# NTSB LAX00IA272: Canadair CL-65, N97325, Monterey, CA, July 19, 2000 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: July 18, 2000, 18:45 local (Jul 19, 2000, 01:45 UTC) - Place: Monterey, CA - Coordinates: 36.600646, -121.880615 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.6006&lon=-121.8806&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 23 uninjured - Status: Completed, report February 20, 2002 - Report: Approved by Office Director - Parties: MESA Airlines, Inc., SAGEM/SFIM, INC., BOMBARDIER AEROSPACE, FEDERAL AVIATION ADMINISTRATION - NTSB case key (mKey): 53337 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX00IA272 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53337/pdf - Page: https://openairdocs.org/ntsb/LAX00IA272 ## Probable cause Fatigue failure of the bell gear in the horizontal stabilizer trim actuator system. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, climb - to cruise - flt control syst,elevator trim/tab control - fatigue (cause) - maintenance,service bulletin/letter - not complied with, company/operator management - flt control syst,elevator trim/tab control - separation (cause) - trim setting - restricted (cause) ## Analysis While climbing through FL200, the autopilot pitch trim master caution warning light and the autopilot pitch trim nose down master caution warning light illuminated, and the trim froze at four units of trim. The autopilot was disengaged in accordance with AFM procedures to resolve the problem. The flight crew had to maintain about 2 inches of forward pressure on the flight control column to maintain level flight. The first officer reported that the stabilizer trim could be manually adjusted up and down, but at no point would the trim go below four units of trim. The Horizontal Stabilizer Trim Actuator (HSTA) and Motor Control Unit (MCU) were replaced, and the airplane underwent a series of diagnostic checks and a functional flight test with no mechanical anomalies noted. During removal of the HSTA and MCU a component was heard moving inside the HSTA. Teardown of the HSTA revealed that the Channel 1 bell gear had separated from its four mounting tabs. It was also noted that two of the main spur gear bolts had backed out, and were loose and out of position in the HSTA. The other two main spur gear bolts were finger-tight, but remained in place. SB 8396-27-02 was developed as a result of repeated bell gear failures, about 66 in the past 6 years. The SB called for replacement of the existing bell gear with a new stronger bell gear. SL 8396-27-01 resulted from repeated main spur gear bolts backing out in service. The main spur gear bolts now require Loctite be used with the new bolts and new torque values be applied to the bolts. Review of the operator's FAA approved Operating Specifications disclosed that compliance with manufacturers SB's and SL's is not mandatory. ## Factual narrative On July 18, 2000, at 1845 hours Pacific daylight time, America West Express Flight 6088, a Bombardier Canadair Regional Jet (CRJ) CL-65, N97325, experienced an autopilot pitch trim master caution light followed by an autopilot pitch trim nose down master caution light, and a pitch trim malfunction. The flight crew elected to divert to the Fresno-Yosemite International Airport, Fresno, California. The airplane, operated by Mesa Airlines d.b.a. America West Express under 14 CFR Part 121, was not damaged. The 3 crew members and 20 passengers were not injured. The flight departed the Monterey Peninsula Airport, Monterey, California, at 1820, and was scheduled to terminate at the Phoenix Sky Harbor International Airport, Phoenix, Arizona. Visual meteorological conditions existed for the scheduled domestic passenger flight and an instrument flight rules (IFR) flight plan had been filed. The pilot reported that while climbing through flight level (FL) 200 the autopilot pitch trim master caution warning light and the autopilot pitch trim nose down master caution warning light illuminated. The captain stated that he disengaged the autopilot in accordance with the airplane flight manual procedures in an attempt to resolve the problem. The flight crew said they had to maintain approximately 2 inches of forward pressure on the flight control column to maintain level flight. The first officer stated that they were able to manually adjust the stabilizer trim up and down, but at no point would the trim go below four units of trim. Company maintenance personnel removed and replaced the horizontal stabilizer trim actuator (HSTA) and the associated motor control unit (MCU) per aircraft maintenance manuals. The system, with the replaced HSTA and MCU, underwent a series of diagnostic checks, as well as a functional flight test with no discrepancies noted. The airplane was returned to service. During removal of the components, technicians heard a component loose inside the trim actuator unit and surmised that an internal failure had occurred. The HSTA and MCU were sent to the manufacturer's facility in Grand Prairie, Texas, for further examination. Review of the Service Difficulty Report (SDR) database for the CRJ revealed that since 1995, there had been 66 HSTA events, where "loss of trim authority" was reported. PERSONNEL INFORMATION The captain held an airline transport pilot certificate with ratings for single engine and multiengine land airplanes. The captain held type ratings for the CL-65 and BE-1900. A first-class medical certificate was issued to the captain on March 9, 2000, with a limitation for corrective lenses - must wear lenses for distant - possess glasses for near vision. Company records indicated the captain completed recurrent training on May 31, 2000. He had 5,000 hours total time, with 125 hours in the CL-65. He had flown 200 hours in the last 90 days, 100 hours in the last 30 days, and 5 hours in the past 24 hours. The first officer (FO) held an airline transport pilot certificate with ratings for single engine land, multiengine land airplanes, and instructor ratings for single engine, multiengine, and instrument airplanes, as well as a ground instructor rating. The FO held a first-class medical certificate issued on May 22, 2000, with no limitations or waivers. Company records indicated the FO completed recurrent training on August 28, 1999. The FO had 3,754 hours total time, with 775 hours in the CL-65. He had flown 167 hours in the last 90 days, and 46 hours in the last 30 days. AIRCRAFT INFORMATION