SEA97IA219

NTSB incident investigation · Boeing 737-3T0 · Seattle, WA · September 27, 1997

Incident · No injuriesIncident investigationFinal report
Date
September 27, 1997, 08:49 local (15:49 UTC)
Place
Seattle, WA
Injuries
134 uninjured
Damage
No damage
Phase of flight
Takeoff
Aircraft
N13331Boeing 737-3T0
Weather
Visual (VMC) · Day
Status
Completed · report April 15, 1999
Report
Approved by Office Director
Case key
42520

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

Separation of the ABSB-4 aileron bus cable, resulting in reduced lateral controllability of the aircraft. Related factors were wear in the cable and inadequate inspection of the cable by company maintenance personnel.

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
Flt control syst,aileron control cable/rod - wornFactor
Maintenance,inspection - inadequateCompany maintenance personnelFactor
Flt control syst,aileron control cable/rod - separationCause
Aircraft control - reduced

Analysis

The crew reported that at liftoff, 'considerable aileron and rudder input' was required to maintain straight and level flight, and that when aileron input was reduced to zero, at least 5 units of left rudder trim was required to maintain wings-level flight. The crew returned to the departure airport and landed without further incident. Postflight troubleshooting revealed that the ABSB-4 right aileron bus cable was broken and the ABSA-4 right aileron bus cable was frayed, both where the cables ride over the right wing/body joint aileron pulleys. Examination of the cables at the NTSB materials laboratory concluded that the ABSB cable failure was the result of severe internal wear due to normal movement of the cable over a pulley for an extended period of time. Examination also noted several areas of severe external wear on the cables. The airplane maintenance manual, which specifies inspection of exposed cables at each 'C' check (approximately once per year), contains procedures for checking cables for broken wires and gauging the extent of external wear. An 'optional as needed' step also specifies cable replacement based on reduction of cable cross sectional area. The airplane received a segmented 'C' check, which included inspection of aileron cables, approximately 6 weeks prior to the incident.

Factual narrative

On September 27, 1997, at 0849 Pacific daylight time, Continental Airlines flight 1046 (a Boeing 737-3T0, registration number N13331), a scheduled domestic 14 CFR 121 passenger/cargo flight enroute from Seattle/Tacoma International Airport, Seattle, Washington, to George Bush Intercontinental Airport, Houston, Texas, returned to Seattle/Tacoma International when the crew noted immediately after becoming airborne that large amounts of aileron and rudder input were required to maintain wings-level flight. The crew was able to land at Seattle/Tacoma International without damage to the aircraft or injuries to the airline transport pilot-in-command, first officer, 4 cabin crewmembers, or 128 passengers aboard. The aircraft was on an instrument flight rules (IFR) flight plan.

The crew reported that at liftoff, "considerable aileron and rudder input" was required to maintain straight and level flight, and that when aileron input was reduced to zero, at least 5 units of left rudder trim was required to maintain wings-level flight (according to Boeing, a minimum of 16.4 units of rudder trim is available.) Upon returning to the gate, it was noted that the right aileron remained up with the control wheel centered. Postflight troubleshooting revealed that the ABSB-4 aileron bus cable was broken and the ABSA-4 cable was frayed. The cable break and fraying occurred where the cables ride over the right wing/body joint aileron pulleys in the right wing root/main wheel well area. Maintenance personnel did not find any discrepancies with the pulleys. There was also no evidence found to indicate that the cables were, or had become, misrouted.

According to Boeing's records, the aircraft was delivered on August 11, 1986. On its NTSB incident report, Continental Airlines reported the aircraft's airframe total time as 34,633 hours. Continental further indicated on its NTSB incident report that the aircraft had 378 hours in service since its last inspection, a continuous airworthiness inspection performed on August 15, 1997, approximately 6 weeks prior to the incident. Continental reported that this inspection was a segmented "C" check, and that aileron cables were to be inspected during the "C" check segment which was performed at that time. Continental further reported to the NTSB that it was unable to determine whether or not the parted and frayed cables were the original cables installed at the time of aircraft delivery.

The ABSA-4 (frayed) and ABSB-4 (fractured) right wing aileron bus cables, which are both similarly constructed from 3/16 inch diameter, 7x19 wire rope, were sent to the NTSB Materials Laboratory in Washington, D.C., for examination. Examination of the fractured ends of the ABSB-4 cable revealed severe amounts of wear between the individual wires and strands (the NTSB metallurgist's factual report stated that this type of wear is generally referred to as internal cable wear.) On the vast majority of parted wires, wear had reduced the individual wire diameters to knife edges with little or no perceptible fracture surfaces. The only wires showing significant fractures were those from the core strand of wires; the features of these fractures were reported to be typical of overstress separations. It was estimated by the NTSB metallurgist that over 90% of the cable's total section had been removed by the internal wear, which appeared to be present along about 2 inches of the cable with some wires showing several locations of severe reduction. Severe external wear was also noted on the cable adjacent to the location of the separation; however, no wires appeared to be fractured at this wear. Energy dispersive x-ray analysis of individual wires found wire composition and tin coating consistent with MIL-W-8342, composition "A" wire rope.

