ERA11IA184

NTSB incident investigation · Cessna 560XL · Haynesville, VA · March 10, 2011

Incident · No injuriesIncident investigationFinal report
Date
March 10, 2011, 08:56 local (13:56 UTC)
Place
Haynesville, VA
Injuries
3 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N588QSCessna 560XL
Defining event
Enroute-climb to cruise: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report February 6, 2012
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Cessna Aircraft Company, FAA/FSDO, Netjets Aviation, Inc.
Case key
78529

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 manufacturer's inadequate design fix for previously known tailcone stinger water ingestion and retention.

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.

Flight control system: rudder control systemAircraft › Aircraft systems · InoperativeCessna 560XL: 3 casesAll aircraft: 93 casesProbable cause
Ceiling/visibility/precip: rainEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentCessna 560XL: 1 caseAll aircraft: 56 casesProbable cause
Design: equipment designOrganizational issues › Development · ManufacturerCessna 560XL: 1 caseAll aircraft: 35 casesProbable cause

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

After a flight earlier in the day, the airplane sat on a ramp in moderate rain for about 1 1/2 hours before departing. During the departure, the airplane encountered light to moderate rain, and, while climbing through about 28,000 feet, the crew found that the rudder was frozen in the neutral position. The crew continued the climb to 40,000 feet and, based on discussions with the company, diverted to an en route airport. Descending through 13,000 feet, normal rudder operation returned, and the subsequent approach and landing were uneventful. After the crew disembarked, they noticed water dripping from the belly of the airplane, and subsequently found ice in the bottom of the tailcone stinger, through which the rudder and elevator control cables ran. About 4 months prior to this incident, two other airplanes had similar incidents that resulted in the manufacturer issuing an alert service letter (ASL). The ASL stated, in part, that the tailcone stinger may not drain water, which could allow ice to form around the rudder cables and pulleys. The ASL required inspection of the two existing drain holes to ensure they were the right size, sealing an existing drain hole, and adding another drain hole in the aft canted bulkhead. This incident airplane had incorporated the ASL prior to the incident. Subsequent flight testing by the manufacturer revealed that, with the tailcone stinger drain hole sealed per the ASL, air could still enter the tailcone through seams at the bottom of the stinger with enough force to splatter water onto the rudder cables and pulleys, which could then freeze. Testing also revealed that air emanating from the new hole in the aft canted bulkhead also resulted in water splattering onto the rudder cables and pulleys and that, after large quantities of water were introduced, water would only drain forward through the new hole only if large quantities were introduced. As a result, the manufacturer issued a service bulletin, in addition to the ASL (which must be completed) that requires the installation of a seal and another drain.

