CHI95IA045

NTSB incident investigation · Fokker F-28-4000 · Evansville, IN · November 23, 1994

Incident · No injuriesIncident investigationFinal report
Date
November 23, 1994, 12:34 local (18:34 UTC)
Place
Evansville, IN
Injuries
53 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N479AUFokker F-28-4000
Weather
Visual (VMC) · Day
Status
Completed · report May 16, 1995
Report
Approved by Office Director
FAA report
19941123048029I
Case key
9755

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

the failure of company maintenance personnel to adequately service (fill) the horizontal stabilizer drive actuator with hydraulic fluid.

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/malfunctionDescent - normal
Fluid,hydraulic - lack ofCause
Flt control syst,horiz stab drive - inoperative
Maintenance,service of aircraft/equipment - improperCompany maintenance personnelCause

Analysis

The flight crew reported that while descending from cruise in preparation for landing, they noticed that the horizontal stabilizer was not responding to trim inputs. The autopilot was disengaged, and both normal and alternate modes of stabilizer trim was attempted without success. The crew followed the jammed stabilizer approach checklist, and was able to effect pitch changes by both crew members exerting force on their control yokes. Postincident inspection of the stabilizer drive actuator discovered no hydraulic leaks. The actuator's gear box was drained, and found to contain approximately one ounce of murky, sludge-like hydraulic fluid. The gear box is required to be filled with seven ounces of hydraulic fluid. The actuators are shipped from the manufacturer essentially devoid of hydraulic fluid, with instructions that they must be filled prior to service.

Factual narrative

History of flight

On November 23, 1994, about 1234 central standard time, a Fokker F-28-4000 airplane, N479AU, operated by USAIR as Flight 689, experienced a sticking horizontal stabilizer while on approach to the Evansville Airport, Evansville, Indiana. The flight made an uneventful landing at Evansville. None of the 49 passengers or four crew members aboard were injured. The 14 CFR Part 121 flight originated in Pittsburgh, Pennsylvania, and operated in visual meteorological conditions.

The captain reported the first officer was flying the airplane. During the descent from cruise into Evansville, with the autopilot engaged, the first officer told the captain that the horizontal stabilizer was not responding to trim inputs. The autopilot was disengaged, and both master caution yellow lights on the hydraulic system flight control panel illuminated. Neither manual or alternate (electric) trim modes had any effect on the horizontal stabilizer. Abnormal checklists were reviewed and followed. Both the captain and first officer found it necessary to exert simultaneous forces on their control yokes in order to accomplish elevator movement and pitch changes for landing.

An after landing functional test of the horizontal trim mechanism discovered no obvious anomalies. Both the hydraulic and electric back-up trim systems were able to move the horizontal stabilizer in the absence of flight loads. At the request of the NTSB, an FAA Inspector assisted USAIR maintenance personnel at Evansville during the trouble shooting of the sticking stabilizer. During the inspection of the hydraulic horizontal stabilizer trim actuator, the gear box was drained of fluid. According to the FAA Inspector, the fluid drained was dark brown in color, and had the consistency of "murky sludge." Approximately one ounce of fluid was recovered from the system. The gear box capacity is approximately seven ounces. No hydraulic leaks were observed emanating from the actuator. Several flushes of the gear box was necessary before a clean fluid sample was obtained. The actuator was serviced with the appropriate quantity of fresh hydraulic fluid, and the airplane was ferried to Pittsburgh.

The airplane's hydraulic stabilizer trim actuator was removed from the airplane and shipped to the manufacturer, Menasco Aerospace, in Oakville, Canada, for inspection and disassembly.

Aircraft information

N479AU is a Fokker F-28-4000 airplane with approximately 18679 service hours on the airframe. The hydraulic horizontal stabilizer actuator, part number 11100-39AA, serial number MC375, was manufactured (and subsequently overhauled) by Menasco Aerospace. It was a replacement unit installed in the airplane on August 4, 1994. It had accumulated approximately 734 service hours since overhaul at the time of the incident.

Tests and research

On December 15, 1994, a functional test and disassembly of the actuator was performed at the Menasco facility at Oakville, Canada, under the direction of the NTSB and the Transportation Safety Board of Canada (TSB).

The actuator was placed on a test stand and pressurized to operating pressure. The actuator functioned within allowable parameters in both the primary and alternate modes. Following the functional test, the gear box was drained of hydraulic fluid. The fluid, which was the new hydraulic fluid placed in the actuator at Evansville, was now a deep, reddish-brown in color.

Disassembly of the gear box disclosed that the worm screw, bevel gear, clutch plates and bearings were visually corroded.

Additional information

The hydraulic horizontal stabilizer actuator is manufactured (or overhauled) and shipped without hydraulic fluid from the manufacturer. Servicing and fill instructions are shipped with the units. The incident operator also has a "job card" which details fill instructions and quantity of the gear box.

Aircraft

Registration
N479AU
Reported as
Fokker F-28-4000
Category
Airplane
Serial number
11228
Airframe hours
18,679
Engine
Rolls-Royce, turbo prop
Damage
No damage
Flight
Part 121
Registered owner
Usair
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 4, 1994 · 734 hours before
Departed
PIT · Pittsburgh, PA
Flight plan
IFR
Airport
EVV · Evansville

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
36
Certificates
Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
7,434 total · 256 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 13 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 21 °F
Altimeter
30.00 inHg
Observed at
EVV

FAA reports on this event · 1

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

Other investigations on N479AU · 1

Matched to the same aircraft by N-number and date.