# NTSB MIA02IA094: Boeing B737-448, Miami, FL, May 8, 2002 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: May 8, 2002, 16:00 local (20:00 UTC) - Place: Miami, FL - Location: 25.7743° N, 80.1937° W: Placed by OpenAirDocs: center of Miami, FL, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=25.7743&lon=-80.1937&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 160 uninjured - Status: Completed, report July 7, 2005 - Report: Approved by Office Director - Parties: Aer Lingus, Ryan International Airlines, Boeing Aircraft Company - NTSB case key (mKey): 54665 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA02IA094 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54665/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54665 - Page: https://openairdocs.org/ntsb/MIA02IA094 ## Probable cause Inadequate maintenance by company maintenance personnel and failure to comply with manufacturer recommended maintence procedures (SB 737-55A1070R1), which resulted in an inflight inseparation of a section of the airplane's right hand elevator control tab. A factor in the incident was the flight crew's continued operation of the airplane with a known deficiency. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, cruise - maintenance - inadequate, company maintenance personnel (cause) - maintenance,service bulletin/letter - not complied with, company maintenance personnel (cause) - operation with known deficiencies in equipment - continued, flightcrew ## Analysis The pilot stated that the aircraft had been performing normally during the flight to Jamaica, West Indies, except for with a slight vibration during the initial flight. During the return leg to Chicago, Illinois, the captain he said that the airplane started vibrating " ten times as bad", so he diverted to, and affected an otherwise uneventful landing, in Miami, Florida. He added that the vibration had continued throughout the flight, until "flaps five" was set during the approach, at which time the vibration stopped. After landing, examination of the airplane showed that about a 24-inch section of the right elevator trim tab had been missing from the aircraft. In addition to the examination of the elevator, the remaining parts adjacent to the separated tab to include two control rods with rod ends, one hinge fitting from the right hand elevator rear spar were removed and examined. The examination revealed the presence of fractures, wear marks to the control rod, as well as post fracture damage to the rods. In addition, the hinge fitting had also incurred fractures as well as severe post fracture rubbing to the lugs, and worn areas between the hinge lugs and the inboard and outboard surfaces of unfractured lugs. On the elevator, rubbing was noted in areas on the aft face and lower skin panels of the elevator rear spar. In addition, the rear spar reinforcing angle and elevator tab control rod inner fairing and external mast fitting had incurred also damage. Boeing reports documenting examinations of the remaining damaged portions of elevator and tab assembly have been included with this report. Pertinent maintenance records were not obtained from Ryan International Airlines or Aer Lingus PLC, and there was no evidence of compliance with Boeing's system maintenance program (SB 737-55A1070R1), pertinent to "freeplay" checks. ## Factual narrative HISTORY OF FLIGHT On May 8, 2002, about 1600, eastern daylight time, a Boeing 737-448, Irish registration EI-BXI, registered to Aer Lingus PLC, Dublin, Ireland, and operated by Ryan International Airlines, as a Title 14 CFR Part 121 international passenger flight for Apple Vacations, had a continuous severe vibration in the flight controls while en route to Chicago O'Hare International Airport, and diverted to Miami, Florida. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The airline transport-rated pilot, first officer, 4 flight attendants, and 154 passengers were not injured, and the aircraft received minor damage. The flight originated from Montego Bay, Jamaica, the same day, about 1535. The pilot stated that the aircraft had been performing normally, except for a slight vibration during the flight to Montego Bay, Jamaica, He said he was not concerned, and the landing had been normal. He further stated that after takeoff from Montego Bay, Jamaica, en route to Chicago, Illinois, the aircraft started vibrating " ten times as bad", and he made the decision to divert and land at Miami, Florida. He said the vibration had continued, until "flaps five" was added and then the vibration stopped. He then executed an uneventful landing with emergency vehicles standing by, taxied to the gate, and deplaned. The NTSB received notification of this incident from an official with Ryan International Airlines, after the airplane had been at Miami International Airport, Miami, Florida, and most of the repairs had been performed. The official stated that an approximate 24-inch section of the right elevator