Accident Details
Probable Cause and Findings
The captain’s use of his pitch trim switch, which had been placarded inoperative but not deactivated, resulting in the airplane pitching up when the captain was trying to trim down. The trim commands were reversed due to maintenance personnel’s incorrect installation of the pitch trim switch. Contributing to the incident was the operator’s delay in incorporating SB 170-27-0051 which would have prevented the switch from being installed inverted.
Aircraft Information
Registered Owner (Current)
Analysis
HISTORY OF FLIGHTOn November 6, 2019, about 2115 eastern standard time, Republic Airways flight 4439, an Embraer EMB-175LR, N117HQ, experienced a pitch trim anomaly shortly after takeoff from Hartsfield-Jackson Atlanta International Airport (ATL), Atlanta, Georgia. The flight crew declared an emergency and returned to ATL. The nine passengers and crewmembers aboard the airplane were not injured, and the airplane was not damaged. The airplane was operating under the provisions of Title 14 Code of Federal Regulations Part 121 as regularly scheduled passenger flight destined for LaGuardia Airport (LGA), New York, New York.
The flight crew reported for duty on the day of the incident about 1400 at Detroit Metropolitan Wayne County Airport (DTW), Detroit, Michigan. The incident occurred during the third flight leg of the day. The captain flew the first leg, from DTW to LGA. According to the captain, while en route, the engine indicating and crew alerting system (EICAS) annunciated the “PITCH TRIM SW 1 [switch 1] FAIL” message. The captain stated that he and the first officer referred to the company’s quick reference handbook and saw that the EICAS message was advisory. As a result, they noted the message in the airplane’s logbook and planned to have the discrepancy addressed after the airplane landed at LGA.
According to the flight crewmembers, maintenance personnel at LGA initially advised that they would change the pitch trim switch on the captain’s yoke to resolve the EICAS message and that it would take about 20 minutes to obtain the part. The maintenance personnel reported that they partially removed the switch before deciding to defer the maintenance per the minimum equipment list. The maintenance personnel then reinstalled the partially removed switch but did not perform a functional test because the switch was a deferred maintenance item. The maintenance personnel placarded the switch inoperative and advised the captain to use the backup trim switch instead of the faulty trim switch on his yoke.
The first officer flew the second leg of the day, from LGA to ATL, which he described as “just a normal leg.” The first officer stated that no further maintenance was performed after arriving at ATL.
The captain was the pilot flying for the third (incident) leg of the day, from ATL to LGA. Air traffic control (ATC) communications showed that the airplane was cleared for takeoff at 2105:05. The flight crew stated the taxi and takeoff were normal. The first officer stated that, during takeoff, the airplane’s climb rate was “moving pretty rapidly” and reached about 4,000 ft per minute, which he described as normal given that the airplane was “very light” with only six passengers aboard.
The captain reported that he was unable to engage the autopilot when the airplane reached an altitude of about 2,200 ft mean sea level. The captain stated that he “knew that something was wrong,” so the captain instructed the first officer to declare an emergency. ATC communications showed that, at 2106:53, the emergency was declared to the controller. The controller confirmed that the airplane needed to return to the airport and provided instructions to the flight crew to enter the downwind leg for runway 10.
The captain thought that a pitch trim runaway was occurring, so he conducted the single memory item on Republic Airways’ runaway trim emergency checklist, which was to push and hold the autopilot/trim disconnect button on his yoke. The captain also stated that he kept pushing the button and that he was unable to pick up the quick reference card from his lap to continue to troubleshoot the issue because he had to keep both of his hands on the yoke to control the airplane.
The first officer stated that the captain was struggling to control the airplane. The captain asked the first officer to push and hold the autopilot/trim disconnect button located on the first officer’s yoke. The flight crewmembers reported that they did not notice any changes in the airplane’s pitch condition and were having difficulty holding the airplane’s nose down. According to the captain, both he and the first officer had to push forward on their control columns to keep the airplane from pitching up.
According to the flight data recorder (FDR), the horizontal stabilizer was initially positioned about 4° nose up. The stabilizer began moving about 2105:50 and reached a maximum noseup position of 13° at 2107:45. Between 2105:50 and 2107:50, the FDR recorded multiple trim-up commands from the captain’s switch (and only one trim-down command from the first officer switch). The airplane experienced several pitch oscillations, reaching a maximum pitch-up attitude of about 27° at 2108:08. About 7 second later, the flight crew told the controller that the airplane was “in a stalling situation.” About 1 minute later, the flight crew reported that “we can’t pitch down,” and FDR data showed that the flight crew banked the airplane to maintain control.
