Flight control systems

Boeing 747SP-38, VH-EAA

Summary

A Boeing 747-SP38 aircraft was maintaining Flight Level (FL) 430 with autopilot `A' engaged, when the aircraft yawed abruptly to the right and rolled to a bank angle of approximately 20 degrees. The autopilot was disengaged and the aircraft stabilised in a straight and level attitude. The uncommanded yaw occurred again. The flight crew broadcast a PAN (radio code indicating uncertainty or alert, not yet the level of a Mayday) and received a descent authorisation to FL380.

The upper rudder position indicator showed a rudder displacement of 5-degrees right and the lower rudder indicator showed zero degrees deflection. The flight crew began activating and de-activating the upper and lower yaw damper switches attempting to isolate the problem. During those actions, the aircraft commenced to `Dutch roll' (lateral oscillations with both rolling and yawing components). The crew then successfully isolated the problem to the upper damper and turned the upper damper switch off. With the aircraft at FL380, normal operations ensued. Autopilot `B' was then engaged and the flight proceeded without further incident.

Investigation by company maintenance personnel confirmed an anomaly of the upper yaw damper computer. The unit was replaced and the system tested. Normal operations ensued.

Analysis of Flight Data Recorder information revealed that during the event the upper rudder displaced 4.7 degrees. The data also indicated that the maximum roll encountered was 13 degrees to the right.

System redundancy had operated as required to limit the effect of the upper yaw damper anomaly.

Occurrence summary

Investigation number 200105429
Occurrence date 13/11/2001
Location Abeam Moomba
Report release date 25/03/2002
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration VH-EAA
Serial number 22495
Sector Jet
Operation type Air Transport High Capacity
Departure point SINGAPORE
Destination Sydney, NSW
Damage Nil

Cessna T207A, VH-KAX

Safety Action

Local safety action

The operator reported that, to ensure integrity, they had conducted an inspection of all flight control rod ends for the company fleet of aircraft.

Summary

A Cessna T207A aircraft, with seven persons on board, was departing Jabiru for a local scenic flight. The operator reported that the control rod end for the right aileron disconnected and the aileron deflected upwards shortly after the aircraft had rotated for take-off. The take-off was continued as there was insufficient runway remaining to stop the aircraft. A significant amount of left aileron input was then required to counteract the tendency for the aircraft to roll right. The pilot was able to conduct a normal left circuit and landed the aircraft safely at the departure runway. There were no injuries to passengers or crew, and no damage to the aircraft.

The investigation found that the swivel joint for the rod end, which attached to the outboard end of the right aileron control rod, had fractured and separated at the base of the threaded section. The rod-end fitting consisted of a rounded but flat-sided cast-alloy housing with a threaded tail section, which was attached to the interconnecting drive rod from the wing. The housing contained a spherical bearing with a bolt through the centre (at ninety degrees to the threaded tail) which connected the drive rod to the aileron control surface.

Metallurgical examination confirmed that the rod-end bearing had seized in the housing due to surface corrosion on the sliding surfaces. That action had exposed the threaded shank section of the fitting to elevated bending loads, rather than the push-pull loads for which it was designed. Cracking then initiated and propagated, through about 50% of the rod-end cross section, under normal operating conditions over an extended period before finally separating.

Examination of the maintenance documentation for the aircraft showed that the failed rod end was fitted to the aircraft as a new item on 14 Oct 1999. The rod end failed in service on 13 June 2001. At that time, it had completed a total of 754.3 hours time-in-service. The rod ends did not have a time-in-service life and were listed by the manufacturer as an "on condition" item.

The company reported that it had a policy of changing all control rod swivel-end fittings when their aircraft underwent repainting; approximately every 4-5 years. The investigation was unable to determine why the rod end was not changed at the last repaint.

