CHI95LA078

NTSB accident investigation · Boeing 747-238B · Belleville, MI · January 29, 1995

Accident · No injuriesLimited investigationFinal report
Date
January 28, 1995, 19:10 local (Jan 29, 1995, 00:10 UTC)
Place
Belleville, MI
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N706CKBoeing 747-238B
Weather
Visual (VMC) · Dusk
Status
Completed · report November 25, 1996
Report
Approved by Office Director
FAA report
19950128048099A
Case key
9830

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

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Probable cause

the failure of company maintenance personnel to adequately secure the cargo pallets, and the failure of the flightcrew to detect the deficiency during their preflight inspection.

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.

Cargo shiftTakeoff
Security of cargo - inadequateCompany maintenance personnelCause
Aircraft preflight - inadequateFlightcrewCause
Fuselage,pressure bulkhead - penetrated

Analysis

The flightcrew reported that the airplane was not pressurized for the 15 minute repositioning flight, and the maximum altitude reached was 3,100 feet. They reported no unusual occurrences during the flight. Postflight inspection revealed that pallets from the 3L position had shifted aft and punctured the aft pressure bulkhead in two places. A flight mechanic reported that he had secured the pallets in position 3L and 3R when they were placed there two flights before the accident flight. He 'flipped up three rows of locks aft of each pallet position.' The flight engineer reported that he had inspected the pallets during the preflight and 'the left side had an overhang' and he could not see the aft locks. He said the front locks were installed.

Factual narrative

On January 28, 1995, at 1910 eastern standard time, a Boeing 747- 238B airplane, N706CK, operated by American International Airways Inc., sustained substantial damage to the aft pressure bulkhead when cargo pallets shifted during takeoff from the Willow Run Airport, Ypsilanti, Michigan. Three crew members and a mechanic onboard the airplane reported no injuries. The repositioning flight, conducted under 14 CFR Part 91, landed uneventfully at the Detroit Metropolitan Wayne County Airport approximately 1930.

Visual meteorological conditions prevailed and an IFR flight plan was filed.

The flight crew reported the airplane was not pressurized for the 15 minute repositioning flight and the maximum altitude reached was 3,100 feet. They reported no unusual occurrences during the flight and did not know the pallets had shifted until they conducted a postflight inspection and discovered the stack of pallets that had been located in position 3L had shifted aft.

In a written statement, the flight mechanic reported that he had secured the pallets in position 3L and 3R when they were placed there, two flights before the accident flight. He "flipped up three rows of locks aft of each pallet position." He stated that "sometime after the airplane arrived in Ypsilanti, the pallets had to be either moved, or the locks disengaged, and not resecured."

The flight engineer reported that he had inspected the pallets during the preflight and "the left side had an overhang" and he could not see the aft locks. He said the front locks were installed.

Photographs of the pressure bulkhead, provided to the NTSB investigator, exhibited two holes in the four o'clock and seven o'clock positions as viewed from the cargo area.

Aircraft

Registration
N706CK
Reported as
Boeing 747-238B
Category
Airplane
Serial number
20010
Engine
P&W JT9D-7J, 49,970 lbs thrust, turbo jet
Damage
Substantial damage
Flight
Positioning · Part 91
Registered owner
American International Airways
Airworthiness certificate
Standard, Transport
Destination
DTW · Detroit, MI
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
19,000 total · 1,500 in this make and model · 10,000 as pilot in command

Weather

Conditions
Visual (VMC) · Dusk
Visibility
15 statute miles
Lowest ceiling
None
Temperature
21 °F, dew point 14 °F
Altimeter
30.00 inHg
Observed at
YIP

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N706CK · 1

Matched to the same aircraft by N-number and date.