General Mitchell International Airport
Aircraft Accident/Incident Report

Milwaukee, Wisconsin 53207
Saturday, June 7, 2003 14:00 CDT

NTSB Narrative Summary Released at Completion of Accident

The flight crew of the incident aircraft reported lateral control problems shortly after takeoff, noting that about 45 degrees of right control wheel deflection was required to maintain straight flight. They noted no other anomalies and seemed to have full flight control authority. However, as a precaution, the flight crew elected to return and land at the departure airport. The crew reported that the landing was normal with the exception of the required control wheel offset. A post incident examination of the aileron control system revealed a 360ยบ fracture in the silver-brazed joint between the drive sprocket and its mating shaft of the left-hand aileron control sprocket assembly. The failure of the brazed joint allowed both control wheels to be rotated approximately 45 degrees from neutral without a corresponding aileron control surface response. NTSB metallurgical examination of the left-hand sprocket assembly revealed that it was not brazed according to the referenced specifications. Specifically, the examination noted that the braze filler material had been introduced from both ends of the joint, resulting in a lack of penetration of about 20 percent of the total joint area. The applicable specification states, "the filler metal shall be introduced at one edge...and shall flow by capillary action to fill the interstice." The NTSB's review of the incident aircraft's maintenance records showed that a flight data recorder (FDR) functional check was completed the night before the incident flight. The roll control parameter, which is designed to measure the aileron surface position, was one of the parameters checked. To verify the accuracy of this parameter, the left control wheel is rotated either clockwise or counterclockwise until the ailerons contact their respective up or down stops. When the stops are contacted, the control wheel is held in position and the FDR roll control parameter value is checked against an approved maintenance manual limit. The control wheel is then rotated in the opposite direction and the FDR parameter is verified. The mechanic who conducted the functional check reported that the FDR functional check was routine. NTSB analysis of available recorded FDR data, incident flight and over 83 flights before the incident flight, showed that the maximum values recorded for the FDR roll control parameter prior to the functional check were 14.6 degrees aileron trailing edge down (TED) and 23.4 degrees aileron trailing edge up (TEU). The recorded aileron TED value was not in the range required by the approved operators B1900D maintenance inspection procedures document. The analysis also showed that, during the FDR functional check, the maximum values recorded for the roll parameter exceeded the maximum values recorded prior to the incident by 1.9 degrees in the aileron TED direction and 1.0 degree in the aileron TEU direction. This was the only time that both FDR values for the roll control parameter were in the TED range required by the functional check. The aircraft manufacturer and the NTSB tested the aileron control system on an exemplar Beechcraft 1900D aircraft in Wichita. The purpose of the test was to determine the amount of tangential force, applied to the control wheel, required to change the FDR roll control parameter value by 1.9 degrees in the aileron TED direction. Results of the testing showed that an additional tangential force of 80 pounds applied to the control wheel, after it was rotated such that an aileron was resting against its control surface stop, increased the roll parameter value by 0.7 degrees in the aileron TED direction and 1.3 degrees aileron TEU. Additional force was not applied to the control wheel because the limit load for the aileron control system is 80.4 pounds. The airplane manufacturer provided a Beechcraft 1900D Engineering report that documented tests that were conducted on the aileron control system to demonstrate compliance with the Code of Federal Regulations. Test data show that the aileron system did not yield while applying a limit tangential load of 80.4 pounds to the control wheel or fail when an ultimate tangential load of 120.6 pounds was applied to the control wheel. The aileron control system, including the brazed joint on the sprocket assembly, met all Federal Aviation Administration airworthiness standards for commuter-category aircraft. The investigation concluded that the failed sprocket assembly significantly reduced the pilots' control of the ailerons because the failure affects pilot input from both control wheels.

NTSB Probable Cause Narrative

Failure of the aileron sprocket assembly at the sprocket-to-shaft braze joint. Contributing factors were the improper braze procedure used by the part manufacturer at the time of fabrication which resulted in an inferior quality joint and the inadequate quality control (inspection) criteria which failed to identify the improperly brazed joint. An additional factor was the improper inspection procedure utilized by the operator's maintenance personnel, during which excessive force was applied to the control wheel in order to obtain acceptable flight data recorder readings during the functional check.

Event Information

Type of Event Incident
Event Date 6/7/2003
Event Day of the Week Saturday
Time of Event 1400
Event Time Zone Central Daylight Time
Event City Milwaukee
Event State WISCONSIN
Event Country --
Zipcode of the event site 53207
Event Date Year 2003
Event Date Month 6
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 425650N
Event Location Longitude 0875348W
Event Location Airport General Mitchell International
Event Location Nearest Airport ID MKE
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 723
Weather Briefing Completeness Full
Investigator's weather source Weather Observation Facility
Time of the weather observation 1352 Central Daylight Time
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID MKE
Elevation of weather observation facility 723
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation CDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 6000
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 4
Air Temperature at event time (in degrees celsius) 18
Dew Point at event time (in degress fahrenheit) 13
Wind Direction (degrees magnetic) 130
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 11
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29.77
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 8
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 17496
NTSB Notification Source
NTSB Notification Date Jun 6 2003 12:00AM
NTSB Notification Time 1630
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Mar 30 2005 6:20AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office Milwaukee FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N901SK
NTSB Number CHI03IA153
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Minor
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Beech
Aircraft Model 1900D
Aircraft Series Identifier --
Aircraft Serial Number UE-90
Certified Max Gross Weight 17230
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 21
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection May 28 2003 12:00AM
Airframe hours since last inspection 42
Airframe Hours 20720
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Firstar Equipment Finance Corp.
Aircraft Owner Street Address 400 Highway 169 S -- Suite 300
Aircraft Owner City Saint Louis Park
Aircraft Owner State MN
Aircraft Owner Country USA
Aircraft Owner Zipcode 55426
Operator is an individual? No
Operator Name Skyway Airlines Inc.
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 4792 S. Howell Avenue
Operator City Milwaukee
Operator State WI
Operator Country USA
Operator Zip code 53207
Operator Code HDWA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code MKE
Departure City Milwaukee
Departure State WI
Departure Country USA
Departure Time 1345
Departure Time Zone CDT
Destination Same as Local Flt --
Destination Airport Code SAW
Destination City Gwinn
Destination State MI
Destination Country USA
Specific Phase of Flight Takeoff - initial climb
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Jun 13 2004 10:06PM
User who most recently changed record SULP
Since inspection or accident Time of Accident
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --