ATL03IA090

NTSB incident investigation · Canadair CL-600-2B19 · Chattanooga, TN · May 8, 2003

Incident · No injuriesIncident investigationFinal report
Date
May 8, 2003, 12:28 local (16:28 UTC)
Place
Chattanooga, TN
Injuries
21 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N829ASCanadair CL-600-2B19
Weather
Visual (VMC) · Day
Status
Completed · report December 28, 2004
Report
Approved by Office Director
Parties
Atlantic Southeast Airlines,Inc., Bombardier Aerospace, FAA Headquarters
Safety recommendations
Yes
FAA report
20030508014979I
Case key
56956

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

Excessive wear on the bushings and the right aileron inboard and outboard power control unit output link resulting in the upward movement of the right aileron during cruise climb, uncommanded right roll. A factor in the accident was inadequate maintenance inspection procedure by the aircraft manufacture for the aileron system backlash check performed by the operator. The inspection procedure did not require the operator to record the tolerance found during the backlash check.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionClimb - to cruise
Flight control,aileron - wornCause
Precautionary landing - performedPilot in command
Maintenance,inspection - inadequateManufacturerFactor

Analysis

After takeoff the flight crew heard a high frequency vibration which could be felt in the feet and control column. The engine indicating and alerting system indicated no messages. The vibration was slow and increased in intensity and lasted about 30 seconds. The flight was cleared to 17,000 feet, and the airplane started an uncommanded roll to the right. The first officer disconnected the autopilot and regained control of the airplane. The captain declared an emergency, and was issued a clearance to an alternate airport. The vibrations continued at all airspeeds during the descent and landing. Examination of the airplane revealed the bushings and right aileron inboard and outboard power control unit output link were worn and exceeded the authorized tolerance allowed by the maintenance manual. The aircraft manufacturers inspection procedures for the aileron system backlash check did not require the operator to record the tolerance found during the backlash check.

Factual narrative

History of flight

On May 8, 2003, at 1228 eastern daylight time, a Canadair CL-600-2B19, N829AS, Flight 4690, registered to State Street Bank Company of Connecticut, and operated by Atlantic Southeast Airlines, Inc., as a 14 CFR Part 121 scheduled domestic/international passenger flight, diverted to Chattanooga, Tennessee, after an uncommanded roll during cruise climb. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The airplane was not damaged. The airline transport rated captain, commercial pilot rated first officer, one flight attendant, and 18 passengers reported no injuries. The flight departed Atlanta, Georgia, at 1219 on May 8, 2003, en route to Montreal, Canada.

After liftoff, the first officer, who was flying the airplane, felt and experienced a high-frequency vibration. The vibration could be felt in his feet and the control column. The engine indicating and crew alerting system (EICAS) indicated no messages. When the airspeed was increased to 250 knots, the vibration started again. The vibration was slow and increased in intensity. The captain contacted company maintenance while the first officer engaged the autopilot. The vibrations continued and lasted about 30 seconds. When the flight was cleared to 17,000 feet, the airplane started an uncommanded 45-degree roll to the right. The first officer disconnected the autopilot and regained control of the airplane. The captain declared an emergency, and was issued radar vectors to Chattanooga. The first officer initiated a power off descent while the captain monitored the instruments and the synoptic pages. The vibrations continued at all airspeeds during the decent and landing.

Review of radar data revealed the airplane deviated to the right while climbing through 15,200 feet at 1228:40. The airplane deviated to the right again at 1229 climbing through 15,500 feet. At 1229:20, the airplane deviated to the right while climbing through 15,900 feet. The airplane deviated to the right at 1230 while climbing through 16,500 feet. The last deviation to the right was at 1230:31 at 17,100 feet.

Personnel information

Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the airline transport rated pilot-in-command was issued an airline transport pilot rating on January 23, 2002, with ratings for airplane single engine land, multiengine land and instrument airplane. In addition the pilot was issued a flight instructor certificate on Feb 9,1998, with ratings for airplane single engine land and instrument airplane. The pilot was hired by Atlantic Southeast Airlines, Inc, on September 9, 1998. The pilot was type rated in the EMB 120 on April 13, 2000, and was type rated in the CL65 on January 23, 2002. The pilot was qualified as a CL65 captain on January 23, 2002. The last recorded line check was on December 31, 2002.The pilot's last recurrent ground training was conducted on December 13, 2002, through December 19, 2002. The pilots last proficiency check ride/biennial flight review was completed on June 17, 2002. The pilot has 1,053 total hours in the CL65.The pilot held a first class medical certificate issued on December 9, 2002, with the limitation must wear corrective lenses.

Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the commercial pilot, first officer, was issued a commercial pilot certificate on September 5, 2000, with ratings for airplane single engine land, multiengine land and instrument airplane. Atlantic Southeast Airlines hired the pilot on January 29, 2001. The pilot was qualified as a CL65 first officer on April 14, 2001.The pilots last proficiency check ride/biennial flight review was completed March 5, 2003. The pilots last recurrent ground training was conducted on April 8, 2003, through April 10, 2003. The pilot has 1,027 total hours in the CL65. The pilot held a first class medical issued on December 18, 2002 with no restrictions.

Review of Atlantic Southeast Airlines, Inc, records revealed the flight attendant successfully completed initial flight attendant training on September 5, 2001, and completed recurrent training on September 19, 2002. The flight attendant was current and qualified.

Aircraft information

Review of aircraft maintenance records revealed the last "A" check was conducted on April 14, 2003. The "C1" check was conducted on March 10, 2002 and required the functional check and backlash check of the aileron control system. No anomalies were noted during the inspection. The last routine service 100-hour/10 day checks was conducted on May 5, 2003. The airframe had 13,127.40 hours and 11,917 cycles on May 8, 2003. The left engine was installed on April 13, 2003. The total time since new was 6,417.6 hours and 131.5 hours since overhaul. The left engine cycles since new was 6,323 hours. The right engine time since new was 6,541.5 hours and 2,883.0 hours since overhaul.

Meteorological information

The nearest weather reporting facility at the time of the incident was Chattanooga, Tennessee. The 1653 surface weather observation was: 1,500 broken, visibility 6 miles, temperature 75 degrees Fahrenheit, dew point temperature 69 degrees Fahrenheit, wind variable at 4 knots, and altimeter 30.05.

Wreckage and impact information

The NTSB Systems Group met at Lovell Field, Chattanooga, Tennessee, to document the airplane and relevant systems. The airframe, auto flight, electrical power, and flight control systems were examined. No anomalies were noted with the airframe, auto flight, and electrical power.

The lateral control system was exercised via the captain's and first officer's control wheels. No anomalies were noted in the captain's control wheel movement. A slight notching was noted in the first officer's control wheel movement. When the captain's control wheel was used to exercise the first officer's lateral control system, no notching was noted.

Hand movement of the right aileron control surface indicated free play within the system. The travel of the trailing edge of the right aileron from a pushed-down position to a pushed-up position was measured as 7/16", with the hydraulic systems turned off. The travel of the trailing edge of the left aileron from a pushed-down position to a pushed-up position was measured as 1/4".

The under wing aileron access panel on the right wing was removed for a visual inspection of the two aileron output linkage connection to the aileron. When the right aileron was manually moved, free play was noted between the power control unit (PCU) output link, the aft attach bolt, and the aileron fitting. The attachment bolt could be moved by hand.

The main landing gear wheel well bay fairings were removed and the aileron control quadrant pulleys were examined. No anomalies were noted in the static condition of the pulleys. When the lateral control system was exercised in the flight deck, no anomalies were noted in the operation of the pulley and cable movement.

Visual inspection of the aileron flight control cables under the cockpit floor revealed no anomalies were noted. The right under wing aileron PCU access panel was removed and the two aileron PCUs were examined. No anomalies were noted.

The over wing aileron access panel was removed on both wings. The outboard aileron pulley was examined on both wings. The outboard aileron pulley on the right wing did not rotate freely and required a higher than normal torque to rotate the pulley.

An aileron control system-backlash check and functional test was performed on the airplane's left and right ailerons in accordance with airline task card 019-27-900-709. The test was altered so only the portions of the test pertaining to the outboard aileron PCU were accomplished. The test on the right outboard PCU, right aileron bearing, and left aileron PCU were accomplish

Aircraft

Registration
N829AS
Reported as
Canadair CL-600-2B19
Category
Airplane
Serial number
7232
Airframe hours
13,127
Engine
General Electric CF34-3BI, 8,729 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Atlantic Southeast Airlines, Inc.
Registered owner
State Street Bank and Trust Company of CT
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 14, 2003 · 131 hours before
Departed
ATL · Atlanta, GA
Destination
CYUL · Montreal
Flight plan
IFR
Airport
CHA · Lovell Field, runway 20, 7,401 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Injuries
None
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
June 17, 2002
Seat
Left
Flight hours
4,439 total · 963 in this make and model · 3,079 as pilot in command · 229 in the last 90 days · 69 in the last 30 days
Role
Co-pilot
Age
34
Injuries
None
Certificates
Private, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
March 5, 2003
Seat
Right
Flight hours
1,446 total · 1,027 in this make and model · 304 as pilot in command · 153 in the last 90 days · 86 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Visibility
6 statute miles
Lowest ceiling
1,500 ft broken
Temperature
75 °F, dew point 70 °F
Altimeter
30.04 inHg
Observed at
CHA

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.