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Aviation safety reports, made easier to study

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October 28, 1991 · Mcdonnell Douglas DC-10-10 · N1820U

Las Vegas, NV

Overview

Report Status
Probable Cause
Event Type
Incident
Date
October 28, 1991
Injury Outcomes
No injuries (179 uninjured)
Location
Las Vegas, NV
Aircraft
Mcdonnell Douglas DC-10-10
Tail Number
N1820U
Operator
United Airlines
Injuries
None
Aircraft Damage
Minor
NTSB Number
LAX92IA027

While climbing through 35,000 ft for a cruise altitude of 37,000 ft, the crew heard a loud 'thump' and the aircraft depressurized. As the crew descended to 11,000 ft, the cabin altitude climbed to 30,000 ft. The flight diverted to a nearby airport and safely landed. Examination of the aircraft disclosed that repetitive pressurization cycles caused the initiation of a fatigue crack and the resultant rupture of a forward pressure bulkhead. Over 14 years earlier, Douglas issued service bulletins advising operators that leaks could occur in the forward pressure bulkhead area because of metal fatigue. Douglas recommended that specific corrective action be taken which involved inspecting the area at 1,500 hour intervals or making permanent structural airframe modifications. Contrary to the majority of aircraft operators, United chose not to structurally modify this aircraft. Rather, it chose to perform recurring visual inspections for leaks in the suspect area. The aircraft's pressure bulkhead ruptured 1,367 hours after its last inspection.

NTSB Probable Cause

RUPTURE OF A FORWARD PRESSURE BULKHEAD BECAUSE OF CYCLICALLY INDUCED METAL FATIGUE. FACTORS WHICH CONTRIBUTED TO THE INCIDENT WERE: THE OPERATOR'S DECISION NOT TO STRUCTURALLY MODIFY ITS AIRPLANE IN ACCORDANCE WITH THE MANUFACTURER'S BUT RATHER TO RELY ON THE MANUFACTURER'S ALTERNATIVE RECOMMENDATION OF PERFORMING REPETITIVE VISUAL INSPECTION IN THE SUSPECT AREA: AND THE OPERATOR'S FAILURE TO UTILIZE AN INSPECTION PROGRAM ADEQUATE TO VISUALLY DETECT CRACK DEVELOPMENT IN A PREVIOUSLY IDENTIFIED SUSPECT AREA.

Full Narrative

WHILE CLIMBING THRU 35,000 FT FOR A CRUISE ALTITUDE OF 37,000 FT, THE CREW HEARD A LOUD 'THUMP' & THE ACFT DEPRESSURIZED. AS THE CREW DESCENDED TO 11,000 FT, THE CABIN ALTITUDE CLIMBED TO 30,000 FT. THE FLT DIVERTED TO A NEARBY ARPT & SAFELY LANDED. EXAM OF THE ACFT DISCLOSED THAT REPETITIVE PRESSURIZATION CYCLES CAUSED THE INITIATION OF A FATIGUE CRACK & THE RESULTANT RUPTURE OF A FORWARD PRESSURE BULKHEAD. OVER 14 YRS EARLIER, DOUGLAS ISSUED SERVICE BULLETINS ADVISING OPERATORS THAT LEAKS COULD OCCUR IN THE FWD PRESSURE BULKHEAD AREA BECAUSE OF METAL FATIGUE. DOUGLAS RECOMMENDED THAT SPECIFIC CORRECTIVE ACTION BE TAKEN WHICH INVOLVED INSPECTING THE AREA AT 1,500 HOUR INTERVALS OR MAKING PERMANENT STRUCTURAL AIRFRAME MODIFICATIONS. CONTRARY TO THE MAJORITY OF ACFT OPERATORS, UNITED CHOSE NOT TO STRUCTURALLY MODIFY THIS ACFT. RATHER, IT CHOSE TO PERFORM RECURRING VISUAL INSPECTIONS FOR LEAKS IN THE SUSPECT AREA. THE ACFT'S PRESSURE BULKHEAD RUPTURED 1,367 HRS AFTER IT LAST INSPECTION.

Flight

Event TypeIncident
Event Time07:05 PST
Nearest Airport0nm N
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftMcdonnell Douglas DC-10-10
Tail NumberN1820U
Aircraft CategoryAir
DamageMinor
OperatorUnited Airlines
Operating RulePart 121
Engines3
Engine TypeTurbofan
Engine DetailsGe · CF 6-6 · Turbofan · 42500
Seats287

People & Injuries

Injury SummaryNo injuries (179 uninjured)
Fatal0
Serious0
Minor0
Uninjured179
Total179
Crew 1Age 56 · First Class

Conditions

ConditionsVMC
LightDaylight
WindCalm
Visibility50 sm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0

Appendix: Source Data