on; the media has hampered aviation safety for years and the travelling public will suffer for the interruptions.

I understand what it means to be an aviation fan; guilty as charged since the early 60s.  But, you in social media who are abusing what you have access to are hurting the industry you claim to love far more than any accident, by being irresponsible you gum up the safe movement of aircraft; you do this by trying to be popular, all the while hindering safety.  Consider this: just because one could do a thing (posting MX logs), doesn’t necessarily mean one should do a thing.

Aircraft Accidents and Lessons Unlearned IV: Colgan Air 9446

I remember watching a 1967 episode of Star Trek: The Original Series called Court Martial … and, yeah, I remember watching it when it originally aired.  Captain Kirk is watching a video of himself on the bridge; the video distinctly shows him ‘jumping the gun’ and pressing a jettison button during Yellow Alert, thereby killing a crewman when danger did not exist.  Kirk’s reaction is (in William Shatner’s voice and style): “But that’s not the way it happened.”

Most of my Lessons Unlearned monthly series will deal with accidents I did not work, but I find them educational to revisit, in the hopes of learning what was missed.  These missed lessons could very well result in future accidents and deaths because we never learned the lessons the first time.

However, Colgan Air 9446 was one that I did work; I was the Aircraft Maintenance accident investigator working at Yarmouth, MA, to find the cause.  Recently, I was reading the National Transportation Safety Board (NTSB) summary of the accident; just like Captain Kirk, I find myself reading the words and saying, “But that’s not how it happened.”

The NTSB’s final report of the Colgan accident’s Probable Cause read:

The improper replacement of the forward elevator trim cable, and subsequent inadequate functional check of the maintenance performed, which resulted in a reversal of the elevator trim system and a loss of control in-flight. Factors were the flight crew’s failure to follow the checklist procedures, and the aircraft manufacturer’s erroneous depiction of the elevator trim drum in the maintenance manual.

Now, to the first question: Why didn’t I point out the true Probable Cause back in 2003?  Answer: I can’t.  The Inspector in Charge of the accident controls the Probable Cause; I don’t get a say.

Colgan Air was a Regional airline for US Air.  Colgan Air flight 9446, tail number N240CJ, was a repositioning flight for US Air Express; a Beech 1900D that was being flown Part 91 from a maintenance base in Yarmouth, MA, to Albany, NY, to recover a flight.  On August 26, 2003, it departed Yarmouth’s airport: Barnstable Municipal airport (HYA), made it 100 yards off the coast before flying into the ocean.  There were no passengers; the only fatalities were the two pilots.  NOTE: It is important to point out that Colgan Air 9446 followed the Air Midwest 5481 accident by almost eight months, that the circumstances were similar – not identical – and the NTSB’s first impression was the Beech 1900D aircraft was the cause of the two accidents.  Although not blameless, Beech aircraft, particularly the 1900D, was not the cause of the accident.

Before we explore the accident, I wish to hammer on, yet again, an important distinction I make in my Lessons Unlearned article series: there is a clear difference between what did CAUSE THE accident and what was THE CAUSE of the accident.  Yes, yes … the first use of ‘cause’ is as a verb, e.g. Engine failure did cause the accident.  The second use is as a noun, e.g. The cause of the accident was engine failure.  This must be distinctly understood because the NTSB focuses on the verb and not the noun.  They target on what made a perfectly good airplane malfunction suddenly, fall out of the sky and hit terrain.  The NTSB rarely walks the accident backwards to determine what series of events led to the malfunction to begin with.  The causes are where things went wrong; they are the Lessons Unlearned; they are why planes crash and people die.

Everything else is irrelevant.

Colgan Air 9446 was pulled out of a maintenance phase check early; US Air Express needed aircraft N240CJ; they deferred the remaining part of the maintenance check until a later date – this is a common practice; it is not dangerous …. at all.

While the check was still in progress, the elevator trim system was inspected and found to have a bad actuator, so the actuator was changed.  NOTE: This actuator change led to the cause of the accident.

In Risk Analysis, we normally ask ‘five whys’; the theory being that if you ask why to every answer, by the time you get to the fifth why, the answer presents itself.  So, let’s utilize the five whys to determine the cause of the accident:

First Why: Why did the plane crash?  The plane crashed because the elevator trim system was reversed through the airplane; in other words, the elevator trim cables were physically run backwards.  The reversal meant that as the pilot trimmed for ‘nose up’, the aircraft flew ‘nose down’ and vice versa.  The inputs put a load on the yoke column that fought the pilots’ attempts to fight the condition.  Lacking altitude and time to recover, the pilots unwittingly continued to feed ‘nose down’ into the aircraft until they hit the water.

Second Why: Why were the cables routed in reverse?  Good question, because the cables were correctly routed when they arrived for maintenance and they were not scheduled for replacement.  Part of the blame lies with Beech Aircraft; its manual shows the proper way to install the trim cable drum in the pedestal.  Unfortunately, the drum is not ‘Murphy proof’ and can be installed backwards, which is what happened.  By being installed backwards, the cables became ‘reversed’ throughout the airframe, even though they were routed correctly.  This error pointed directly back to Beech Aircraft.

The NTSB felt that the answer had been found and focused little energy to look further.  I felt there was more to the problem, so asked the question that the NTSB didn’t feel needed asking:

Third Why: Why were the elevator trim cables replaced to begin with?  This is where the transition between ‘cause the’ and ‘the cause’ takes place.  In the second why paragraph, I said the aircraft arrived in maintenance with properly routed cables and they were not scheduled to be changed.  During an elevator trim actuator change, the cables came loose and unraveled off the elevator trim cable drum in the pedestal.  When they tightened the cables up, the cable didn’t sit correctly on the drum.  When they tested the system, the cable got pinched inside the pedestal, damaging the cable and requiring replacement.  NOTE: if done correctly, a cable should never come loose during an actuator change, so …

Fourth Why: Why did the cable come loose during maintenance?  And here is where the plot thickens: the cable came loose off the drum because a newly hired mechanic did not employ proper procedures in changing out the elevator trim actuator; no one taught him practices, e.g. ‘blocking cables’ to maintain tension.  Instead he used masking tape to hold the greasy cables to the side of the vertical stabilizer.  Masking tape, being an inadequate ‘cable block’, allowed the cables to loosen; they unwound off the cable drum in the pedestal.

Fifth Why: Why was an untrained mechanic working by himself?  This question speaks to the Training program for the Colgan mechanics and the lack of oversight conducted by Colgan’s management to make sure all mechanics receive proper training as per their approved training manuals.

The first thing people say is why didn’t the Federal Aviation Administration (FAA) get in front of this?  Let’s use some perspective: Many airlines employ hundreds of mechanics and pilots; major airlines employ thousands of each, located all around the world, 24/7, 365 days a year.  An FAA office in charge of an airline, employs perhaps 30 to 50 inspectors to oversee, not only several thousand mechanics, but the maintenance they perform on hundreds of aircraft in its fleet.  The strain on Operations inspectors is similar: 30 to 50 inspectors overseeing thousands of pilots worldwide.  One must do the math to understand.

This accident demonstrates why it is important to look beyond what caused the accident to the cause.  Whatever caused the accident is over with; it ended when the aircraft arrived at the point of impact.  What was the cause of the accident can continue, unchanged, until someone recognizes the problem and fixes it.  This was the second time in eight months that a Beech 1900D crashed due in large part to improper training.  This was the true cause of the accident.

This was the Lesson Unlearned.