The CL-65 attains its pitch trim through movement of the horizontal stabilizer. The pitch trim can be operated in one of four modes; manual trim, autopilot trim, auto trim, and Mach trim. During the incident encountered by flight 6088, the airplane was operated in the autopilot mode. The horizontal stabilizer is positioned to the desired pitch setting via the HSTA output jackscrew. The HSTA is mounted on the vertical stabilizer and is attached to the leading edge of the horizontal stabilizer's forward spar. The HSTA contains two electric motor assemblies, one jackscrew and gearbox module, four position sensors, and two speed sensors. The two motors in the HSTA are controlled by the MCU. The MCU is an electric unit, which controls the speed and direction of the motors in the HSTA. The MCU is mounted forward of the HSTA on the vertical stabilizer. The MCU receives pitch commands from the horizontal stabilizer trim control unit (HSTCU). The HSTCU sends control and feedback signals though the active control channel. There are two feedback control channels, and the horizontal stabilizer control system is operated when either trim channel engage switch is activated (pushed in). When the flight crew selects both channels; Channel 1 operates as the primary system, and Channel 2 operates as the standby system. If Channel 1 is selected and Channel 2 is not selected, Channel 1 operates as the primary system, with no standby system available. If a Channel fault failure of the primary system is detected by the HSTCU, automatic changeover to the standby system (Channel 2) will occur. The flight crew will be notified via Electronic Information Control Advisory System (EICAS) that a STAB CH1 (CH2) INOP has occurred. The flight crew reported that during the incident both switches were engaged and there was not a fault failure indication on EICAS. According to Bombardier, this may have occurred due to a detached bell gear, which drives the Channel 1 position sensor (dual channel). The HSTCU monitors and compares the two channels of position sensor for both the primary and standby systems. Bombardier further reported that the HSTCU monitors the channel position sensor and compares it to the actual motor velocity for each system independently. Should the compared values exceed a given threshold within a specific time period, the HSTCU will automatically switch to the standby system and post an EICAS message indicating a fault. Bombardier reported that in the case of America West flight 6088, a difference in the two values was not sensed, and therefore, no channel changeover took place. It should be noted that Channel 1 and Channel 2 position sensors are not cross-compared in normal operation. The sensors are cross-compared during a ground Built In Test (BIT), conducted as part of the first flight of the day acceptance checks performed by maintenance personnel. COCKPIT VOICE RECORDER The CVR was shipped to the Safety Board Vehicle Recorder Laboratory in Washington D.C. Examination of the CVR revealed that the extracted information was overwritten and did not contain pertinent data to the investigation. FLIGHT DATA RECORDER The flight data recorder was shipped to the Safety Board Vehicle Recorder Laboratory in Washington D.C. The Safety Board specialist reported that at 24,954 seconds (elapsed time) at an airspeed of 315.8 knots, and an altitude of 16,417 feet, the autopilot was disengaged. The autopilot was reengaged at 25,082 seconds. While the autopilot was disengaged, the pilot trim command was activated several times. The copilot trim command was only active from 25,042 to 25,048 seconds. Approximately 1 second after the autopilot was reengaged, the autopilot trim command became active. According to the data, the autopilot trim command was active multiple times until it remained inactive after 25,115 seconds. The maximum pitch attitude experienced by the airplane was 3.1 degrees at 25,027 seconds. The lowest value for the stabilizer trim was 0.9 degrees at 24,975 seconds. (See attached report) TEST AND RESEARCH On August 22, 2000, a Safety Board investigator examined the HSTA (model number 8396-3, serial number 496), and the MCU (model number 7062-3, serial number 313), at SFIM Inc., in Grand Prairie, Texas. Also in attendance were the FAA, Bo ## Aircraft - Registration: [N97325](https://openairdocs.org/deregistered/N97325-2013-09-06), registration cancelled 2013-09-06, S/N 7325, built 1999 (OpenAirDocs) - Reported make and model: Canadair CL-65 - Registry model: [Bombardier CL-600-2B19](https://openairdocs.org/model/bombardier-cl-600-2b19) (registry code 1390008) (OpenAirDocs) - Registry engine: [GE CF34 series](https://openairdocs.org/engine/ge-cf34-series) (registry code 30015, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 7325 - Engines: GE CF-34-3B1 91400 lbs thrust turbo jet - Damage: No damage - Flight: Part 121 - Registered owner: Mesa Airlines - Airworthiness certificate: Standard, Transport - Departed: MRY, MONTEREY, CA - Destination: PHX, PHOENIX, AZ - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review May 31, 2000; seat: left; toxicology performed; flight hours: 5,000 total, 125 in this make and model, 1,500 as pilot in command, 200 in the last 90 days, 100 in the last 30 days, 5 in the last 24 hours - Co-pilot; age 25; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review August 21, 1999; seat: rear; toxicology performed; flight hours: 3,754 total, 775 in this make and model, 1,593 as pilot in command, 167 in the last 90 days, 46 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 12 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 93 °F, dew point 54 °F - Altimeter: 30.00 inHg - Observed at: FAT ## 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 20000718035389I](https://openairdocs.org/incident/20000718035389I), Jul 18, 2000: Cndair CL6002B19, Fresno, CA. (-23) After departing monterey airport (mry) on a revenue flight, a mesa aircraft, N97325, experienced during climbout an autopilot pitch trim warning light… ## Other investigations on N97325 (1) 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. - [NTSB LAX03IA199](https://openairdocs.org/ntsb/LAX03IA199), Jun 14, 2003: Bombardier CL-600-2B19 (N97325), Phoenix, AZ, incident, no damage. Probable cause: the simultaneous failure of both horizontal stabilizer trim channels on two separate occasions for undetermined reasons. 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.