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Accident Investigations

Rapid Decompression Due to Fuselage Rupture

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  • Accident No: DCA11MA039
  • Accident Type: Office of Aviation Safety
  • Location: Yuma, AZ
  • Date: 4/1/2011

On April 1, 2011, Southwest Airlines flight 812, a Boeing 737-300 registration N632SW, experienced a rapid depressurization caused by a rupture in the fuselage. The flight was at 34,000 feet when the depressurization occurred. The flight crew conducted an emergency descent and diverted the flight to Yuma International Airport, Yuma, AZ. At the time of the accident, the aircraft had accumulated 48,740 hours of service and 39,781 cycles (a cycle is a takeoff and landing). The accident aircraft was delivered to Southwest Airlines on June 13, 1996.
Joe Sedor is serving as Investigator-in-Charge for the team. Board Member Robert Sumwalt accompanied the team to Yuma and served as principal spokesman for the on-scene investigation.
On-scene inspection by NTSB investigators revealed an approximately 9-inch wide by 59-inch long rectangular-shaped hole in the fuselage crown on the left side of the airplane, aft of the over-wing exit. The fracture was through the lower skin and connected 58 consecutive rivet holes in the lower row of lap joint rivets.
Following an on-scene examination of the accident aircraft, a portion of the fuselage skin that contained the hole and another portion of the skin located forward of the hole (total size 116 inches by 19 inches) were removed from the accident aircraft and transported to the NTSB Materials Laboratory in Washington, DC.
At the NTSB Materials Laboratory, microscope examination of the fracture faces of the ruptured skin revealed fatigue cracks emanating from at least 42 of the 58 rivet holes connected by the fracture.
Inspections conducted around intact rivets on the removed skin section forward of the rupture revealed crack indications at nine rivet holes in the lower rivet row of the lap joint. X-ray inspections were performed on the skin located forward of the rupture location, and revealed gaps between the shank portions of several rivets and the corresponding rivet holes. Upon removing selected rivets, the holes in the upper and lower skin were found to be slightly offset relative to each other and many of the holes on the lower skin were out of round.
In this ongoing investigation, the NTSB Materials Laboratory work is actively conducting additional inspections and examinations in the following areas:
  1. Removal of rivets and examination of rivet hole dimensions, rivet dimensions, and rivet hole alignment between upper and lower skins.
  2. Detailed fractographic analysis of the skin fractures emanating from the rivet holes using optical and scanning electron microscopes.
  3. Fatigue striation analysis using a scanning electron microscope of specific skin fractures to determine the rate of crack propagation.
  4. Additional portions of the lap joints from the accident aircraft.
On April 4, 2011, Boeing issued Alert Service Bulletin SB 737 53A1319-00 instructing operators of certain Boeing 737-300, 400, and 500 aircraft to inspect for cracking in the lower skin of the lap joint on airplanes. On April 5, 2011, The FAA issued Emergency Airworthiness Directive AD 2011-08-51 mandating the inspections in the Boeing Service Bulletin.
Several inspected airplanes were found to have crack indications at a single rivet and one airplane was found to have crack indications at two rivets. These airplanes had accumulated between 40,000 and 45,000 total cycles. The lap joints from these areas of the subject airplanes have been removed and will be fully documented as part of the NTSB investigation.



Contact: NTSB Media Relations
Terry Williams
(202) 314-6100