Investigation Summary
The maintenance work performed on September 10, 1991, involved replacing the de-ice boots on the horizontal stabilizer. This task required removing the leading edge assemblies. During the second shift, two mechanics removed the screws from the top of the left leading edge. However, a shift change occurred before the work was completed. The second-shift supervisor failed to provide a verbal turnover or complete the required maintenance shift turnover forms for the incoming third shift. Consequently, the third-shift crew, seeing the leading edge still in place, assumed the work was finished or had not yet begun on that side. The aircraft was returned to service with the upper part of the left leading edge held in place only by gravity and its lower screws. The aircraft completed its first flight of the day without incident, likely because it did not reach the high speeds or aerodynamic loads encountered during the accident flight's descent, which was the second leg of the day.
Final Conclusions
The NTSB determined the probable cause was the failure of Continental Express maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures. This led to the loss of the partially secured left horizontal stabilizer leading edge and an immediate severe nose-down pitchover. Contributing factors included management's failure to ensure compliance with approved procedures and the FAA's failure to detect these deficiencies during surveillance. The accident is cited as a landmark case in the study of safety culture, a term championed by NTSB member Dr. John Lauber in his dissenting opinion regarding the role of corporate management in the accident, and led to significant changes in how shift handovers and corporate safety orientations are managed in aviation.
Photographic Evidence (1)
Video Analysis
Breakup Over Texas - Continental Express Flight 2574 — A detailed look at the maintenance errors and shift-change failures that led to the structural breakup of Jetlink 2574.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Age 29
First Officer
Age 43
Systems & Failure Modes
Horizontal Stabilizer Leading Edge
A composite structure attached to the front of the horizontal stabilizer. Its separation caused an aerodynamic stall of the tail, removing the downward force required to balance the aircraft's nose.
De-ice Boots
Pneumatic surfaces on the leading edges that inflate to shed ice. Their scheduled replacement was the reason the leading edge screws were removed.
Shift Turnover Procedures
Administrative safety systems including verbal briefings and turnover forms designed to ensure maintenance tasks are not left incomplete between work shifts.
Interesting Facts
- 01None of the 47 screws for the upper surface of the left leading edge were found in the wreckage or at the attachment points.
- 02The pilots were subjected to G-forces of at least 3.375g during the breakup sequence.
- 03The horizontal stabilizer was located 650 feet away from the main wreckage site.
- 04The flight crew could not have seen the missing screws during pre-flight because the T-tail is approximately 20 feet above the ground.
- 05The aircraft had 7,229 flight hours and 10,009 cycles at the time of the accident.
Safety Actions & Advisories
AIR 21 Enactment
The Wendell H. Ford Aviation Investment and Reform Act for the 21st Century was enacted in 2000, partly influenced by the safety culture issues identified in this crash.
NASIP Procedure Improvements
The NTSB recommended the FAA improve National Aviation Safety Inspection Program procedures to better detect deficiencies in shift-turnover and maintenance management.