NYC01IA107

NTSB incident investigation · Embraer EMB-145 · Norfolk, VA · April 25, 2001

Incident · No injuriesIncident investigationFinal report
Date
April 25, 2001, 18:15 local (22:15 UTC)
Place
Norfolk, VA
Injuries
53 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N29917Embraer EMB-145
Weather
Visual (VMC) · Day
Status
Completed · report February 20, 2002
Report
Approved by Office Director
Parties
FAA FSDO-21, Parker Aerospace, Embraer, Continental Express
FAA report
20010425013839I
Case key
53371

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

On this page

Probable cause

The manufacturer's inadequate quality control, which resulted in a jammed elevator trim actuator.

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/malfunctionCruise
Inadequate quality controlManufacturerCause
Flt control syst,elevator trim/tab control - jammed

Analysis

During cruise flight, the horizontal stabilizer jammed in the (-1)-degree trim position. After an uneventful landing, the elevator trim actuator was forwarded to the manufacturer for examination under the supervision of a Safety Board investigator. The elevator trim actuator contained a primary and back-up clutch gear, and each gear had a respective torque nut and lock washer. The examination revealed that that the tabs on the lock washers were not bent over into the locked position. Additionally, there was no evidence that the tabs had ever been bent into the locked position. The back-up clutch torque nut had backed off and down the shaft, coming to rest against the clutch gear cluster bearing outer race. The backed-off nut exhibited a scratch around the outer edge of the face, consistent with fouling against the clutch gear cluster bearing outer race, subsequently jamming the unit. The manufacturer identified the isolated error in the production process.

Factual narrative

On April 25, 2001, about 1815 eastern daylight time, an Embraer EMB-145, N29917, was not damaged during an elevator trim malfunction, while in cruise flight near Norfolk International Airport (ORF), Norfolk, Virginia. The airplane was operated by Continental Express Airlines Inc. as flight 3365. There were no injuries to the 3 crewmembers and 50 passengers. Visual meteorological conditions prevailed for the flight that originated from Newark International Airport (EWR), Newark, New Jersey; destined for ORF. An instrument flight rules flight plan was filed for the air carrier flight conducted under 14 CFR part 121.

The flight crew reported that they departed EWR about 1700. About 1815, at 5,000 feet, the horizontal stabilizer jammed in the (-1)-degree trim position. The flight crew completed the emergency checklist items, but the primary and secondary trim actuation systems did not respond. The flight crew then declared an emergency and landed uneventfully at ORF, at 1833.

Examination of the airplane by a Federal Aviation Administration inspector revealed that the elevator trim actuator had failed. The unit was forwarded to the manufacturer's facility in Irvine, California, and examined under the supervision of a Safety Board investigator.

The unit contained a primary and back-up clutch gear, and each gear had a respective torque nut and lock washer. The examination revealed that that the tabs on the lock washers were not bent over into the locked position. Additionally, there was no evidence that the tabs had ever been bent into the locked position. The back-up clutch torque nut had backed off and down the shaft, coming to rest against the clutch gear cluster bearing outer race. The backed-off nut exhibited a scratch around the outer edge of the face, consistent with fouling against the clutch gear cluster bearing outer race, subsequently jamming the unit. The manufacturer identified the error in the production process.

After the examination, the manufacturer inspected all new production units in-house, and reviewed repair records on over 200 units. No discrepancies were detected during the in-house inspection or record review. The manufacturer also issued service bulletins and added quality control information and steps to the production process.

Aircraft

Registration
N29917
Reported as
Embraer EMB-145
Category
Airplane
Serial number
145-414
Airframe hours
31
Engines
Allison AE3100A1/3, 7,450 lbs thrust, turbo fanAllison AE3100A1/3, 7,450 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Continental Express Inc
Registered owner
Wells Fargo Bank Northwest NA Trustee
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 9, 2001 · 31 hours before
Departed
EWR · Newark, NJ
Destination
ORF · Norfolk, VA
Flight plan
IFR
Airport
ORF · Norfolk International Airport, runway 5, 9,001 × 150 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
February 4, 2001
Seat
Left
Flight hours
4,800 total
Role
Co-pilot
Age
23
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
April 12, 2001
Seat
Right
Flight hours
1,400 total

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 16 knots
Visibility
10 statute miles
Lowest ceiling
2,400 ft broken
Temperature
48 °F, dew point 43 °F
Altimeter
30.18 inHg
Observed at
ORF, 50 nm away

FAA reports on this event · 1

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