NTSB issues safety recommendations to prevent B737 elevator jam due to FOD

February 14, 2011

The U.S. National Transportation Safety Board (NSTB) issued five safety recommendations to the Federal Aviation Administration (FAA) to prevent the elevator of certain Boeing 737 models to become jammed as a result of foreign object damage to the elevator power control unit input arm assembly.

The recommendations were issued as a result of an incident involving a Boeing 737-400 in June 2009.

On June 14, 2009, a Boeing 737-400, registration number TC-TLA, operated as Tailwind Airlines  flight OHY036, experienced an uncommanded pitch-up event at 20 feet above the ground during approach to Diyarbakir Airport (DIY), Turkey. The flight crew performed a go-around maneuver and controlled the airplane’s pitch with significant column force, full nose-down stabilizer trim, and thrust. During the second approach, the flight crew controlled the airplane and landed by inputting very forceful control column inputs to maintain pitch control. Both crewmembers sustained injuries during the go-around maneuver; none of the 159 passengers or cabin crewmembers reported injuries. The airplane was undamaged during the scheduled  commercial passenger flight.

An investigation found that the incident was caused by an uncommanded elevator deflection as a result of a left elevator power control unit (PCU) jam due to foreign object debris (FOD). The FOD was a metal roller element (about 0.2 inches long and 0.14 inches in diameter) from an elevator bearing. During  its investigation of this incident, the NTSB identified safety issues relating to the protection of the elevator PCU input arm assembly, design of the 737 elevator control system, guidance and training for 737 flight crews on a jammed elevator control system, and upset recovery training.

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

Require Boeing to develop a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris. (A-11-7)

Once Boeing has developed a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris as requested in Safety Recommendation A-11-7, require operators to modify their airplanes with this method of protection. (A-11-8)

Require Boeing to redesign the 737-300 through -500 series airplane elevator control system such that a single-point jam will not restrict the movement of the elevator control system and prevent continued safe flight and landing. (A-11-9)

Once the 737-300 through -500 series airplane elevator control system is redesigned as requested in Safety Recommendation A-11-9, require operators to implement the new design. (A-11-10)

Require Boeing to develop recovery strategies (for example, checklists, procedures, or memory items) for pilots of 737 airplanes that do not have a mechanical override feature for a jammed elevator in the event of a full control deflection of the elevator system and incorporate those strategies into pilot guidance. Within those recovery strategies, the consequences of removing all hydraulic power to the airplane as a response to any uncommanded control surface should be clarified. (A-11-11)


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