Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Las Vegas, Nevada 89111
Monday, October 28, 1991 7:05 PST
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Incident |
| Event Date | 10/28/1991 |
| Event Day of the Week | Monday |
| Time of Event | 705 |
| Event Time Zone | Pacific Standard Time |
| Event City | LAS VEGAS |
| Event State | NEVADA |
| Event Country | -- |
| Zipcode of the event site | 89111 |
| Event Date Year | 1991 |
| Event Date Month | 10 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | |
| Event Location Nearest Airport ID | |
| Indicates whether the acc/inc occurred off or on an airport | Off Airport/Airstrip |
| Distance from airport in statute miles | 0 |
| Degrees magnetic from airport | 0 |
| Airport Elevation | -- |
| Weather Briefing Completeness | Full |
| Investigator's weather source | Unknown |
| Time of the weather observation | 0 |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | |
| Elevation of weather observation facility | 0 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 0 |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 50 |
| Air Temperature at event time (in degrees celsius) | -- |
| Dew Point at event time (in degress fahrenheit) | -- |
| Wind Direction (degrees magnetic) | 0 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 0 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Unknown |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | -- |
| Density Altitude (feet) | 0 |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 179 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 5039 |
| NTSB Notification Source | -- |
| NTSB Notification Date | -- |
| NTSB Notification Time | 0 |
| Fiche Number and/or location -used to find docket information | 46059 |
| Date of most recent change to record | Dec 18 2002 11:28AM |
| User who most recently changed record | NTSB\GIUV |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N1820U |
| NTSB Number | LAX92IA027 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | -- |
| Damage | Minor |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | MCDONNELL DOUGLAS |
| Aircraft Model | DC-10-10 |
| Aircraft Series Identifier | DC-10-10 |
| Aircraft Serial Number | 46619 |
| Certified Max Gross Weight | 391600 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | -- |
| Cabin Crew Seats | -- |
| Passenger Seats | -- |
| Total number of seats on the aircraft | 287 |
| Number of Engines | 3 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | May 18 1991 12:00AM |
| Airframe hours since last inspection | 1367 |
| Airframe Hours | 50708 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | -- |
| Aircraft Owner Name | UNITED AIRLINES |
| Aircraft Owner Street Address | P.O. BOX 66100 |
| Aircraft Owner City | CHICAGO |
| Aircraft Owner State | IL |
| Aircraft Owner Country | |
| Aircraft Owner Zipcode | 60666 |
| Operator is an individual? | -- |
| Operator Name | UNITED AIRLINES |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | P.O. BOX 66100 |
| Operator City | CHICAGO |
| Operator State | IL |
| Operator Country | |
| Operator Zip code | 60666 |
| Operator Code | UALA |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | Unknown |
| Operator Certificate Number | -- |
| Indicates whether an air carrier operation was scheduled or not | Scheduled |
| Indicates Domestic or International Flight | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only |
| Type of Flying (Per_Bus / Primary) | Unknown |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | LAX |
| Departure City | LOS ANGELES |
| Departure State | CA |
| Departure Country | |
| Departure Time | 637 |
| Departure Time Zone | PST |
| Destination Same as Local Flt | -- |
| Destination Airport Code | DEN |
| Destination City | DENVER |
| Destination State | CO |
| Destination Country | |
| Specific Phase of Flight | Cruise |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Dec 20 2002 12:42PM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |