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National Transportation Safety Board NTSB ID: CHI07FA107 Aircraft Registration Number: N77181

FACTUAL REPORT Occurrence Date: 04/07/2007 Most Critical Injury: None

AVIATION Occurrence Type: Accident Investigated By: NTSB

Location/Time
Nearest City/Place State Zip Code Local Time Time Zone
Lake Michigan MI 49512 2123 EDT

Airport Proximity: Off Airport/Airstrip Distance From Landing Facility:

Aircraft Information Summary

Aircraft Manufacturer Model/Series Type of Aircraft

Canadair CL-600-2B19 Airplane

Revenue Sightseeing Flight: No Air Medical Transport Flight: No

Narrative
Brief narrative statement of facts, conditions and circumstances pertinent to the accident/incident:
HISTORY OF FLIGHT
On April 7, 2007, about 2123 eastern daylight time, a Canadair CL-600-2B19 (CRJ), N77181, operated
by Mesa Airlines as flight 7264, was substantially damaged when the thrust reverser translating
cowling separated from the left engine during cruise flight and struck the horizontal and vertical
stabilizers. The airplane was near the eastern shore of Lake Michigan, about 35 miles
west-northwest of Grand Rapids, Michigan, when the accident occurred. The revenue air carrier
flight was operating under 14 CFR Part 121 on an instrument flight rules (IFR) flight plan. Visual
meteorological conditions prevailed in the vicinity at the time of the accident. The one
passenger, one flight attendant, and two pilots on-board were not injured. The flight departed
Capital City Airport (LAN), Lansing, Michigan, at 2054. The flight continued to the intended
destination, Chicago O'Hare International Airport (ORD), Chicago, Illinois, and landed without
further incident at 2136.

The captain noted that air traffic into ORD was under flow restrictions and the flight had to wait
for its assigned release time. While holding for takeoff at LAN, the flight crew received a left
thrust reverser unlock master caution and associated Engine Indicating and Crew Alert System
(EICAS) indications. The captain contacted maintenance and cycled the reverser a few times in an
attempt to clear the indications. He had decided to return to the gate when the messages cleared.
He subsequently cycled the thrust reversers two or three more times and both appeared to be
operating and stowing properly. Since the thrust reversers seemed to be operating normally, he
elected to depart for ORD.

The captain reported experiencing a small vibration on climb out. The flight climbed to a cruise
altitude of 16,000 feet mean sea level. The vibration persisted and the captain became concerned
about the thrust reverser. He stated that about 35 miles west-northwest of Grand Rapids, 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 hand flew the airplane for a time. He ultimately elected to
continue to ORD because the thrust reverser unlock messages had cleared and the vibrations had
stopped. The flight subsequently landed uneventfully at ORD. The autopilot and trim system worked
properly after the event. The missing left engine cowling and damage to the empennage were
observed during the post flight inspection.

PERSONNEL INFORMATION
The pilot-in-command (captain) held an Airline Transport Pilot certificate with multi-engine and
single-engine airplane ratings. His certificate included CL-65 and EMB-145 type ratings. He was
issued a First Class Airman Medical Certificate without limitations or waivers on December 8, 2006.
He had accumulated approximately 8,000 hours total flight time, with about 500 hours in CRJ
aircraft. His most recent flight check was completed on February 22, 2007.

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National Transportation Safety Board NTSB ID: CHI07FA107

FACTUAL REPORT Occurrence Date: 04/07/2007

AVIATION Occurrence Type: Accident

Narrative (Continued)

The second-in-command (first officer) held an Airline Transport Pilot certificate with multi-engine
and single-engine airplane ratings. The single-engine rating was limited to commercial pilot
privileges only. His certificate included a CL-65 type rating limited to second-in-command
privileges only. He was issued a First-Class Airman Medical Certificate without limitations or
waivers on December 8, 2006. He had accumulated approximately 5,600 hours total flight time, with
about 2,920 hours in CRJ aircraft. His most recent flight check was completed on January 13, 2007.

AIRCRAFT INFORMATION
The accident airplane was a 1997 Canadair (Bombardier) CL-600-2B19, serial number 7181. It was
certificated as a transport category airplane under Type Certificate A21EA. It was configured with
50 passenger seats. The airplane was powered by two General Electric CF34-3B1 turbofan engines,
rated at 9,300 lbs. of thrust. At the time of the accident, the airplane had accumulated 24,805
hours flight time. The left engine, serial number GE-E872898, had accumulated 11,489 hours time in
service. The right engine, serial number GE-E872265, had accumulated 22,856 hours time in service.

