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Safety Recommendation Details

Safety Recommendation A-89-093
Details
Synopsis: ON FEBRUARY 24, 1989, UNITED AIRLINES, INC., (UAL), FLIGHT 811, A BOEING 747-122, N4713U, WITH 3 FLIGHT CREWMEMBERS, 15 CABIN CREWMEMBERS, AND 337 PASSENGERS ON BOARD, EXPERIENCED AN EXPLOSIVE DECOMPRESSION AS A RESULT OF THE IN-FLIGHT LOSS OF THE RIGHT FORWARD LOWER LOBE CARGO COMPARTMENT DOOR AND A PART OF THE RIGHT CABIN FUSELAGE. FLIGHT 811 WAS EN ROUTE FROM LOS ANGELES, CALIFORNIA, TO SYDNEY, AUSTRALIA (SYD) WITH INTERMEDIATE STOPS IN HONOLULU, HAWAII (HNL) AND AUCK LAND, NEW ZEALAND (AKL). IT WAS A REGULARLY SCHEDULED FLIGHT CONDUCTED UNDER THE PROVISIONS OF 14 CODE OF FEDERAL REGULATIONS (CFR) PART 121.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN AIRWORTHINESS DIRECTIVE FOR NON-PLUG CARGO DOORS ON ALL TRANSPORT CATEGORY AIRPLANES REQUIRING THE INSTALLATION OF POSITIVE INDICATORS TO GROUND PERSONNEL AND FLIGHTCREWS CONFIRMING THE ACTUAL POSITION OF BOTH THE LATCH CAMS AND LOCKS, INDEPENDENTLY.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: HONOLULU, HI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA89MA027
Accident Reports: Explosive Decompression - Loss of Cargo Door in Flight, United Airlines Flight 811 Boeing 747-122, N4713U
Report #: AAR-92-02
Accident Date: 2/24/1989
Issue Date: 8/23/1989
Date Closed: 11/4/1993
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/4/1993
Response: THE BOARD NOTES THAT THE FAA HAS ISSUED FIVE FINAL RULES CONCERNING NON-PLUG CARGO DOORS ON TRANSPORT-CATEGORY AIRPLANES. THESE FINAL RULES HAVE REQUIRED THE MODIFICATION AND INSTALLATION OF POSITIVE INDICATORS TO GROUND PERSONNEL AND FLIGHTCREWS THAT ALLOW THEM TO CONFIRM THE ACTUAL POSITION OF BOTH THE LATCH CAMS AND LOCKS. BASED ON THIS INFORMATION, THE BOARD CLASSIFIES RECOMMENDATION A-89-93 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 6/29/1993
Response: THE FAA HAS ISSUED FIVE FINAL RULES AND ONE NOTICE OF PROPOSED RULEMAKING (NPRM) WHICH ADDRESS THIS SAFETY RECOMMENDATION. ON NOVEMBER 28, 1989, THE FAA ISSUED A FINAL RULE APPLICABLE TO CERTAIN MCDONNELL DOUGLAS DC-9 SERIES AIRPLANES, AND ON FEBRUARY 27, 1990, THE FAA ISSUED A FINAL RULE APPLICABLE TO CERTAIN DC-8 SERIES AIRPLANES. THESE TWO RULES REQUIRE INSTALLATION OF A MAIN CARGO DOOR HYDRAULIC ISOLATION VALVE; INSTALLATION OF AN ADDITIONAL (AND MODIFICATION OF AN EXITING) DOOR-OPEN INDICATING SYSTEM; INSTALLATION OF A MAIN CARGO DOOR LOCK PIN VIEWING WINDOW; INSTALLATION OF A MAIN CARGO DOOR VENT SYSTEM; INSTALLATION OF A "VENT DOOR-OPEN" INDICATING SYSTEM; INSTALLATION OF A MAIN CARGO DOOR HINGE PIN RETAINER; AND MODIFICATION TO THE MAIN CARGO DOOR LATCH OPERATING MECHANISM.

From: FAA
To: NTSB
Date: 11/3/1989
Response: The FAA is reviewing all outward opening (nonplug) doors on all jet-powered transport category airplanes to determine what, if any, modifications are needed to ensure that these doors will not open in flight. The door latch indicating system is only part of this review. Door designs are being evaluated against criteria specified in 14 CFR 25.783 as amended by Amendment 25-54, and the policy material published in Advisory Circular (AC) 25.783-1, Fuselage Doors, Hatches, and Exits. These standards were adopted in 1980 and account for human factors involved in the routine operation of closing and locking doors to ensure that the latch and lock systems are fail-safe.