MIA95IA214

NTSB incident investigation · Boeing 737-3B7 · Fort Lauderdale, FL · August 25, 1995

Incident · No injuriesIncident investigationFinal report
Date
August 25, 1995, 12:30 local (16:30 UTC)
Place
Fort Lauderdale, FL
Injuries
50 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N373USBoeing 737-3B7
Weather
Visual (VMC) · Day
Status
Completed · report January 16, 1996
Report
Approved by Office Director
FAA report
19950825033929I
Case key
37679

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

Low electrical resistance of the autopilot aileron actuator for unspecified reasons which resulted in an uncommanded roll to the right.

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
Autopilot/flight director,servo - otherCause
Autopilot/flight director,servo - undetermined
Autopilot/flight director,servo - uncommanded

Analysis

The flight experienced an uncommanded roll to the right during descent for landing. The 'b' autopilot system was engaged at the time. Post incident examination showed the 'b' autopilot aileron actuator had low electrical resistance. Tests by Boeing commercial airplane company have shown that low electrical resistance within the autopilot aileron actuator will cause uncommanded roll occurrences.

Factual narrative

On August 25, 1995, about 1230 eastern daylight time, a Boeing 737-3B7, N373US, registered to Society National Bank and operated by USAir, Inc., as flight No. 93, a 14 CFR Part 121 scheduled, domestic, passenger service from Philadelphia, Pennsylvania, to Fort Lauderdale, Florida, experienced an uncommanded roll to the right 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, 4 flight attendants, and 44 passengers were not injured. The flight originated from Philadelphia on August 25, 1995, about 1027.

The captain stated to USAir personnel that about 25 nautical miles northeast of Fort Lauderdale, the flight was descending to 6,000 feet, on a 222-degree heading, at 250 knots. The "B" autopilot system was on longitudinal and vertical navigation. The first officer was flying the aircraft. They felt a small "bump" and the aircraft suddenly rolled uncommanded to the right to about 30 degrees of bank angle. The captain disconnected the autopilot system and returned the aircraft to wings level with aileron control. There was no yaw associated with the roll event. The flight continued to Fort Lauderdale without further incident.

Postincident readout of the digital flight data recorder was performed by USAir personnel. The data shows the aircraft was descending through 6,250 feet on a 225-degree heading when the aircraft rolled to the left about 4 degrees and then rolled to the right to about 20 degrees of bank. It took about 4 seconds for the aircraft roll from 4 degrees left bank to 20 degrees right bank. See the Aircraft 373 Flight Recorder Data.

Postincident examination of the aircraft showed the "B" system aileron actuator had low electrical resistance when tested on the aircraft. Additionally a shear rivet was found failed in the aileron autopilot lever arm which connects the aileron autopilot actuators to the aileron bellcrank and aileron position sensor. Examination of the failed rivet showed it had been failed for a long period of time and the second shear rivet had moved in its hole causing elongation of the hole.

Testing of the "B" system autopliot actuator was performed by the manufacturer. The actuator manifold and electrical hydraulic valve failed the insulation resistance test and the de-energize friction test. See E Systems Failure Analysis Report.

Testing performed by Boeing Commercial Airplane Company after previous uncommanded roll incidents showed that low electrical resistance within the aileron autopilot actuator would cause uncommanded rolls. See Boeing 737 Autopilot Review.

Aircraft

Registration
N373US
Reported as
Boeing 737-3B7
Category
Airplane
Serial number
22952
Airframe hours
31,239
Engine
CFM CFM 56-3, 22,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Usair, Inc.
Registered owner
Society National Bank
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · August 25, 1995 · 4 hours before
Departed
PHL · Philadelphia, PA
Destination
FLL
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
45
Certificates
Flight instructor, 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
10,820 total · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 6 knots
Visibility
10 statute miles
Lowest ceiling
10,000 ft broken
Temperature
82 °F, dew point 79 °F
Altimeter
29.00 inHg
Observed at
FLL, 25 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.

Other investigations on N373US · 1

Matched to the same aircraft by N-number and date.