Review of the aircraft's maintenance records revealed a history of anomalies related to the left
engine thrust reverser. On March 11, 2007, the aircraft maintenance log contained the discrepancy,
"L Rev Unlock Caution." The entry was deferred in accordance with the Mesa Airlines CRJ Minimum
Equipment List (MEL). On March 18, 2007, the left pneumatic drive unit was replaced; however,
operational testing determined that the discrepancy was not resolved. The maintenance record noted
binding in the drive assembly to the ballscrew actuator. On March 20, 2007, the left engine thrust
reverser flex shafts were replaced. Again, the discrepancy was not resolved. On March 22, 2007, a
ballscrew actuator and a cascade assembly were replaced. The maintenance record indicated that
rigging and operational checks were satisfactory. The MEL item was closed at that time.

Routine maintenance was conducted on March 30, 2007, at which time the thrust reverser and
ballscrew actuators were lubricated. No defects were noted in the records. Subsequent to the date
the MEL was closed, there were no entries related to the left thrust reverser in the aircraft
maintenance log.

The flight log indicated that on the day of the accident, the airplane flew from Columbia
Metropolitan Airport (CAE), Columbia, South Carolina, to ORD. The airplane then flew to Harrisburg
International Airport (MDT), Harrisburg, Pennsylvania, and back to ORD. The next flight, which was
the flight prior to the accident flight, was from ORD to LAN. According to the log, that flight
landed at 1943.

The Mesa Airlines CRJ MEL, dated July 14, 2006, stated that an airplane may be dispatched with one
of the engine thrust reversers inoperative. The MEL required that the inoperative reverser be
inspected for structural damage, deactivated, and stowed and locked in the forward thrust position.

METEOROLOGICAL CONDITIONS
Surface weather conditions recorded at the Gerald R. Ford Airport (GRR), Grand Rapids, Michigan, at
2056, were: Winds from 280 degrees at 9 knots; 10 miles visibility; broken clouds at 5,500 feet
above ground level (agl); overcast clouds at 7,500 feet agl; temperature and dew point -03 and -07
degrees Celsius, respectively; altimeter 29.93 inches of mercury.

FLIGHT RECORDERS
The NTSB Vehicle Recorders Laboratory downloaded the flight data recorder (FDR) and the data were
reviewed. Elapsed time is noted in minutes and seconds (MM:SS) relative to the airplane becoming
fully airborne (weight-off-wheels signals from all three landing gear). The data indicated that:

At 03:14 (MM:SS) after liftoff, as the airplane climbed through approximately 8,500 feet
pressure altitude, the left engine thrust reverser unlock parameter indicated "On" for about one
second.

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National Transportation Safety Board NTSB ID: CHI07FA107

FACTUAL REPORT Occurrence Date: 04/07/2007

AVIATION Occurrence Type: Accident

Narrative (Continued)

At 05:42 into the flight, the left engine fuel flow began to decrease, followed by the engine
speed (N1 and N2 parameters). The fuel flow decreased over a period of approximately 20 seconds
before returning to the previous level. The engine speed followed that trend.

At 11:20, both engine fuel flows and engine speeds again began to decrease. Just prior to
this, the left engine vibration parameter increased for approximately 2 seconds, before dropping
below the left engine vibration level recorded earlier in the flight. As this fuel flow decrease
was occurring, the airplane rolled right, left, and right again over about a 4-second period. The
decrease in the left engine parameters lasted over 3 minutes. The decrease in the right engine
parameters lasted for approximately 2 minutes before both began to increase again to normal levels.

At 14:46, the left engine thrust reverser unlocked parameter again indicated "On" for 4
seconds. It remained "Off" for the remainder of the flight. This occurred about the time the
engine parameters returned to normal.

At 32:12, while the airplane was descending, the left engine thrust reverser arm advisory
indicated "On" and remained in that state for the remainder of the flight.

The left engine thrust reverser deploy parameter remained in the "Off" state for the entire flight.
The right engine reverser deploy parameter indicated "On" for approximately 9 seconds during
landing. This was concurrent with the right engine thrust reverser unlocked parameter indicating
"On" for about 13 seconds during the landing.

The FDR data related to the two flights prior to the accident flight indicated that the left engine
thrust reverser did not deploy properly. On the flight prior to the accident flight, during
landing, both the left and right engine thrust reverser unlocked parameters indicated "On" for
approximately 20 seconds. However, the left engine thrust reverser deployed parameter remained
"Off" during that time period. The right engine thrust reverser deployed parameter indicated "On"
for about 15 seconds during that time.

