Kahului Airport
Aircraft Accident/Incident Report

Kahului, Hawaii 96732
Saturday, January 11, 2003 21:15 HST

NTSB Narrative Summary Released at Completion of Accident

The airplane unexpectedly rolled to the left during the climb to cruise. The takeoff and initial area departure phases were normal. The captain engaged the autopilot at 3,000 feet mean sea level (msl). Passing 8,900 feet msl, the airplane experienced a sudden upset resulting in a rapid roll of 35 degrees to the left. The captain countered with 50 to 60 degrees of right aileron input. The autopilot had been engaged, but disengaged automatically during the pilot control input. The first officer (FO) asked the captain if he wanted some aileron trim. The captain responded that he desired only a small amount, reasoning that he did not want to mask a major problem. He did not feel any vibration, binding, or unusual control feel other than the effort and aileron input required to hold wings level. He remembered seeing the right aileron and right elevator deflected upward on the Configuration synoptic page on the systems display, and thought that the aileron deflection would be consistent with his control input to lower the right wing against a left rolling tendency. He flew the airplane to a landing with approximately 45 degrees yoke deflection required to maintain a level wing attitude. Analysis of the digital flight data recorder (DFDR) data indicated that the aileron trim value was 90 percent of full aileron trim authority prior to pushback, engine start, taxi, and takeoff. The data from the previous inbound flight, which had the same flight crew showed that the trim changed from 10 to 90 percent authority about 3 minutes after the previous flight landed. The trim again shifted following the landing and taxi back of the event flight from 85 percent to 10 percent. The captain said that he felt that the airplane was not tracking properly after takeoff. The airline's debrief of the flight crew indicated that they did not see or recognize the excessive aileron deflection on the cockpit screens before or after the event worsened and resulted in autopilot disengagement. The autopilot was trying to roll out of a turn, and was commanding aileron in a direction opposite to the trim position, which resulted in the aileron torque limiter reducing the aileron authority. With the reduced authority, the aileron position could not keep up with the autopilot command, which triggered a autopilot disconnect. The airline indicated that the Rudder and Aileron check for zero is done during the Cockpit Preparation Checklist, which a crew accomplishes just prior to the Before Starting Engines Checklist. DFDR data about 2/3 of the way through the flight indicated that the trim did respond when the copilot manipulated it. The data also showed that the trim repositioned back to zero at the end of the flight. Thorough post accident tests of the system found that the aileron trim control switches and the aileron trim control actuator unit functioned per design specifications with no mechanical or circuit discrepancies noted. Testing demonstrated that there was no evidence of any uncommanded motion. Tests were also performed on the Aileron and Rudder Trim Control Module (ARTCM) and no faults were found.

NTSB Probable Cause Narrative

the flight crew's failure to follow the checklist and detect an out of trim condition prior to takeoff.

Event Information

Type of Event Incident
Event Date 1/11/2003
Event Day of the Week Saturday
Time of Event 2115
Event Time Zone Hawaii Standard Time
Event City KAHULUI
Event State HAWAII
Event Country --
Zipcode of the event site 96732
Event Date Year 2003
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 205400N
Event Location Longitude 1562600W
Event Location Airport KAHULUI
Event Location Nearest Airport ID OGG
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 2054 Hawaii Standard Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID OGG
Elevation of weather observation facility 54
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation HST
Lighting Conditions Night
Lowest Ceiling Height 3500
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 20
Dew Point at event time (in degress fahrenheit) 17
Wind Direction (degrees magnetic) 70
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 5
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.04
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 87
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 20832
NTSB Notification Source FAA
NTSB Notification Date Jan 12 2003 12:00AM
NTSB Notification Time 215
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jan 31 2007 9:40AM
User who most recently changed record NTSB\johb
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-HNL-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N482HA
NTSB Number LAX03IA098
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage None
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Boeing
Aircraft Model 717-200
Aircraft Series Identifier --
Aircraft Serial Number 55127
Certified Max Gross Weight 122000
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 134
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection --
Date of Last Inspection --
Airframe hours since last inspection --
Airframe Hours --
ELT Installed --
ELT Activated --
ELT Aided Location of Event Site --
ELT Type --
Aircraft Owner Name HAWAIIAN AIRLINES, INC.
Aircraft Owner Street Address PO Box 30008
Aircraft Owner City HONOLULU
Aircraft Owner State HI
Aircraft Owner Country USA
Aircraft Owner Zipcode 96820
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code HALA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code OGG
Departure City KAHULUI
Departure State HI
Departure Country USA
Departure Time 2100
Departure Time Zone HST
Destination Same as Local Flt --
Destination Airport Code HNL
Destination City HONOLULU
Destination State HI
Destination Country USA
Specific Phase of Flight Climb - to cruise
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Nov 4 2006 1:43PM
User who most recently changed record COOS
Since inspection or accident --
Event Location Runway Number and Location 02
Runway Length 6995
Runway Width 150
Sight Seeing flight No
Air Medical Flight No
Medical Flight --