MIA96IA179

NTSB incident investigation · Short Brothers SD3-60-200 · San Juan, PR · July 9, 1996

Incident · No injuriesIncident investigationFinal report
Date
July 9, 1996, 16:05 local (20:05 UTC)
Place
San Juan, PR
Injuries
12 uninjured
Damage
No damage
Phase of flight
Initial climb
Aircraft
N384MQShort Brothers SD3-60-200
Weather
Visual (VMC) · Day
Status
Completed · report April 24, 1998
Report
Approved by Office Director
FAA report
19960709045599I
Case key
37923

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

Fatigue failure of a segment of the elevator trim control cable. Contributing to the accident was the failure of the airplane manufacturer to require a replacement interval of the cables.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionTakeoff - initial climb
Flt control syst,elevator trim/tab control - fatigueCause
Maintenance,replacement - not identifiedManufacturerFactor

Analysis

The first officer was flying the airplane and after takeoff and flap retraction while manually retrimming the airplane, the elevator control system failed. The flight returned and landed uneventfully. Examination of the elevator control system revealed a failed cable segment between fuselage station 74 in the cockpit to fuselage station 310 in the cabin. The cable failed about midpoint between a 45-degree change in direction. Metallurgical examination of the failed cable revealed it failed due to fatigue and wear. The airplane manufacturer requires the cables to be inspected every 4,800 hours but the airplane operator reduced the time interval to 2,400 hours. The cables were last inspected 2,247.5 hours earlier. The airplane manufacturer requires cable replacement only on condition.

Factual narrative

On July 9, 1996, about 1605 Atlantic Standard Time, a Short Brothers SD3-60-200, N384MQ, operated by Executive Airlines, Inc., dba American Eagle as flight No. 5514, experienced failure of a segment of the elevator trim cable system during the initial climb after takeoff at the Luis Munoz Marin International Airport, San Juan, Puerto Rico. Visual meteorological conditions prevailed at the time and an IFR flight plan was filed for the scheduled, domestic, passenger flight operated in accordance with 14 CFR Part 121. The airplane was not damaged and the airline transport-rated pilot and first officer, 1 flight attendant, and 9 passengers were not injured. The flight originated about 5 minutes earlier.

The first officer who was flying the airplane stated that after flap retraction while retrimming the airplane to a nose-up attitude, he felt no resistance from the manual elevator trim wheel. The flight then returned and landed uneventfully.

Examination of the elevator trim control system revealed a failed cable segment between fuselage station 74 in the cockpit and fuselage station 310 in the cabin area. The cable failed about midpoint between a 45-degree change in direction and was for nose-up trim. The failed cable was removed for further examination.

Metallurgical examination of the failed cable revealed that 36 of the 49 individual wire strands failed due to fatigue. Additionally, wear was noted adjacent to the fatigue failed strands. The remaining strands failed due to overload.

The airplane manufacturer requires the elevator trim control system to be inspected every 4,800 hours of 4 years, but replacement is on condition. The airplane operator introduced an engineering change order to the fleet which required inspection every 2,400 hours. Review of the airplane maintenance records revealed that the trim control system was last inspected 2,247.5 hours and 3,969 cycles earlier at the time of the failure.

The airplane was released to Mr. Ramon Ruiz, Director of Quality Assurance on July 11, 1996. The retained cable was released to Mr. Luiz Ruiz, Stores Regional Manager, on May 12, 1997.

Aircraft

Registration
N384MQ
Reported as
Short Brothers SD3-60-200
Category
Airplane
Serial number
SH3711
Airframe hours
16,554
Engine
P&W PT6A-65AR, 1,424 horsepower, turbo prop
Damage
No damage
Flight
Part 121
Operator
Executive Airlines, Inc., doing business as American Eagle
Registered owner
First Security Bank Of Ut Trus
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · February 24, 1995 · 2,248 hours before
Departed
SJU
Destination
STT · St. Thomas
Flight plan
IFR
Airport
SJU · Luis Munoz Marin Int'L

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Certificate
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
6,500 total · 1,404 in this make and model · 3,600 as pilot in command · 218 in the last 90 days · 70 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 14 knots, gusting 18
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 73 °F
Altimeter
29.00 inHg
Observed at
SJU

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.