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National Transportation Safety Board Printed on : 1/11/2011 1:56:16 PM

Washington, DC 20594

Brief of Accident

Adopted 12/24/2008

CHI07FA107
File No. 24111 04/07/2007 Lake Michigan, MI Aircraft Reg No. N77181 Time (Local): 21:23 EDT

Make/Model: Canadair / CL-600-2B19 Fatal Serious Minor/None


Engine Make/Model: General Electric / CF34-3B1 Crew 0 0 3
Aircraft Damage: Substantial Pass 0 0 1
Number of Engines: 2
Operating Certificate(s): Flag Carrier/Domestic
Name of Carrier: Mesa Airlines, Inc.
Type of Flight Operation: Scheduled; Domestic; Passenger Only
Reg. Flight Conducted Under: Part 121: Air Carrier

Last Depart. Point: Lansing, MI Condition of Light: Night


Destination: Chicago, IL Weather Info Src: Weather Observation Facility
Airport Proximity: Off Airport/Airstrip Basic Weather: Visual Conditions
Lowest Ceiling: 5500 Ft. AGL, Broken
Visibility: 10.00 SM
Wind Dir/Speed: 280 / 009 Kts
Temperature (°C): -3
Precip/Obscuration: No Obscuration; No Precipitation

Pilot-in-Command Age: 34 Flight Time (Hours)

Certificate(s)/Rating(s) Total All Aircraft: 8000


Airline Transport; Multi-engine Land; Single-engine Land Last 90 Days: 100
Total Make/Model: 500
Instrument Ratings Total Instrument Time: UnK/Nr
Airplane

The flight crew received a left thrust reverser unlock indication while holding for takeoff. The captain cycled the reverser, and had
decided to return to the gate when the messages cleared. With the issue apparently resolved, he elected to takeoff. The captain
reported experiencing a small vibration on climb out and, a short time later, he heard a "loud bang" and the "aircraft pitched and
yawed/rolled to [the] left." The autopilot disengaged and the left thrust lever moved to idle during the event. The first officer ran
the checklist to stow the reverser. The captain decided to continue to the intended destination because the thrust reverser messages had
cleared and the vibrations had stopped. The flight subsequently landed uneventfully. The flight data recorder (FDR) indicated that the
left engine vibration levels were elevated during the accident flight. Approximately 3 minutes into the flight, the left engine thrust
reverser unlocked parameter changed to "On" for about 1 second. About 11:20 (MM:SS) after takeoff, the left engine vibration level
increased momentarily, and both the left and right engine speeds and fuel flows began to decrease. As the decrease in fuel flows was
occurring, the airplane rolled right, left, and right again over about a 4-second period. The decrease in engine parameters lasted over
3 minutes before returning to normal. The left engine thrust reverser unlock parameter indicated "On" for about 4 seconds during that
time. The left engine vibration levels decreased after the event, below the levels previously recorded during the flight, and
approximately to the level of the right engine vibration. The vibration and engine speed variations suggested separation of the left
engine translating cowling at that point. The left engine thrust reverser deploy parameter remained in the "Off" state for the entire
flight. Additionally, the FDR data revealed that the left engine vibration levels were elevated and left engine thrust reverser did not
deploy on the two previous flights. The post accident inspection revealed that the left engine translating cowl had separated from the
engine assembly and damaged the empennage. Damage to the thrust reverser components was consistent with prior operation with the
Brief of Accident (Continued)

CHI07FA107
File No. 24111 04/07/2007 Lake Michigan, MI Aircraft Reg No. N77181 Time (Local): 21:23 EDT

reverser out of alignment and jamming of the translating structure. Review of the aircraft's maintenance records revealed a history of
anomalies related to the left engine thrust reverser. About one month prior to the accident, the aircraft maintenance log contained the
discrepancy, "L Rev Unlock Caution." The entry was deferred in accordance with the minimum equipment list (MEL). The left pneumatic
drive unit and the left thrust reverser flex shafts were subsequently replaced; however the discrepancy was not resolved. Eleven days
after the initial write-up, a ballscrew actuator and a cascade assembly were replaced. The maintenance record indicated that rigging and
operational checks were satisfactory, and the MEL item was closed. There were no further entries related to the left thrust reverser in
the aircraft maintenance log. The MEL allowed the airplane to be dispatched with one of the engine thrust reversers inoperative. It
required that the inoperative reverser be inspected for structural damage, deactivated, and stowed and locked in the forward thrust
position. In the event of an in-flight unlock or deploy indication, the flight manual instructed the crew to manually stow the reverser.
There was no guidance in the event of an indication on the ground. Bombardier has initiated a revision to the flight manual to include
instructions in the event of a thrust reverser unlock message received during ground operations.
Updated at Dec 24 2008 10:30AM
Brief of Accident (Continued)

CHI07FA107
File No. 24111 04/07/2007 Lake Michigan, MI Aircraft Reg No. N77181 Time (Local): 21:23 EDT

Occurrence #1: AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTION


Phase of Operation: CRUISE

Findings
1. (C) THRUST REVERSER - BINDING(MECHANICAL)
2. (C) THRUST REVERSER - SEPARATION
3. (F) MAINTENANCE,INSPECTION - INADEQUATE - COMPANY MAINTENANCE PERSONNEL
4. (F) AIRCRAFT SERVICE - NOT OBTAINED - PILOT OF A PREVIOUS FLIGHT
5. (F) PROCEDURE INADEQUATE - COMPANY/OPERATOR MANAGEMENT
6. (F) PROCEDURE INADEQUATE - MANUFACTURER

Findings Legend: (C) = Cause, (F) = Factor


__________________________________________________________________________________________________________________________________________

The National Transportation Safety Board determines the probable cause(s) of this accident as follows.
In-flight separation of the left engine thrust reverser translating cowling due to intermittent binding and jamming of the reverser on
the accident flight and on previous flights. Contributing factors were the inadequate maintenance action by the operator due to their
failure to properly resolve the prior reverser malfunctions, the failure of the pilots of previous flights in not referring earlier
reverser deployment failures for maintenance action, and incomplete company/manufacturer's procedures because they did not address
anomalous reverser indications during ground operations.