Occurrence summary

Investigation number 200102538
Occurrence date 10/06/2001
Location Jabiru, (ALA)
State Northern Territory
Report release date 14/03/2002
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 207
Registration VH-KAX
Serial number 20700630
Sector Piston
Operation type Charter
Departure point Jabiru, NT
Destination Jabiru, NT
Damage Nil

Boeing 737-33A, VH-CZX

Safety Action

As a result of this occurrence, the aircraft operator updated the Flight Spoiler System Engineering Release to ensure the continued integrity of B737 spoiler cables. In addition, the operator subsequently reviewed the duty time limitations for maintenance personnel and issued guidance material indicating that duty times be limited to a maximum of 16 hours in any 24-hour period.

In February 2001, The Australian Transport Safety Bureau (ATSB) released an Air Safety Information Paper titled "ATSB Survey of Licenced Aircraft Maintenance Engineers in Australia" One of the safety deficiencies identified during the survey was a "current lack of programs to limit the extent of fatigue experienced by maintenance workers". As a result of that deficiency, the ATSB issued the following safety recommendation to the Civil Aviation Safety Authority (CASA):

R20010033 issued February 2001

"The Australian Transport Safety Bureau recommends that CASA ensures through hours of duty limits, or other means, that maintenance organisations manage work schedules of staff in a manner that reduces the likelihood of those staff suffering from excessive levels of fatigue while on duty."

The Civil Aviation Safety Authority responded to the safety recommendation on 31 August 2001. That response stated:

"Given that "fatigue was listed as a contributing factor in just over 12% of occurrences", CASA believes that there is clearly a need for the appropriate regulation of this issue.

CASA has addressed the issue of hours of duty rules and fatigue management in relation to aircraft maintenance engineers in the proposed Civil Aviation Safety Regulations Part 43 -Maintainers Responsibilities and Part 145 - Approved Maintenance Organisations, (CASR Part 43 and CASR Part 145).

Draft regulations for CASR Part 43 were released as a Discussion Paper for public comment on 22 February 2001. A working draft of the proposed regulations for CASR Part 145 was released for public comment on 5 July 2001.

Proposed sub-regulation 145.190 requires an approved maintenance organisation to ensure that each maintenance worker takes enough rest as specified in CASR Part 43.

Proposed sub-regulation 43.400 (2) specifies the following in relation to an appropriate work schedule for a maintenance worker:

At least 1 period of 24 hours of complete rest away from the workplace in any period of seven days; and

At least 10 hours of complete rest away from the workplace in any day.

Proposed sub-regulation 43.400 (3) provides that a maintenance worker must not continue for so long a period that the worker's capacity to carry out the work becomes significantly impaired.

I would like to note that the Authority has recently established a Fatigue Management Committee to review fatigue risk management issues, fatigue standards development and implementation.

As part of this review, the Committee will be asked to review the fatigue regulations contained in CASR Parts 43 and 145, for consistency against CASA's fatigue management approach.

CASA anticipates that following consideration and, if appropriate, incorporation of comments received from interested parties, including the Fatigue Management Committee, CASR Parts 43 and Part 145 will be released as Notices of Proposed Rule Makings for public comment later this year."

ATSB response status: CLOSED-ACCEPTED.

Summary

The crew of the Boeing 737 reported that when the speed brake was selected, during descent into Sydney with the autopilot engaged, the aircraft rolled slightly to the right. The autopilot was disengaged, and the speed brake was again selected with the same result. The speed brake was restowed and the flight continued and landed without further incident.

The operator reported that inspection of the aircraft, on 15 February 2001, revealed that the left-wing number three flight spoiler "UP" cable (P/No. WSA2-3) had failed at a pulley in the left wheel well at Wing Buttock Line (WBL) 73.00. The failure was due to corrosion as evidenced by rust deposits at the failure location. During rectification, all other left wing spoiler cables were replaced due to evidence of minor corrosion. Following repair, the aircraft was returned to service.

The operator reported that, after a previous spoiler cable failure in 1997 due to corrosion, an Engineering Release (ER) had been issued to require the inspection of all spoiler cables at the next Phase 20 check and subsequent 2C check with cable replacement at the next 4C check. Replacement at the 4C check terminated the inspection requirements of the ER.

As a result of the cable failure on 15 February 2001, the ER was revised to require inspection of the cables on an ongoing basis with cable replacement at every 4C check interval to preclude recurrence.

