NTSB Factual Report

HISTORY OF FLIGHT

On January 11, 1999, at 1548 eastern standard time, a Cessna 310R, N87365, operated by Primac Courier, Inc., was destroyed when it struck the ground in Kearny, New Jersey. The certificated airline transport pilot was fatally injured. Visual meteorological conditions prevailed for the positioning flight that had departed from Teterboro Airport (TEB), Teterboro, New Jersey, about 1543. No flight plan had been filed for the flight that was conducted under 14 CFR Part 91.

The airplane was en route to Atlantic City, New Jersey, for a revenue cargo flight that was to be conducted under 14 CFR Part 135. The flight was cleared for takeoff on runway 24 at 1542:47, after which the pilot departed to the southeast. At 1545:55, the local controller advised the pilot to set his transponder to code 1200, and cleared him to change frequencies.

At 1546:01, the pilot replied, "oh kay three six five, I'm having a problem here, I've got a elevator control, I want to come back for a landing or at least attempt [to return for a landing]." The local controller cleared the flight for a left down wind for runway 24.

The local controller inquired about the problem the pilot was experiencing and at 1546:31, the pilot reported, "I have ah no elevator control sir."

At 1546:37, the pilot further transmitted, "I just need to ah [be] able to go into ah Class B [airspace], if [I] need to."

At 1547:36, the pilot inquired about the winds and if he could make a straight in approach to Runway 1. The local controller reported that Runway 1 was available, and that the winds were from 270 degrees at 15 knots.

At 1547:59, the local controller transmitted, "twin cessna three six five do you want runway one."

At 1548:03, the pilot replied, "yes sir." Subsequent radio calls from the local controller were not answered.

One witness located in Jersey City, New Jersey, observed the accident through the window of a 14th floor apartment which faced west. He reported that the airplane was headed northwest, straight and level. He looked away for a few seconds and when he looked back, the airplane was in a near vertical nose down descent, and not rotating. After the airplane struck the ground, he observed a black column of smoke rise up.

The accident occurred during the hours of daylight at 40 degrees, 44 minutes, 32.2 seconds north latitude, and 74 degrees, 06 minutes, 01.8 seconds west longitude.

OTHER DAMAGE

One end of a 5 unit rail car used to haul double stack containers was damaged. The deck plating was penetrated by the airplane and one truck used to hold the two axles in place was fractured. The cost of repair to the car was estimated to be about $13,000.

PERSONNEL INFORMATION

The pilot held an airline transport pilot certificate for multi-engine airplanes and a commercial pilot certificate for single engine airplanes. He was issued a First Class Federal Aviation Administration (FAA) Airman Medical Certificate on April 10, 1998. According to the pilot's log book which was current through January 9, 1999, he had a total time of 3,401.5 hours, with 530.7 hours in multi-engine airplanes, including 366.0 hours in the Cessna 310. He had logged 231.6 hours and 77.9 hours in the preceding 90 days and 30 days respectively.

The pilot satisfactorily completed his 14 CFR Part 135 flight check in the Cessna 310 on October 9, 1998.

AIRCRAFT INFORMATION

The airplane was a 1976 Cessna 310R, which was maintained under an approved aircraft inspection program which followed the manufacturers inspection program, and was conducted under 14 CFR Part 135. The latest 100 hour inspection was conducted on December 16, 1998.

According to maintenance records, on January 8, 1999, the airplane's elevator trim actuator was overhauled. The maintenance was signed off , "I/A/W C.M.M." (In Accordance With Cessna Maintenance Manual). According to the Cessna Aircraft Company Maintenance Manuals, the procedure prescribed called for the removal of the elevator from the airplane during the work. The mechanic reported that he completed the overhaul without removal of the elevator. A review of the procedure used by the mechanic, by representatives of the FAA and the Cessna Aircraft Company, did not find anything that could explain the loss of elevator control reported by the pilot.

A check of another Cessna 310R owned by the company revealed that both trim actuators were installed identically, and the trim cables were aligned identically.

The aileron and rudder trims were manually actuated by trim wheels located on the lower throttle pedestal. The elevator trim could be actuated either manually by movement of the trim wheel located to the left side of the throttle pedestal, or electrically by a electric trim button located on the left side of the pilot's control yoke.

A check of the other airplane revealed that with the elevator trim set in the middle of the green band for takeoff and if the electric trim motor was actuated, it would take 16 seconds to reach the full nose up trim position, or 25 seconds to reach the full nose down trim position.

RADAR AND OTHER REMOTELY RECORDED DATA

Radar data was received from the New York TRACON (Newark Antenna). The data revealed that after departure, the airplane entered a shallow climb to about 1,000 feet heading southeast. Upon reaching 1,000 feet, the airplane momentarily descended to 800 feet, and then initiated a climb that peaked at 1,900 feet. According to times listed on a transcript of the air/ground communications, and the times of the radar contacts, the pilot first reported he was experiencing elevator problems about the time the climb was initiated. The pilot's second call of no elevator control occurred during the climb. During this time the airplane heading continued to change course to the right. The last radar contact was recorded at 1548:16.6. The recorded position of the airplane was about 550 feet southeast of the accident site, and the recorded altitude was 900 feet..

