Air Midwest 5481 by

GMF Polsri Batch 5

Group 1

Name : Adam Lazuardi

Aqil Yuan Kumara
Ardhi Prawira Dwi Cahya
Bayu Putra Cakrawala
Fadhillah Shabah Ramadhan
Jimmy Alvindo
Ilham Perdana
M. Pasha Aryo Bimo Indarto
Air Midwest 5481 Accident On January 8, 2003 in the Human Factor perspective.

Air Midwest flight 5481 left the gate at approximately 8:30 am Eastern Standard Time. At 08:37, ground
controllers allowed Flight 5481 to taxi to runway 18R for departure. At 08:46, tower controllers allowed Flight
5481 to take off, and the pilots applied take off power and began rolling their take off.

Immediately after take off, Flight 5481's nose began to rapidly lift. By the time it reached 90 feet above the
ground, the nose of the plane had gone up 20 degrees. Although both pilots tried forcefully to press the nose
down, the aircraft continued to lift the nose, achieving a maximum of 54° pitch. The plane's warning horn
sounded, and the pilot declared an emergency to air traffic controllers. After rising to an altitude of 1,150 feet,
the plane came to a stop, suddenly descending into an uncontrollable descent. About 35 seconds after takeoff,
Flight 5481 crashed into the aircraft maintenance hangar and caught fire. 19 passengers, both pilots were killed
and a US Airways mechanic was on the ground.

Two nights earlier the plane was making repairs at the Repair Facility at Tri State Airport in Huntington, West
Virginia, mechanics discovered that the elevator was out of limits. As part of the procedure, the mechanic makes
adjustments to the cable. But it is known that the mechanics have never worked on the Beechcraft 1900 D which
is the type of Air Midwest plane that crashed.

Previously, the fact that the work he was doing was part of his training. The mechanic has misplaced the
turnbuckel that controls the tension cable to the elevator. Turnbuckle elevator downward pitch was to tightened
which resulted in a pitch down of 7 degrees which is normally 14 degrees. This condition was actually prevented
by the pilot by trying to push the nose down during the accident.

Normally a post adjustment check is performed to ensure that the adjustments have been made correctly. But
the Mechanic supervisor decided to pass the test. The NTSB noted the FAA had recognized serious deficiencies
in its procedures training facilities, and did nothing about it. Lucky or not the aircraft successfully flew nine times
following the faulty repair until it crashed.

In addition, the NTSB also found that the pilot calculated that the plane was not overweight, even though Air
Midwest used the average weight for calculation instead of the actual weight. They use average 175lbs per
passenger & 20lbs per bag. In flight the Air Midwest 5481 was actually 580lbs over the maximum weight, so the
aircraft became tail heavy fatigue.
Air Midwest Flight 5481

1. Occurrence
Moments after take off, precisely after the landing gear retracted, the nose of the aircraft continued to rise
higher (not in a straight line) which caused the plane to stall and bank to the left.

2. Number of Victims
The number of victims killed 22 people including: 19 passengers, 2 crew members & 1 person on the
ground.

3. Technical causes
Faulty rigging of the elevator control system and exacerbated by the rear center of gravity of the aircraft
substantially at the rear exceeding the certified rear limit.

4. Human Factor
- Lack Of Knowledge, Lack Of Resources
The mechanics had never worked on the Beechcraft 1900 D which was the type of Air Midwest plane
that crashed.
- Complacency As Mechanic
The mechanic has misplaced the turnbuckel that controls the tension cable to the elevator. Turnbuckle
elevator downward pitch was to tightened which resulted in a pitch down of 7 degrees which is
normally 14 degrees.
- Lack Of Awereness, Norms, Pressure
The mechanic supervisor decided to pass the test.
- Lack Of Awareness
The pilot calculated that the plane was not overweight, even though Air Midwest used the average
weight for calculation instead of the actual weight. They use average 175lbs per passenger & 20lbs per
bag. In flight Air Midwest 5481 was actually 580lbs over maximum weight

5. Conclusion
The crash of Air Midwest 5481 after 35 seconds of takeoff was caused by faulty rigging of the elevator
control system and exacerbated by the aircraft's rear center of gravity exceeding the weight limit.
Accompanied by mechanical negligence in the aircraft's readiness to fly. Mechanics who had never handled
the Beechcraft 1900 D Series Aircraft made the wrong decision to repair the plane and passed tests to make
sure the plane was repaired properly. In addition, the communication between the Pilot and the Airline
regarding the average weight for calculation is not the actual weight that makes the maximum excess
weight.
Picture :

Source :

Air Midwest Flight 5481 - https://en.m.wikipedia.org/wiki/Air_Midwest_Flight_5481

Dead Weight | Air Midwest Flight 5481 - https://www.youtube.com/watch?v=LkObvOgPaZc

“ The Dirty Dozen ” in Context : Aviation Case Studies -

https://www.faa.gov/about/initiatives/maintenance_hf/fatigue/publications/media/June_2016_newsletter-
s508.pdf

Air Midwest Flight 5481 - Crash Animation - https://www.youtube.com/watch?v=vcl6kgU1Uqs