Factual narrative

On March 10, 2011, at 0856 eastern standard time, while climbing through approximately 28,000 feet near Haynesville, Maryland, a Cessna 560XL, N588QS, operated by NetJets Aviation, Inc., experienced stuck rudder controls. There was no damage to the airplane, and the two pilots and one passenger were not injured. Visual meteorological conditions prevailed. The airplane was operating on an instrument flight rules flight plan from Baltimore/Washington International Thurgood Marshall Airport (BWI), Baltimore, Maryland, to Lynden Pindling International Airport (MYNN), Nassau, The Bahamas. The personal flight was being operated under the provisions of 14 Code of Federal Regulations Part 91, Subpart K. According to the company's director of aviation safety, the incident flight was the second of the day for the airplane, with the first being a positioning flight from Malcolm McKinnon Airport (SSI), Brunswick, Georgia to BWI. The airplane departed SSI at 0520, flew at an en route cruise altitude of 37,000 feet and landed at BWI at 0702. Other than encountering light to moderate rain upon arrival, the flight was uneventful with no anomalies noted with the airplane. While the airplane was on the ground at BWI, there was occasionally moderate rain at a temperature of 9 degrees C. The airplane departed the ramp at 0831 for MYNN with the copilot at the controls, flying from the right seat. During the departure, the airplane again encountered light to moderate rain. As the airplane was climbing through approximately 28,000 feet, the copilot noted that the yaw damper was "not functioning properly." The copilot disconnected the autopilot and yaw damper, and as he exercised the flight controls, he found that the rudder was "frozen" in the neutral position. The crew continued the climb to 40,000 feet, and based on the captain's discussions with the company, then diverted to Myrtle Beach International Airport (MYR), Myrtle Beach, South Carolina. Descending through 13,000 feet, normal rudder operation returned, and the subsequent approach and landing were uneventful. After the crew disembarked, they noticed water dripping from the belly of the airplane. Panel 321ABC was subsequently removed, and water and ice were found in the bottom of the compartment, through which, also ran the rudder and elevator control cables. On December 1, 2010, another Cessna 560XL, N607QS, had landed without damage after the crew experienced rudder binding during the landing flare. According to the preliminary report for NTSB incident investigation CEN11IA087, a postflight examination of the inside of the tailcone stinger revealed an accumulation of ice that interfered with the rudder control cables and pulleys. It also noted that the airplane had previously been parked in light rain and subsequently departed in light to moderate rain before breaking out of clouds at 14,000 feet en route to a final altitude of 40,000 feet. On December 13, 2010, another Cessna 560XL, N498AB, had landedwithout damage after the crew experienced rudder binding in flight. According to the preliminary report for NTSB incident investigation CEN11IA111, a postflight examination of the inside of the tailcone stinger revealed an accumulation of ice around the rudder control cables and pulleys. The report did not provide atmospheric conditions. On January 21, 2011, Cessna issued Alert Service Letter [ASL]560XL-53-08, "Fuselage – Aft Canted Bulkhead Drain Installation," which stated, in part, that the tailcone stinger "may not drain water, and in turn, could allow ice to form around the rudder bias cable pulleys." The ASL provided instructions to inspect two 0.201 inch diameter drain holes in frames immediately forward and aft of access panel 321ABC and drill them if necessary, to seal an existing 0.201 inch diameter drain hole in the tailcone stinger, and to add a 0.75 inch diameter drain hole in the aft canted bulkhead. According to the NetJets director of aviation safety, on March 7, 2011, another Cessna 560XL, N691QS, had landed in Canada without damage after the crew experienced rudder binding in flight after having parked in and taken off during rain. Ice was again found in the tailcone stinger that bound the rudder controls, but the ASL had not yet been incorporated into the airplane. On March 15, 2011, the NTSB issued Safety Recommendation A-11-16, which recommended that the Federal Aviation Administration (FAA) issue an airworthiness directive to mandate that all Cessna 560XL operators comply with the ASL. According to maintenance records, the ASL requirements were completed on N588QS on January 31, 2011. Subsequent to the rudder binding of N588QS, Cessna, with FAA oversight, conducted further testing. According to an FAA response to the NTSB Safety Recommendation, flight testing occurred on another Cessna 560XL that had also incorporated the requirements of the ASL, and was modified with onboard video cameras, tufts to indicate ventilation, light sources, and tubing for the introduction of water to the stinger area during flight. Flight tests revealed that even though the previously existing tailcone stinger drain hole had been sealed per the ASL, air was still coming through seams at the bottom of the stinger with enough force to splatter water onto the rudder cables and pulleys. Testing also revealed that air emanating from the new hole in the aft canted bulkhead also resulted in splattered water onto the rudder cables and pulleys, and that after large quantities of water were introduced, water would only drain forward through the hole. As a result of the testing, Cessna issued Service Bulletin [SB]560XL-53-16, "Fuselage-Stinger Drain Installation" on October 4, 2011. The stated purpose of the SB was to reduce the amount of water entering the tailcone stinger and to improve drainage by installing a seal and an additional drain. The SB also noted that the ASL was to be completed prior to, or in conjunction with the SB. The Cessna 560XLreceived FAA certification in April 1998; however, except for the events listed in this report, no previous documentation of rudder control binding due to internal tailcone stinger icing could be found in either the FAA Service Difficulty Report database or the NTSB accident database

Aircraft

Registration
N588QS
Reported as
Cessna 560XL
Category
Airplane
Serial number
560-5721
Airframe hours
3,141
Engines
P&W Canada PW545B, 4,119 lbs thrust, turbo fanP&W Canada PW545B, 4,119 lbs thrust, turbo fan
Damage
No damage
Flight
Personal · Part 91 subpart K
Operator
Netjets Aviation, Inc.
Registered owner
Netjets Sales, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · January 25, 2011 · 153 hours before
Departed
BWI · Baltimore, MD
Destination
MYNN · Nassau
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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
62
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
January 28, 2011
Seat
Left
Flight hours
10,000 total · 3,473 in this make and model · 104 in the last 90 days · 38 in the last 30 days · 3 in the last 24 hours
Role
Co-pilot
Age
35
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
November 5, 2010
Seat
Right
Flight hours
7,412 total · 1,744 in this make and model · 147 in the last 90 days · 63 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 6 knots
Visibility
4 statute miles
Lowest ceiling
1,300 ft broken
Temperature
52 °F, dew point 48 °F
Altimeter
30.01 inHg
Observed at
NUI, 15 nm away

Docket · 9

The files NTSB released with the investigation on December 14, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.8 MB in all.