# NTSB DCA08IA019: Embraer 145, N272SK, Jamaica, NY, December 17, 2007 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: December 17, 2007, 15:30 local (19:30 UTC) - Place: Jamaica, NY - Coordinates: 40.650119, -73.790252 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.6501&lon=-73.7903&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 53 uninjured - Status: Completed, report June 27, 2011 - Report: Approved by Office Director - NTSB office: Major Investigations Division - Parties: Federal Aviation Administration, AAI-100 - ADs cited in the narratives: [AD 2005-26-15](https://openairdocs.org/ad/2005-26-15), [AD 2008-03-03](https://openairdocs.org/ad/2008-03-03), [AD 2008-10-08](https://openairdocs.org/ad/2008-10-08), [AD 2002-01-01](https://openairdocs.org/ad/2002-01-01) (OpenAirDocs) - NTSB case key (mKey): 67264 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA08IA019 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67264/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67264 - Page: https://openairdocs.org/ntsb/DCA08IA019 ## Probable cause the failure of the elevator control rods due to exposure to high winds while the aircraft was parked overnight. Contributing to this incident was the failure of the existing airworthiness directive to adequately detect this discrepancy given the known deficiency with the mechanical gust lock design. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water encounter with weather, standing - engine(s) not operating - weather condition - gusts (cause) - flt control syst,elevator control cable/rod - failure,total (cause) - Airframe/component/system failure/malfunction, standing - engine(s) not operating ## Analysis Prior to the incident flight, the Embraer EMB-145 was parked overnight with its tail pointed into the wind. During this time period, the winds were reported to be very high (on the order of 30-40 kts). The aircraft was equipped with a mechanical gust lock system designed to immobilize the forward torque tube of the elevator control system when the system is engaged. During takeoff, the flightcrew performed an emergency high-speed aborted takeoff because the captain felt a control anomaly during rotation. An inspection of the elevator control system components revealed that both left and right elevator control rods had fractured completely, rendering the elevator system inoperable. The elevator control rods fractured when the elevator surfaces repeatedly moved off the rear elevator stops due to wind gusts. An airworthiness directive issued by the Federal Aviation Administration (AD 2005-26-15) was already in place at the time of this incident, which mandated replacement of the mechanical gust lock system on the Embraer 145 airplane with a more effective electromechanical gust lock system and required some repetitive inspections be performed until such time as the electromechanical system was installed. However, based on the findings in this incident, the FAA determined that the interim inspections mandated by AD 2005-26-15 were not adequate to detect the discrepancies exhibited in this event. As a result, the FAA subsequently issued a new airworthiness directive (AD 2008-03-03) to improve the interim inspections required until terminating action was taken by operators and also superceded AD 2005-26-15 with AD 2008-10-08 to shorten the compliance time for installation of the electromechanical gust lock system. ## Factual narrative HISTORY OF FLIGHT On December 17, 2007, at 3:30 pm, Eastern Standard Time, the flight crew of a Chautauqua Airlines Embraer EMB-145 performed an emergency high-speed aborted takeoff at John F. Kennedy International Airport (JFK) due to a serious elevator malfunction. The malfunction completely disabled the elevator system of the aircraft, either before or while the captain was rotating the aircraft for flight. The captain stated that during the rotation maneuver he felt an anomaly that caused him to abort the takeoff and stop the aircraft. Taxi back to the gate was uneventful and all 50 passengers and three flight deplaned normally. INJURIES TO PERSONS No injuries were reported. DAMAGE TO AIRPLANE Following the incident, an internal inspection of the elevator control system components revealed that both left and right elevator control rod assemblies (P/N 145-22141-405) had fractured completely through their circumferences rendering the elevator control of the aircraft inoperable. In addition, damage to control stops and horizontal stabilizer sheet metal was observed. A metallurgical examination of the control rods indicated that both failed in compression with some bending moment observed. OTHER DAMAGE None. AIRCRAFT INFORMATION A gust lock system is installed on the aircraft to lock the elevator to avoid damage to elevator components when the aircraft is subjected to strong gusts on the ground. The EMB 145 can be equipped with either a mechanical gust lock system or an electromechanical gust lock system. The incident aircraft was equipped with a mechanical gust lock system. The mechanical gust lock is designed to immobilize the forward torque tube, which is attached to the control column, when it is engaged. Some stretching of elevator cables will occur when the elevator surface is exposed to high loads. The electromechanical gust lock system uses a locking mechanism that acts directly on the elevator. The gust lock lever in the cockpit activates an electromechanical actuator that drives locking pins into the elevator panels. No stretching of the elevator cables can occur with the electromechanical gust lock system engaged. On September 27, 2002, Embraer issued Service Bulletin 145-27-0087 which called for repetitive inspections of components of the elevator system due to possible damage caused by strong wind gusts on the ground. On November 8, 2002, the Brazilian Servico Publico Federal Departamento de Aviacao Civil issued Airworthiness Directive 2002-01-01R3, with similar instructions to operators. This airworthiness directive also called for the