Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Honolulu, Hawaii 96815
Friday, February 24, 1989 2:09 HST
NTSB Narrative Summary Released at Completion of Accident
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 Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 2/24/1989 |
| Event Day of the Week | Friday |
| Time of Event | 209 |
| Event Time Zone | Hawaii Standard Time |
| Event City | HONOLULU |
| Event State | HAWAII |
| Event Country | -- |
| Zipcode of the event site | 96815 |
| Event Date Year | 1989 |
| Event Date Month | 2 |
| 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 | 0 |
| Weather Briefing Completeness | Not pertinent |
| Investigator's weather source | Pilot |
| 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 | Night/Dark |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 0 |
| Sky/Lowest/Cloud Conditions | Unknown |
| Sky Condition for Lowest Ceiling | Unknown |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 0 |
| Air Temperature at event time (in degrees celsius) | -18 |
| 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) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | 9 |
| Injury Total Minor | 33 |
| Injury Total None | 309 |
| Injury Total Serious | 5 |
| Injury Total All | 47 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 63 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Feb 24 1989 12:00AM |
| NTSB Notification Time | 800 |
| Fiche Number and/or location -used to find docket information | 37772 |
| Date of most recent change to record | Dec 13 2000 12:28PM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N4713U |
| NTSB Number | DCA89MA027 |
| Missing Aircraft Indicator | N |
| Federal Aviation Reg. Part | Part 121: Air Carrier |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | In-flight |
| Aircraft Explosion | In-flight |
| Aircraft Manufacturer's Full Name | BOEING |
| Aircraft Model | 747-122 |
| Aircraft Series Identifier | 747-122 |
| Aircraft Serial Number | N4713U |
| Certified Max Gross Weight | 734000 |
| 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 | 400 |
| Number of Engines | 4 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | -- |
| Airframe hours since last inspection | -- |
| Airframe Hours | -- |
| ELT Installed | Unknown |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| 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? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | |
| Operator City | |
| Operator State | |
| Operator Country | |
| Operator Zip code | |
| 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 | International |
| 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 | HNL |
| Departure City | HONOLULU |
| Departure State | HI |
| Departure Country | |
| Departure Time | 0 |
| Departure Time Zone | |
| Destination Same as Local Flt | -- |
| Destination Airport Code | AKL |
| Destination City | AUCKLAND |
| Destination State | OF |
| Destination Country | |
| Specific Phase of Flight | Climb |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo |
| Since inspection or accident | -- |
| Event Location Runway Number and Location | 0 |
| Runway Length | 0 |
| Runway Width | 0 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |