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Safety Recommendation Details

Safety Recommendation A-90-057
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: AMEND 14 CFR 121.309 (F) TO REQUIRE A READILY ACCESSIBLE MEGAPHONE AT EACH SEAT ROW AT WHICH A FLIGHT ATTENDANT IS STATIONED.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 12/22/1993
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/22/1993
Response: THE SAFETY BOARD CONTINUES TO BELIEVE THAT THE CIRCUMSTANCES OF THE ACCIDENT INVOLVING UNITED AIRLINES FLIGHT 811 ON FEBRUARY 23, 1988, PROVIDE JUSTIFICATION FOR A RULE CHANGE. IN A LETTER TO THE FAA DATED JANUARY 24, 1991, THE BOARD ACKNOWLEDGE THAT USING MULTIPLE MEGAPHONES ON WIDE-BODY AIRPLANES WOULD REQUIRE AIR CARRIERS TO ESTABLISH GUIDELINES FOR THEIR USE. HOWEVER, THIS GUIDANCE COULD BE READILY DEVELOPED TO PRECLUDE CONFUSION AMONG PASSENGERS IN AN EMERGENCY. BASED ON THE FAA'S FAILURE TO TAKE ACTION CONCERNING THIS RECOMMENDATION, THE BOARD CLASSIFIES RECOMMENDATION A-90-57 "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 7/12/1993
Response: THE FAA DOES NOT AGREE TO ISSUE REGULATORY CHANGE AS REQUESTED IN THIS RECOMMENDATION. ON APRIL 6, 1993, THE FAA ISSUED HANDBOOK BULLETIN 93-01, B-747 UPPER DECK MEGAPHONE PROVISIONS: PASSENGER-CARRYING OEPRATIONS. THIS BULLETIN DIRECTS PRINCIPAL OPERATIONS INSPECTOR TO ENCOURAGE THEIR RESPECTIVE OEPRATORS WHO CONDUCT B-747 PASSENGER-CARRYING OPERATIONS USING THE UPPER DECK PASSENGER COMPARTMENT TO INSTALL A MEGAPHONE ON THE B-747 UPPER DECK THAT WOULD BE READILY ACCESSIBLE FOR USE AT THE FLIGHT ATTENDANT DUTY STATION. FAA CONSIDERS IT'S ACTION TO BE COMPLETED, AND PLAN NO FURTHER ACTION OF THIS SAFETY RECOMMENDATION.

From: NTSB
To: FAA
Date: 1/24/1991
Response: Safety Recommendation A-90-57 states that the FAA should require a readily accessible megaphone at each seat row at which a flight attendant is stationed. The Safety Board notes that the FAA does not believe that such an arrangement would provide an added safety benefit. The flight attendants, including the one in the upper cabin of the accident airplane who could not see all passengers, had to hold up passenger safety briefing cards and hope that passengers would understand. Under the current regulations, this was the only method available to flight attendants because there were only two megaphones in the lower cabin and none in the upper cabin area. Because the passengers were subjected to decompression, loss of lighting, anxiety, high ambient noise, and confusion, their reading ability and comprehension of the information was minimal at best. Providing the flight attendants with megaphones would have alleviated this situation. The Safety Board acknowledges that using multiple megaphones on wide-body airplanes would require air carriers to establish guidelines for their use. However this guidance could be readily developed to preclude confusion among passengers in an emergency. The Safety Board urges the FAA to reconsider this issue and has classified Safety Recommendation A-90-57 as "Open--Unacceptable Response," pending further information.

From: FAA
To: NTSB
Date: 7/26/1990
Response: THE FAA DOES NOT AGREE WITH THIS REC. THE CURRENT REGULATION, WHICH REQUIRES THAT EACH PASSENGER CARRYING PLANE HAVE A PORTABLE BATTERY-POWERED MEGAPHONE(S) READILY ACCESSIBLE TO THE CREWMEMBERS ASSIGNED TO DIRECT EMERGENCY EVACUATION, IS ADEQUATE. THE FAA DOES NOT BELIEVE THAT THERE IS AN ADDED SAFETY BENEFIT TO REQUIRING AN ACCESSIBLE MEGAPHONE AT EACH SEAT ROW AT WHICH A FLIGHT ATTENDANT IS STATIONED. IN FACT, THE POSSIBILITY OF CONFUSION DURING AN EMERGENCY COULD RESULT FROM MULTIPLE MEGAPHONE USE WITH EACH USER SIMULTANEOUSLY GIVING DIFFERENT INSTRUCTIONS TO PASSENGERS.