CHI96LA011

NTSB accident investigation · McDonnell Douglas DC-9-31 · Cedar Rapids, IA · October 14, 1995

Accident · No injuriesLimited investigationFinal report
Date
October 13, 1995, 20:51 local (Oct 14, 1995, 01:51 UTC)
Place
Cedar Rapids, IA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N945AXMcDonnell Douglas DC-9-31
Weather
Visual (VMC) · Night/dark
Status
Completed · report November 11, 1996
Report
Approved by Office Director
FAA report
19951013047669A
Case key
10134

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

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Probable cause

inadequate installation of a thrust reverser, driver linkage arm pivot bolt and nut, which resulted in the nut and bolt becoming disconnected. A factor relating to the accident was: the manufacturer's unclear information regarding the type and number of washers to be installed on the pivot bolt assembly.

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
Miscellaneous,bolt/nut/fastener/clamp/spring - not safetiedCause
Maintenance,installation - inadequateCause
Information unclearManufacturerFactor
Thrust reverser - failureCause

Analysis

Shortly after an intermediate level-off at 13,000 feet, the crew heard a loud bang and felt the airplane shudder. They diverted to a nearby airport. During the landing roll, the engine's thrust reversers were deployed. The right engine thrust reverser deploy light illuminated. The left engine thrust reverser deploy light did not illuminate. Maintenance personnel found the left engine lower thrust reverser door had been struck repeatedly by the top reverser door. An investigation revealed broken and bent thrust reverser linkages. A pivot bolt, washers, castellated nut, and cotterpin associated with a driver linkage arm were missing. Two other company airplanes were found with a missing cotterpin from the pivot bolt. Examination of these assemblies revealed the bolt end did not protrude beyond the nut's outer edge. The result was that the cotterpin could not fit through the hole in the bolt. The manufacturer's parts manual and maintenance manual text indicated that one countersunk washer should have been below the bolt head and one flat washer under the nut. However, the corresponding illustration in the maintenance manual showed an additional washer (2 washers) under the nut.

Factual narrative

On October 13, 1995, at 2051 central daylight time (cdt), a McDonnell-Douglas DC-9-31, N945AX, operated as Flight 135 by Airborne Express, Incorporated, of Wilmington, Ohio, and crewed by an airline transport rated flight crew, was substantially damaged during cruise flight. The left engine's top thrust reverser door became partially detached and struck the engine's thrust reverser door repeatedly. Visual meteorological conditions existed at the time of the accident. The 14 CFR Part 121 cargo flight was operating on an IFR flight plan. The captain and first officer reported no injuries. The flight departed Des Moines, Iowa, at 2043 cdt.

The flight crew reported hearing a loud bang and felt the airplane shuddering shortly after leveling off from a climb. The flight crew declared an emergency after observing no problems on the airplane. During the landing the thrust reversers were deployed. The 2 yellow thrust reverser unlock lights illuminated and then the right engine's thrust reverser's blue light illuminated. The airplane decelerated and was able to taxi to the parking area.

An on-scene investigation was conducted by a Federal Aviation Administration (FAA) Principal Maintenance Inspector (PMI). The PMI reported the left engine's thrust reverser door had one of its driver linkages broken. Damage from the thrust reverser doors striking each other broke the left engine mount and pylon spar strap. The thrust reverser doors and exhaust nozzle were wrinkled. The exhaust nozzle end had about 25 percent of its end crushed upward. The outboard driver linkage arm (arm) was broken near its pivot point. The arm was bent upward 90 degrees about 24 inches forward of the break. The bolt and associated hardware were not found. One overcenter link was bent about 45 degrees at its midpoint.

Examination of the thrust reverser assembly revealed that a pivot bolt had worked its way out of the driver linkage arm assembly. Excerpts from the McDonnell-Douglas DC-9 maintenance manual are appended to this report. These excerpts illustrate the bolt's location and relationship to the thrust reverser assembly. Due to the missing bolt, washers, nut and the cotterpin the reason for the bolt separation could not be determined. Evidence of a broken bolt was not found.

The company examined other airplanes in its fleet. One airplane was found that had a missing cotterpin in a castellated nut on the same bolt as was missing on N945AX. A second airplane was found with a loose lower thrust reverser door. Examination of this airplane revealed the washers were overly thick. The overly thick washers would not allow the bolt threads to protrude beyond the end of the castellated nut. This situation would not allow the cotterpin to be installed because the hole in the bolt was not adequately exposed.

The manufacturer's illustrated parts catalog and maintenance manual show different combinations of washers being used on the pivot point bolt. The maintenance manual text calls for a countersunk washer to be installed under the bolt head and one plain washer under the nut. The manual's illustration of this area shows the washer under the bolt head and two washers under the nut. The illustrated parts catalog illustration of this area illustrates what the maintenance manual text called for.

Aircraft

Registration
N945AX
Reported as
McDonnell Douglas DC-9-31
Category
Airplane
Serial number
47551
Airframe hours
50,975
Engine
P&W JT8D-9A, 14,500 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Airborne Express Inc, doing business as Airborne Express
Registered owner
Abx Air Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · December 26, 1995 · 584 hours before
Departed
DSM · Des Moines, IA
Destination
ILN · Willmington, OH
Flight plan
IFR

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
40
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
10,775 total · 5,250 in this make and model · 9,000 as pilot in command · 140 in the last 90 days · 70 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
240° at 5 knots
Visibility
20 statute miles
Lowest ceiling
15,000 ft overcast
Temperature
54 °F, dew point 46 °F
Altimeter
29.00 inHg
Observed at
CID

FAA reports on this event · 1

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