In the NTSB Materials Laboratory examination, magnified optical examinations of the frayed location on the ABSA cable uncovered many of the same features as at the separation on the ABSB cable, including severe internal wear of the wires and strands. Visual examinations of the cables also disclosed several other areas of locally severe external wear, as well as several locations where the overall diameter of the cable had been reduced without damage to the exterior cable surface, which the NTSB metallurgist characterized as indicative of internal cable wear. In some locations, the cable diameter was reduced by as much as 0.03 inches (corresponding to approximately a 30% reduction in cable cross-sectional area for a nominal 3/16 inch diameter cable.)

The ABSA-4 and ABSB-4 cables were subsequently examined at Boeing's Equipment Quality Analysis (EQA) Laboratory in Renton, Washington. This examination was performed with the NTSB investigator-in-charge (IIC) along with representatives of the FAA, Boeing, and Continental Airlines in attendance. Boeing's examination of the ABSA-4 cable found wear "on the exterior of one side of the cable, the side which contacted the OD of the pulley, and not on the other side." The EQA report also stated that internal wear was also evident on this cable. The EQA report stated that on the ABSB-4 cable, "the wear occurred on the exterior of one side of the cable; the side which contacted the OD of the pulley, and not the other side." The EQA examination also noted wear on the interior of the ABSB-4 cable, between the bundles. Boeing's conclusion was: "The cables exhibited external wear which is believed to have resulted from contact with their respective pulleys. This external wear is likely the cause of the cable fraying and separation....The existence of external wear was evidenced on several portions of the cable....The internal wear was likely subsequent to the excessive external wear...."

A similar B-737 incident to the one involving Continental flight 1046 occurred at Newark, New Jersey, on March 15, 1993 (NTSB incident number NYC93IA059.) In that incident, involving a B-737-130 series aircraft also operated by Continental as flight 1659, the airplane rolled left immediately after liftoff but the pilot controlled the roll with right aileron and was able to return to Newark and land without further incident. Post-incident examinations of the left wing ABSA and ABSB aileron bus cables from that aircraft revealed that the left aileron down cable had parted in the same location (but on the left side) and manner as the parted right wing ABSB cable on Continental 1046. The NTSB determined the probable cause of the 1993 incident to be "inadequate maintenance/inspection by company maintenance personnel, the manufacturer's inadequate inspection and/or replacement procedures for the aileron cables, and subsequent failure of the 'down' aileron control cable due to wear." Based on the March 1993 Continental Airlines B-737 incident at Newark, the NTSB issued Safety Recommendations A-94-64 through A-94-66 to the FAA as follows:

A-94-64. Issue an Airworthiness Directive (AD) to operators of Boeing 727 and 737 airplanes requiring periodic inspection of the aileron cables for both internal and external wear, and for broken wires, with particular attention to the area of the cable contacting the pulleys. The inspection should include releasing cable tension to better detect cable wear and wire breakage and establishing a maximum allowable reduction in cable diameter where pulley contact occurs. Based on the inspections, develop specific flight hour intervals for replacement of the cables.

A-94-65. Require that the Boeing Company examine the consequences of a 737-100 aileron cable failure, and provide appropriate flightcrew operational guidance for the best landing configuration in the event of such a failure.

A-94-66. Conduct a comprehensive study to determine the frequency of spoiler, rudder, and aileron cable failures on airplanes weighing 12,500 pounds or greater. Where the study reveals flight control inspection procedures

Aircraft

Registration
N13331
Reported as
Boeing 737-3T0
Category
Airplane
Serial number
23569
Airframe hours
34,633
Engine
Cfm CFM56-3B, 20,100 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Continental Airlines
Registered owner
Wilmington Trust Co.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 15, 1997 · 378 hours before
Departed
SEA
Destination
IAH · Houston, TX
Flight plan
IFR
Airport
SEA · Seattle-Tacoma Intl, runway 16L, 11,900 × 150 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Certificates
Flight engineer, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
20,000 total · 6,107 in this make and model · 212 in the last 90 days · 68 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 15 knots
Visibility
10 statute miles
Lowest ceiling
18,000 ft broken
Temperature
55 °F, dew point 50 °F
Altimeter
30.00 inHg
Observed at
SEA