trim tab had been missing from the aircraft. Upon receiving notification the NTSB responded to Miami International Airport, and observed that repairs had been performed and that remaining affected parts wjich included the damaged right elevator tab, control rods, and tab hinge clevis fitting had been removed and shipped to Boeing Aircraft Company, Seattle, Washington, and the elevator had been shipped to Aero Fabricator, Dallas, Texas, for examination. In addition, flight data recorder data had already been downloaded, and sent to Boeing Aircraft Company, and the airplane was being readied to be returned to service. On October 22, 2002, the NTSB conducted a detailed examination of the parts pertaining to the damaged/missing right hand elevator trim tab at Boeing Materials Laboratory, Seattle, Washington. The pieces examined included the remaining portion of the right hand elevator tab, the inboard control rod on the right elevator tab, a portion of the outboard control rod on right elevator tab, the forward portion of the outboard control rod on right hand elevator tab, and the number one elevator tab hinge fitting on the right elevator tab. The portion of the right hand elevator tab showed signs that there was a fracture inboard of the inboard end of the No. 2 hinge fitting. The fracture ran approximately perpendicular to the span of the tab, along the cord of the tab. On the bottom of the tab, the skin was torn away from the tab outboard. A debonding was noted on the upper surface between the leading edge of the spar cap, and the spar, starting from the No. 2 hinge fitting and extending outboard. To crack appeared to follow the leading-edge connection to the tab spar. In addition, two areas of tab repair were noted, one was located between the No. 2 and the No. 3 hinge, and the other was located at the outboard end of the tab. After inspection the tab x-rayed to determine the presence of moisture in the tab and none was noted. In addition, the tab was examined using Thorough Transmission Ultrasound (TTU), to determine in areas of composite delamination or debonding. The inspection indicated that delamination/debonding had occurred in the area of the fracture continuing outboard for about 4 inches. The inspection also noted debonding along the bottom line between the spar cap, and the spar leading edge, extending outboard from the No. 2 hinge fitting. In addition, the elevator tab was subjected to a manual calls tactical ultrasound inspection. The inspection verified the area of debonding/delamination in the area, the fracture and a crack from the No. 2 hinge fitting. Examination of the inboard elevator control rod from the right hand elevator tab revealed that the rod was fractured at the aft fitting. The rod end jam nut was found at the end of the rod, and visual inspection of the rod revealed several rub marks along the rod. The forward end appeared undamaged. Examination of the fractured surface of the rod was accomplished using a scanning electron microscope, which revealed fatigue that had initiated at the six and 12 o'clock positions of the rod. The portion of the outboard control rod on the right hand elevator tab showed that this portion of the elevator tab was approximately 12 1/8 inches long, and it exhibited fractures at both ends of the rod. The fracture surfaces showed signs of damage due to repeated contact, such that no assessment of the fracture type was possible. Examination of the forward portion of the outboard control rod on the right hand elevator tab had about a 5 1/2-inch long piece that was fractured at the aft end, and the damage precluded any assessment as to the nature of the fracture. The No. 1 hinge fitting on the right hand elevator tab was examined, and it revealed an indentation between the two attachment lugs on the bottom edge of the fitting, slightly offset to the outboard side of the fitting. The outboard lug was fractured, while the inboard lug was not fractured, and when examined with a scanning electron microscope, indicated that a ductile failure had occurred. Observation of the lower fracture service indicated the presence of postfracture damage to the fracture surface, which precluded a determination as to the failure mode. The left elevator tab was also removed by Ryan airlines and shipped to Boeing for examination, and the examination the presence of two small 5/16 inch debond had occurred to the upper surface between the leading edge of the spar cap and the spar, starting at the inboard edge of the spar cap, outboard of the number two hinge fitting, and emanating in the chordwise direction. On May 20-22, 2002, an examination of the elevator was performed at Aero Fabricators, Dallas, Texas. Fasteners were removed to gain access to inner surfaces of the skin panels, spars, and ribs. In addition the tab control rod inner faring and elevator, rear spar reinforcing angle were disassembled from the elevator rear spar to enable further examination. The elevator skin panels, spars and ribs are made of graphite epoxy composite fabric and tape materials. The internal and external tab rod and mast fittings are made of fiberglass epoxy composite materials, and the hinge and actuator fittings are made of aluminum alloys. The examination included external surfaces and fittings. During examination, the external surfaces of upper and lower skin panels the half edge of the lower skin panel at the inboard tab hinge location was notched in the aft edge and there a was damage at the aft edge of the upper skin panel at the corresponding location. The inboard end between a closure rib on the upper and lower honeycomb were soft to external pressure. 