CHICAGO, IL, USA
N575UA
Boeing 757-222
The pilot reported, "We encountered substantial vertical control flutter FL310-350 .78-.80 Mach with left, center, right autopilot and no autopilot. Flutter stopped when IAS was decreased. Descended to FL310, 250 kts., .75 Mach and had no more flutter. The flight diverted to O'Hare Airport and made an uneventful landing. Maintenance inspections revealed excessive free play in the elevator flight controls. The allowable limit is 0.340 inch and 0.50 inch was measured. The free play was corrected in accordance with the current maintenance manual. The bushings, the left center power control actuator (PCA), two reaction links, and four ilder links were replaced. During a subsequent test flight, vertical oscillations were still present. Further maintenance action included replacing all elevator hinge bearings and four PCA's. The third flight test was successful and the airplane was returned to service. Inspection of two reaction link rod ends revealed axial and radial wear which exceeded allowable limits. Inspection of the 16 hinge bearings revealed 3 bearings had axial and radial wear which exceeded limits and had moderate to severe corrosion. On October 11, 2001, the FAA issued Airworthiness Directive (AD) 2001-20-11 that was applicable to all B-757 series airplanes to "prevent unacceptable airframe vibration during flight, which could lead to excessive wear of elevator bearings and result in reduced controllability of the airplane…" The AD required, "Before further flight after the free-play checks, lubricate the bearings in the elevator PCA load loop and hinge line." Lubrication of the hinge bearings had not been required in a previous AD. The new AD required recurrent inspections every 18 months instead of the previous requirement of 4,000 hours, or 3,000 hours for some models. On January 28, 2001, Boeing issued a maintenance manual revision that corrected improper instructions for elevator free-play checks. The improper procedures in the maintenance manual had been in effect from September 20, 1997, to January 28, 2001.
HISTORY OF FLIGHT On October 28, 1999, at approximately 2132 central daylight time, a Boeing B757-222, N575UA operated by United Airlines (UAL) as Flight 225, experienced an airframe vibration and diverted to O'Hare International Airport, Chicago, Illinois, for a precautionary landing. The 14 CFR Part 121 revenue flight had departed Dulles International Airport, Herndon, Virginia, at 1943 eastern daylight time with San Francisco International Airport, San Francisco, California, as the destination airport. While in cruise flight, a series of airframe vibrations occurred. The airspeed was reduced to 250 knots and the decision to divert to O'Hare was made. The landing was uneventful. None of the 2 pilots, 4 flight attendants, or 62 passengers were injured. Visual meteorological conditions prevailed and the flight was on an IFR flight plan. After the incident, the Captain made the following write-up in the airplane's maintenance logbook: "We encountered substantial vertical control flutter FL310-350 .78-.80 Mach with left, center, right autopilot and no autopilot. Flutter stopped when IAS was decreased. Descended to FL310, 250 kts., .75 Mach and had no more flutter. Two similar write-ups Oct. 17 and 21. Called SAMC [Systems Aircraft Maintenance Control]. They said they did not know what was wrong and that we might have some loose parts in the tail. Dispatch indicated Lt. to Mod. turbulence ahead over Nebraska and Colorado. Their advice was to divert to ORD. I agree and we diverted to ORD." The First Officer reported the incident in the following manner: "We left IAD on time at approximately 19:45. The departure and climb-out were normal. However, shortly after leveling out at FL 350 we felt a moderately strong vibration and were advised by the flight attendants that the entire cabin had felt it as well. The most accurate way to describe it would be to say that it felt as if something in the tail section was moving, causing the front section of the plane to oscillate very rapidly up and down. We disconnected the center autopilot and descended to FL 310, slowing to approximately mach .78. The vibration stopped temporarily, returning a few minutes later. We tried the left autopilot, and the vibration occurred with it as well, and did not stop until we descended and slowed later. [The Captain] requested that I handfly while he got on the radio with SAM, SFO Engineering, and Chicago Dispatch. We called a UAL pilot from the back to come up to the cockpit and help us out. At this point we were