CEN09IA578

NTSB incident investigation · Cessna 421 · Sugar Land, TX · September 4, 2009

Incident · No injuriesIncident investigationFinal report
Date
September 4, 2009, 17:55 local (22:55 UTC)
Place
Sugar Land, TX
Injuries
1 uninjured
Damage
Minor damage
Phase of flight
Other
Aircraft
N2349SCessna 421
Defining event
Other: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report October 3, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Houston FSDO, Cessna, Cobham
Case key
74714

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

On this page

Probable cause

The improper installation of the pitch trim cable which resulted in it making improper contact with a guard pin that led to the fatigue failure of the cable.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelCessna 421C: 4 casesAll aircraft: 1,386 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedCessna 421C: 8 casesAll aircraft: 2,247 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane was on an autopilot descent when the pilot noticed the elevator pitch trim was rotating continuously in the nose-up position. He disconnected the autopilot and immediately heard a popping sound. The movement of the pitch trim stopped, and the pilot could manually turn the pitch trim wheel without force or resistance. He then hand flew the airplane using spoilers, 15 degrees of flaps and exerted approximately 10 to 20 pounds of back pressure on the yoke to keep the airplane in level flight. The pilot executed an emergency landing without further incident. A postincident examination of the airplane revealed that the pitch trim cable had fractured and separated in the area where it passed over the rearmost pulley in the tail. A subsequent materials laboratory examination revealed the pitch trim cable displayed evidence of permanent curved deformation near the fracture location, with localized smearing wear. Several of the fractured cable wires showed evidence of fatigue fracture and some showed the presence of cadmium. One of the cadmium plated pulley guard pins showed evidence of rubbing contact with the cable. The smearing wear and the presence of the cadmium on the cable wires is consistent with a misrouting of the cable over the cable guide pins instead of the proper routing over the cable pulley. Examination of partial aircraft maintenance records did not show entries for any maintenance events when the pitch trim cable was rerouted or reinstalled. The circumstances leading up to the improper misrouting of the pitch trim cables could not be determined.

Factual narrative

On September 4, 2009, about 1755 central daylight time, a Cessna 421C, N2349S, experienced an in-flight separation of the elevator pitch trim cable during a descent for landing at Sugar Land Regional Airport (SGR), Sugar Land, Texas. The airplane was owned by TMC Aviation, Inc. and was being operated by the pilot on a 14 Code of Federal Regulations Part 91 business flight. Visual meteorological conditions prevailed and the pilot had filed and activated an instrument flight rules (IFR) flight plan. The airplane sustained minor damage. The pilot who was the only person on board was not injured. The flight originated from Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico, about 1340 mountain daylight time. While the airplane was in an 800 feet per minute descent at about 180 to 190 knots the pilot noticed the elevator pitch trim was rotating continuously in the nose up position. He disconnected the autopilot and immediately heard a "popping sound". The movement of the pitch trim stopped, and the pilot could manually turn the pitch trim wheel without force or resistance. He then hand flew the airplane using spoilers, 15 degrees of flaps and exerted approximately 10 to 20 pounds of back pressure on the yoke to keep the airplane in level flight. The subsequent emergency landing at SGR was otherwise uneventful. Examination of the airplane revealed the elevator trim tab was fixed in approximately the neutral position and the pitch trim cable had fractured and separated in the area where it passes over the rearmost pulley in the tail. Cable pulleys in the area of the cable separation appeared to rotate freely on their respective bearings and did not display any significant flat spots within the cable groove. A subsequent materials laboratory examination was conducted of several components. The pitch trim cable displayed evidence of permanent curved deformation near the fracture location, with localized smearing wear and corresponding cracking of the cable wires at the approximate inner radius of the curvature. At the fracture location, some of the cable wire ends were locally curved, and splayed out. Some of the individual wires were bent "L" shape near the fracture with smearing wear and microcracking found on several wire surfaces. Several of the fractured cable wires showed evidence of fatigue fractures. Some of the worn surface areas on the cable wires near the fracture showed the presence of cadmium. One of the cadmium plated pulley guard pins showed evidence of rubbing contact with the cable. Aircraft maintenance records were available for examination for only the previous six years. Those recent records showed numerous times when the pitch trim cables were inspected and cable tension was checked. The records did not show entries for any maintenance events when the pitch trim cable was rerouted or reinstalled.

Aircraft

Registration
N2349S
Reported as
Cessna 421 (C)
Category
Airplane
Serial number
421C1209
Airframe hours
2,570
Engines
Continental GTSIO520, 375 horsepower, reciprocatingContinental GTSIO520, 375 horsepower, reciprocating
Damage
Minor damage
Flight
Business · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 24, 2008 · 48 hours before
Departed
SAF · Santa Fe, NM
Destination
SGR · Sugar Land, TX
Flight plan
IFR
Airport
SGR · Sugar Land Regional Airport, runway 17, 8,000 × 100 ft, concrete

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
March 7, 2009
Seat
Left
Flight hours
2,300 total · 800 in this make and model · 2,300 as pilot in command · 50 in the last 90 days · 25 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 68 °F
Altimeter
29.95 inHg
Observed at
SGR

Docket · 13

The files NTSB released with the investigation on July 1, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 MB in all.