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Safety Recommendation Details

Safety Recommendation A-90-060
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: DEMONSTRATE FOR EACH MAKE AND MODEL OF LIFE PRESERVER THAT IT CAN BE DONNED, ADJUSTED, AND TIGHTENED WITHIN THE ELAPSED TIME REQUIRED BY TSO-13D. DIRECT PARTICULAR ATTENTION TO THE EASE WITH WHICH STRAPS PASS THROUGH ADJUSTMENT FITTINGS WHEN THE STRAPS ARE PULLED AT ALL POSSIBLE ANGLES.
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: 12/6/1996
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/6/1996
Response: THE BOARD NOTES THAT TSO-C13F WAS ISSUED ON 9/24/92. ALL NEW MODELS OF LIFE PRESERVERS THAT ARE MANUFACTURED ON OR AFTER THIS DATE MUST MEET THE REQUIREMENTS OF THIS TSO. WHILE DEVICES MANUFACTURED UNDER TSO-C13D ARE STILL BEING APPROVED, TSO-C13D DEVICES REQUIRE AN ELAPSED TIME TEST AND ARE IN CONFORMANCE WITH DONNING REQUIREMENTS. THE BOARD CLASSIFIES A-90-60 & 61 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 5/9/1996
Response: THE FAA ISSUED TECHNICAL STANDARD ORDER (TSO) C13F WHICH, AMONG OTHER THINGS, REQUIRES THAT THE WEARER BE ABLE TO DO & FIT THE LIFE PRESERVER BY SECURING NO MORE THAN ONE ATTACHMENT & BY MAKING NO MORE THAN ONE ADJUSTMENT. THE TSO-C13F WAS ISSUED ON 9/24/92. ALL NEW MODELS OF LIFE PRESERVERS THAT ARE MANUFACTURED ON OR AFTER THIS DATE MUST MEET THE REQUIREMENTS OF THIS TSO. WHILE DEVICES MANUFACTURED UNDER TSO-C13D ARE STILL BEING APPROVED, TSO-C13D DEVICES REQUIRE AN ELAPSED TIME TEST & ARE IN CONFORMANCE WITH THE DONNING REQUIREMENTS. THE BOARD CLASSIFIES A-90-60 & -61 AS "CLOSED--ACCEPTABLE ACTION."

From: NTSB
To: FAA
Date: 1/24/1991
Response: Safety Recommendation A-90-60 states that each make and model of life preserver should have donning, adjustment, and tightening capabilities demonstrated within the time required by TSO-13d. Safety Recommendation A-90-61 states that after 1 year, life preservers manufactured for passenger-carrying aircraft would be required to meet the specifications of TSO-C13e. The Safety Board has made numerous safety recommendations regarding water survival equipment for passengers and is aware of the history of TSO-C13e. Although the TSO has been written, its implementation has been postponed indefinitely. Therefore, while the FAA has initiated implementation of A-90-60 by writing TSO-C13e, the FAA has made no progress toward the implementation of Safety Recommendation A-90-61. Safety Recommendation A-90-60 is classified "Open--Acceptable Response," and Safety Recommendation A-90-61 is classified "Open--Unacceptable Response."

From: FAA
To: NTSB
Date: 7/26/1990
Response: THE LIFE PRESERVER REQUIREMENTS WERE REVISED ON 4/23/86, WITH THE ISSUANCE OF TECHNICAL STANDARD ORDER (TSO) C13E, TO IMPROVE DONNING AND RETENTION CHARACTERISTICS. THE IMPROVED REQUIREMENTS SPECIFY A SERIES OF DONNING TESTS, STARTING WITH AN UNOPENED LIFE PRESERVER PACKAGE IN HAND, EMPLOYING A RANGE OF NOVICE TEST SUBJECTS REPRESENTING TYPICAL AIRLINE PASSENGERS. IN CONTRAST, THE EARLIER TSO-C13D SPECIFIED A DONNING TEST BY A SINGLE SUBJECT, STARTING WITH THE LIFE PRESERVER REMOVED FROM ITS PACKAGE.