NTSB CAROL · Event
Event LAX95IA027
Aircraft involved
Probable cause & findings
the company maintenance personnel's improper installation of the aileron cable.
Factual narrative
On October 29, 1994, at 0745 hours Pacific daylight time, a Fairchild SA-227AC, N191AF, experienced a loss of aileron control shortly after departing runway 27L at Oakland International Airport, Oakland, California. The airplane was operating as Ameriflight (AMF) flight 1894, a nonscheduled cargo flight, under Title 14 CFR Part 135. The pilot had filed and began a company visual flight rules flight plan to Reno, Nevada. The airplane, operated by Ameriflight, Burbank, California, did not sustain any damage. The certificated airline transport pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed. The pilot returned to Oakland International Airport without further incident. Ameriflight maintenance personnel told National Transportation Safety Board investigators that the right aileron cable broke at its 90-degree pulley attach points. They also said that the cable had accrued 15 hours since it was installed. The cable replacement was required by a Federal Aviation Administration (FAA) airworthiness directive. Safety Board investigators sent the broken aileron cable, with an exemplar from the cable stock used by Ameriflight maintenance personnel, to the Safety Board Metallurgical Laboratory. The Safety Board metallurgist reported that during examination of the cable, he found substantial bending deformation in a uniform direction in most wires next to the separation. He also said that a magnified optical examination revealed no evidence of wear or corrosion near the separation or anywhere else on the cable. The metallurgist conducted a scanning electron microscope (SEM) examination of the broken cable. The examination showed that some separated ends displayed necking down or fractures in a 45-degree plane. This condition is typical of overstress separations. Additionally, the metallurgist said, in part, that he . . .found many of the cable ends contained relatively flat fracture areas on a transverse plane, which could result from fatigue cracking. These flat surface areas usually terminated at a longitudinal fracture area . . . . A detailed SEM examination of the flat fracture area on these cable ends revealed ". . .a somewhat roughened and micro fissured fracture morphology, but no classical fatigue striations were found. Ductile dimples, a characteristic of overstress separations, were found in portions of the wire separations outside of the flat fracture areas. . . ." The cable material quality and strength conformed to the manufacturer's specifications. The operator reported that the mechanics and inspectors who changed the cable said the new cable could not have been kinked due to the procedure used. The mechanics said that the new cable end was attached to the old cable after cutting off the swaged-on fitting at the underfloor bellcrank end. The new cable is then pulled in by pulling out the old cable from the control yoke end. If the new cable were kinked, it would not pass through the keepers around the pulleys in the control circuit and other confined areas in the cable run. The operator did not say that during the final connection of the cable the attached ends could be twisted. The airplane manufacturer's representative told Safety Board investigators in a telephone interview conducted on December 7, 1994, that a kink could be induced during the installation process. He said that the maintenance procedures required the mechanic to swage the ends of the cable and conduct a pull-test greater than 1,200 pounds. He also said that if the cable was kinked, it would fail during the pull-test preinstallation. THE PILOT EXPERIENCED A LOSS OF AILERON CONTROL SHORTLY AFTER TAKEOFF. THE PILOT RETURNED TO THE AIRPORT AND LANDED WITHOUT FURTHER INCIDENT. EXAMINATION OF THE AIRPLANE REVEALED THE CABLE BROKE NEAR ITS 90-DEGREE ATTACH PULLEYS. THE SAFETY BOARD MATERIALS LABORATORY CONDUCTED A METALLURGICAL EXAMINATION OF THE CABLE'S FRACTURED SURFACES. THE EXAMINATION REVEALED THE CABLE SEPARATED DUE TO HIGH-STRESS/LOW-CYCLE FATIGUE CRACKING. MOST WIRE ENDS IN THE VICINITY OF THE SEPARATION WERE SEVERELY BENT. SUCH DAMAGE WOULD MOST LIKELY BE PRODUCED BY A KINK IN THE CABLE. A CABLE KINK CREATES VERY HIGH TENSILE STRESSES ALONG THE OUTSIDE OF THE KINK AND WOULD GENERATE PREMATURE HIGH-STRESS FATIGUE CRACKING. THE 15 HOURS OF TIME SINCE INSTALLATION IS CONSISTENT WITH SOME SORT OF SEVERE CONDITION SUCH AS A KINK. THE MECHANIC MOST LIKELY INSTALLED THE CABLE WITH ONE END TWISTED COMPARED WITH THE OTHER END. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1994_LAX95IA027.txt.
Findings + structured fields enriched from FAA avall.mdb.
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Related research
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Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2023 · Conference paper
The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- NASA NTRS 2026 · Conference Paper
Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
This study presents a computational investigation of steady state aerodynamics of the Subsonic Ultra-Green Aircraft Research (SUGAR) Transonic Truss-Braced Wing (TTBW) configuration over a wide range …
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
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