Uncommanded Roll and Descent Following Autopilot Disengagement

Casualties unknown • San Juan, PR, US

An aircraft experienced an immediate 60-degree left bank and descent after the pilot disconnected the autopilot, leading to speeds exceeding VNE.

What happened

Following takeoff, the pilot engaged the autopilot at 1,000 feet. After engagement, aileron trim was utilized, and the pilot was assigned a heading change to the right. However, the autopilot heading bug was not turned by the crew.

At 2,200 feet, the pilot disconnected the autopilot. Upon disengagement, the aircraft immediately rolled into a left bank of 60 degrees and began a descent. The pilot then applied aileron trim to the right, and working together with the copilot on the controls, the crew successfully recovered the aircraft.

Data from the DFDR and radar indicated that the event occurred at 3,300 feet. Analysis showed that for 45 seconds prior to the event, the ailerons had been deflected to the right by 2 to 5 degrees. During the subsequent descending left turn, the pilots did not reduce power for 60 seconds, causing the aircraft speed to exceed the VNE speed of 250 knots.

The investigation

A post-crash examination of the aircraft structure, flight controls, and autopilot system found no evidence of pre-incident failure or malfunction. Following the incident, the aircraft manufacturer issued a restriction regarding the use of aileron trim while the autopilot is engaged, limiting use to 1 dot rather than the previously permitted 3 dots.

Frequently asked questions

What happened in the 1990-11-06 Aerospatiale ATR-42-300 accident near San Juan, PR?

An aircraft experienced an immediate 60-degree left bank and descent after the pilot disconnected the autopilot, leading to speeds exceeding VNE.

What aircraft was involved and where did it happen?

The accident on 1990-11-06 involved a Aerospatiale ATR-42-300, registration N972NA, operated by Executive Air Charter, Inc., at San Juan, PR.

What was the probable cause of the accident?

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…

Investigation report by the U.S. National Transportation Safety Board (NTSB) historical archive. Original record: https://carol.ntsb.gov/event/20001212X24656. This page is a structured re-presentation; facts and quotes are in the National Transportation Safety Board (NTSB), United States.

Loading the flight search…