5the aft edge of the lower skin outer plies were delaminated in several places between stations. There were indications of a possible repair or delamination in the outboard bay of the upper panel at locations aft of the front spar. A rubbing abrasion was noted in areas of the aft face of the upper and lower skin panels and elevator rear spar. The upper and lower skin panels and internal surfaces had minimal damage in this damage was at stations in between closure ribs, areas of the inner skin and core. There were no signs of distress in the fasteners attaching the panels to the front and rear ## Aircraft - Registration: EI-BXI (not matched to a registry record) - Reported make and model: Boeing B737-448 - Category: Airplane - Serial number: 25052 - Airframe hours: 26400 - Engines: CFM International CFM563B-2 22500 lbs thrust turbo fan; CFE Company CFM563B-2 22500 lbs thrust turbo fan - Damage: Minor damage - Flight: Part 121 - Operator: Ryan Air Inc, doing business as Ryan International Airlines - Registered owner: Aer Lingus - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, December 14, 2001, 787 hours before - Departed: MKJS, Montego Bay - Destination: ORD, Chicago - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 29; injuries: none; airline transport, commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review May 3, 2002; seat: left; flight hours: 3,916 total, 660 in this make and model, 2,900 as pilot in command, 199 in the last 90 days, 70 in the last 30 days, 6 in the last 24 hours - Co-pilot; age 32; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; medical: class 1, valid medical--no waivers/lim.; last flight review December 3, 2001; seat: right; flight hours: 2,860 total, 605 in this make and model, 182 as pilot in command, 146 in the last 90 days, 42 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 12 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 66 °F - Altimeter: 30.05 inHg - Observed at: MIA ## Docket (11 files) The files NTSB released with the investigation on May 10, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54665. 8.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 638 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438399&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Other Pertinent Forms and Reports: Service Bulletin 737-55A1070R1 (item 2, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230524&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Service%20Bulletin%20737-55A1070R1-Master.PDF - FDR Data (item 3, .PDF, 314 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438400&FileExtension=.PDF&FileName=FDR%20Data-Redacted.PDF - Miami Dade Aviation Department (item 4, .PDF, 360 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438401&FileExtension=.PDF&FileName=Miami%20Dade%20Aviation%20Department-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438402&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Witness Statements and Records of Conversation (item 6, .PDF, 436 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438403&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Records%20of%20Conversation-Redacted.PDF - Ryan Line Service Report (item 7, .PDF, 557 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438404&FileExtension=.PDF&FileName=Ryan%20Line%20Service%20Report-Redacted.PDF - Miscellaneous: Excerpt of Applicable System Maintenance Program (item 8, .PDF, 722 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230536&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpt%20of%20Applicable%20System%20Maintenance%20Program-Master.PDF - Miscellaneous: Airworthiness Directive 2002-01-01 (item 9, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40230537&FileExtension=.PDF&FileName=Miscellaneous%3A%20Airworthiness%20Directive%202002-01-01-Master.PDF - Boeing Materials Technology Elevator Tab Reports (item 10, .PDF, 988 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438405&FileExtension=.PDF&FileName=Boeing%20Materials%20Technology%20Elevator%20Tab%20Reports-Redacted.PDF - Boeing Report On Graphite Elevator (item 11, .PDF, 327 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438406&FileExtension=.PDF&FileName=Boeing%20Report%20On%20Graphite%20Elevator-Redacted.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.