The captain pressed the button to cut out pitch trim system 1 because that was the system associated with the EICAS message. FDR data showed that all recorded pitch trim commands from both the captain’s and the first officer’s pitch trim control switches corresponded to the stabilizer movement until 2110:36, at which time the stabilizer parameter suddenly went to 0°, which was consistent with trim cutout switch actuation. According to Embraer, if only one cutout switch is pressed, the system is still capable of moving the horizontal stabilizer, but if both cutout switches are pressed, the system stops moving the horizontal stabilizer. The first officer stated that the airspeed dropped to 138 knots before they regained control of the airplane.
Between 2110:40 and 2113:30, the FDR recorded multiple trim-down commands from only the first officer’s switch (except for one instance of backup switch usage at 2111:00). Between 2114:30 and 2116:40, the FDR recorded multiple trim-up commands from only the captain’s switch. Afterward, the captain transferred control of the airplane to the first officer. (The captain wanted to talk with ATC and continue to troubleshoot.) The first officer stated that, with pitch trim system 1 cut out, he was able to trim the airplane nose down and regain airspeed. Between 2116:40 and the 2118:10, the FDR recorded multiple trim-down commands from only the first officer’s switch; between 2118:10 and the end of the flight, the FDR recorded multiple trim-up and -down commands from only the first officer’s switch.
At 2119:58, the controller instructed the flight crew to join the localizer for runway 10. At 2121:16, the controller cleared the airplane to land on runway 10. The crew acknowledged those instructions. The airplane landed uneventfully about 2125. A cockpit voice recorder summery transcript was prepared to document the communications between maintenance personnel after the incident airplane arrived at the gate. The incident flight had been recorded over. AIRCRAFT INFORMATIONPitch Trim System
The horizontal stabilizer control surface provides the airplane with stability and control during pitch trim adjustments. The control surface is moved by the horizontal stabilizer trim actuator, which is driven by two electric motors.
A manual pitch trim control switch is located on each control yoke, and a backup manual pitch trim control switch is located on the center pedestal. All three switches are dual-split switches that are spring loaded to neutral. Two stabilizer cutout switches are located on the center pedestal. If both cutout switches are pressed, the stabilizer actuator would be locked in place. If one cutout switch is pressed, the pitch trim system, including all three manual pitch trim switches, would continue to work normally.
An autopilot/trim quick disconnect switch button is located on each control yoke. Pressing and holding either quick disconnect switch, while both cutout switches are in the normal (not pressed) position, prevents any active manual or autotrim command. Pressing either switch also disengages the autopilot. Releasing the pressed quick disconnect button allows trim commands. If only one cutout switch is pressed, the associated quick disconnect switch would not function.
Pitch Trim Runaway Procedures
Republic Airways’ quick reference handbook had one memory item for a pitch trim runaway: the autopilot/trim disconnect button was required to be pressed in and held. The Embraer 170/175 Airplane Operations Manual required two memory items; the autopilot/trim disconnect button had to be pressed in and held, and both cutout buttons had to be pushed in. Figure 1 compares the two documents and shows other steps to address a pitch trim runaway.
Figure 1. Company and manufacturer pitch trim runaway procedures (Source: Republic Airways and Embraer).
Maintenance Records
The airplane’s flight logs from August 7 to November 5, 2019, were reviewed for items related to the pitch trim system. The table below shows the items that were noted.
Table. Pitch trim system discrepancies before the incident.
Date
Discrepancy
Corrective action
8/7/2019
Pitch trim switch 1 fail
Performed related Fault Isolation Manual (FIM) task. Message cleared; operational check good.
8/19/2019
Pitch trim switch 1 fail EICAS message with aural trim
Performed related FIM task. Removed and replaced captain’s side pitch trim switch.
8/24/2019
Pitch trim switch 1 fail
Performed related FIM task and aircraft maintenance manual (AMM) procedure. Operational checks okay.
9/3/2019
EICAS message en route while on autopilot pitch trim switch-1 fail. Captain trim switch verified inoperative.
Performed related FIM task. Message cleared; operational checks good.
9/8/2019
Pitch trim switch 1 fail
Deferred captain’s pitch trim switch in accordance with the minimum equipment list. Removed and replaced captain’s pitch trim switch; operational checks good.
9/8/2019
Backup pitch tr...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# DCA20IA014