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Safety Recommendation Details

Safety Recommendation A-90-055
Details
Synopsis: ON FEBRUARY 24, 1989, A BOEING 747-122 OPERATED BY UNITED AIRLINES AS FLIGHT 811 DEPARTED LOS ANGELES, CALIFORNIA, AS A SCHEDULED FLIGHT TO SYDNEY, AUSTRALIA, WITH EN ROUTE STOPS AT HONOLULU, HAWAII, AND AUCKLAND, NEW ZEALAND. THE FLIGHT DEPARTED HONOLULU AT 0155 ON FEBRUARY 24, 1989, WITH 3 FLIGHT CREWMEMBERS, 15 CABIN ATTENDANTS, AND 337 PASSENGERS. ABOUT 20 MINUTES INTO THE FLIGHT, AND NEAR 23,000 FEET, A RAPID DECOMPRESSION OCCURRED WHEN THE FORWARD STARBOARD CARGO DOOR SEPARATED FROM PART OF THE CABIN FUSELAGE. THE AIRPLANE RETURNED TO HONOLULU INTERNATIONAL AIRPORT, LANDING SAFELY ON RUNWAY 8L AT 0234 WHERE AN EMERGENCY EVACUATION WAS CONDUCTED. OF THE 355 OCCUPANTS ON BOARD WHEN THE FLIGHT DEPARTED HONOLULU, 9 WERE LOST DURING THE DECOMPRESSION; AND 1 CREWMEMBER, 15 FLIGHT ATTENDANTS, AND 22 PASSENGERS WERE INJURED DURING THE DECOMPRESSION AND EMERGENCY EVACUATION.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE, IN ACCORDANCE WITH THE REQUIREMENTS OF 14 CFR 25 1447 (C)(4), THAT A PORTABLE OXYGEN BOTTLE BE LOCATED AT THE FLIGHT ATTENDANT STATIONS AT EXIT DOOR 5 RIGHT AND AT EXIT DOOR 5 LEFT IN B-747 AIRPLANES.
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: 5/4/1990
Date Closed: 10/20/1992
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/20/1992
Response: THE BOARD NOTES THAT THE AIRLINE RECONFIGURED ITS BOEING 747-100 AIRCRAFT IN LATE 1991, BY REINSTALLING THE TWO OXYGEN BOTTLES IN THE LEFT CLOSET AT DOOR 5. FURTHERMORE, A REVIEW OF OTHER U.S. OPERATORS INDICATES THAT PORTABLE OXYGEN BOTTLES ARE INSTALLED AT BOTH SIDES OF THE AIRCRAFT AT DOORS 5 LEFT & RIGHT, WHICH MEETS THE INTENT OF THIS RECOMMENDATION. THEREFORE, THE BOARD CLASSIFIES RECOMMENDATION A-90-55 AS "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 7/28/1992
Response: THE INSTALLATION OF THE PORTABLE OXYGEN BOTTLES IN THE DOOR 5 RIGHT AND LEFT CLOSETS MEETS THE INTENT OF 14 CFR 25.1447 (C) (4) SINCE, WHEN CONSIDERED WITH THE OTHER PORTABLE OXYGEN UNITS IN THE AIRCRAFT, THEY PROVIDE FOR A UNIFORMLY DISTRIBUTED AND SUFFICIENTLY AVAILABLE OXYGEN SUPPLY FOR A TRAINED FLIGHT ATTENDANT. THE INSTALLATION OF PORTABLE OXYGEN BOTTLES IN THE CLOSETS ADJACENT TO DOORS 5 LEFT AND RIGHT ARE SUFFICIENTLY CLOSE TO THE FLIGHT ATTENDANT SEAT TO MEET THE INTENT OF THIS SAFETY RECOMMENDATION.

From: NTSB
To: FAA
Date: 3/9/1992
Response: Safety Recommendation A-90-55 proposes that the FAA require, in accordance with the requirements of 14 CFR 25.1447(c)(4), that a portable oxygen bottle be located at the flight attendant stations at exit door 5 right and at exit door 5 left in B-747 airplanes. The Safety Board notes that the FAA is reviewing the oxygen bottle arrangement on the United Airlines B-747 fleet to determine regulatory compliance with the requirements of 14 CFR 25.1447(c)(4). Pending the FAA's further report, this safety recommendation is classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 9/23/1991
Response: THE FAA IS REVIEWING THE OXYGEN BOTTLE ARRANGEMENT ON THE UNITED AIRLINES (UAL) BOEING 747 FLEET WITH RESPECT TO THE REQUIREMENT OF 14 CFR 25.1447 (C)(4) TO DETERMINE REGULATORY COMPLIANCE AND THE APPROVAL STATUS OF THE MODIFICATION.

From: NTSB
To: FAA
Date: 1/24/1991
Response: Safety Recommendation A-90-55 states that the FAA should require that a portable oxygen bottle be located at the flight attendant stations at exit doors 5 right and left in B-747 airplanes. The airplane involved in the accident that prompted the recommendation was not equipped with oxygen bottles in the closets aft of doors 5 right and left, as described in the FAA letter of July 26, 1990. This fact is discussed in the Safety Board letter of May 4, 1990. The Safety Board requests that the FAA inspect the B-747 airplanes of United Airlines and other operators for regulatory compliance or approved modifications that do not meet the intent of the type certification. Further, the Safety Board believes that the rationale for locating these two oxygen bottles in the closets is flawed because it does not recognize the potentially incomplete mental capabilities of the crew due to oxygen deprivation or the excitement and confusion of an emergency situation. The design of the flight attendant station could easily accommodate the concerns cited in the FAA letter by placing a guard around the bottle. Pending the results of the requested review, Safety Recommendation A-90-55 is classified "Open--Unacceptable Response."

From: FAA
To: NTSB
Date: 7/26/1990
Response: THE FAA DOES NOT AGREE WITH THIS SAFETY RECOMMENDATION. THE AIRPLANE WAS TYPE CERTIFIED WITH TWO PORTABLE OXYGEN BOTTLES INSTALLED IN THE CLOSET AFT OF DOOR 5 LEFT AND ONE BOTTLE IN THE CLOSET AFT OF DOOR 5 RIGHT. THE FAA BELIEVES THAT THE PORTABLE BOTTLES MOUNTED ON THE FORWARD CLOSTET WALL AND THE FLIGHT ATTENDANT SEAT MOUNTED TO THE OPPOSITE SIDE OF THAT WALL ARE SUFFICIENTLY CLOSE TO THE FLIGHT ATTENDANT. THE FAA BELIEVES THAT THE PORTABLE BOTTLE, WHEN MOUNTED IN THE CLOSET, IS LESS SUSCEPTIBLE TO DAMAGE, ACCIDENT OR TURBULENCE, AND LESS LIKELY TO BECOME DETACHED IN AN ACCIDENT.