NTSB Identification: CHI94IA111.
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Incident occurred Wednesday, March 16, 1994 in ROCHESTER, IN
Probable Cause Approval Date: 03/27/1995
Aircraft: BEECH BE200, registration: N210SU
Injuries: 5 Uninjured.
NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.
THE PILOTS REPORTED THEY WERE IN CRUISE FLIGHT AT 16,000 FEET, WHEN THEY HEARD A LOUD NOISE, FOLLOWED BY 'MASTER WARNING' AND 'CABIN ALTITUDE' LIGHTS, AND A LOSS OF CABIN PRESSURIZATION. THEY STATED WHEN THEY LOOKED BACK TO THE REAR CABIN THEY SAW THE RIGHT REAR CABIN WINDOW HAD FAILED. THE PILOTS DIVERTED AND LANDED WITHOUT FURTHER INCIDENT. POSTINCIDENT INVESTIGATION REVEALED THE FAILED WIND0W WAS INSTALLED IN OCTOBER, 1985. THE AIRPLANE HAD FLOWN APPROXIMATELY 2100 HOURS AND BEEN REPAINTED TWICE SINCE THAT DATE. THE AIRPLANE HAD FLOWN 4.8 HOURS SINCE THE MOST RECENT REPAINTING. THE MANUFACTURER'S MANUALS AND SERVICE INSTRUCTIONS CAUTIONED THAT EXPOSURE TO PAINT, PAINT STRIPPER, SOLVENTS AND FUMES COULD RESULT IN CRACKED WINDOWS. THEY RECOMMENDED THE USE OF PRESSURE SENSITIVE MASKS, AND STATED, '...THE MASK MUST EXTEND BEYOND THE WINDOW CUTOUTS...[TO] PREVENT THE CHEMICAL COMPOUNDS FROM ATTACKING THE WINDOW EDGES.' EXAMINATION OF THE AIRPLANE'S WINDOWS REVEALED EVIDENCE OF STRIPPER AND PAINT OVERSPRAY.
The National Transportation Safety Board determines the probable cause(s) of this incident to be: the airplane painter/refinishers' failure to follow appropriate procedures/directives pertinent to the masking, stripping, painting and cleaning of the airplane cabin windows, which resulted in the in-flight failure of the right aft cabin window. A related factor is inadequate maintenance inspection by company maintenance personnel. Full narrative available
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