Subsequently, on 28 February 2001, the incident aircraft underwent overnight maintenance at Melbourne. During the maintenance inspection, the left-wing spoiler cables, that had previously been changed at Sydney on 15 February 2001, were found to be mis-routed. The operator's investigation revealed that the maintenance engineers involved in the original rectification had travelled from Brisbane to Sydney that day and had worked a period in excess of 24 hours with minimal breaks. Excessive hours worked and fatigue of the maintenance engineers was considered to have contributed to the misrouting of the cables and the failure to detect the misrouting during a duplicate inspection of the spoiler control system.

Occurrence summary

Investigation number 200100905
Occurrence date 15/02/2001
Location 56 km SW Sydney, Aero.
State New South Wales
Report release date 02/10/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-CZX
Serial number 24029
Sector Jet
Operation type Air Transport High Capacity
Departure point Adelaide, SA
Destination Sydney, NSW
Damage Nil

Cessna 441, VH-NAX

Summary

The pilot of the Cessna Conquest reported that during the take-off roll, the aircraft started to rotate of its own accord at 70 knots indicated airspeed.

With what he thought to be full forward trim selected and full forward pressure on the control yoke, the aircraft continued to climb. The pitch attitude increased further as the landing gear and flaps were retracted. Approaching 4,000 ft, the pilot reduced power and was able to maintain level flight. After checking the aircraft controllability in the approach and landing configurations, the pilot returned the aircraft to the departure airfield for an uneventful, although overweight, landing.

The subsequent maintenance investigation found the spiral groove in the trim wheel that drove the trim indicator needle had a piece broken out of it. This caused the trim needle to stick in the take-off position. Maintenance personnel reported that the pilot later stated that during the climb he had attempted to trim in order to compensate for the pitch up. While doing so he felt a resistance in the trim wheel and assumed that the trim system had failed. Therefore, he stopped trying to operate it. The pin was stuck in the damaged groove section and had increased the force required to move the trim wheel. Had the pilot applied additional pressure to the trim wheel, he would have overcome the restriction and regained trim authority. However, as he was not aware of the cause of the increased resistance in the trim system, he elected not to do so in case this action aggravated the situation.

A major defect report was submitted to CASA.

Occurrence summary

Investigation number 200006277
Occurrence date 20/12/2000
Location Meekatharra, Aero.
State Western Australia
Report release date 03/04/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 441
Registration VH-NAX
Serial number 4410106
Sector Turboprop
Operation type Charter
Departure point Meekatharra, WA
Destination Perth, WA
Damage Nil

British Aerospace Plc BAe 146-200A, VH-JJX

Safety Action

The operator replaced both right wing aileron trim cables and chains on the aircraft. As a result of this incident the operator carried out an aileron trim cable inspection of its fleet of twelve BAe146 aircraft. Notable corrosion in the rib 14 pulley area was found in both wings of another aircraft. All aileron trim (wing loop) cables of that aircraft were subsequently replaced.

On 27 July 2000 the operator issued an Engineering Release (ER) that required a more thorough inspection of aileron trim cables for corrosion at each C check. The inspection aimed to ensure that any hidden corrosion at pulley locations did not pass through major checks undetected. Inspection highlighted the need to operate flight controls over their complete range of movement allowing inspection of cable obscured by pulleys. The ER also called for cleaning and lubrication of cables, paying particular attention to the lengths of cable passing through the pulley bank.

Summary

During climb-out from Darwin, passengers on the British Aerospace Bae146 advised the cabin manager that about 3 metres of cable was trailing from the trailing edge of the right wing. After the first officer had conducted a visual inspection, the crew advised Darwin ATC that they had a problem and required a return for landing. Fuel was burnt off to achieve maximum landing weight. Controllability checks found no handling problems with the aircraft, which was landed safely.

An inspection identified the trailing cable as an aileron trim cable (upper). Failure of the cable had occurred at the outboard pulley located at wing rib 14. The cable was found to have failed as a result of significant corrosion between the pulley bank and the wing rear spar. Corrosion was also present on the failed cable coinciding with the location of the inboard pulley at wing rib 14. No corrosion was found on the left-wing aileron trim cables. Previous inspection of the area was reportedly carried out during a 6C check in May 1999, 3,495 flight hours earlier.