passing abeam ORD on our flight planned route. After [the Captain] talked with maintenance in San Francisco and was advised we might have 'a loose part in the tail,' and considering possible moderate turbulence past Denver, we elected to divert to Chicago. ATC gave us an immediate right turn and vectored us to ORD, giving us priority handling without declaring an emergency. We requested emergency equipment standby for the landing, which turned out uneventfully. We released the equipment upon rollout, and after debriefing maintenance at the gate, we exchanged planes and continued on into San Francisco." During an interview, the Captain related the events concerning the in-flight vibration incident. He reported that the departure and climb out from Dulles were normal. The airplane leveled off at 35,000 feet with the center autopilot (AP) engaged. About 20 to 25 minutes after departure and south of Pittsburgh, the airplane experienced flutter (Captain's word). He reported that he clicked the center AP off and slowed the aircraft. He descended to 31,000 feet and stabilized at 31,000 feet. He reported that he increased the airspeed with the left AP engaged. A short period later the flutter came back. He did not know what speed the airplane was flying. He reported that the flutter came back for 5 to 10 seconds. During that time, the Captain reported, he turned the left AP off and engaged the right AP. The flutter continued. He turned the right AP off and flew the airplane by hand. The flutter continued. He reported that when he reduced airspeed the flutter stopped. He reported that he thought the airspeed was controlling the vibration. He reported he had reduced the airspeed to about .78 mach or about 250 kts. He reported that the vibration was felt throughout the airplane, but that it was not a violent vibration. He reported the vibration was a vertical vibration caused by the elevators. He reported the flight attendants and the dead heading pilot felt the vibration. He characterized the vibration as what you would feel when taxiing over the bridge at O'Hare Airport. He felt the aircraft was completely sound. He reported that he checked the flight manual, but could not find a procedure that applied to the situation. He reported that he checked the aircraft logbook for previous write-ups. He found that the write-up from 8/21/99 seemed to be similar. He contacted SAMC for their assistance. He described the problem and SAMC said they would check with engineering and get back to them. The Captain reported that it took SAMC about 20 to 30 minutes to call back. SAMC and Dispatch contacted the flight. SAMC informed the Captain that there might be "...loose parts in the tail," and that some bushings or bearing might have more play than normal. During the three-way discussion between the Captain, SAMC, and Dispatch, it was decided that the flight should divert into Chicago. During the interview, the Captain was asked if he had any theories concerning the vibration. He responded that he thought it was related to the airspeed. When the aircraft was slowed, the vibration stopped. During the interview, the Captain was asked if he would do the same thing under similar circumstances. He responded that he would. He reported that there were no specific procedures for this type of occurrence, and that he would rely on his experience and airmanship. During the interview, the Captain was asked why he tried all three AP's. He responded that he suspected the vibration was related to the AP. He was making a quick check of each AP since they are stand-alone systems. During the interview, the Captain was asked if he had considered landing at Dulles since the flutter occurred within the first 20 to 25 minutes of a flight that lasted approximately 1.5 to 1.8 hours. He responded that he did not think it was necessary. AIRCRAFT INFORMATION The airplane was a twin engine Boeing B-757-222, serial number 26689, manufactured in 1993. The airplane seated 196 and its maximum gross weight was 241,000 pounds. The engines were Pratt and Whitney PW2037 turbofan engines that delivered 37,000 pounds of thrust each. The last inspection was on November 16, 1998, and was part of the continuous maintenance inspection program. The airplane had accumulated 3,160 hours since the last inspection and had a total time of 23,631 hours. TESTS AND RESEARCH UAL Maintenance and Test Flights A maintenance inspection was performed on N575UA at the UAL maintenance hangar at O'Hare Airport. The free play of the elevator was found to be out of limits. It measured 0.5 inch and the allowable limit was 0.340 