Vliegtuigongeval op 24 FEB 1989 met Boeing 747-122 N4713U

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Accident

Last updated: 20 May 2013

Status:	Definitief
Datum:	24 FEB 1989
Type:	Boeing 747-122
Luchtvaartmaatschappij:	United Air Lines
Registratie:	N4713U
Constructienummer:	19875/89
Bouwjaar:	1970-10-20 (18 years 4 months)
Aantal vlieguren:	58814
Aantal vluchten:	15027
Bemanning:	slachtoffers: 0 / inzittenden: 18
Passagiers:	slachtoffers: 9 / inzittenden: 337
Totaal:	slachtoffers: 9 / inzittenden: 355
Schade:	Groot
Gevolgen:	Repaired
Plaats:	Pacific Ocean (Grote Oceaan)
Fase:	Kruisvlucht (ENR)
Soort vlucht:	Internationale lijnvlucht
Vliegveld van vertrek:	Honolulu International Airport, HI (HNL/PHNL), Verenigde Staten
Vliegveld van aankomst:	Auckland International Airport (AKL/NZAA), Nieuw-Zeeland
Vluchtnummer:	811

Beschrijving:
United Airlines flight 811 experienced an explosive decompression as it was climbing between 22,000 and 23,000 feet after taking off from Honolulu, Hawaii, en route to Auckland and Sydney. The airplane made a successful emergency landing at Honolulu and the occupants evacuated the airplane. Examination of the airplane revealed that the forward lower lobe cargo door had separated in flight and had caused extensive damage to the fuselage and cabin structure adjacent to the door. Nine of the passengers had been ejected from the airplane and lost at sea.

PROBABLE CAUSE: "The sudden opening of the forward lower lobe cargo door in flight and the subsequent explosive decompression. The door opening was attributed to a faulty switch or wiring in the door control system which permitted electrical actuation of the door latches toward the unlatched position after initial door closure and before takeoff. Contributing to the cause of the accident was a deficiency in the design of the cargo door locking mechanisms, which made them susceptible to deformation, allowing the door to become unlatched after being properly latched and locked. Also contributing to the accident was a lack of timely corrective actions by Boeing and the FAA following a 1987 cargo door opening incident on a Pan Am B-747."

Bronnen:
» NTSB/AAR-92/02
» CVR transcript United Air Lines Flight 811 (Neil Krey's CRM Developers Forum)

