Aircraft Accident/Incident Report

Coupeville, Washington 98239
Tuesady, July 22, 2003 10:15 PDT

NTSB Narrative Summary Released at Completion of Accident

The corporate jet airplane experienced a loss of elevator trim control (runaway trim) that resulted in an uncommanded nose-low pitch attitude. The pilot reported that following the loss of elevator trim authority the airplane was extremely difficult to control and the elevator control forces were extremely high. The pilot continued to maneuver the airplane, but eventually ditched it into a nearby marine cove. The runaway trim condition was not immediately recognized by the pilot and he stated that, by that point in the event sequence, the control forces were so great that he had little time to troubleshoot the system and elected to continue on his established heading and ditch the airplane. Pulling the circuit breaker, which is called for by the checklist in the event of a trim runaway, would have arrested the trim movement. Post accident examination and functional testing of the airplane's electric pitch trim printed circuit board (PCB) showed a repeatable fault in the operation of the PCB's K6 relay, resulting in the relay contacts remaining closed. This condition would be representative of the autopilot pitch trim remaining engaged, providing an electrical current to drive continuous nose-down trim to the elevator trim motor. Examination of the airplane's maintenance records showed that the PCB was removed and replaced in conjunction with the phase inspection prior to the accident. Further examination of the airplane's maintenance records revealed that the replacement PCB was originally installed in an airplane that experienced an "electric trim runaway on the ground." Following the trim runaway, the PCB was removed and shipped to the manufacturer. After receiving the PCB the manufacturer tested the board and no discrepancies were noted. The unit was subsequently approved for return to service and later installed on the accident airplane. The investigation revealed a single-point failure of trim runaway (failed K6 relay) and a latent system design anomaly in the autopilot/trim disconnect switch on the airplane's pitch trim PCB. This design prohibited the disengagement of the electric trim motor during autopilot operation. As a result of the investigation, the FAA issued three airworthiness directives (AD 2003-21-07, AD 2003-23-20, and AD 2004-14-20), and the pitch trim printed circuit board was redesigned and evaluated for compliance with safety requirements via system safety assessment

NTSB Probable Cause Narrative

The loss of airplane pitch control (trim runway and mistrim condition) resulting from a failure in the airplane's electric pitch trim system. Factors that contributed to the accident were the manufacturer's inadequate design of the pitch trim circuitry that allowed for a single-point failure mode, and the absence of an adequate failure warning system to clearly alert the pilot to the pitch trim runaway condition in sufficient time to respond in accordance with the manufacturer's checklist instructions.

Event Information

Type of Event Accident
Event Date 7/22/2003
Event Day of the Week Tuesday
Time of Event 1015
Event Time Zone Pacific Daylight Time
Event City Coupeville
Event State WASHINGTON
Event Country --
Zipcode of the event site 98239
Event Date Year 2003
Event Date Month 7
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 481229N
Event Location Longitude 1223435W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 955 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 350
Weather Observation Facility ID KNUW
Elevation of weather observation facility 47
Distance of event from weather observation facility (units?) 7
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 100
Lowest Non-Ceiling Height 100
Sky/Lowest/Cloud Conditions Partial Obscuration
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 1
Air Temperature at event time (in degrees celsius) 13
Dew Point at event time (in degress fahrenheit) 12
Wind Direction (degrees magnetic) 290
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 6
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.13
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 2
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 18674
NTSB Notification Source FAA-ROC
NTSB Notification Date Jul 22 2003 12:00AM
NTSB Notification Time 1125
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Oct 27 2005 6:51AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office Seattle, Washington

Aircraft Involved

Aircraft #1

Aircraft Registration Number N996JR
NTSB Number SEA03FA147
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Cessna
Aircraft Model Citation 525
Aircraft Series Identifier --
Aircraft Serial Number 0147
Certified Max Gross Weight 10400
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 7
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Aug 1 2002 12:00AM
Airframe hours since last inspection 82
Airframe Hours 590
ELT Installed No
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Tango Corporation
Aircraft Owner Street Address 2241 Park Place Suite 1A
Aircraft Owner City Minden
Aircraft Owner State NV
Aircraft Owner Country USA
Aircraft Owner Zipcode 89423
Operator is an individual? No
Operator Name James C. Ray
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 2241 Park Place Suite 1A
Operator City Minden
Operator State NV
Operator Country USA
Operator Zip code 89423
Operator Code --
Owner has at least one certificate None
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 --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code CYYJ
Departure City Sidney
Departure State --
Departure Country CA
Departure Time 1005
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code BOI
Destination City BOISE
Destination State ID
Destination Country USA
Specific Phase of Flight Descent - emergency
Report sent to ICAO? No
Evacuation occurred Yes
Date of most recent change to record --
User who most recently changed record --
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 --