Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-89-094
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: REQUIRE THAT FAIL-SAFE DESIGN CONSIDERATIONS FOR NON PLUG CARGO DOORS ON PRESENT AND FUTURE TRANSPORT CATEGORY AIRPLANES ACCOUNT FOR CONCEIVABLE HUMAN ERRORS IN ADDITION TO ELECTRICAL AND MECHANICAL MALFUNCTIONS.
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: 10/30/1996
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/30/1996
Response: THE BOARD NOTES THAT THE FAA URGED THE AIRCRAFT INDUSTRY TO FORM A TASK GROUP TO REVIEW CARGO DOOR DESIGNS & TO PROVIDE THE FAA WITH RECOMMENDATIONS REGARDING ANY DEFICIENCIES NOTED DURING THE REVIEW. SUBSEQUENTLY, THE FAA ISSUED AIRWORTHINESS DIRECTIVES IN RESPONSE TO THE RECOMMENDATIONS DEVELOPED BY THE TASK GROUP TO PREVENT NON-PLUG DOORS FROM OPENING IN FLIGHT. THE FAA ALSO DEVELOPED A TRAINING COURSE FOR ALL AIRCRAFT CERTIFICATION ENGINEERS TO ADDRESS THE FAIL-SAFE DESIGN REQUIREMENTS & THE HUMAN FACTORS ASPECTS OF PROPER DOOR LOCKING & LATCHING MECHANISMS. ALL CERTIFICATION ENGINEERS ASSIGNED TO WORK ON DOOR ISSUES HAVE RECEIVED THE TRAINING. IN VIEW OF THE ACTIONS TAKEN BY THE FAA, THE BOARD CLASSIFIES A-89-94 "CLOSED--ACCEPTABLE ACTION"

From: FAA
To: NTSB
Date: 9/5/1996
Response: THE FAA ASKED THE AIRCRAFT INDUSTRY TO FORM AN INDUSTRY TASK GROUP TO REVIEW CARGO DOOR DESIGNS ON THE FLEET OF TRANSPORT AIRPLANES & TO PROVIDE THE FAA WITH RECOMMENDATIONS REGARDING ANY DEFICIENCIES FOUND AS A RESULT OF THE REVIEW. SUBSEQUENTLY, THE FAA ISSUED AIRWORTHINESS DIRECTIVES (AD'S) IN ACCORDANCE WITH THE RECOMMENDATIONS RECEIVED FROM THE TASK GROUP TO PREVENT NON-PLUG CARGO DOORS FROM OPENING IN FLIGHT. COPIES OF THE AD'S WERE PROVIDED TO THE BOARD IN RESPONSE OF A-89-93. THE FAA IS SATISFIED THAT THE TASK GROUP REVIEWED THESE DESIGNS I AN EFFECTIVE & COMPREHENSIVE CONSIDERATIONS IN BOTH 14 CFR 25.783 (AS AMENDED BY AMENDMENT 25-72 & ADVISORY CIRCULAR 25-783-1 ARE ADEQUATE FOR THE CURRENT FLEET OF TRANSPORT CATEGORY AIRPLANES. THE FAA ALSO DEVELOPED A TRAINING COURSE FOR AIRCRAFT CERTIFICATION ENGINEERS TO ADDRESS THE FAIL-SAFE DESIGN REQUIREMENTS & THE HUMAN FACTORS ASPECTS OF PROPER DOOR LOCKING & LATCHING MECHANISMS. ALL CERTIFICATION ENGINEERS ASSIGNED TO WORK ON DOOR ISSUES HAVE RECEIVED THE TRAINING. I BELIEVE THAT THE FAA HAS TAKEN APPROPRIATE ACTION TO ADDRESS THIS RECOMMENDATION, & I CONSIDER THE FAA'S ACTION TO BE COMPLETED.

From: NTSB
To: FAA
Date: 11/4/1993
Response: THE BOARD NOTES THAT THE FAA IS CONSIDERING THE ISSUANCE OF A NOTICE OF PROPOSED RULEMAKING TO ADDRESS THIS RECOMMENDATION AND HAS ASKED THE AVIATION RULEMAKING ADVISORY COMMITTEE TO PARTICIPATE IN THE DRAFTING OF THE DOCUMENT. BASED ON THIS INFORMATION, THE BOARD CLASSIFIES RECOMMENDATION A-89-94 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 6/29/1993
Response: THE FAA IS CONSIDERING THE ISSUANCE OF AN NPRM TO ADDRESS THIS SAFETY RECOMMENDATION. THE FAA HAS ASKED THE AVIATION RULEMAKING ADVISORY COMMITTEE TO PARTICIPATE IN THE DRAFTING OF THIS DOCUMENT.

From: FAA
To: NTSB
Date: 11/3/1989
Response: The FAA will determine its course of action to address this safety recommendation as soon as its review in response to Safety Recommendation A-89-93 is completed. As stated in our response to Safety Recommendation A-89-93, 14 CFR 25.783 and AC 25.783-1 consider human factors in the routine operation of closing and locking doors to ensure that the latch and lock systems are fail-safe. To emphasize the importance of human factors, the FAA has developed a training program for FAA certification personnel to enhance their knowledge of human factors in aircraft design. This training program will be offered to approximately 100 certification personnel during the next year. I believe that this training program will result in more effective review of designs for human factor considerations as required by present regulations.