ANC05IA016

NTSB incident investigation · Boeing 747SR-146B SF · Anchorage, AK · December 5, 2004

Incident · No injuriesIncident investigationFinal report
Date
December 5, 2004, 14:00 local (18:00 UTC)
Place
Anchorage, AK
Injuries
3 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
JA8158Boeing 747SR-146B SF
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 2006
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
FAA Anchorage, FSDO-03
Case key
60696

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The fatigue and subsequent fracture of a portion of the airplane's pressure bulkhead, which resulted in a rapid decompression during cruise flight.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionCruise - normal
Fuselage,pressure bulkhead - fatigueCause
Fuselage,pressure bulkhead - fracturedCause
DecompressionCruise - normal
Forced landingEmergency descent/landing

Analysis

The 14 CFR Part 129 non-scheduled international cargo flight had a rapid decompression at 30,000 feet msl, and returned to the takeoff airport. An examination revealed an elliptical tear in the right side of the pressure bulkhead web separating the electronics service bay from the nose wheel well. The tear extended about 12-inches along a horizontal rivet line, with both ends of the torn skin turned downward approximately 80-90 degrees. The damaged area (STA 260-280, WL 160-170) was excised from the structure, and an examination of the fracture mechanism was conducted. The fracture examination disclosed that the web fracture was initiated by fatigue from multiple origins on the outboard web surface within the pressure vessel. Ten separate fatigue cracks propagated through the full web thickness before the onset of rapid ductile tearing. Each fatigue crack formed adjacent to a fastener hole common with the WL 170 beam, and was in line with the edge of the bonded strip doublers on the inboard surface (wheel well side). The web material met all the engineering specifications. At the time of the incident, the airplane had logged 58,185 flight hours, and 27,243 cycles/landings. Inspection criteria for the affected area is contained in a manufacturer's Service Bulletin and their Alert Revisions 1 thru 4. Following the examination of the incident airplane, Alert Revision 4 was amended to specify more frequent inspections of the affected area.

Factual narrative

History of flight

On December 5, 2004, about 1400 Alaska standard time, a Boeing 747SR-146B SF airplane, Japanese registration JA8158, sustained minor damage during a rapid decompression event while in normal cruise flight, about 137 miles west of Anchorage, Alaska. The airplane was being operated as Flight KZ103, by Nippon Cargo Airlines of Tokyo, Japan, as an instrument flight rules (IFR) non-scheduled international cargo flight under Title 14, CFR Part 129, when the incident occurred. The three flight crew members were not injured. Visual meteorological conditions prevailed, and an instrument flight plan was filed. The flight originated at the Ted Stevens International Airport, Anchorage, about 1338, and was bound for the Narita International Airport, Tokyo, Japan.

Upon reaching an altitude of 30,000 feet the airplane had a rapid decompression, and returned to the Ted Stevens International Airport.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on December 5, the FAA aviation safety inspector who examined the airplane said he saw a 12-inch elliptical tear in the right side of the pressure bulkhead web separating the electronics service bay from the nose wheel well.

During an examination of the airplane by the IIC on December 7, a rupture of the right side pressure bulkhead web inside the nose wheel well was seen. The tear extended about 12-inches along a horizontal rivet line. Both ends of the torn skin turned downward approximately 80-90 degrees, and the skin was bent outward 90 degrees to the bulkhead. No other damage resulting from the rupture was seen.

The damaged area (STA 260-280, WL 160-170) was excised from the structure by a team from Boeing, and delivered to the IIC.

Aircraft information

The accident airplane is a Boeing 747-100SR (cargo configuration), serial number 22711. At the time of the incident the airplane had logged 58,185 flight hours, and 27,243 cycles/landings.

Test and research

On January 19, the excised material was hand-delivered to the Boeing Material and Process Technology Fracture Analysis Group, Seattle, Washington. Under the supervision of the NTSB, a detailed examination of the fracture mechanism was conducted. The fracture exam concluded that the web fracture was initiated by fatigue from multiple origins on the outboard surface within the pressure vessel. A total of 10 separate fatigue cracks, ranging from 0.48 to 0.94 inch in width, propagated through the full web thickness, before the onset of rapid ductile tearing. Each fatigue crack formed adjacent to a fastener hole common with the WL 170 beam. The cracking was in line with the edge of the bonded strip doublers on the inboard surface (wheel well side). Metallurgical analysis showed the material met all the engineering drawing requirements. A copy of the fracture examination is attached to the docket for this case.

Other information

Inspection criteria for the affected area is contained in Boeing Service Bulletin 747-53A24645 (April 5, 2001), and Alert Revisions 1 thru 4. Information gathered during the material analysis of this incident investigation was instrumental in the creation/adoption of Alert Revision 4 (February 24, 2005). Alert Revision 4 adds the requirement for repeated inspections of areas 1 and 2, at 500 flight-cycle intervals once the airplane has reached 20,000 flight cycles. It also decreased the inspection intervals of area 3 from 6,000 flight-cycles to 1,500 flight-cycles.

Aircraft

Registration
JA8158
Reported as
Boeing 747SR-146B SF
Category
Airplane
Serial number
22711
Airframe hours
58,179
Engine
General Electric CF6-50E2, 51,800 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 129
Registered owner
Nippon Cargo Airlines
Airworthiness certificate
Standard, Transport
Departed
PANC · Anchorage, AK
Destination
NRT · Tokyo-Narita
Flight plan
IFR

Flight crew · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Injuries
None
Certificate
Foreign
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Seat
Left
Flight hours
17,678 total · 4,370 in this make and model · 13,649 as pilot in command · 133 in the last 90 days · 69 in the last 30 days · 7 in the last 24 hours
Role
Co-pilot
Age
36
Injuries
None
Certificate
Foreign
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Seat
Right
Flight hours
5,673 total · 2,584 in this make and model · 101 as pilot in command · 161 in the last 90 days · 46 in the last 30 days · 7 in the last 24 hours
Role
Flight engineer
Injuries
None
Certificate
Foreign
Seat
Rear

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 5 knots
Visibility
7 statute miles
Lowest ceiling
1,100 ft broken
Temperature
12 °F, dew point 10 °F
Altimeter
29.64 inHg
Observed at
PANC