Accident Details
Probable Cause and Findings
The separation of the pushrod from the elevator trim tab actuator, which rendered controlled flight impossible. Contributing to the separation of the pushrod was the failure of maintenance personnel to properly secure it to the elevator trim tab actuator.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn September 13, 2017, about 0723 eastern daylight time, a Cessna 402B, N836GW, was substantially damaged during a rejected takeoff at the Nantucket Memorial Airport (ACK), Nantucket, Massachusetts. The commercial pilot/airplane owner sustained minor injuries. The airplane was being operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for the flight that was originating at the time of the accident. The flight was destined for Barnstable Municipal Airport-Boardman/Polando Field Airport, Hyannis, Massachusetts.
The pilot stated that he had completed his routine "takeoff flow" confirmed by the airplane before takeoff checklist, and was then cleared to take off from runway 24. The airplane accelerated to between 90 and 95 knots, and he began to rotate. The airplane achieved a positive rate of climb and he retracted the landing gear; however, after becoming airborne he was "fighting the controls to keep the aircraft from a nose down configuration." He used manual trim and verified the autopilot was not engaged; however, the nose-down tendency continued and "controlling the airplane was increasingly difficult along with maintaining altitude." At that time he rejected the takeoff and executed an emergency landing on the remaining portion of the runway. PERSONNEL INFORMATIONThe pilot, age 56, held a commercial pilot certificate with airplane multi-engine land and instrument airplane ratings issued December 5, 2005, and a private pilot certificate with airplane single engine land rating issued January 12, 2003. He held a first-class medical certificate with a limitation to possess glasses for near and intermediate vision issued August 12. 2017. He reported 1,500 hours total flight time, of which 1,100 were in the accident make and model airplane. His last flight review was conducted in the accident airplane on July 15, 2017. AIRCRAFT INFORMATIONThe seven-place, low-wing airplane, was manufactured in 1977. It was powered by two 300-horsepower Continental TSIO-520-E engines and equipped with constant-speed, manual feathering three-blade McCauley propellers.
The elevator trim control system was operated by a control wheel mounted on the left side of the pedestal in the cockpit. The control wheel was attached to a sprocket which operated a chain and cables. The chain and cables were routed to pulleys, forward and down through the pedestal under the floor and aft to the tailcone of the airplane. In the tailcone, the cables were routed aft to pulleys just forward of the horizontal stabilizer rear spar, then up and through the right horizontal stabilizer to a chain which operated the trim actuator. A push rod connected the trim tab actuator to the elevator trim tab which was mounted to the right elevator by a continuous hinge. The published maximum elevator trim tab trailing edge up deflection with the elevator in the neutral position was 5° +1°, -0°.
Airworthiness Directive (AD) 2016-07-24, with an effective date of April 26, 2016, specified replacement within 90 days of the effective date of attaching hardware of the elevator trim pushrod at the elevator trim tab actuator and trim tab ends. A review of the maintenance records revealed that between March 3, 2016, and February 6, 2017, there was no entry indicating compliance with the AD. The airplane owner/pilot later reported that he was not aware of the AD when it came out, but he felt confident that the maintenance facility would comply with it during the annual inspection.
On August 31, 2016, the owner flew the airplane to a repair station in New Bedford, MA, for an annual inspection.
As part of the repair station incoming process, the chief inspector performed an AD search of the airplane using Avantext. At that time, AD 2016-07-24, was on the recurring list of the AD service provider; however, the chief inspector did not include this in the handwritten notes of recurring AD's that were applicable to the airplane. Subsequently, AD 2016-17-08, with an effective date of September 12, 2016, which replaced AD 2016-07-24, also required replacement of the hardware but revised the repetitive inspection intervals and allowed for a longer bolt for the attachment of the elevator trim tab actuator rod end to the push-pull tube connection and/or for the elevator trim tab horn end to the push-pull tune connection. The AD's were issued to prevent jamming of the elevator trim tab in a position outside the normal limits of travel due to the loss of the attachment hardware connecting the elevator trim tab actuator to the elevator trim tab push-pull rod, which could result in loss of control.