The aileron trim cable material was zinc coated carbon steel (MIL-W-83420, Type 1, Composition A). Stainless steel trim cables were not available from the aircraft manufacturer.

No other reported failures of BAe146 aileron trim cables were found in a search of the Civil Aviation Safety Authority major defect and ATSB incident databases. The operator advised that corroded cables and seized pulleys at that location had been recorded on various BAe146 aircraft since 1992. The aircraft maintenance manual required special attention for corrosion during inspection of cable sections in contact with pulleys.

Occurrence summary

Investigation number 200002622
Occurrence date 22/06/2000
Location 28 km E Darwin, Aero.
State Northern Territory
Report release date 25/05/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer British Aerospace
Model BAe 146
Registration VH-JJX
Serial number E2127
Sector Jet
Operation type Air Transport High Capacity
Departure point Darwin, NT
Destination Gove, NT
Damage Minor

Boeing 737-476, VH-TJY

Summary

While on final approach to Brisbane at about 1,000 ft, the crew of the Boeing 737 reported feeling a 'kick' in the rudder pedals accompanied by a minor aircraft yaw oscillation. It was reported that there was no aircraft ahead to cause wake turbulence.

Investigation by the aircraft operator suggested a problem with the rudder power control unit. The aircraft manufacturer recommended that the standby rudder actuator and the standby input rod bearings should also be examined for wear; no wear was evident.

The rudder power control unit had accumulated 3,064 hours since its overhaul by the manufacturer in May 1999. It was removed from the aircraft and forwarded to the USA for examination.

The examination was conducted by the component manufacturer and supervised by the National Transportation Safety Board of the USA on behalf of the Australian Transport Safety Bureau. No discrepancies that may have led to the anomaly in the operation of the rudder power control unit were found. The internal and external components contained no evidence of excessive wear, damage or overtravel and met the manufacturer's standards for in-service units.

In support of the investigation, the National Transportation Safety Board also conducted a performance simulation study based on the actual aircraft configuration data at the time of the incident. The study concluded that the rudder had oscillated.

The investigation was unable to determine why the rudder reportedly oscillated.

Occurrence summary

Investigation number 200001362
Occurrence date 18/04/2000
Location Brisbane, Outer Marker
State Queensland
Report release date 06/02/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-TJY
Serial number 28151
Sector Jet
Operation type Air Transport High Capacity
Departure point Melbourne, VIC
Destination Brisbane, QLD
Damage Nil

Boeing 747-200, DQ-FJI

Factual Information

Following flap retraction shortly after the Boeing 747 departed Sydney, the crew reported a flap disagreement indication. The flaps could not be extended and were stuck in the up position. The aircraft returned to Sydney where the crew carried out a flapless landing.

An inspection revealed that the right inboard fore-flap carriage stop had failed. This resulted in extensive damage to the fore flap, mid flap, and overload failure of the right flap drive torque tubes.

Specialist examination found that the fore-flap carriage stop failed due to stress corrosion cracking. The cracking initiated at the bolt hole surface. The manufacturer's instructions require that the bolt should be installed with wet sealant, however inspection indicated that the sealant did not cover the centre portion of the bolt, potentially allowing moisture to enter.

Occurrence summary

Investigation number 199901111
Occurrence date 16/03/1999
Location Sydney, Aero.
State New South Wales
Report release date 02/01/2001
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Accident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration DQ-FJI
Serial number 22145
Sector Jet
Operation type Air Transport High Capacity
Departure point Sydney, NSW
Destination Nadi, FIJI
Damage Substantial

Cessna 441, VH-LFD

Summary

The pilot of the Cessna 441 reported that while checking the aircraft's flight controls during a pre-flight inspection, a rubbing sound was evident in the vicinity of the inboard section of the left aileron. The ailerons were capable of full deflection in the correct sense with no noticeable restriction of movement. After an inspection by the operator's chief pilot and the check and training pilot, the aircraft was deemed to be serviceable. A precautionary note was made in the aircraft's Maintenance Release for the aileron system to be inspected by the operator's maintenance organisation. The pilot then continued operating the aircraft. On return to the operator's main base at Jandakot, an inspection by maintenance personnel revealed that the aileron control cable was incorrectly rigged and fouling the airframe structure.