inch. Parts that were replaced included bushings, the left center power control actuator (PCA), two reaction links, and four idler links. The first test flight was conducted on October 31, 1999. The airplane failed the test flight since it still exhibited a vertical vibration throughout the airplane. The logbook test pilot narrative write-up read as follows: "ACFT fluttered noted at FL350 and .81M with CTR AP engaged, disengaged CTR AP, selected L & R AP's fluttering continued, turned AP's off and fluttering continued. Descended to FL310 and reduced speed to 250 kts and fluttering subsided. Fluttering occurred in pitch motion, all trim indications normal per crew. [name deleted]. See previous history." During a conference call, the test pilot reported that the airplane still had a vertical bounce. He characterized the bounce in the cockpit like bouncing a baby on the knee at 2 to 3 cycles per second. He reported he observed the food carts in the aft galley were bouncing slightly off the floor. He reported the vibration was mach related, but that it would go away with slight control wheel pressure. He reported that the bouncing lasted about two minutes. He reported that it would stop briefly and then return. He reported that he had no difficulty controlling the airplane. He reported the free-play in the elevator did not get translated to the yoke because of the PCA's. N575UA landed at Indianapolis International Airport (IND) at the conclusion of the test flight. Further maintenance was performed on the airplane at the UAL maintenance facilities. The free-play and rigging were re-checked. The only significant problem they identified was the cable tensions from the pilot and copilot yokes back to the elevator actuators. The cable tension required was 135 pounds. The cable tension was measured at 110 pounds. On November 1, 1999, the airplane was flight tested for a second time. The airplane failed the test flight. The logbook pilot narrative write-up read as follows: "Aircraft still has rapid pitch oscillation. Oscillation started while climbing through 32,000', mach 0.813. Oscillation occurs with any autopilot or no autopilot engaged. Oscillation stopped immediately when applying very slight<<" N575UA returned to IND for further maintenance actions performed by UAL and Boeing technicians. Boeing provided assistance to perform an instrumented test flight on N575UA. The following is a list of maintenance actions that were completed prior to the third test flight: 1. All hinge bearings on the right and left elevators were removed and replaced. 2. The PCA from the right outboard position was removed due to questionable rod end bearing corrosion/wear. 3. The PCA from the right middle position was removed due to questionable rod end bearing corrosion/wear. 4. The PCA from the left outboard position was removed due to questionable rod end bearing corrosion/wear. 5. The borrowed PCA from America West Airlines that had been used on the left center elevator during the two test flights was replaced. The airplane was instrumented with eight accelerometers to determine the source of the vibration. A third test flight was flown on November 10, 1999, and all vibrations detected at all speeds and flight levels were within normal ranges. The logbook pilot narrative write-up read as follows: "Aircraft test flown with Boeing instrumentation after elevator bearing replacement. Aircraft flew with no vibs-oscillations noted at speeds up to MM0 and altitudes up to 41000 feet. Aircraft was flown using each A-P individually and manually- Hydraulic systems were turned off, input to elev, rudder and aileron were made - all normal. APU started at 35000 - no problems noted. Aircraft can be returned to revenue service." UAL Parts Removal and Inspection Numerous parts were removed from N575UA for inspection and analysis during the course of the investigation. In particular, the elevator bearings, bushings, reaction links, and PCA's were inspected at the UAL San Francisco Maintenance Base, Flight Control shop, with FAA oversight. A cursory examination of the bearings revealed that a majority of the bearings had sustained varying degrees of removal damage. The following is a list of the elevator hinge bearings with their vendor part number and position on the stabilizer from left to right. Item # Part Name Part number Position 1) Bearing DAS6-23A-48 1 2) Bearing DAS6-23A-48 2 3) Bearing DAS6-23A-48 3 4) Bearing DAS6-23A-48 4 5) Bearing DAS6-23A-48 7 6) Bearing DAS6-23A-48 8 7) Bearing DAS6-23A-48 9 8) Bearing DAS6-23A-48 10 9) Bearing DAS6-23A-48 13 10) Bearing DAS6-23A-48 14 11) Bearing DAS6-23A-48 15 12) Bearing DAS6-23A-48 16 13) Bearing DAS8-27B-48 5 14) Bearing DASS-27B-48 6 15) Bearing DAS8-27B-48 11 16) Bearing DAS8-27B-48 12 The following is a list of the upper reaction link rod ends and PCA's that were inspected: 1) Left hand, Middle, Upper Reaction Link Rod End, P/N DRX34B, S251N214-11 2) Left hand, Inner, Upper Reaction Link Rod End, P/N DRX34B, S251N214-11 3) Left hand, Outboard, PCA (s/n 9293315) Rod End, P/N DRX32B 4) Right hand, Outboard, PCA (s/n 5304) Rod End, P/N DRX32B Notes: 1) Part number DAS6-23A-48 falls under Boeing Specification BACB10CH60C 2) Part number DAS8-27B-48 falls under Boeing Specification BACB10CH85C 3) The serial number for the right hand PCA is not the actual unit serial number. The data plate was missing when the unit arrived in the shop. The number 5304 was derived from a pressure differential sensor serial number. Both units are identified with the following UAL part number and dash number: Left hand, Outboard, PCA (s/n 9293315) UAL p/n MR27314 - 269 Right hand, Outboard, PCA (s/n 5304) UAL p/n MR27314 - 268 The UAL examination of the 16 hinge bearings, two reaction links and two PCA rod end bearings yielded the following results: 1. All hinge bearings P/N DAS6-23A-48 (positions 1-4, 7-10 and 13-16) were received with the retaining sleeve still installed over the outside diameter and were observed to have moderate to extensive damage to the sleeves and bearings as a result of the removal process. Several bearings would not rotate as a result. All of these bearings exhibited a radial play of approximately 0.001 to 0.0015 inch with a load applied. 2. The four hinge bearings P/N DAS8-27B-48 (positions 5, 6, 11 and 12) were observed to have moderate to extensive damage to the bore inside diameter as well as the dust shields as a result of the removal process. These bearings do not utilize sleeves for retention. All bearings would rotate. Bearing numbers 5, 6 and 12 exhibited a radial play of approximately 0.001 to 0.0015 inch with a load applied. Bearing number 11 exhibited a radial play of approximately 0.035 to 0.040 inch with a load applied and an axial play of approximately 0.095 to 0.100 inch. External examination revealed the lubricant was present, but appeared reddish in color. Removal of the dust shield from one side, which was partially dislodged from the removal process, revealed lubricant that was reddish in color with a dried cake-like appearance. The bearing was mildly cleaned and microscopic examination showed severe corrosion damage to the rollers and races. 3. The left hand, middle, upper reaction link rod end (P/N DRX34B, S251N214-11) was examined and exhibited a radial play of approximately 0.008 inch with a load applied. External observations revealed lubrication that is reddish in color and some, non-location specific, gritty feel when rotated by hand. 4. The left hand, inner, upper reaction link rod end (P/N DRX34B, S251N214-11) was examined and exhibited a radial play of approximately 0.008 inch with a load applied. External observations revealed lubrication that is reddish in color and some, non-location specific, gritty feel when rotated by hand. 5. The left hand outboard PCA (UAL -269) Rod End and the right hand outboard PCA rod end (UAL -268) bearings both exhibited a radial play of approximately 0.001 to 0.0015 inch with a load applied. 6. The right hand outboard PCA rod end (UAL -268) bearing had a gritty feel during rotation by hand. The lubrication, that was visible externally, was reddish in color. Removal of the dust covers and mild cleaning revealed moderate to severe corrosion common to all roller surfaces and the ball. The corroded side was opposite the zerk fitting. The side common to the zerk fitting has minimal corrosion on the rollers and moderate corrosion on the ball. UAL reported that it had complied with all the requirements of the Boeing 757 Maintenance Planning Document (MPD) and utilized Boeing's maintenance manual procedures to maintain the elevator control system. Boeing Inspection of Parts The 16 hinge bearings a
the in-flight vibration of the airplane's elevator due to excessive freeplay in the elevator control system. Factors included the corrosion of the elevator PCA reaction link bearings and the elevator hinge bearings, excessive axial and radial wear of the elevator PCA reaction link bearings, the inadequate procedures for lubricating the elevator hinge bearings, and the incorrect procedures for measuring elevator free play.
Source: NTSB Aviation Accident Database
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