WRECKAGE AND IMPACT INFORMATION

The airplane was examined at the accident site on January 11th, and 12th. The examination revealed that the airplane impacted on the east end of a railcar, in the Conrail, South Kearny, Trailvan Terminal. All major components of the airplane, including both wing tips, the tail, and engines, were identified at the accident site. Debris was scattered in a fan shaped pattern, about 90 degrees either side of the final airplane course of 325 degrees magnetic. Debris was scattered for about 200 feet, across several rows of flat cars and train tracks.

Most of the debris on both sides of the track was made up of small unidentified pieces of crushed skin or internal structure from the wings and fuselage. The left engine had lodged in the end of the flatcar, and the right engine was buried in the ballast of an adjacent track. Both engines were in a nose down attitude of about 70 degrees, and angled nose right about 15 degrees.

Several of the items at the accident site had surfaces with soot present. None of the soot patterns conformed to an aerodynamic air flow consistent with flight.

The impact damage precluded a check of flight control, or trim control continuity. Multiple breaks were observed in the flight control and trim cables. All breaks in trim and flight control cables occurred at other than attach points, and the cable ends were frayed. Crush marks were found on the leading edge of the elevators which were consistent with them being in a trailing edge down position as the time of impact.

The rudder and aileron trim actuators were found to be near neutral while the elevator trim actuator was found in an over extended position that corresponded to trailing edge elevator trim tab up (airplane nose down).

MEDICAL AND PATHOLOGICAL INFORMATION

The toxicological testing report from the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for the pilot.

An autopsy was conducted by the State of New Jersey Regional Medical Examiner, Newark, New Jersey.

TESTS AND RESEARCH

A reexamination of the wreckage was conducted on January 27, 1999. A separated elevator trim cable was identified and forwarded to the NTSB metallurgical laboratory for further examination. According to the factual report, "...Nearly all of the broken wires on this segment of cable had separated along an angle, consistent with an overstress separation." No evidence of a wear pattern consistent with cable rubbing was reported.

ADDITIONAL INFORMATION

The investigation revealed that the accident flight was the first flight following an overhaul of the elevator trim actuator. During interviews, the mechanic who performed the work, and the director of maintenance who supervised the work, stated no work had been performed on the elevators or elevator actuator. No discrepancies were found with the elevator trim actuator. The cockpit elevator trim wheel was not identified, and its pre-impact position was not determined.

Examination of maintenance records revealed that the work was signed off on January 8, 1999, after which the airplane was parked outside. According to the TEB weather reports, snow and light freezing rain fell on January 8, and the temperature remained below freezing for entire day. On January 9, the temperature increased a few degrees above freezing for 19 hours. During that time, there were periods of rain. On the evening of January 9, at 2051, the temperature was recorded as below freezing, and remained below freezing, with no further precipitation through the time of the departure and accident on January 11, 1999. A witness reported that the external surfaces of the airplane were free of snow and ice when the pilot departed TEB.

The Director of Maintenance was questioned about water accumulations in the lower aft fuselage. He reported he had occasionally seen water accumulations of 2 to 3 ounces in the lower aft fuselage.

According to AC 61-21A - FLIGHT TRAINING HANDBOOK \ Chapter 16 - Transition to Other Airplanes \ Checkout in a Multiengine Airplane:

"4. Use of Trim Tabs. The trim tabs in a multiengine airplane serve the same purpose as in a single engine airplane, but their function is usually more important to safe and efficient flight. This is because of the greater control forces, weight, power,...range of operating speeds, and range of center of gravity location. In some multiengine airplanes it taxes the pilot's strength to overpower an improperly set elevator trim tab on takeoff or go-around...."

The director of operations for Primac Courier reported that after the accident, he wanted to see what the control forces in a Cessna 310 were like when the elevator was trimmed nose down. He reported that while flying another Cessna 310R, at a safe altitude, and an indicated airspeed of about 180 knots, he slowly applied nose down trim while increasing his back pressure to hold altitude. He reported that he was not able to increase the nose down trim even halfway from neutral to full nose down before the control forces exceeded what he could hold for more than a few seconds. He then retrimed the elevator to neutral force and continued with his flight.

On another Cessna 310R flown by the operator, a test was performed. The elevator movement was intentionally restricted and the elevator trim tab was actuated. When the cockpit trim wheel was moved to airplane nose down, the trailing edge of the elevator trim tab moved up. When the cockpit trim wheel was moved to airplane nose up, the trailing edge of the elevator trim tab moved down.

The airplane wreckage was released to a representative of the Aircraft Insurance Group on January 12, 1999.

NTSB Probable Cause

a loss of elevator control for undetermined reasons.