Continental Express Flight 2574

Continental Express Flight 2574

CGI of N33701. note that the leading edge of the Horizontal Stabilizer has separated.
Accident
Date	September 11, 1991
Summary	Maintenance error leading to Structural Failure
Site	Colorado County, near Eagle Lake, Texas, USA 29.5048°N 96.3906°W / 29.5048; -96.3906
Aircraft type	Embraer EMB 120RT Brasilia
Operator	Britt Airways, Inc., dba Continental Express
Registration	N33701
Passengers	11
Crew	3
Fatalities	14 (all)
Injuries	0
Survivors	0

Continental Express Flight 2574 (Jetlink 2574) was a scheduled domestic passenger airline flight operated by Britt Airways from Laredo International Airport in Laredo, Texas to Bush Intercontinental Airport in Houston, Texas. On September 11, 1991, the Embraer EMB 120 Brasilia, registered N37701, crashed as it was approaching the runway for landing, killing all 14 people on board. The aircraft wreckage hit an area near Eagle Lake, Texas.

The media stated that initially people speculated that a bomb had destroyed the aircraft; the National Transportation Safety Board discovered that missing screws on the horizontal stabilizer led to the crash.

Aircraft

The Embraer Brasilia was built three years before it crashed. Federal Aviation Administration records stated that in its lifetime the aircraft had been sent to the maintenance hangar 33 times for unscheduled repairs.

Crash

29-year old Brad Patridge of Kingwood, Texas was the pilot, while 43-year old Clint Rodosovich of Houston was the first officer.

The wreckage fell in southeast Colorado County, Texas, off of Farm to Market Road 102, seven miles (11 km) southeast of Eagle Lake, Texas, and 60 miles (97 km) west of Downtown Houston. The Texas Department of Public Safety said rescue units discovered no survivors. The wreckage was spread over a 2- to 4-square-mile (10 km²) area; some pieces fell into the Colorado River. About 1991-value $500,000 ($1118494.99 in current money) worth of diamonds were discovered in the wreckage; they had no role in the crash.

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.

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, 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.

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".

References

• Meshkati, N. (1997, April). Human performance, organizational factors and safety culture. Paper presented on National Summit by NTSB on transportation safety. Washington, D.C.

External links

• Final Accident Report (Archive) - National Transportation Safety Board
• 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.