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Safety Recommendation Details

Safety Recommendation A-90-059
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: ISSUE AN AIRWORTHINESS DIRECTIVE TO REQUIRE THAT STRONGER LATCHES BE INSTALLED IN OVERSIZED STORAGE COMPARTMENTS THAT FORMALLY HELD LIFERAFTS ON ALL B-747 AIRPLANES AND ALSO LIMIT THE DISTANCE THAT THESE COMPARTMENTS CAN BE OPENED.
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: 5/15/1992
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/15/1992
Response: To prevent inadvertent or unrestrained opening of overhead stowage compartment doors, that could result in injury to passengers or flight attendants, Safety Recommendation A-90-59 asked 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 to limit the distance that these compartments could be opened. The Safety Board notes that on October 7, 1991, the FAA issued AD 91-22-05 (Docket No. 91-NM-55-AD) fulfilling the intent of Safety Recommendation A-90-59, which is now classified as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 3/9/1992
Response: ON 10-7-91, THE FAA ISSUED A FINAL RULE (DOCKET NO. 91-NM-55-AD; AMENDMENT 39-8065) TO ADOPT AN AD APPLICABLE TO CERTAIN BOEING MODEL 747 SERIES AIRPLANES. THE AD REQUIRES REPLACEMENT OF THE OVERHEAD STOWAGE COMPARTMENT DOORS AND COUNTERBALANCE ASSEMBLIES; REWORK AND ADJUSTMENT OF COMPARTMENTS; INSTALLATION OF NEW WIRING PROVISION; AND OPERATIONAL CHECKS OF ASSOCIATED EQUIPMENT FOR CERTAIN STOWAGE COMPARTMENTS LOCATED NEAR ENTRY DOORS OR THE DEACTIVATION OF THOSE COMPARTMENTS.

From: NTSB
To: FAA
Date: 3/9/1992
Response: On October 7, 1991, the FAA issued a final rule (Docket No. 91-NM-55-AD; Amendment 39-8065) to adopt an airworthiness directive (AD) applicable to certain Boeing Model 747 series airplanes. This AD requires replacement of the overhead stowage compartment doors and counterbalance assemblies; rework and adjustment of compartments; installation of new wiring provisions; and operational checks of associated equipment for certain stowage compartments located near entry doors or the deactivation of those compartments. I have enclosed a copy of the AD for the Board's information.

From: FAA
To: NTSB
Date: 9/23/1991
Response: THE FAA ISSUED A NOTICE OF PROPOSED RULEMAKING (NPRM) (DOCKET NO. 91-NM-55-AD) APPLICABLE TO CERTAIN BOEING 747 SERIES AIRPLANES. THIS NPRM PROPOSES TO REQUIRE REPLACEMENT OF THE OVERHEAD STOWAGE COMPARTMENT DOOR AND COUNTERBALANCE ASSEMBLIES.

From: NTSB
To: FAA
Date: 1/24/1991
Response: Safety Recommendation A-90-59 states that the FAA should require the installation of stronger latches in oversized storage compartments that formally held liferafts on all B-747 airplanes. In its letter of October 26, 1990, the FAA describes a review of compartment door to pin assembly fastener designs. The Safety Board notes that by replacing an earlier design in which the door was held in place by two fasteners, the current latching mechanisms meet the requirements of 14 CFR Part 25.561. Safety Recommendation A-90-59 also states that the FAA should require limiting the distance that these compartment can be opened. The FAA letter describes a modification that would implement this safety recommendation by use of rubber snubbers, as in similar compartments used on the B-747-400. Since the FAA is considering an airworthiness directive to require the six-fastener assembly for attaching the pin assemblies, as well as requiring the rubber snubbers, Safety Recommendation A-90-59 is classified "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 10/26/1990
Response: THE FAA REVIEW SHOWED THAT COMPARTMENT HINGES, AS WELL AS LATCHES, FAILED. SINCE THE COMPARTMENTS CAME COMPLETELY LOOSE, THE CONTENTS SPILLED. THE COMPARTMENT IS HELD BY TWO PINS, OPERATED BY A CENTER LATCH. AN ANALYSIS SHOW THAT THE COMPARTMENT WILL REMAIN CLOSED WITH ONLY ONE PIN ENGAGED, THEREFORE, THEY MEET 14 CFR PART 25.561. HOWEVER, THREE METHODS HAVAE BEEN USED TO ATTACH THE PINS TO THE DOOR, VERSIONS WITH 2, 4, OR 6 FASTENERS. THE 2 FASTENER WAS ORIGINALLY USED & FOUND INSUFFICIENT. ONLY THE 4 AND 6 FASTENER ASSEMBLIES ARE NOW USED. THE UNITED 811 AIRPLANE WAS OF 4 FASTENER DESIGN. ANOTHER PROBLEM IS THAT SOME 747 AIRPLANES HAVE COUNTERBALANCES FOR THE COMPARTMENT DOORS WHICH MAY HAVE ALLOWED UNRESTRAINED DOORS FROM OPENING FASTER THAN EXPECTED. THE 747-400 HAS AN IMPROVED DESIGN WHICH USES RUBBER SNUBBERS. THE FAA IS CONSIDERING ISSUANCE OF A NPRM TO REQUIRE THE RUBBER SNUBBERS AND REPLACING THE 2 AND 4 FASTENER COMPARTMENT LATCHES WITH THOSE HAVING SIX.

From: NTSB
To: FAA
Date: 9/5/1990
Response:

From: FAA
To: NTSB
Date: 7/26/1990
Response: IN 1980, 14 CFR 121.311 AND 25.785 WERE REVISED TO REQUIRE DUAL LATCHING OR EQUIVALENT ON GALLEYS AND STOWAGE UNITS LOCATED NEAR FLIGHT ATTENDANT SEATS. ADEQUATE LATCHING IS THE BEST APPROACH TO KEEP STOWAGE COMPARTMENTS CLOSED IN AN ACCIDENT AND PREVENT INJURY TO FLIGHT ATTENDANTS. THE FAA IS CURRENTLY REVIEWING THE DESIGN OF THE LATCHES ON THESE COMPARTMENTS TO ENSURE THAT THE DEVICES MEET THE ANTICIPATED STRENGTH REQUIREMENTS.

From: FAA
To: NTSB
Date: 6/25/1990
Response: