# NTSB MIA96IA179: Short Brothers SD3-60-200, N384MQ, San Juan, PR, July 9, 1996 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: July 9, 1996, 16:05 local (20:05 UTC) - Place: San Juan, PR - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 12 uninjured - Status: Completed, report April 24, 1998 - Report: Approved by Office Director - NTSB case key (mKey): 37923 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA96IA179 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37923/pdf - Page: https://openairdocs.org/ntsb/MIA96IA179 ## 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 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,elevator trim/tab control - fatigue (cause) - maintenance,replacement - not identified, manufacturer (contributing factor) ## 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](https://openairdocs.org/deregistered/N384MQ-2017-05-31), registration cancelled 2017-05-31, S/N SH3711 (OpenAirDocs) - Reported make and model: Short Brothers SD3-60-200 - Registry model: [Short Bros SD3-60](https://openairdocs.org/model/short-bros-sd3-60) (registry code 8100606) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-60A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-60a) (registry code 52043, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: SH3711 - Airframe hours: 16554 - Engines: P&W PT6A-65AR 1424 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; 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 (OpenAirDocs). - [Incident 19960709045599I](https://openairdocs.org/incident/19960709045599I), Jul 9, 1996: Stbros SD360, San Juan, Puerto Rico. Elevator trim cable failed on climbout. Returned. Cable in fuselage failed. Recent inspection indicated looked ok. 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.