Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-90-056
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 THAT NO ARTICLES BE PLACED IN STORAGE COMPARTMENTS THAT ARE LOCATED OVER EMERGENCY EXIT DOORS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 6/21/1993
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/21/1993
Response: THE BOARD NOTES THAT THE FAA ISSUED AIRWORTHINESS DIRECTIVE (AD) 91-22-05 TO REQUIRE THAT STRONGER LATCHES BE INSTALLED IN OVERSIZED STORAGE COMPARTMENTS THAT FORMERLY HELD LIFERAFTS ON ALL B-747 AIRPLANES. SINCE THE STRONGER LATCHES SHOULD PREVENT COMPARTMENT DOORS FROM INADVERTENTLY OPENING WHEN SUBJECT TO INERTIA FORCES, THE BOARD CLASSIFIES RECOMMENDATION A-90-56 "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: FAA
To: NTSB
Date: 3/25/1993
Response: ON SEPTEMBER 23, 1991, THE FAA TOLD THE BOARD THAT THEY IT DID NOT AGREE WITH THE RECOMMENDATION. NOT ALLOWING OBJECTS TO BE STORED IN COMPARTMENTS OVER EMERGENCY EXITS WOULD BE INEFFECTIVE AND FAIL TO CORRECT THE UNSAFE CONDITION. AS AN ALTERNATE ACTION TO ADDRESS THIS SAFETY ISSUE, THE FAA ISSUED AIRWORTHINESS DIRECTIVE (AD) 91-22-05 TO REQUIRE THAT STRONGER LATCHES BE INSTALLED IN OVERSIZED STORAGE COMPARTMENTS THAT FORMERLY HELD LIFERAFTS ON ALL B-747 AIRPLANES. THIS AD ADDRESSES THE SAFETY INTENT OF THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 3/9/1992
Response: Safety Recommendation A-90-56 states that the FAA should prohibit the storage of items in storage compartments that are located over emergency exist doors. Safety Recommendation A-90-59 urges the FAA to issue an airworthiness directive (AD) to require that stronger latches be installed in oversized storage compartments that formerly held liferafts on all B-747 airplanes and also limit the distance that these compartments can be opened. Although the FAA has reviewed its position in regard to Safety Recommendation A-90-56 and is opposed to it, we note that the FAA is addressing the intent of the recommendation, along with Safety Recommendation A- 90-59, by requiring more secure storage compartments. Pending the issuance of an AD to accomplish the modification described in the FAA's notice of proposed rulemaking (Docket No. 91-NM-55-AD), Safety Recommendation A-90-56 is classified as "Open-- Acceptable Alternate Response" and A-90-59 is classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 9/23/1991
Response: THE FAA HAS REVIEWED ITS POSITION IN RESPONSE TO THIS SAFETY RECOMMENDATION AND CONTINUES TO BELIEVE THAT NOT ALLOWING OBJECTS TO BE STORED IN COMPARTMENTS OVER EMERGENCY EXITS, AS RECOMMENDED BY THE SAFETY BOARD, WOULD BE INEFFECTIVE AND FAIL TO CORRECT THE UNSAFE CONDITION. THE FAA BELIEVES THAT THE BEST APPROACH TO ADDRESS THIS SAFETY ISSUE IS TO ENSURE THAT STORAGE COMPARTMENTS ARE PROPERLY AND SAFELY SECURED. THIS ACTION WILL AVOID THE HAZARDS OF THE CONTENTS FALLING FROM THE COMPARTMENTS AND THE PROBLEM OF OPEN COMPARTMENT DOORS. CONSEQUENTLY, IT IS IMPERATIVE THAT ALL STORAGE COMPARTMENTS BE DESIGNED SO THAT THEY WILL NOT OPEN AND RELEASE CONTENTS UNDER CRASH LANDING CONDITIONS, REGARDLESS OF WHETHER OR NOT THEY ARE LOCATED OVER EMERGENCY EXITS. AS NOTED PREVIOUSLY IN RESPONSE TO A-90-59, THE FAA HAS INITIATED ACTION TO REPLACE THE COUNTERBALANCE MECHANISM USE IN STORAGE COMPARTMENTS WITH SNUBBERS AND TO REPLACE THE TWO-AND FOUR-FASTENER ATTACHMENTS OF THE LATCHES WITH A SIXFASTENER ATTACHMENTS OF THE LATCHES WITH A SIX-FASTENER DESIGN. THE FAA IF PRESENTLY CONSIDERING THE ISSUANCE OF AN AD TO ACCOMPLISH THIS ACTION. THE FAA IS CONVINCED THAT THIS ACTION ADDRESSES FULLY THE INTENT OF A-90-56 BECAUSE IT WILL ENSURE THE SECURITY OF ARTICLES PLACED IN THE SUBJECT STORAGE COMPARTMENTS.

From: NTSB
To: FAA
Date: 1/24/1991
Response: Safety Recommendation A-90-56 states that the FAA should require that no articles be placed in storage compartments located over emergency exit doors. Although it may be impossible to predict the movement of objects during an accident, every effort should be made to minimize the possibility of obstruction to passenger egress paths. Furthermore, the extra weight of luggage within a compartment can cause inertia loads on the compartment latch mechanism. Unless a longitudinal loading or deceleration is encountered, compartment contents will likely fall in the area under the compartment. Since these compartments are hinged at the centerline of the airplane and can spill their contents outboard, they can create obstacles near an emergency exit. The Safety Board noted that the contents of the compartments on the accident airplane did not hinder passengers as much as the opened compartment doors. In its response to Safety Recommendation A-90-59, the FAA acknowledges the inadequacy of compartment latching requirements near flight attendant seats. It is inconsistent not to consider the similar problem as it relates to the emergency exits and luggage areas, which are directly above passengers. The Safety Boards request that the FAA reexamine these potential obstacles to passenger safety. Pending further information, Safety Recommendation A-90-56 is classified "Open-- Unacceptable Response."

From: FAA
To: NTSB
Date: 7/26/1990
Response: THE FAA DOES NOT AGREE WITH THIS SAFETY RECOMMENDATION. THE FINAL RESTING PLACE OF OBJECTS THROWN FROM OVERHEAD COMPARTMENTS MAY NOT BE DETERMINED, THEREFORE, THE SAFETY RECOMMENDATION WOULD BE INEFFECTIVE.