# NTSB LAX95IA027: Fairchild SA-227AC, N191AF, Oakland, CA, October 29, 1994 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: October 29, 1994, 07:45 local (14:45 UTC) - Place: Oakland, CA - Location: 37.8044° N, 122.2708° W: Placed by OpenAirDocs: center of Oakland, CA, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=37.8044&lon=-122.2708&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report October 13, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28950 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX95IA027 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28950/pdf - Page: https://openairdocs.org/ntsb/LAX95IA027 ## Probable cause the company maintenance personnel's improper installation of the aileron cable. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, takeoff - initial climb - flt control syst,aileron control cable/rod - separation - flt control syst,aileron control cable/rod - fatigue - maintenance,installation - improper, company maintenance personnel (cause) ## Analysis THE PILOT EXPERIENCED A LOSS OF AILERON CONTROL SHORTLY AFTER TAKEOFF. THE PILOT RETURNED TO THE AIRPORT AND LANDED WITHOUT FURTHER INCIDENT. EXAMINATION OF THE AIRPLANE REVEALED THE CABLE BROKE NEAR ITS 90-DEGREE ATTACH PULLEYS. THE SAFETY BOARD MATERIALS LABORATORY CONDUCTED A METALLURGICAL EXAMINATION OF THE CABLE'S FRACTURED SURFACES. THE EXAMINATION REVEALED THE CABLE SEPARATED DUE TO HIGH-STRESS/LOW-CYCLE FATIGUE CRACKING. MOST WIRE ENDS IN THE VICINITY OF THE SEPARATION WERE SEVERELY BENT. SUCH DAMAGE WOULD MOST LIKELY BE PRODUCED BY A KINK IN THE CABLE. A CABLE KINK CREATES VERY HIGH TENSILE STRESSES ALONG THE OUTSIDE OF THE KINK AND WOULD GENERATE PREMATURE HIGH-STRESS FATIGUE CRACKING. THE 15 HOURS OF TIME SINCE INSTALLATION IS CONSISTENT WITH SOME SORT OF SEVERE CONDITION SUCH AS A KINK. THE MECHANIC MOST LIKELY INSTALLED THE CABLE WITH ONE END TWISTED COMPARED WITH THE OTHER END. ## Factual narrative On October 29, 1994, at 0745 hours Pacific daylight time, a Fairchild SA-227AC, N191AF, experienced a loss of aileron control shortly after departing runway 27L at Oakland International Airport, Oakland, California. The airplane was operating as Ameriflight (AMF) flight 1894, a nonscheduled cargo flight, under Title 14 CFR Part 135. The pilot had filed and began a company visual flight rules flight plan to Reno, Nevada. The airplane, operated by Ameriflight, Burbank, California, did not sustain any damage. The certificated airline transport pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed. The pilot returned to Oakland International Airport without further incident. Ameriflight maintenance personnel told National Transportation Safety Board investigators that the right aileron cable broke at its 90-degree pulley attach points. They also said that the cable had accrued 15 hours since it was installed. The cable replacement was required by a Federal Aviation Administration (FAA) airworthiness directive. Safety Board investigators sent the broken aileron cable, with an exemplar from the cable stock used by Ameriflight maintenance personnel, to the Safety Board Metallurgical Laboratory. The Safety Board metallurgist reported that during examination of the cable, he found substantial bending deformation in a uniform direction in most wires next to the separation. He also said that a magnified optical examination revealed no evidence of wear or corrosion near the separation or anywhere else on the cable. The metallurgist conducted a scanning electron microscope (SEM) examination of the broken cable. The examination showed that some separated ends displayed necking down or fractures in a 45-degree plane. This condition is typical of overstress separations. Additionally, the metallurgist said, in part, that he . . .found many of the cable ends contained relatively flat fracture areas on a transverse plane, which could result from fatigue cracking. These flat surface areas usually terminated at a longitudinal fracture area . . . . A detailed SEM examination of the flat fracture area on these cable ends revealed ". . .a somewhat roughened and micro fissured fracture morphology, but no classical fatigue striations were found. Ductile dimples, a characteristic of overstress separations, were found in portions of the wire separations outside of the flat fracture areas. . . ." The cable material quality and strength conformed to the manufacturer's specifications. The operator reported that the mechanics and inspectors who changed the cable said the new cable could not have been kinked due to the procedure used. The mechanics said that the new cable end was attached to the old cable after cutting off the swaged-on fitting at the underfloor bellcrank end. The new cable is then pulled in by pulling out the old cable from the control yoke end. If the new cable were kinked, it would not pass through the keepers around the pulleys in the control circuit and other confined areas in the cable run. The operator did not say that during the final connection of the cable the attached ends could be twisted. The airplane manufacturer's representative told Safety Board investigators in a telephone interview conducted on December 7, 1994, that a kink could be induced during the installation process. He said that the maintenance procedures required the mechanic to swage the ends of the cable and conduct a pull-test greater than 1,200 pounds. He also said that if the cable was kinked, it would fail during the pull-test preinstallation. ## Aircraft - Registration: [N191AF](https://openairdocs.org/deregistered/N191AF-2023-12-19), registration cancelled 2023-12-19, S/N AC-491, built 1981 (OpenAirDocs) - Reported make and model: FAIRCHILD SA-227AC - Registry model: [Swearingen SA227-AC](https://openairdocs.org/model/swearingen-sa227-ac) (registry code 8780603) (OpenAirDocs) - Registry engine: [AiResearch TPE331 series](https://openairdocs.org/engine/airesearch-tpe331-series) (registry code 01514, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: AC-491 - Airframe hours: 22395 - Engines: GARRETT TPE-331-11U 1000 horsepower turbo prop - Damage: No damage - Flight: Part 135 - Registered owner: Ameriflight, Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 12, 1994, 15 hours before - Departed: OAK - Destination: RNO, RENO, NV - Flight plan: VFR - Airport: OAK, Oakland International ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 5,200 total ## Weather - Conditions: Visual (VMC), Day - Visibility: 6 statute miles - Lowest ceiling: none ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19941029047799A](https://openairdocs.org/incident/19941029047799A), Oct 29, 1994: Swrngn SA227AC, Oakland, CA. Lost aileron control on climbout. Returned. Aileron cable broke at 90 degree pulley attachment. 15 hrs installed. 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.