# NTSB DCA15LA011: Boeing 737 330, N301KH, Lanai, HI, October 17, 2014

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: October 16, 2014, 14:47 local (Oct 17, 2014, 00:47 UTC)
- Place: Lanai, HI
- Coordinates: 20.78, -156.949996 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=20.7800&lon=-156.9500&mi=10
- Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping)
- Defining event: [Prior to flight: Aircraft loading event](https://openairdocs.org/ntsb-events/010)
- Highest injury: No injuries
- Injuries: 3 uninjured
- Status: Completed, report April 6, 2020
- Report: Approved by Office Director
- NTSB office: Major Investigations Division
- NTSB case key (mKey): 90269
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA15LA011
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90269/pdf
- Page: https://openairdocs.org/ntsb/DCA15LA011

## Probable cause

the improper loading and securing of the cargo pallets, which shifted on departure, resulting in substantial damage to the aft pressure bulkhead.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Loading](https://openairdocs.org/ntsb-findings/01011500): Aircraft › Aircraft handling/service · Incorrect use/operation (probable cause); cases with it: [Boeing 737-330, 1 case](https://openairdocs.org/ntsb-findings/01011500/cases.md?model=13844BJ), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01011500/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Prior to flight: Aircraft loading event](https://openairdocs.org/ntsb-events/010) (defining event); cases with it: [Boeing 737-330, 1 case](https://openairdocs.org/ntsb-events/010/sequence.md?model=13844BJ), [All aircraft, 84 cases](https://openairdocs.org/ntsb-events/010/sequence.md)
- [Enroute-climb to cruise: Pressure/environ sys malf/fail](https://openairdocs.org/ntsb-events/331); cases with it: [Boeing 737-330, 1 case](https://openairdocs.org/ntsb-events/331/sequence.md?model=13844BJ), [All aircraft, 116 cases](https://openairdocs.org/ntsb-events/331/sequence.md)

## Analysis

Aloha Air Cargo flew to an out-station with none of their personnel located there. The decision was made to limit the number of Additional Crew Members (ACMs) due to concerns about the return flight's weight and balance. With the choice of taking the load planner or the mechanic, Aloha Air Cargo made the decision to take the mechanic, which was against the company loading procedures since the mechanic was not trained on cargo securing nor were there any approved personnel at the destination to assist with loading and securing the empty pallets. Since the load planner would not be making the flight, he discussed with the mechanic on how to load the empty pallets for the return flight, which was to load and lock each empty pallet in their original loaded location. However, while in LNY, Aloha Air Cargo dispatch recommended that all the pallets be placed in position 9 due to concerns about weight and balance. It is unknown if the mechanic tried to contact the load planner to discuss the new configuration. The cargo floor locks will only secure the bottom pallet when engaged properly and not the stacked pallets. The decision was made to secure the stacked pallets with a cargo strap which was insufficient to keep the pallets from moving. Even though it was stated that during the loading process that the locks were "up" and locked, when the Marshaller entered the airplane he observed the locks between station 8 and 9 were down/unlocked. In addition, there was damage found to the right hand forward and aft locking mechanisms, implying these locks were used but failed due to overload.