During landing on the second flight prior to the accident flight, the left and right thrust
reverser unlocked parameters went from "Off" to "On" within about 1 second of each other. The left
engine reverser unlocked parameter remained "On" for approximately 13 seconds. It went to "Off"
for 9 seconds, and then indicated "On" again briefly for 1 second and again for 3 seconds, before
remaining "Off" for the remainder of the flight. During that time, the left engine thrust reverser
deployed parameter indicated "Off" for the entire time. The right engine thrust reverser unlocked
parameter indicated "On" for approximately 22 seconds. It then switched to "Off" and remained in
that state for the remainder of the flight. The right engine thrust reverser deployed parameter
indicated "On" beginning about 3 seconds after the reverser unlocked parameter went to "On." The
reverser deployed parameter remained on for about 16 seconds. It subsequently went to "Off" and
remained in that state for the remainder of the flight.

The aircraft maintenance log did not contain any entries related to any left engine thrust reverser
malfunctions during these flights.

WRECKAGE AND IMPACT INFORMATION

A post accident inspection revealed that the left engine translating cowl had separated from the
aircraft. The inboard leading edge of the left horizontal stabilizer was dented and crushed aft
consistent with impact damage. The left side skin of the vertical stabilizer was punctured
immediately forward of the center spar. The puncture was approximately 8 inches long by 2 inches
wide, oriented vertically parallel to the spar.

The engine and available thrust reverser components were examined. The translating cowl was not
recovered. A portion of the lower translating cowling hinge remained attached to the track. Two
translating cowling interlock fittings had separated from the assembly. The fittings remained

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National Transportation Safety Board NTSB ID: CHI07FA107

FACTUAL REPORT Occurrence Date: 04/07/2007

AVIATION Occurrence Type: Accident

Narrative (Continued)

secured to the torque box at the latch fittings with the shoot bolts engaged.

The upper thrust reverser pylon attachment track exhibited scoring along the Auto Throttle Retard
(ATR) cam. The track was bowed approximately 3/8 inch in an area about 9 inches from the aft end
of the component. No anomalies associated with the lower attachment track were observed.

One torque box interlock fitting was fractured and missing. The remaining five interlock fittings
were intact. The torque box itself was twisted, and the outer skin and rear bulkhead were creased.
The upper inboard actuator clevis end attachment pin was sheared. The jackscrew mechanism rotated
without binding.

TESTS AND RESEARCH

The left engine thrust reverser Pneumatic Drive Actuator (Part number 126785-7 / Serial number
2240) was tested by the component manufacturer under direct supervision of the Federal Aviation
Administration. No anomalies consistent with an in-flight un-commanded thrust reverser deployment
were observed. The thrust reverser deployment lockout mechanism appeared undamaged.

ADDITIONAL INFORMATION
The Mesa Airlines CRJ Company Flight Manual, dated December 12, 2007, specified that in the case of
a left or right reverser unlock message (L/R REV UNLOCKED), the flight crew is to confirm that the
affected thrust lever is at idle, and to select the corresponding Thrust Reverser Emergency Stow
switch. According to the manual, "improved airplane handling and normal operation of [the]
affected thrust lever," indicated successful stowage of the thrust reverser.

An Auto Throttle Retard (ATR) System is designed to insure that the throttle lever is at idle
whenever the thrust reverser is in transit. In flight, if a thrust reverser is inadvertently
deployed, the affected throttle lever is automatically retarded to idle to minimize asymmetric
thrust. An ATR commanded thrust reduction normally occurs in less than one second.

According to the Federal Aviation Administration and Bombardier, this event is the only known
CRJ-100/200 in-flight translating cowl separation.

Bombardier revised the flight manual to include detailed instructions in the event that a left or
right reverser unlock message (L or R REV UNLOCKED) is received during ground operations.
Updated on Dec 24 2008 10:30AM

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NTSB ID: CHI07FA107

National Transportation Safety Board

FACTUAL REPORT Occurrence Date: 04/07/2007

AVIATION Occurrence Type: Accident

Landing Facility/Approach Information

Airport Name Airport ID: Airport Elevation Runway Used Runway Length Runway Width
Chicago O'Hare Intl ORD Ft. MSL N/A

Runway Surface Type:

Runway Surface Condition:

Approach/Arrival Flown: NONE

VFR Approach/Landing: None

Aircraft Information
Aircraft Manufacturer Model/Series Serial Number
Canadair CL-600-2B19 7181

Airworthiness Certificate(s): Transport

Landing Gear Type: Retractable - Tricycle

Amateur Built Acft? No
Engine Type:
Turbo Fan
- Aircraft Inspection Information
Type of Last Inspection
Number of Seats: 54 Certified Max Gross Wt. 53000 LBS Number of Engines: 2
Engine Manufacturer: Model/Series: Rated Power:
General Electric CF34-3B1 9357 LBS
Date of Last Inspection Time Since Last Inspection Airframe Total Time

