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NTSB Report

September 4, 2009 · Cessna 421 C · N2349S

Sugar Land, TX

Overview

Report Status
Final with probable cause
Event Type
Incident
Date
September 4, 2009
Injury Outcomes
No injuries (1 uninjured)
Location
Sugar Land, TX
Aircraft
Cessna 421 C
Tail Number
N2349S
Injuries
None
Aircraft Damage
Minor
NTSB Number
CEN09IA578

The airplane was on an autopilot descent when the pilot noticed the elevator pitch trim was rotating continuously in the nose-up position. He disconnected the autopilot and immediately heard a popping sound. The movement of the pitch trim stopped, and the pilot could manually turn the pitch trim wheel without force or resistance. He then hand flew the airplane using spoilers, 15 degrees of flaps and exerted approximately 10 to 20 pounds of back pressure on the yoke to keep the airplane in level flight. The pilot executed an emergency landing without further incident. A postincident examination of the airplane revealed that the pitch trim cable had fractured and separated in the area where it passed over the rearmost pulley in the tail. A subsequent materials laboratory examination revealed the pitch trim cable displayed evidence of permanent curved deformation near the fracture location, with localized smearing wear. Several of the fractured cable wires showed evidence of fatigue fracture and some showed the presence of cadmium. One of the cadmium plated pulley guard pins showed evidence of rubbing contact with the cable. The smearing wear and the presence of the cadmium on the cable wires is consistent with a misrouting of the cable over the cable guide pins instead of the proper routing over the cable pulley. Examination of partial aircraft maintenance records did not show entries for any maintenance events when the pitch trim cable was rerouted or reinstalled. The circumstances leading up to the improper misrouting of the pitch trim cables could not be determined.

NTSB Probable Cause

The improper installation of the pitch trim cable which resulted in it making improper contact with a guard pin that led to the fatigue failure of the cable.

Full Narrative

On September 4, 2009, about 1755 central daylight time, a Cessna 421C, N2349S, experienced an in-flight separation of the elevator pitch trim cable during a descent for landing at Sugar Land Regional Airport (SGR), Sugar Land, Texas. The airplane was owned by TMC Aviation, Inc. and was being operated by the pilot on a 14 Code of Federal Regulations Part 91 business flight. Visual meteorological conditions prevailed and the pilot had filed and activated an instrument flight rules (IFR) flight plan. The airplane sustained minor damage. The pilot who was the only person on board was not injured. The flight originated from Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico, about 1340 mountain daylight time. While the airplane was in an 800 feet per minute descent at about 180 to 190 knots the pilot noticed the elevator pitch trim was rotating continuously in the nose up position. He disconnected the autopilot and immediately heard a "popping sound". The movement of the pitch trim stopped, and the pilot could manually turn the pitch trim wheel without force or resistance. He then hand flew the airplane using spoilers, 15 degrees of flaps and exerted approximately 10 to 20 pounds of back pressure on the yoke to keep the airplane in level flight. The subsequent emergency landing at SGR was otherwise uneventful. Examination of the airplane revealed the elevator trim tab was fixed in approximately the neutral position and the pitch trim cable had fractured and separated in the area where it passes over the rearmost pulley in the tail. Cable pulleys in the area of the cable separation appeared to rotate freely on their respective bearings and did not display any significant flat spots within the cable groove. A subsequent materials laboratory examination was conducted of several components. The pitch trim cable displayed evidence of permanent curved deformation near the fracture location, with localized smearing wear and corresponding cracking of the cable wires at the approximate inner radius of the curvature. At the fracture location, some of the cable wire ends were locally curved, and splayed out. Some of the individual wires were bent "L" shape near the fracture with smearing wear and microcracking found on several wire surfaces. Several of the fractured cable wires showed evidence of fatigue fractures. Some of the worn surface areas on the cable wires near the fracture showed the presence of cadmium. One of the cadmium plated pulley guard pins showed evidence of rubbing contact with the cable. Aircraft maintenance records were available for examination for only the previous six years. Those recent records showed numerous times when the pitch trim cables were inspected and cable tension was checked. The records did not show entries for any maintenance events when the pitch trim cable was rerouted or reinstalled.

Flight

Event TypeIncident
Event Time17:55 CDT
Nearest AirportSugar Land Regional Airport (0nm)
Runway17
Runway Length8000 ft
Runway Width100 ft
Flight Plan FiledIFR
Flight Plan ActivatedYes
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftCessna 421 C
Tail NumberN2349S
Aircraft CategoryAir
DamageMinor
Operating RulePart 91
Engines2
Engine TypeReciprocating
Engine DetailsContinental · GTSIO520 · Reciprocating · 375 | Continental · GTSIO520 · Reciprocating · 375
Seats7

People & Injuries

Injury SummaryNo injuries (1 uninjured)
Fatal0
Serious0
Minor0
Uninjured1
Total1
Crew 1Age 60 · Second Class · None

Conditions

ConditionsVMC
LightDaylight
Wind150° @ 10 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point68 F
Altimeter29.95 inHg
Observation Time21:53
Weather SourceWFAC

Appendix: Source Data