DCA11MA039

NTSB accident investigation · Boeing 737 · Yuma, AZ · April 1, 2011

Accident · Minor injuriesMajor investigationFinal report
Date
April 1, 2011, 15:57 local (22:57 UTC)
Place
Yuma, AZ
Injuries
2 minor, 120 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N632SWBoeing 737
Defining event
Enroute-climb to cruise: Aircraft structural failure
Weather
Visual (VMC) · Day
Status
Completed · report February 26, 2014
Report
Approved by Office Director
NTSB office
Major Investigations Division
FAA report
20110401007039A
Case key
78737

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

On this page

Probable cause

the improper installation of the fuselage crown skin panel at the S-4L lap joint during the manufacturing process, which resulted in multiple site damage fatigue cracking and eventual failure of the lower skin panel. Contributing to the injuries was flight attendant A's incorrect assessment of his time of useful consciousness, which led to his failure to follow procedures requiring immediate donning of an oxygen mask when cabin pressure is lost.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Knowledge: knowledge of proceduresPersonnel issues › Experience/knowledge · Cabin crewAll aircraft: 41 casesProbable cause
Fuselage: fuselage main structureAircraft › Aircraft structures · Incorrect service/maintenanceAll aircraft: 24 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Aircraft structural failureEnroute-climb to cruiseAll aircraft: 290 casesDefining event

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Brief number is NTSB/AAB-13/02. On April 1, 2011, about 1558 mountain standard time (MST), a Boeing 737-3H4, N632SW, operating as Southwest Airlines flight 812 experienced a rapid decompression while climbing through flight level 340. The flight crew conducted an emergency descent and diverted to Yuma International Airport (NYL), Yuma, Arizona. Of the 5 crewmembers and 117 passengers on board, one crewmember and one nonrevenue off-duty airline employee passenger sustained minor injuries. The airplane sustained substantial damage; postaccident inspection revealed that a section of fuselage skin about 60 inches long by 8 inches wide had fractured and flapped open on the upper left side above the wing. The flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a regularly scheduled domestic passenger flight from Phoenix Sky Harbor International Airport, Phoenix, Arizona, to Sacramento International Airport, Sacramento, California.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Brief number is NTSB/AAB-13/02. On April 1, 2011, about 1558 mountain standard time (MST), a Boeing 737-3H4, N632SW, operating as Southwest Airlines flight 812 experienced a rapid decompression while climbing through flight level 340. The flight crew conducted an emergency descent and diverted to Yuma International Airport (NYL), Yuma, Arizona. Of the 5 crewmembers and 117 passengers on board, one crewmember and one nonrevenue off-duty airline employee passenger sustained minor injuries. The airplane sustained substantial damage; postaccident inspection revealed that a section of fuselage skin about 60 inches long by 8 inches wide had fractured and flapped open on the upper left side above the wing. The flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a regularly scheduled domestic passenger flight from Phoenix Sky Harbor International Airport, Phoenix, Arizona, to Sacramento International Airport, Sacramento, California.

Aircraft

Registration
N632SW
Reported as
Boeing 737 (300)
Category
Airplane
Serial number
27707
Engines
CFM 56, turbo fanCFM 56, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Southwest Airlines Co
Registered owner
Southwest Airlines Co
Airworthiness certificate
Standard, Transport
Departed
PHX · Phoenix, AZ
Destination
SMF · Sacramento, CA
Flight plan
IFR
Airport
NYL · Yuma International Airport

Weather

Conditions
Visual (VMC) · Day

Docket · 30

The files NTSB released with the investigation on March 7, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 70.3 MB in all.

Materials Laboratory Factual Report 11-092 (contains 18 pages of figures)Item 1 · .PDF · 9.5 MBMaterials Laboratory Factual Report 11-070 (contains 3 pages of figures)Item 2 · .PDF · 418 KBMaterials Laboratory Factual Report 12-010Item 3 · .PDF · 222 KBMaterials Laboratory Factual Report 12-011 (with 2 figures)Item 4 · .PDF · 709 KBMaterials Laboratory Factual Report 12-033 (with 1 figure)Item 5 · .PDF · 553 KBMaterials Laboratory Factual Report 12-012 (with 10 figures)Item 6 · .PDF · 2.4 MBSurvival Factors 6 - Factual Report of Group ChairmanItem 7 · .PDF · 1.0 MBOperations 2 - Flight Crew StatementsItem 8 · .PDF · 185 KBSurvival Factors 6 - Attachment 1 - Flight Attendant StatementsItem 9 · .PDF · 185 KBSurvival Factors 6 - Attachment 2 - Passenger QuestionnairesItem 10 · .PDF · 10.3 MBStructures 7 - Factual Report of Group ChairmanItem 11 · .PDF · 67 KBStructures 7 - Appendix A - FiguresItem 12 · .PDF · 326 KBStructures 7 - Addendum 1 - Skin Panel Information (3 embedded photos)Item 13 · .PDF · 418 KBFlight Data Recorder 10 - Specialist's Factual ReportItem 14 · .PDF · 2 photos · 100 KBFlight Data Recorder 10 - Incident Flight Tabular DataItem 15 · .CSV · 3.7 MBMaintenance Records 11 - Factual Report of Group ChairmanItem 16 · .PDF · 270 KBMaintenance Records 11 - Attachment 1 - Air Carrier CertificateItem 17 · .PDF · 67 KBMaintenance Records 11 - Attachment 2 - Supplemental Type CertificatesItem 18 · .PDF · 400 KBMaintenance Records 11 - Attachment 3 - Airworthiness Directives and Service Bulletin ListingItem 19 · .PDF · 3.6 MBMaintenance Records 11 - Attachment 4 - Aircraft Flight LogsItem 20 · .PDF · 21.1 MBMaintenance Records 11 - Attachment 5 - Weight and BalanceItem 21 · .PDF · 219 KBMaintenance Records 11 - Attachment 6 - Service Difficulty Report and Mechanical Interruption Summary ReportItem 22 · .PDF · 66 KBMaintenance Records 11 - Attachment 7 - Major Repairs and AlterationsItem 23 · .PDF · 508 KBMaintenance Records 11 - Attachment 8 - Time Limit Component ListingItem 24 · .PDF · 416 KBMaintenance Records 11 - Attachment 9 - Spirit AerosystemsItem 25 · .PDF · 7.6 MBCockpit Voice Recorder 12 - Specialist's Factual ReportItem 26 · .PDF · 82 KBCockpit Voice Recorder 12 - Errata 1Item 27 · .PDF · 95 KBExterior and interior views of the skin showing fracture along the lower row of rivets.Item 28 · .PDF · 2.1 MBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 29 · .PDF · 177 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 30 · .PDF · 3.4 MB

FAA reports on this event · 1

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