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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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NTSB Report

February 24, 1989 · Boeing 747-122 · N4713U

Honolulu, HI

Overview

Report Status
Probable Cause
Event Type
Accident
Date
February 24, 1989
Injury Outcomes
47 injuries (9 fatalities, 5 serious injuries, 33 minor injuries), 309 uninjured
Location
Honolulu, HI
Aircraft
Boeing 747-122
Tail Number
N4713U
Operator
United Airlines
Injuries
Fatal
Aircraft Damage
Substantial
NTSB Number
DCA89MA027

The Safety Board's full report on this investigation is provided as Aviation Accident Report number AAR-92/02. To obtain a copy of this report, or to view the executive summary online, please see the Web site at http://www.ntsb.gov/publictn/publictn.htm FTL #811 WAS A SCHEDULED PASSENGER FLIGHT FROM LOS ANGELES TO SYDNEY, AUSTRALIA, WITH STOPS IN HONOLULU (HNL), HI, AND AUCKLAND, NEW ZEALAND. THE FLT WAS UNEVENTFUL UNTIL AFTER DEPARTURE FROM HNL. WHILE CLIMBING FROM FL220 TO FL230 THE CREW HEARD A 'THUMP' FOLLOWED BY AN EXPLOSION. AN EXPLOSIVE DECOMPRESSION WAS EXPERIENCED AND THE #3 AND #4 ENGS WERE SHUTDOWN BECAUSE OF FOD. THE FLT RETURNED TO HNL AND PASSENGERS WERE EVACUATED. INSPECTION REVEALED THE FORWARD LOWER LOBE CARGO DOOR DEPARTED INFLT CAUSING EXTENSIVE DAMAGE TO THE FUSELAGE AND CABIN ADJACENT TO THE DOOR. NINE PASSENGERS WERE EJECTED AND LOST AT SEA. INVESTIGATION CENTERED AROUND DESIGN AND CERTIFICATION OF THE DOOR WHICH ALLOWED IT TO BE IMPROPERLY LATCHED, AND THE OPERATION AND MAINTENANCE TO ASSURE AIRWORTHINESS OF THE DOOR AND LATCHING MECHANISM. (SEE NTSB/AAR-90/01)

NTSB Probable Cause

THE SUDDEN OPENING OF THE IMPROPERLY LATCHED FORWARD LOBE CARGO DOOR IN FLIGHT AND THE SUBSEQUENT EXPLOSIVE DECOMPRESSION. CONTRIBUTING TO THE ACCIDENT WAS A DEFICIENCY IN THE DESIGN OF THE CARGO DOOR LOCKING MECHANISMS, WHICH MADE THEM SUSCEPTIBLE TO INSERVICE DAMAGE, AND WHICH ALOWED THE DOOR TO BE UNATCHED, YET TO SHOW A PROPERLY LATCHED AND LOCKED POSITION. ALSO CONTRIBUTING TO THE ACCIDENT WAS THE LACK OF PROPER MAINTENANCE AND INSPECTION OF THE CARGO DOOR BY UNITED AIRLINES, AND A LACK OF TIMELY CORRECTIVE ACTIONS BY BOEING AND THE FAA FOLLOWING A PREVIOUS DOOR OPENING INCIDENT.

Full Narrative

The Safety Board's full report on this investigation is provided as Aviation Accident Report number AAR-92/02. To obtain a copy of this report, or to view the executive summary online, please see the Web site at http://www.ntsb.gov/publictn/publictn.htm FTL #811 WAS A SCHEDULED PASSENGER FLIGHT FROM LOS ANGELES TO SYDNEY, AUSTRALIA, WITH STOPS IN HONOLULU (HNL), HI, AND AUCKLAND, NEW ZEALAND. THE FLT WAS UNEVENTFUL UNTIL AFTER DEPARTURE FROM HNL. WHILE CLIMBING FROM FL220 TO FL230 THE CREW HEARD A 'THUMP' FOLLOWED BY AN EXPLOSION. AN EXPLOSIVE DECOMPRESSION WAS EXPERIENCED AND THE #3 AND #4 ENGS WERE SHUTDOWN BECAUSE OF FOD. THE FLT RETURNED TO HNL AND PASSENGERS WERE EVACUATED. INSPECTION REVEALED THE FORWARD LOWER LOBE CARGO DOOR DEPARTED INFLT CAUSING EXTENSIVE DAMAGE TO THE FUSELAGE AND CABIN ADJACENT TO THE DOOR. NINE PASSENGERS WERE EJECTED AND LOST AT SEA. INVESTIGATION CENTERED AROUND DESIGN AND CERTIFICATION OF THE DOOR WHICH ALLOWED IT TO BE IMPROPERLY LATCHED, AND THE OPERATION AND MAINTENANCE TO ASSURE AIRWORTHINESS OF THE DOOR AND LATCHING MECHANISM. (SEE NTSB/AAR-90/01)

Flight

Event TypeAccident
Event Time02:09 HST
Nearest Airport0nm N
Runway0
Runway Length0
Runway Width0
Flight Plan FiledIFR
Aircraft FireIflt
Aircraft ExplosionIflt

Aircraft

AircraftBoeing 747-122
Tail NumberN4713U
Aircraft CategoryAir
DamageSubstantial
OperatorUnited Airlines
Operating RulePart 121
Engines4
Engine TypeTurbofan
Engine DetailsP&W · JT9D-3A · Turbofan · 43000
Seats400

People & Injuries

Injury Summary47 injuries (9 fatalities, 5 serious injuries, 33 minor injuries), 309 uninjured
Fatal9
Serious5
Minor33
Uninjured309
Total356
Crew 1Age 59 · First Class

Conditions

ConditionsVMC
LightDark Night
WindCalm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0
Weather SourcePILO

Appendix: Source Data