CHI97IA074

NTSB incident investigation · de Havilland DHC-8-311 · Rapid City, SD · February 24, 1997

Incident · No injuriesIncident investigationFinal report
Date
February 24, 1997, 06:36 local (13:36 UTC)
Place
Rapid City, SD
Injuries
45 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N430AWde Havilland DHC-8-311
Weather
Visual (VMC) · Day
Status
Completed · report January 30, 1998
Report
Approved by Office Director
FAA report
19970224009429I
Case key
10458

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

a missing 'C' clip, which resulted in the master link coming apart, allowing the electric elevator trim chain and cable to become entangled in the elevator trim cables.

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
Miscellaneous,bolt/nut/fastener/clamp/spring - missingCause
Flt control syst,elevator trim/tab control - disconnectedCause

Analysis

The captain said that he engaged the airplane's autopilot while passing through 10,000 feet mean sea level (msl). About 10 minutes later, the crew noticed illumination of a 'PITCH MISTRIM, TRIM NOSE DOWN' annunciator light. The captain attempted to trim the airplane using the manual elevator trim, but it would allow only limited movement. The crew declared an emergency, returned to Rapid City, and landed the airplane without further incident. A postincident inspection of the aft fuselage compartment revealed that one of the two master links (which held the chain and cable assembly to the electric elevator trim system) had come apart. The chain had subsequently entangled itself in the elevator trim cables. Further examination revealed that the 'C' clip (which snaps to the two posts of the master link base plate and held the master link cover plate in place) was missing.

Factual narrative

History of flight

On February 24, 1997, at 0636 mountain standard time (mst), a Dehavilland DHC-8-311, N430AW, operated as United Express Flight 7451, by an airline transport pilot, experienced an elevator control malfunction during initial climb to cruise altitude. The pilot declared an emergency and landed the airplane at Rapid City Regional Airport, South Dakota, without further incident. Visual meteorological conditions prevailed at the time of the incident. The flight was being conducted as domestic commuter air carrier service under 14 CFR Part 121. An IFR flight plan was on file. There were no reported injuries by the 2 flight crew members, 1 flight attendant or 42 passengers on board the airplane. The flight originated at Rapid City, South Dakota, at 0615 mst, and was en route to Denver, Colorado.

In his written statement, the captain said that he engaged the airplane's autopilot while passing through 10,000 feet mean sea level (msl). Approximately 10 minutes later, the crew noticed illumination of a "PITCH MISTRIM, TRIM NOSE DOWN" annunciator light. The captain attempted to trim the airplane using the manual elevator trim, but it was jammed and would allow only limited movement. The captain then disconnected the autopilot to see if it would free up the trim. This action was unsuccessful. The crew determined that they had a jammed elevator and referred to the Quick Reference Handbook checklist addressing elevator trim malfunctions. The checklist required the crew to use the standby elevator trim system. The captain said that he attempted to do this several times, but it seemed ineffective. The crew declared an emergency and returned to Rapid City, South Dakota. The crew landed the airplane without further incident.

Aircraft information

The airplane, a Dehavilland DHC-8-311, serial number 279, was manufactured in 1991. The airplane had undergone a 50-hour line check at Grand Junction, Colorado, on February 16, 1997. At the time of the incident, the airplane had 13,374 total airframe hours. The airplane had flown 20 hours since the last line check.

A post-incident inspection was conducted by the Federal Aviation Administration and Mesa Airlines at Rapid City, South Dakota, on February 24, 1997. An examination of the aft fuselage compartment revealed that one of the two master links which hold together the chain and cable assembly to the electric elevator trim system had come apart. The chain had subsequently entangled itself in the elevator trim cables. No other elevator trim system anomalies were found. The electric elevator trim servo motor, chain pieces and cable were retained for further examination.

Tests and research

The electric elevator trim servo motor, chain, cable, and pieces of the master link were examined by the investigator-in-charge at Grand Junction, Colorado, on March 4, 1997. It was revealed that the "C" clip which snaps to the two posts of the master link base plate, and holds the master link cover plate in place was missing. Examination of the electric elevator trim servo motor revealed no anomalies.

The NTSB investigator-in-charge (IIC) examined the electric elevator trim system chain and cable assembly in another Dehavilland DHC-8 airplane, at Grand Junction, Colorado. On that airplane, the IIC slid the "C" clip off of the cover plate with his finger nail.

An engineer for the National Transportation Safety Board examined the electric elevator trim system chain and cable assemblies in three production DHC-8 airplanes, in Toronto, Canada, on June 20, 1997. It was found that the "C" clips on the master links of these airplanes could not be removed without the use of specialized tools.

Additional information

Parties to the investigation were the Federal Aviation Administration, the Transportation Safety Board of Canada, Bombardier, Incorporated, and Mesa Airlines.

The airplane was released and put back into service on February 26, 1997. The flight data recorder, electric elevator trim servo motor, chain, and cable parts were released and returned to Mesa Airlines.

Aircraft

Registration
N430AW
Reported as
de Havilland DHC-8-311
Category
Airplane
Serial number
279
Airframe hours
13,374
Engine
P&W PW123, 2,380 horsepower, turbo prop
Damage
No damage
Flight
Part 121
Operator
Mesa Airlines, doing business as United Express
Registered owner
Wilmington Trust Co
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · February 16, 1997 · 20 hours before
Departed
RAP
Destination
DEN · Denver, CO
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
32
Certificates
Flight instructor, 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
8,500 total · 2,000 in this make and model · 6,500 as pilot in command · 200 in the last 90 days · 70 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
19 °F, dew point 14 °F
Altimeter
30.00 inHg
Observed at
RAP, 1 nm away

FAA reports on this event · 1

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