Continuous Airworthiness 03/2007 Hours 24805 Hours

- Emergency Locator Transmitter (ELT) Information

ELT Installed?/Type Yes / ELT Operated? No ELT Aided in Locating Accident Site? No

Owner/Operator Information
Registered Aircraft Owner Street Address

Wells Fargo Bank Northwest City State Zip Code

Salt Lake City UT 84111
Street Address
Operator of Aircraft
City State Zip Code
Mesa Airlines, Inc.
Phoenix AZ
Operator Does Business As: United Express Operator Designator Code: MASA
- Type of U.S. Certificate(s) Held:
Air Carrier Operating Certificate(s): Flag Carrier/Domestic

Operating Certificate: Operator Certificate:

Regulation Flight Conducted Under: Part 121: Air Carrier

Type of Flight Operation Conducted: Scheduled; Domestic; Passenger Only

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National Transportation Safety Board NTSB ID: CHI07FA107

FACTUAL REPORT Occurrence Date: 04/07/2007

AVIATION Occurrence Type: Accident

First Pilot Information

Name City State Date of Birth Age

On File On File On File On File 34

Sex: M Seat Occupied: Left Occupational Pilot? Yes Certificate Number: On File

Certificate(s): Airline Transport

Airplane Rating(s): Multi-engine Land; Single-engine Land

Rotorcraft/Glider/LTA: None

Instrument Rating(s): Airplane

Instructor Rating(s):

Current Biennial Flight Review? 02/2007

Medical Cert.: Class 1 Medical Cert. Status: Without Waivers/Limitations Date of Last Medical Exam: 12/2006

This Make Airplane Airplane Instrument Lighter

All A/C
- Flight Time Matrix and Model Single Engine Mult-Engine
Night
Actual Simulated
Rotorcraft Glider
Than Air

Total Time 8000 500

Pilot In Command(PIC)

Instructor

Instruction Received

Last 90 Days 100

Last 30 Days

Last 24 Hours 10
Seatbelt Used? Yes Shoulder Harness Used? Yes Toxicology Performed? No Second Pilot? Yes

Flight Plan/Itinerary
Type of Flight Plan Filed: IFR
Departure Point State Airport Identifier Departure Time Time Zone

Lansing MI LAN 2036 EDT

Destination State Airport Identifier

Chicago IL ORD

Type of Clearance: IFR

Type of Airspace:

Weather Information
Source of Wx Information:

Company

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National Transportation Safety Board NTSB ID: CHI07FA107

FACTUAL REPORT Occurrence Date: 04/07/2007

AVIATION Occurrence Type: Accident

Weather Information
WOF ID Observation Time Time Zone WOF Elevation WOF Distance From Accident Site Direction From Accident Site

GRR 2056 EDT 794 Ft. MSL 35 NM 120 Deg. Mag.

Sky/Lowest Cloud Condition: Ft. AGL Condition of Light: Night

Lowest Ceiling: Broken 5500 Ft. AGL Visibility: 10 SM Altimeter: 29.93 "Hg

Temperature: -3 ° C Dew Point: -7 ° C Weather Conditions at Accident Site: Visual Conditions

Wind Direction: 280 Wind Speed: 9 Wind Gusts:

Visibility (RVR): Ft. Visibility (RVV) SM

Precip and/or Obscuration:

No Obscuration; No Precipitation

Accident Information
Aircraft Damage: Substantial Aircraft Fire: None Aircraft Explosion None

- Injury Summary Matrix Fatal Serious Minor None TOTAL

First Pilot 1 1
Second Pilot 1 1
Student Pilot

Flight Instructor

Check Pilot

Flight Engineer

Cabin Attendants 1 1
Other Crew

Passengers 1 1
- TOTAL ABOARD - 4 4
Other Ground

- GRAND TOTAL - 4 4

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NTSB ID: CHI07FA107

National Transportation Safety Board

FACTUAL REPORT Occurrence Date: 04/07/2007

AVIATION Occurrence Type: Accident

Administrative Information
Investigator-In-Charge (IIC)
Timothy Sorensen

Additional Persons Participating in This Accident/Incident Investigation:

David Keenan
FAA-AAI 100
Washington, DC

John Britten
Transportation Safety Board of Canada
Gatineu, Quebec,

Abdul Khaliq Durrani

Transport Canada
Ottawa, Ontario,

Greg Browning
Bombardier Aerospace (Canada)
Dorval, Quebec,

Mark McConnell
Bombardier Aerospace (Northen Ireland)
Belfast,

Edward Arriaga
Mesa Airlines
Chicago, IL

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