MIA95IA187

NTSB incident investigation · Boeing 737-3B7 · Orlando, FL · July 18, 1995

Incident · No injuriesIncident investigationFinal report
Date
July 18, 1995, 16:30 local (20:30 UTC)
Place
Orlando, FL
Injuries
120 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N390USBoeing 737-3B7
Weather
Visual (VMC) · Day
Status
Completed · report September 3, 1996
Report
Approved by Office Director
FAA report
19950718026339I
Case key
37677

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

On this page

Probable cause

Contamination of the wiring harness and electrical connectors to the E-1-2 and E-1-3 shelf disconnect brackets in the electronics compartment, which resulted in an electrical fault and an uncommanded roll malfunction of the autopilot. A factor relating to the incident was: inadequate maintenance inspection of the aircraft by company maintenance personnel.

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.

Airframe/component/system failure/malfunctionDescent
Water and waste system - leakFactor
Door,passenger - leakFactor
Automatic flight control system (afcs) - contamination,other than waterCause
Automatic flight control system (afcs) - contamination,waterCause
Maintenance,inspection - inadequateCompany maintenance personnelFactor
Autopilot/flight director - malfunctionCause

Analysis

The flight experienced an uncommanded roll to the left during descent for landing. The flight crew disengaged the autopilot and yaw damper, but reengaged the yaw damper since there was no apparent yaw problem. The descent was continued and a landing was made without further incident. Examintation revealed the connector plugs and wiring harness to the E-1-2 and E-1-3 shelf disconnect brackets in the electronics compartment were contaminated with water and a blue residue. The sources of contamination were water from a current main cabin door leak and blue residue from a previous leak of the forward lavatory.

Factual narrative

On July 18, 1995, about 1630 eastern daylight time, a Boeing 737-3B7, N390US, registered to and operated by USAIR, Inc., as flight 855, a 14 CFR Part 121 scheduled domestic passenger service from Pittsburgh, Pennsylvania, to Orlando, Florida, experienced an uncontrolled roll to the left during descent for landing. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The aircraft was not damaged and the airline transport-rated pilot, first officer, 3 flight attendants, and 115 passengers were not injured. The flight originated from Pittsburgh, on July 18, 1995, about 1504.

The captain stated that about 65 nautical miles north of Ormond Beach, Florida, the flight was descending through 28,000 feet. The "A" autopilot system was on longitudinal navigation and vertical speed was selected for pitch control. The aircraft suddenly rolled hard to the left to about 25 degrees of bank angle. He overrode the roll with aileron control and returned the aircraft to wings level. The aircraft again rolled to the left and he disengaged the autopilot and yaw dampener. He reengaged the yaw dampener, left the autopilot off, and continued the flight to Orlando, without further incident.

Examination of the aircraft showed the connector plugs and wiring harness to the E-1-2 and E-1-3 shelf disconnect brackets in the electronics compartment were contaminated with blue residue and water. The flight control computers and flight management computer mounts on these shelves. Evidence indicated the forward lavatory located above the electronics compartment had leaked at one time but was not currently leaking. Additionally, the main cabin door drain was found to not be properly sealed and water was leaking from the drain and dripping on to the wiring harness and migrating into the connectors.

The flight control computer, and roll actuators were removed from the aircraft and tested. No failures which would cause an uncommanded roll were noted.

For additional information see attached Boeing Commercial Airplane Company report, the Honeywell test report, and the FAA test report.

Aircraft

Registration
N390US
Reported as
Boeing 737-3B7
Category
Airplane
Serial number
23312
Airframe hours
29,494
Engine
GE CFM56-3, 22,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
Usair
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · July 18, 1995 · 6 hours before
Departed
PIT · Pittsburgh, PA
Destination
MCO
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
49
Certificates
Flight instructor, Flight engineer, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
14,651 total · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 12 knots
Visibility
10 statute miles
Lowest ceiling
14,000 ft broken
Temperature
82 °F, dew point 73 °F
Altimeter
29.00 inHg
Observed at
MCO, 110 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.