MIA91IA022

NTSB incident investigation · Aerospatiale ATR-42-300 · San Juan, PR · November 6, 1990

Incident · No injuriesIncident investigationFinal report
Date
November 6, 1990, 15:16 local (19:16 UTC)
Place
San Juan, PR
Injuries
44 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N972NAAerospatiale ATR-42-300
Weather
Visual (VMC) · Day
Status
Completed · report August 6, 1993
Report
Approved by Office Director
FAA report
19901106055109I
Case key
32765

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The improper use of aileron trim and the improper preparation for auto pilot disconnect by the flight crew combined with excessive forces applied by the aileron trim system resulting in a departure from controlled flight. Contributing factors to the incident were inadequate and misleading autopilot warnings, lack of conspicuity of the aileron trim indicator, lack of FAA regulation governing control authority in mistrim conditions, autopilot system masking of mistrim conditions, and the lack of FAA requirement for recurrent pilot training in autopilot use.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightClimb - to cruise
Autopilot - information insufficientManufacturerFactor
Acft/equip,inadequate designManufacturerFactor
Insufficient standards/requirements,aircraftFaa(organization)Factor
Aileron trim - improper use ofPilot in commandCause
Aileron trim - excessiveCause
Acft/equip,inadequate handling/perf capabilitiesManufacturerFactor
Insufficient standards/requirements,aircraftFaa(organization)Factor
Autopilot - exceededCause
Autopilot - inadvertent deactivationCause
Directional control - not maintainedPilot in commandCause
Altitude deviation,uncontrolledClimb - to cruise

Analysis

Plt stated autopilot engaged at 1,000 feet after t/o. aileron trim was used after autopilot engagement. Flt was given heading change to rt. Autopilot hdg bug did not turn a cft. He disconnected the autopilot at 2,200 ft and the acft immediately rolled into a left 60 degree bank and began descending. He then activated aileron trim to the rt and along with the copilot on the controls they recovered. Post crash examination of the acft structure, flt controls, and autopilot system revealed no evidence to indicate preincident failure or malfunction of these. The dfdr and radar data indicated the event occurred at 3,300 feet and that for 45 seconds before the event occurred the ailerons were deflected to the rt 2 to 5 degrees. After the descending left turn began plts did not reduce power for 60 seconds and acft speed exceeded 250 knot vne speed. After the incident the acft mfg restricted use of the aileron trim to 1 dot with autopilot engaged, not three dots as had been previously allowed.

Aircraft

Registration
N972NA
Reported as
Aerospatiale ATR-42-300 (ATR 42-300)
Category
Airplane
Serial number
023
Engine
P&W PW-120, 2,100 horsepower, turbo prop
Damage
No damage
Flight
Part 121
Operator
Executive Air Charter, Inc., doing business as American Eagle
Registered owner
Executive Air Charter, Inc
Airworthiness certificate
Standard, Transport
Destination
STX · St. Croix
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
40
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
19,813 total · 1,641 in this make and model · 73 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 8 knots
Visibility
15 statute miles
Lowest ceiling
25,000 ft broken
Temperature
90 °F, dew point 73 °F
Altimeter
29.00 inHg
Observed at
SJU, 5 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.