During the annual inspection, the airplane was stripped and painted. As part of that process, and also because the right elevator control tube assembly end fitting part was cracked, an employee of the repair station removed the right elevator requiring separation of the elevator trim push rod from the trim tab end only. Repair station personnel reported that the elevator trim push rod remained connected at the elevator trim tab actuator and was safety wired to prevent movement of the elevator trim tab actuator.
In conflict with the report that the push rod remained connected at the elevator trim tab actuator, subsequent pictures of the airplane taken by the airplane owner while in the hangar in December 2016, depicted the right elevator removed and the push rod disconnected from the elevator trim tab actuator. The repair station owner reported he installed the right elevator after painting. When he did so, the elevator trim push rod assembly was already attached at the actuator, and the appropriate securing hardware was in-place at the actuator; however, the hardware at the actuator and trim tab ends were not replaced as specified by AD 2016-17-08, because the repair station owner interpreted it to only require an inspection of the hardware and not replacement of the attachment hardware.
The airplane was flown on January 28, 2017, and approved for return to service on February 6, 2017. According to the airplane owner, no work, repairs, or adjustments were made to the elevator primary or secondary flight control system between the annual sign-off date and the accident date. The airplane had accrued 58 hours since the inspection at the time of the accident. METEOROLOGICAL INFORMATIONAt 0653, a surface weather observation taken at ACK reported wind 280° at 5 knots, 6 miles visibility with moderate mist, clear skies, temperature 17°C, dew point 17°C, and altimeter setting 29.90 inches of mercury. AIRPORT INFORMATIONThe seven-place, low-wing airplane, was manufactured in 1977. It was powered by two 300-horsepower Continental TSIO-520-E engines and equipped with constant-speed, manual feathering three-blade McCauley propellers.
The elevator trim control system was operated by a control wheel mounted on the left side of the pedestal in the cockpit. The control wheel was attached to a sprocket which operated a chain and cables. The chain and cables were routed to pulleys, forward and down through the pedestal under the floor and aft to the tailcone of the airplane. In the tailcone, the cables were routed aft to pulleys just forward of the horizontal stabilizer rear spar, then up and through the right horizontal stabilizer to a chain which operated the trim actuator. A push rod connected the trim tab actuator to the elevator trim tab which was mounted to the right elevator by a continuous hinge. The published maximum elevator trim tab trailing edge up deflection with the elevator in the neutral position was 5° +1°, -0°.
Airworthiness Directive (AD) 2016-07-24, with an effective date of April 26, 2016, specified replacement within 90 days of the effective date of attaching hardware of the elevator trim pushrod at the elevator trim tab actuator and trim tab ends. A review of the maintenance records revealed that between March 3, 2016, and February 6, 2017, there was no entry indicating compliance with the AD. The airplane owner/pilot later reported that he was not aware of the AD when it came out, but he felt confident that the maintenance facility would comply with it during the annual inspection.
On August 31, 2016, the owner flew the airplane to a repair station in New Bedford, MA, for an annual inspection.
As part of the repair station incoming process, the chief inspector performed an AD search of the airplane using Avantext. At that time, AD 2016-07-24, was on the recurring list of the AD service provider; however, the chief inspector did not include this in the handwritten notes of recurring AD's that were applicable to the airplane. Subsequently, AD 2016-17-08, with an effective date of September 12, 2016, which replaced AD 2016-07-24, also required replacement of the hardware but revised the repetitive inspection intervals and allowed for a longer bolt for the attachment of the elevator trim tab actuator rod end to the push-pull tube connection and/or for the elevator trim tab horn end to the push-pull tune connection. The AD's were issued to prevent jamming of the elevator trim tab in a position outside the normal limits of travel due to the loss of the attachment hardware connecting the elevator trim tab actuator to the elevator trim tab push-pull rod, which could result in loss of control.
During the annual inspection, the airplane was stripped and painted. As part of that process, and also because the right elevator control tube assembly end fitting part was cracked, an employee of the repair station removed the right elevator requiring separation of the elevator trim push rod from the trim tab end only. Repair station personnel reported that the elevator trim push rod remained connected at the elevator trim tab actuator and was safety wired to prevent movement of the elevator trim tab actuator.
In conflict with the report that the push...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA17LA329