MIA95IA194

NTSB incident investigation · Boeing 737-3B7 · Charlotte, NC · August 5, 1995

Incident · No injuriesIncident investigationFinal report
Date
August 5, 1995, 10:00 local (14:00 UTC)
Place
Charlotte, NC
Injuries
83 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N396USBoeing 737-3B7
Weather
Visual (VMC) · Day
Status
Completed · report September 3, 1996
Report
Approved by Office Director
Case key
37678

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

Improper installation of the 'a' system flight control computer by company maintenance personnel, which resulted in pin connector(s) being pushed loose and subsequent malfunction of the autopilot.

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
Maintenance,installation - improperCompany maintenance personnelCause
Automatic flight control system (afcs) - loose part/bolt/nut/clamp/etcCause
Autopilot/flight director - malfunctionCause

Analysis

The captain reported that during descent through 12,000 feet with the 'a' system autopilot engaged and with an airspeed of 250 knots, there was an uncommanded roll to the left. He disengaged the autopilot and rolled the the airplane to wings level flight, then continued the flight with the autopilot off. Postincident examination of the aircraft revealed an intermittent electrical connection in an 'a' autopilot circuit, due to pin connector(s) being pushed out of place on the flight control computer shelf connector. One of the pins was in the aileron position sensor excitation circuit. The 'a' flight control computer had been removed and reinstalled the day before the incident to inspect the rack for fluid contamination.

Factual narrative

On August 5, 1995, about 1000 eastern daylight time, a Boeing 737-3B7, N396US, operated by USAir, Inc., as flight 7, a 14 CFR Part 121 domestic passenger flight from Albany, New York, to Charlotte, North Carolina, had an uncommanded roll to the left while descending to land at Charlotte. 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 78 passengers were not injured. The flight originated from Albany, New York, on August 5, 1995, about 0833.

The captain stated that during descent through 12,000 feet at 250 knots airspeed, the "A" autopilot system was on LNAV and level change. The aircraft shuttered and then rolled to the left to a 30-degree bank angle. He disengaged the autopilot and rolled the aircraft level. The flight was continued with the autopilot off.

Postincident investigation revealed the "LO" side of the roll sensor excitation from the "A" autopilot system flight control computer (FCC) to the "A" aileron autopilot actuator LVDT and "A" airleron postion sensor was intermittently open due to a socket pushed out of the locked position in the connector. Intermittent contact of this socket with its pin in the connector could cause airplane roll oscillations. The "A" system FCC had been removed and reinstalled the day before the incident to inspect the connectors for contamination. See attached Boeing Commercial Airplane Company report.

Aircraft

Registration
N396US
Reported as
Boeing 737-3B7
Category
Airplane
Serial number
23318
Airframe hours
27,857
Engine
GE CFM56-3, 22,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Usair
Registered owner
Society National Bank
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · August 5, 1995 · 11 hours before
Departed
ALB · Albany, NY
Destination
CLT
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
40
Certificates
Airline transport, Flight engineer, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
11,300 total · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 6 knots
Visibility
7 statute miles
Lowest ceiling
2,700 ft overcast
Temperature
75 °F, dew point 72 °F
Altimeter
30.00 inHg
Observed at
CLT, 40 nm away