# NTSB ERA12IA097: Cessna 560XL, N576CS, Ocoee, FL, December 2, 2011

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: December 2, 2011, 12:28 local (17:28 UTC)
- Place: Ocoee, FL
- Coordinates: 28.639999, -81.650001 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=28.6400&lon=-81.6500&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-climb to cruise: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report April 20, 2012
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 82454
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12IA097
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82454/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82454
- Page: https://openairdocs.org/ntsb/ERA12IA097

## Probable cause

Water contamination in the pitch trim actuators.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Flight control system: elevator tab control system](https://openairdocs.org/ntsb-findings/01022731): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022731/cases.md)
- [Fluids: grease](https://openairdocs.org/ntsb-findings/01071035): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01071035/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-climb to cruise: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md)

## Analysis

The flight crew reported that a "pitch trim miscompare" message illuminated in the cockpit just before they were to level off at 41,000 feet mean sea level (msl). After accomplishing the checklist items and disconnecting the autopilot, the flight crew had to exert considerable forward yoke pressure to maintain level flight. The flight crew found the manual pitch trim control wheel to be "frozen" in the forward position and were unable to move it. They declared an emergency and initiated a descent. Upon reaching 8,000 feet msl, the trim wheel released and the system returned to normal. The airplane landed uneventfully. Maintenance personnel inspected the left and right pitch trim actuators and found that the grease was contaminated with water. The actuators had been inspected and lubricated within the required 1,200-hour interval.

## Factual narrative

On December 2, 2011, about 1228 eastern daylight time, a Cessna 560XL, N576CS, landed at Orlando International Airport (MCO), Orlando, Florida, following an in-flight pitch trim malfunction that occurred near Ocoee, Florida. The airline transport-rated pilot and co-pilot were not injured. The airplane was not damaged. The airplane was registered to CitationShares Sales, Inc. and operated by CitationShares Management LLC under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand air taxi flight. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated at Naples Municipal Airport, Naples, Florida, at 1150 and was destined for Washington Dulles International Airport, Dulles, Virginia. The flight crew reported the following. While approaching their level off altitude of flight level 410, a "Pitch Trim Miscompare" message illuminated in the cockpit. After accomplishing the checklist items and disconnecting the autopilot, considerable forward yoke pressure was required to maintain level flight. The crewmembers found the manual pitch trim control wheel to be "frozen" in the forward position and were unable to move it. The crew declared an emergency and diverted to MCO. During the descent for landing, upon reaching 8,000 feet mean sea level, the trim wheel released and the system returned to normal. The crew cancelled the emergency and landed at MCO uneventfully. After the aircraft was secured, maintenance personnel inspected the flight control system. The grease in the left and right elevator trim actuators was found to be contaminated with water. The trim actuators were replaced and the airplane was returned to service. According to the operator, the elevator trim actuators were last inspected and lubricated 562 hours prior to the incident. The inspection requirement for the actuators was at 2,400 hours initially and at 1,200-hour intervals thereafter.

## Aircraft

- Registration: N576CS (not matched to a registry record)
- Reported make and model: CESSNA 560XL
- Category: Airplane
- Serial number: 560-5794
- Airframe hours: 2623
- Engines: P&W CANADA PW545B 4119 lbs thrust turbo fan; P&W CANADA PW545B 4119 lbs thrust turbo fan
- Damage: No damage
- Flight: Part 135
- Operator: CitationShares Management LLC
- Registered owner: Citationshares Sales Inc
- Airworthiness certificate: Standard, Transport
- Last inspection: AAIP, August 13, 2011
- Departed: APF, Naples, FL
- Destination: IAD, Dulles, VA
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 62; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review October 14, 2011; seat: left; flight hours: 10,623 total, 678 in this make and model, 8,568 as pilot in command, 83 in the last 90 days, 17 in the last 30 days
- Co-pilot; age 62; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review October 19, 2011; seat: right; flight hours: 5,108 total, 1,093 in this make and model, 3,617 as pilot in command, 118 in the last 90 days, 35 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 50° at 10 knots, gusting 17
- Visibility: 10 statute miles
- Lowest ceiling: 5,500 ft broken
- Temperature: 73 °F, dew point 54 °F
- Altimeter: 30.30 inHg
- Observed at: MCO, 20 nm away

## Docket (2 files)

The files NTSB released with the investigation on March 14, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82454. 725 KB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 661 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364232&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- FAA Service Difficulty Report (item 2, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364233&FileExtension=.PDF&FileName=FAA%20Service%20Difficulty%20Report-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.

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