LAX95FA303

NTSB accident investigation · Lockheed L-1011-385-1 · Pacific Ocean (Pacific Ocean) · August 24, 1995

Accident · No injuriesField investigationFinal report
Date
August 23, 1995, 20:13 local (Aug 24, 1995, 03:13 UTC)
Place
Pacific Ocean (Pacific Ocean)
Injuries
236 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N781DLLockheed L-1011-385-1
Weather
Visual (VMC) · Dusk
Status
Completed · report April 29, 1996
Report
Approved by Office Director
FAA report
19950823036159A
Case key
28935

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

inadequate certification/approval of the airframe structure. Contributing was the lack of required inspections of the failure area.

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.

Airframe/component/system failure/malfunctionCruise
Fuselage,pressure bulkhead - failureCause
Fuselage,stringer - failureCause
Inadequate certification/approval,aircraftManufacturerFactor
DecompressionCruise

Analysis

The aircraft experienced a rapid decompression at 33,000 feet msl. The aircraft made a rapid descent to 14,000 feet where it was able to maintain a 7,000-foot cabin pressure. The aircraft returned to Los Angeles and made an uneventful landing. Postaccident examination revealed that around fuselage station 1800, 20 stringer end fittings were severed, allowing the aft pressure bulkhead to separate from the fuselage crown. Metallurgical analysis revealed that the origional manufacturer had predrilled the stringer end fittings. During assembly not all holes aligned. The unused holes were plugged. The fastener edge distance was below minimums. Fitting eccentricity was also noted as a problem. Combined, they increased stress levels at crack initiation sites. Operator inspections have reported 97 aircraft without cracks and 29 with various cracks of the stringer end fittings.

Factual narrative

History of flight

On August 23, 1995, at 2013 hours Pacific daylight time, a Lockheed L-1011-385-1, N781DL, operated by Delta Airlines as Flight 157, sustained substantial damage followed by a rapid decompression over the Pacific Ocean while in cruise flight at 33,000 feet mean sea level (msl). The flight crew reported hearing a loud bang immediately prior to the decompression event. The pilot initiated an emergency descent to 14,000 feet msl, and returned to Los Angeles, California, for an uneventful landing at 2217 hours.

The crew reported that they were unable to regain control of the pressurization; however, the cabin was eventually stabilized at 7,000 feet when the aircraft leveled off at 14,000 feet msl. Other than reports of ear discomfort, there were no injuries to the 226 passengers and crew of 10. Three passengers were taken to a local hospital for a brief check then released. Flight number 157, a regularly scheduled domestic flight, departed Los Angeles International Airport at 1810 en route to Honolulu, Hawaii. The flight was approximately 450 miles west of Los Angeles at the time of the depressurization.

Aircraft information

Postaccident examination of the aircraft revealed that around fuselage station 1800, 20 stringer end fittings were severed, allowing the aft pressure bulkhead to separate from the fuselage crown. The separation was over a length of about 12 feet of the pressure bulkhead circumference. Also, at fuselage station 1809, the "Z" frame was found bent and torn. No external fuselage damage was found. The crack extended from stringer 10 through 0 (top center) to stringer 55.

According to information provided by Lockheed, seven of the stringer end fittings had failed on the L-1011 fatigue test aircraft. This led to the issuance of service bulletin 093-53-105, which recommended the inspection/replacement of the stringer end fittings on serial numbers 193A-1002 through 1012. The accident aircraft is the third production aircraft, serial number 1003. A review of the Lockheed records revealed that no operators have complied with SB 093-53-105 as of this date.

Although the redesigned fittings were installed on serial number 1013 and up, Lockheed has received several reports of the redesigned fittings cracking on aircraft with serial numbers later than 1012.

The area of the failure is not covered on an inspection work card during routine inspections; however, the exterior of the aircraft is inspected. On July 23, 1995, a "C" check inspection had been performed on the accident aircraft. At that time, the aircraft had accumulated 51,951 hours and 25,691 cycles. At the time of the accident, the aircraft had 52,210 hours and 25,813 cycles.

As a result of this accident, on August 29, 1995, the FAA issued a telegraphic airworthiness directive (T95-18-52 amended with AD95-18-52 on September 28, 1995, and superseded by AD95-26-11) was issued to all operators of Lockheed model L-1011-385 series airplanes certificated in any category. The AD mandated the compliance/inspection called out in the text within a certain time frame. On August 24,1995, Lockheed Aeronautical Systems Support Company notified all foreign operators of the rapid decompression during flight and referenced S/B 093-53-105.

According to Lockheed, there are about 250 L-1011's in service. As of February 24, 1996, as a result of Lockheed's notification to operators, there have been 29 reports of aircraft having various cracks to the end fittings and 97 reports of no cracks. The cycles of these aircraft ranged from a high of 33,375 to a low of 21,657.

Metallurgical analysis

According to the report, during the manufacturing process, stringer end fittings were predrilled. During the assembly process not all of the predrilled holes aligned. The unused holes were then plugged/filled by the original manufacturer. Plugged holes oriented in the direction of maximum tension stress near the aft most fastener hole resulted in increased stress levels at crack initiation sites.

Short fastener edge distance on some of the stringer end fittings contributed to increased stress levels at crack initiation sites. (Ref.: FAA AC 43.13-1A, paragraph 99, figure 2.18.)

Fitting eccentricity also contributed to high stress levels at crack initiation sites. For more detailed information, refer to the attached Structure Technology Group Engineering Report (February 5, 1996).

Additional information

Due to the cost of repairs, Delta Airlines subsequently retired the aircraft. The aircraft was purchased by Lockheed Aircraft for aging aircraft testing. On October 11, 1995, the aircraft was ferried to Dobbins AFB, Marietta, Georgia. Prior to releasing the aircraft to Lockheed, Delta Airlines personnel removed the failed aft pressure dome components for metallurgical analysis.

Aircraft

Registration
N781DL
Reported as
Lockheed L-1011-385-1 (L-1011-385)
Category
Airplane
Serial number
1003
Airframe hours
52,210
Engine
Rolls-Royce RB211-22B02, 42,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Registered owner
Delta Air Lines, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · June 25, 1995 · 259 hours before
Departed
LAX · Los Angeles, CA
Destination
HNL · Honolulu, HI
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
55
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
22,330 total · 2,000 in this make and model

Weather

Conditions
Visual (VMC) · Dusk
Lowest ceiling
None

Docket · 13

The files NTSB released with the investigation on March 26, 1996, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.1 MB in all.

FAA reports on this event · 1

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