# NTSB CHI95LA078: Boeing 747-238B, N706CK, Belleville, MI, January 29, 1995 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 28, 1995, 19:10 local (Jan 29, 1995, 00:10 UTC) - Place: Belleville, MI - Coordinates: 42.200603, -83.480216 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.2006&lon=-83.4802&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report November 25, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 9830 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI95LA078 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9830/pdf - Page: https://openairdocs.org/ntsb/CHI95LA078 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Cargo shift, takeoff - security of cargo - inadequate, company maintenance personnel (cause) - aircraft preflight - inadequate, flightcrew (cause) - 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](https://openairdocs.org/deregistered/N706CK-2014-02-07), registration cancelled 2014-02-07, S/N 21827, built 1979 (OpenAirDocs) - Reported make and model: Boeing 747-238B - Registry model: [Boeing 747-249F](https://openairdocs.org/model/boeing-747-249f) (registry code 1384849) (OpenAirDocs) - Registry engine: [Pratt & Whitney JT9D series](https://openairdocs.org/engine/pratt-whitney-jt9d-series) (registry code 52054, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 20010 - Engines: P&W JT9D-7J 49970 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; 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 (OpenAirDocs). - [Accident 19950128048099A](https://openairdocs.org/incident/19950128048099A), Jan 28, 1995: Boeing 747238B, Detroit, MI, No damage. (-23) Takeoff from kyip on position flight to kdtw for loading. Aircraft was not pressurized, climb to 3000 feet, approach and landing kdtw was normal. On post… ## Other investigations on N706CK (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB MIA95WA143](https://openairdocs.org/ntsb/MIA95WA143), Jun 3, 1995: Boeing B-747-238 (N706CK), Panama City, Panama, substantial damage From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.