replacement of the mechanical gust lock system with an electromechanical system within 10,000 flight hours or 60 calendar months. This AD only applied to Brazilian registered airplanes. On February 3, 2006, the FAA issued airworthiness directive 2005-26-15, that required US operators of EMB 145 aircraft to also perform similar repetitive inspections and also install electromechanical gust lock systems within 10,000 flight hours or 60 months. In response to the Chautauqua Airlines JFK incident, Embraer issued Alert Service Bulletin 145-27-A106R0 on December 23, 2007. This service bulletin advised operators to perform a detailed inspection of the elevator control system (including a check to insure that the elevators responded properly to control column inputs) within the next 20 flight hours, and it also advised the operators to repeat these inspections any time the aircraft was exposed to wind gusts over 35 knots while on the ground. This service bulletin only applied to aircraft that did not already have the electromechanical gust lock system installed. This service bulletin was revised on December 27, 2007. The revised service bulletin advised operators to perform the detailed inspection of the elevator control system, perform a daily check prior to the first flight of the day to insure proper elevator response to control column movements, and to repeat the detailed elevator control system check every 600 flight hours or if the aircraft is exposed to wind gusts over 50 knots while on the ground. These actions would be no longer required when an electromechanical gust lock system was installed on the aircraft. The service bulletin was revised again on December 28, 2007. This revision modified the daily elevator inspection to include a provision for performing a detailed check of the elevator skin around the hinge areas while the elevators were held in a trailing edge up position. The FAA incorporated the service bulletin’s recommended actions (with some minor revisions) in Airworthiness Directive AD 2008-03-03, effective February 14, 2008. And last, on May 23, the FAA issued AD 2008-10-08. This AD superseded AD 2005-26-15, called for repetitive inspections, and shortened the compliance time for the electromechanical gust lock retrofit to 90 days after May 23, 2008, or 500 flight hours, whichever occurs first. All EMB 145 aircraft now have electromechanical gust lock systems. METEOROLOGICAL INFORMATION Prior to the accident flight, the aircraft was parked overnight at JFK airport with its tail pointed into the wind. During the night the winds were reported to range between 30 and 40 knots. ## Aircraft - Registration: [N272SK](https://openairdocs.org/deregistered/N272SK-2018-09-19), registration cancelled 2018-09-19, S/N 145306, built 2000 (OpenAirDocs) - Reported make and model: EMBRAER 145 (LR) - Registry model: [Embraer EMB-145LR](https://openairdocs.org/model/embraer-emb-145lr) (registry code 3260212) (OpenAirDocs) - Registry engine: [Allison AE-3007A](https://openairdocs.org/engine/allison-ae-3007a) (registry code 03030, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 145306 - Damage: Minor damage - Flight: Part 121 - Operator: Chautauqua Airlines, doing business as Delta Connection - Registered owner: Wells Fargo Bank Northwest NA - Airworthiness certificate: Standard, Transport - Departed: JKF, New York, NY - Destination: BUF, Buffalo, NY - Flight plan: IFR - Airport: JFK, John F. Kennedy International, runway 31L, 14,572 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review July 6, 2007; seat: left; flight hours: 3,900 total, 1,950 in this make and model, 1,900 as pilot in command - Co-pilot; age 23; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review January 1, 2007; seat: right; flight hours: 1,100 total, 53 in this make and model, 857 as pilot in command, 53 in the last 90 days, 19 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 17 knots, gusting 27 - Visibility: 10 statute miles - Altimeter: 30.01 inHg - Observed at: BUF ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20071217831309I](https://openairdocs.org/incident/20071217831309I), Dec 17, 2007: Emb EMB145LR, New York, NY, Minor damage. (-23) This aircraft sustained high gust winds for a period of twenty hours prior to takeoff while parked with gust locks reported to be engaged while ron at… ## Docket (9 files) The files NTSB released with the investigation on February 25, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67264. 1.9 MB in all. - NTSB 6120.1 Form (item 1, .PDF, 358 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40328858&FileExtension=.PDF&FileName=NTSB%206120.1%20Form-Redacted.PDF - Materials Laboratory 15 - Factual Report 08-002 (item 2, .PDF, 591 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40288477&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2008-002-Master.PDF - Airworthiness Factual Report of Group Chairman (item 3, .PDF, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40292764&FileExtension=.PDF&FileName=Airworthiness%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Brazil AD 2002-01-01R3 (item 4, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316668&FileExtension=.PDF&FileName=Brazil%20AD%202002-01-01R3-Master.PDF - FAA AD 2005-26-15 (item 5, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347178&FileExtension=.PDF&FileName=FAA%20AD%202005-26-15-Master.PDF - Embraer SB 145-27-A106 Rev 1, 12/27/2007 (item 6, .PDF, 331 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316670&FileExtension=.PDF&FileName=Embraer%20SB%20145-27-A106%20Rev%201,%2012%2F27%2F2007-Master.PDF - FAA AD 2008-03-03 (item 7, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347172&FileExtension=.PDF&FileName=FAA%20AD%202008-03-03-Master.PDF - FAA AD 2008-10-08 (item 8, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347170&FileExtension=.PDF&FileName=FAA%20AD%202008-10-08-Master.PDF - Weather Information (item 9, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40316671&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.