# NTSB DCA89MA027: Boeing 747-122, N4713U, Honolulu, HI, February 24, 1989

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: February 24, 1989, 02:09 local (12:09 UTC)
- Place: Honolulu, HI
- Coordinates: 21.270326, -157.819931 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=21.2703&lon=-157.8199&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 9 fatal, 5 serious, 33 minor, 309 uninjured
- Status: Completed, report June 25, 1990
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Major Investigations Division
- Safety recommendations: Yes
- NTSB case key (mKey): 15916
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA89MA027.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15916/pdf
- Board report AAR9202 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9202.pdf
- Page: https://openairdocs.org/ntsb/DCA89MA027

## Probable cause

THE SUDDEN OPENING OF THE IMPROPERLY LATCHED FORWARD LOBE CARGO DOOR IN FLIGHT AND THE SUBSEQUENT EXPLOSIVE DECOMPRESSION. CONTRIBUTING TO THE ACCIDENT WAS A DEFICIENCY IN THE DESIGN OF THE CARGO DOOR LOCKING MECHANISMS, WHICH MADE THEM SUSCEPTIBLE TO INSERVICE DAMAGE, AND WHICH ALOWED THE DOOR TO BE UNATCHED, YET TO SHOW A PROPERLY LATCHED AND LOCKED POSITION. ALSO CONTRIBUTING TO THE ACCIDENT WAS THE LACK OF PROPER MAINTENANCE AND INSPECTION OF THE CARGO DOOR BY UNITED AIRLINES, AND A LACK OF TIMELY CORRECTIVE ACTIONS BY BOEING AND THE FAA FOLLOWING A PREVIOUS DOOR OPENING INCIDENT.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, climb - to cruise
  - door,cargo/baggage - unlatched (cause)
  - door,cargo/baggage - separation (cause)
  - maintenance,inspection - improper, company maintenance personnel (contributing factor)
  - acft/equip,inadequate design, manufacturer (contributing factor)
  - acft/equip,inadequate standard/requirement, faa(other/organization) (contributing factor)
  - air cond/heating/pressurization - decompression (cause)

## Analysis

The Safety Board's full report on this investigation is provided as Aviation Accident Report number AAR-92/02. To obtain a copy of this report, or to view the executive summary online, please see the Web site at http://www.ntsb.gov/publictn/publictn.htm

FTL #811 WAS A SCHEDULED PASSENGER FLIGHT FROM LOS ANGELES TO SYDNEY, AUSTRALIA, WITH STOPS IN HONOLULU (HNL), HI, AND AUCKLAND, NEW ZEALAND. THE FLT WAS UNEVENTFUL UNTIL AFTER DEPARTURE FROM HNL. WHILE CLIMBING FROM FL220 TO FL230 THE CREW HEARD A 'THUMP' FOLLOWED BY AN EXPLOSION. AN EXPLOSIVE DECOMPRESSION WAS EXPERIENCED AND THE #3 AND #4 ENGS WERE SHUTDOWN BECAUSE OF FOD. THE FLT RETURNED TO HNL AND PASSENGERS WERE EVACUATED. INSPECTION REVEALED THE FORWARD LOWER LOBE CARGO DOOR DEPARTED INFLT CAUSING EXTENSIVE DAMAGE TO THE FUSELAGE AND CABIN ADJACENT TO THE DOOR. NINE PASSENGERS WERE EJECTED AND LOST AT SEA. INVESTIGATION CENTERED AROUND DESIGN AND CERTIFICATION OF THE DOOR WHICH ALLOWED IT TO BE IMPROPERLY LATCHED, AND THE OPERATION AND MAINTENANCE TO ASSURE AIRWORTHINESS OF THE DOOR AND LATCHING MECHANISM. (SEE NTSB/AAR-90/01)

## Aircraft

- Registration: N4713U (not matched to a registry record)
- Reported make and model: BOEING 747-122
- Category: Airplane
- Serial number: N4713U
- Engines: P&W JT9D-3A 43000 lbs thrust turbo fan
- Damage: Substantial damage
- Fire: In-Flight
- Flight: Part 121
- Operator: United Airlines, doing business as United Airlines,Inc.
- Registered owner: United Airlines
- Airworthiness certificate: Standard, Transport
- Departed: HNL, HONOLULU, HI
- Destination: AKL, AUCKLAND, OF
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 59; airline transport; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 28,000 total, 1,650 in this make and model

## Weather

- Conditions: Visual (VMC), Night/dark
- Temperature: -0 °F

## 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 19890224002409A](https://openairdocs.org/incident/19890224002409A), Feb 24, 1989: Boeing 747122, Honolulu, HI, Substantial damage, 9 fatal. Improperly latched lower lobe cargo door opened with subsequent explosive decompression.

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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