NTSB Identification: LAX94IA181.
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Scheduled 14 CFR
Incident occurred Monday, April 04, 1994 in ONTARIO, CA
Probable Cause Approval Date: 03/27/1995
Aircraft: FAIRCHILD SA-227AC, registration: N174SW
Injuries: 1 Minor,11 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 aircraft was climbing at 1,000 feet per minute to a cruising altitude of 21,000 feet. Passing 19,800 feet, a loud 'bang' was heard and the captain was partially sucked through the broken left side window. After about 4 seconds, he was able to pull himself back into the aircraft unassisted. He declared an emergency and landed the aircraft without further incident. A review of the maintenance records revealed that an applicable airworthiness directive requiring an inspection of the windows was complied with within the last 143.8 flight hours. The technical representative for Fairchild stated that maintenance personnel who conducted the AD inspection and service bulletin inspections may have failed to detect the crack, due to the subtle inspection procedures employed. The approved inspection procedures allow for two methods: 1) removal of the outer frame retainer for direct viewing of the screw holes, and 2) using a 90-degree prism seated in mineral oil for an indirect view of the screw holes. The airline was using the second method.

The National Transportation Safety Board determines the probable cause(s) of this incident to be:

the failure of maintenance personnel to detect a crack in the windscreen which exceeded the operational limits for pressurized flight. A factor in the accident was the inadequacy of the inspection method published by the manufacturer.

Full narrative available

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