## Factual narrative

On October 16, 2014, at about 1447 local time, an Aloha Air Cargo flight 601 B737-330, N301KH, experienced a cargo shift shortly after takeoff from Lanai Airport (LNY), Lanai City, Hawaii, causing substantial damage to the aft pressure bulkhead and the airplane was not able to pressurize. The flight continued to its destination and was towed to a hanger. Upon further examination it was found that a stack of cargo "cookie sheets" came free of their cargo locks in position 9 and shifted rearward. There were no injuries to the two flight crew and one onboard mechanic. The flight was operating under 14 Code of Federal Regulations Part 121 as a non-scheduled cargo flight from LNY to Daniel K Inouye International Airport (HNL), Honolulu, Hawaii. Aloha Air Cargo was chartered, by Hawaii Island Air, to fly round trip from HNL to LNY to deliver lumber for an impeding hurricane. LNY was not a station Aloha Air Cargo normally flew to, nor did they have employees there. In addition to the flight crew, a flight mechanic and a load planner were scheduled to fly with the aircraft to provide support. Just prior to the flight's departure, dispatch noted that due to weight and balance concerns on the return trip only one of the additional employees could ride with the aircraft. The choice was made to leave the load planner behind and take the aircraft mechanic as the Additional Crew Member (ACM). This was contrary to company guidance. Flight 600, departed HNL at 1240 HST and arrived in LNY at 1253 HST. After arriving in LNY, the aircraft was off loaded and then the, now empty, cargo pallet cookie sheets were loaded for the return flight. Aloha Air Cargo used various unit load devices (ULDs) in its freighter operation. The LD7 cargo pallet "cookie sheets" consisted of a single skinned pallet with four edge rails, four corner castings and a center sheet section. The pallet sheet and edge rails are attached to each other by rivets. The edge rails are attached to each other at the four corners by means of corner castings. The mechanic, first officer (FO), and Island Air employees helped to load the aircraft and verified that the locks were up and locked in all positions. There were a total of 8 empty pallet cookie sheets. Of these sheets 7 were strapped down and secured to the 8th sheet. The 8th sheet was then locked down in position 9 (the aircraft was equipped with 9 cargo positions on the main deck with the ninth position being the most aft and turned lengthwise). This was done per dispatch's request for center of gravity (CG) consideration, even though before departure from HNL the load planner had discussed with the mechanic that each pallet should go back in their original position and locked down. Flight 601, departed LNY at 1449 HST and arrived in HNL at 1514 HST. Nothing out of the ordinary was noticed by the crew in the feel of the aircraft nor did they hear anything unusual. The auto fail light came on during climb and the quick reference handbook (QRH)was then followed. No door lights illuminated and the outflow valve indicated "Closed." However, upon reaching 10,000 ft. the altitude alert horn came on so the crew leveled at 10,000 ft. No emergency was declared. The aircraft landed uneventfully. Upon arrival the flight crew notified dispatch of the pressurization issue, made a log book entry, and was assigned a new aircraft for continued flight. Dispatch notified maintenance of the aircraft pressurization problem. Per company procedures, Marshaller A performs a post arrival check of the aircraft and verifies the content of the cargo before unloading can begin. Marshaller A noticed that all of the pallets were loaded into position 9, that none of the locks between position 8 and 9 were up, and the straps holding the sheets had allowed the sheets to shift aft making contact with the aft pressure bulkhead. Post event examination revealed that the aft pressure bulkhead had substantial damage, left aft (L2) door panel was damaged, and the right hand forward and aft pop up locking mechanism "claws" were detached/torn from their seat tracks. (See Figure 1) Figure 1: Pallet cookie sheets and damage to aft pressure bulkhead

## Aircraft

- Registration: [N301KH](https://openairdocs.org/aircraft/N301KH), registered now, S/N 27904, built 1995 (OpenAirDocs)
- Reported make and model: BOEING 737 330 (330)
- Registry model: [Boeing 737-330](https://openairdocs.org/model/boeing-737-330) (registry code 13844BJ) (OpenAirDocs)
- Registry engine: [CFM International CFM56-3C1](https://openairdocs.org/engine/cfm-international-cfm56-3c1) (registry code 13077, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 27904
- Year built: 1995
- Airframe hours: 41163
- Engines: CFM INTL CFM56-3C1 10460 lbs thrust turbo fan; CFM INTL CFM56-3C1 10460 lbs thrust turbo fan
- Damage: Substantial damage
- Flight: Part 121
- Operator: Aloha Airlines Inc
- Registered owner: Aeko Kula Inc DBA
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, October 16, 2014
- Departed: LNY, Lanai, HI
- Destination: HNL, Honolulu, HI
- Flight plan: IFR
- Airport: LNY, Lanai Airport, runway 21, 5,001 × 150 ft, asphalt
- Equipment: Data recorder, Auto-pilot, Angle of attack indicator, Stall warning system, Onboard weather, Electronic primary flight display

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 59; injuries: none; airline transport, commercial; airplane ratings: single-engine land, multi-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review April 25, 2015; seat: left; restraint: 5-point; toxicology performed; flight hours: 17,840 total, 14,330 in this make and model, 14,995 as pilot in command, 17 in the last 90 days, 8 in the last 30 days, 2 in the last 24 hours
- Co-pilot; age 42; injuries: none; commercial, airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 19, 2014; seat: right; restraint: 5-point; toxicology performed; flight hours: 6,000 total, 880 in this make and model, 4,448 as pilot in command, 160 in the last 90 days, 66 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Lowest ceiling: none

## 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 20141016022899A](https://openairdocs.org/incident/20141016022899A), Oct 16, 2014: Boeing 737-330, Honolulu, HI, Substantial damage. The pallets in the aircraft was not properly secured to the aircraft prior to flight.

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.

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