The BASI investigation revealed the following deficiencies:

  1. a maintenance oversight and inadequate procedures for the release of an aircraft after undergoing maintenance to the flight controls;
  2. sixty flying hours had elapsed since maintenance was last performed on the aileron control system. The defect was apparently not recognised during that time; and
  3. the flight crew did not consult with company engineering personnel for technical advice prior to commencing the flight.

During the BASI onsite investigation, the details of this occurrence, together with occurrences 9804343, 9900874 and 9900556, which identified similar deficiencies, were discussed with the operating company's management and staff. Concerns identified by the BASI team were translated into company recommended safety actions, which management undertook to implement. The company immediately introduced changes to the duplicate inspection procedures, and would introduce education and awareness safety notices regarding effective communication between flight and maintenance personnel. It would also emphasise the responsibilities incumbent on the crew when carrying out the daily inspection procedure. The implementation and effectiveness of these company initiatives will be monitored by BASI.

Occurrence summary

Investigation number 199900673
Occurrence date 11/02/1999
Location Port Hedland, Aero.
State Western Australia
Report release date 08/12/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 441
Registration VH-LFD
Serial number 4410164
Sector Turboprop
Operation type Aerial Work
Departure point Port Hedland, WA
Destination Meekatharra, WA
Damage Nil

Cessna 402C VH-RMI, Darwin Airport, on 6 February 1998

Summary

After full flap was selected on late final approach, the pilot heard a loud thud, the aircraft pitched nose up and the flaps retracted rapidly. A go around was conducted while the pilot established that the aircraft operated normally, apart from the flaps. A flapless landing was carried out.

Examination of the flap system revealed a failure on the idler gear of the flap drive gearbox. The gearbox had been in service for 12,546 hours, since the aircraft was manufactured. The manufacturer had not specified any inspection schedules, the gearbox being required "on condition".

Occurrence summary

Investigation number 199800423
Occurrence date 06/02/1998
Location Darwin Airport
State Northern Territory
Report release date 29/10/2002
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer Cessna Aircraft Company
Model 402
Registration VH-RMI
Serial number 402C0408
Sector Piston
Operation type Air Transport Low Capacity
Departure point Garden Point, NT
Destination Darwin, NT
Damage Nil

Boeing 747-312, VH-INJ

Safety Action

As a result of the investigation into this occurrence, the Bureau of Air Safety Investigation issued the following Interim Recommendation on 16 September 1997:

"IR970138

The Bureau of Air Safety Investigation recommends that Boeing Commercial Airplane Group issue service information and appropriate corrective action to applicable B747 operators requiring fleet checks for:

  1. correct placement of aileron control cables on the cable drum located at WS776.98; and
  2. correct installation of aileron control position decals at WS767 and WS780".

Boeing response
The Boeing Commercial Airplane Group response, dated 13 November 1997 stated:

"The reference cover letter provided a copy of your report of an incident involving a 747-300 airplane, Serial Number 23029. The report indicates that one of the left aileron cables was broken during taxi prior to departure. The report stated that the aileron cable failures may be due to misrouting which may occur as a result of incorrectly installed markers. A check by the Australian Bureau of Air Safety Investigation found eight airplanes with incorrectly installed markers.

Your report recommended that Boeing initiate a fleet check for proper placement of the aileron control cables at Wing Station (WS) 776.98 and correct installation of aileron cable markers at WS767 and 780.

It has not been determined whether the incorrect marker installations occurred during or after manufacture. As a result of these findings, we plan to issue a service bulletin to 747 operators recommending fleet checks of all 747 airplanes prior to Line Position 1130, except Line Position 1122, for

  1. Correct routing of aileron control cables on the aileron cable drum located at wing station 777
  2. Correct installation and replacement as required, of aileron cable position markers at wing station 767 and wing station 780

Airplane Line Position 1130 was delivered in September 1997. Airplane Line Position 1122 was checked at Boeing. A review of the applicable engineering drawings shows that the marker installation and cable installation drawings are correct, and have always been correct. In addition, a check of airplanes in the factory and on the flight line indicates that both the markers and cables are currently being installed per drawing".

BASI response status: Closed - Accepted

Subsequent safety action

Boeing issued Service Bulletin 747-27-2367 (Flight controls - aileron - aileron control cable inspection and control cable marker inspection, replacement) on 25 June 1998.

As a result of the Bureau's interim recommendation, the US National Transportation Safety Board (NTSB) conducted an independent review of the circumstances of this occurrence and subsequently issued recommendation A-98-6 to the US Federal Aviation Administration (FAA) on 3 February 1998. This recommendation stated:

"The National Transportation Safety Board recommends that the Federal Aviation Administration:

Issue an airworthiness directive to require operators of Boeing 747 airplanes, produced before production line number 1130, to conduct a one-time inspection of the aileron control system to ensure correct routing of the aileron control cables on the aileron cable drum located at wing station (WS) 776.98 and correct installation of aileron cable decals at WS767 and WS780 at the earliest possible inspection interval".

Significant Factors

  1. The markers which provided visual guidance for the installation of the aileron control cables were transposed.
  2. The aileron control cables were incorrectly installed.
  3. Accelerated wear of the cables resulted in premature failure.

Analysis

The transposition of the markers provided incorrect guidance for the installation of the cables to the control drum. The two top cables then interfered with each other and resulted in an accelerated wear rate and subsequent cable failure. As the cable control drum area was difficult to see, and the aileron system operated correctly during funtional testing, incorrect installation of the cables was difficult to detect.

Summary

While taxiing for departure, the crew of the Boeing 747 selected the flaps to the take-off position. As the flaps extended, the left outboard aileron deflected to the full down position. The aircraft returned to the gate for rectification.

Investigation revealed that the left aileron cable (AA-11), which connected the inboard aileron quadrant to the aileron cable drum at wing station (WS) 776.98, had failed immediately outboard of the cable drum. The adjacent cable (AB-13), which connected the outboard aileron quadrant to the aileron control drum, was frayed at a location consistent with having been in contact with the other cable. The aileron cable drum had four grooves to accommodate the four separate aileron cables which ran inboard and outboard from the drum and connected to the inboard and outboard aileron quadrants. Markers were installed at the WS767 and WS780 locations to provide visual guidance for the routing and attachment of the aileron cables to specific grooves on the cable drum.

The aileron control drum forward guide pin was bent and displayed evidence of abrasion from interference by the cables. There was also abrasion to the top two grooves of the cable drum. Further examination revealed that the two aileron cable markers (decals) attached to the aileron drum's inboard and outboard mounting brackets at WS767 and WS780 were installed incorrectly. The marker for WS767 was fitted at WS780 and vice versa.

The aircraft had been manufactured in 1983 and had operated 62,399 hours to the time of the incident. Since 2 June 1997, when both cables were changed due to wear, the aircraft had operated 1,022 hours. The appropriate dual certifications, for the aileron control system, had been carried out at that time.

The investigation determined that another aircraft in the operator's fleet had had the same aileron cables changed, due to fraying and wear, about 12 months prior to the incident. This aircraft was inspected, and it was found that the aileron cable markers at WS767 and WS780 were also transposed.

The investigation also found that eight other aircraft, from various operators, had aileron cable markers incorrectly installed at the WS767 and WS780 locations. However, it was not possible to determine if the markers had been transposed during, or after, aircraft manufacture.

Occurrence summary

Investigation number 199702693
Occurrence date 20/08/1997
Location Brisbane, Aero.
State Queensland
Report release date 01/02/1999
Report status Final
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Flight control systems
Occurrence class Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 747
Registration VH-INJ
Serial number 23029
Sector Jet
Operation type Air Transport High Capacity
Damage Minor