Veiligheidsmaatregelen

NTSB issued 17 Safety Recommendations

Issued: 23-AUG-1989	To: FAA	A-89-092
ISSUE AN AIRWORTHINESS DIRECTIVE (AD) TO REQUIRE THAT THE MANUAL DRIVE UNITS AND ELECTRICAL ACTUATORS FOR BOEING 747 CARGO DOORS HAVE TORQUE LIMITING DEVICES TO ENSURE THAT THE LOCK SECTORS, MODIFIED PER AD-88-12-04, CANNOT BE OVERRIDDEN DURING MECHANICAL OR ELECTRICAL OPERATION OF THE LATCH CAMS. (Closed - Reconsidered)
Issued: 23-AUG-1989	To: FAA	A-89-093
ISSUE AN AIRWORTHINESS DIRECTIVE FOR NON-PLUG CARGO DOORS ON ALL TRANSPORT CATEGORY AIRPLANES REQUIRING THE INSTALLATION OF POSITIVE INDICATORS TO GROUND PERSONNEL AND FLIGHTCREWS CONFIRMING THE ACTUAL POSITION OF BOTH THE LATCH CAMS AND LOCKS, INDEPENDENTLY. (Closed - Acceptable Action)
Issued: 23-AUG-1989	To: FAA	A-89-094
REQUIRE THAT FAIL-SAFE DESIGN CONSIDERATIONS FOR NON PLUG CARGO DOORS ON PRESENT AND FUTURE TRANSPORT CATEGORY AIRPLANES ACCOUNT FOR CONCEIVABLE HUMAN ERRORS IN ADDITION TO ELECTRICAL AND MECHANICAL MALFUNCTIONS. (Closed - Acceptable Action)
Issued: 04-MAY-1990	To: FAA	A-90-054
AMEND 14 CFR 1447 (C)(4) TO REQUIRE THAT FACE MASKS BE ATTACHED TO THE REGULATORS OF PORTABLE EMERGENCY OXYGEN BOTTLES. (Closed - Unacceptable Action)
Issued: 04-MAY-1990	To: FAA	A-90-055
REQUIRE, IN ACCORDANCE WITH THE REQUIREMENTS OF 14 CFR 25 1447 (C)(4), THAT A PORTABLE OXYGEN BOTTLE BE LOCATED AT THE FLIGHT ATTENDANT STATIONS AT EXIT DOOR 5 RIGHT AND AT EXIT DOOR 5 LEFT IN B-747 AIRPLANES. (Closed - Acceptable Action)
Issued: 04-MAY-1990	To: FAA	A-90-056
REQUIRE THAT NO ARTICLES BE PLACED IN STORAGE COMPARTMENTS THAT ARE LOCATED OVER EMERGENCY EXIT DOORS. (Closed - Acceptable Alternate Action)
Issued: 04-MAY-1990	To: FAA	A-90-057
AMEND 14 CFR 121.309 (F) TO REQUIRE A READILY ACCESSIBLE MEGAPHONE AT EACH SEAT ROW AT WHICH A FLIGHT ATTENDANT IS STATIONED. (Closed - Unacceptable Action)
Issued: 04-MAY-1990	To: FAA	A-90-058
TAKE CORRECTIVE ACTION TO IMPROVE DIRECT VISIBILITY TO PASSENGERS FROM THE UPPER LEVEL FLIGHT ATTENDANT JUMPSEAT IN THE B-747 AIRPLANES USING EYE REFERENCE DATA CONTAINED IN FEDERAL AVIATION ADMINISTRATION REPORT FAA-AM-75-2 ANTHROPOMETRY OF AIRLINE STEWARDESSES. (Closed - Reconsidered)
Issued: 04-MAY-1990	To: FAA	A-90-059
ISSUE AN AIRWORTHINESS DIRECTIVE TO REQUIRE THAT STRONGER LATCHES BE INSTALLED IN OVERSIZED STORAGE COMPARTMENTS THAT FORMALLY HELD LIFERAFTS ON ALL B-747 AIRPLANES AND ALSO LIMIT THE DISTANCE THAT THESE COMPARTMENTS CAN BE OPENED. (Closed - Acceptable Action)
Issued: 04-MAY-1990	To: FAA	A-90-060
DEMONSTRATE FOR EACH MAKE AND MODEL OF LIFE PRESERVER THAT IT CAN BE DONNED, ADJUSTED, AND TIGHTENED WITHIN THE ELAPSED TIME REQUIRED BY TSO-13D. DIRECT PARTICULAR ATTENTION TO THE EASE WITH WHICH STRAPS PASS THROUGH ADJUSTMENT FITTINGS WHEN THE STRAPS ARE PULLED AT ALL POSSIBLE ANGLES. (Closed - Acceptable Action)
Issued: 04-MAY-1990	To: FAA	A-90-061
ESTABLISH A CUTOFF DATE OF WITHIN 1 YEAR OF THIS RECOMMENDATION AFTER WHICH ALL LIFE PRESERVERS MANFACTURED FOR PASSENGER-CARRYING AIRCRAFT WOULD BE REQUIRED TO MEET THE SPECIFICATIONS OF TSO-C13E. (Closed - Acceptable Action)
Issued: 04-MAY-1990	To: STATE OF HAWAII DEPARTMENT OF TRANSPORTATION	A-90-062
DEVELOP, IN COOPERATION WITH THE DEPARTMENT OF DEFENSE, PROCEDURES FOR DIRECT RADIO COMMUNICATION BETWEEN AIRCRAFT RESCUE AND FIREFIGHTING VEHICLES OPERATED BY THE STATE OF HAWAII AND HICKAM AIR FORCE BASE THAT WOULD BE USED WHEN RESPONDING TO AIRPORT EMERGENCIES AT HONOLULU INTERNATIONAL AIRPORT. (Closed - Acceptable Action)
Issued: 04-MAY-1990	To: U.S. DoD	A-90-063
DEVELOP, IN COOPERATION WITH THE STATE OF HAWAII DEPARTMENT OF TRANSPORTATION, PROCEDURES FOR DIRECT RADIO COMMUNICATION BETWEEN AIRCRAFT RESCUE AND FIREFIGHTING VEHICLES OPERATED BY HICKAM AIR FORCE BASE AND THE STATE OF HAWAII THAT WOULD BE USED WHEN RESPONDING TO AIRPORT EMERGENCIES AT HONOLULU INTERNATIONAL AIRPORT. (Closed - Acceptable Action)
Issued: 04-MAY-1990	To: U.S. DoD	A-90-064
COMPLY WITH FEDERAL REGULATION 14 CFR 139.319(F)(2) AND THE GUIDANCE CONTAINED IN FEDERAL AVIATION ADMINISTRATION ADVISORY CIRCULAR 150/5220-14 BY USING HIGH VISIBILITY COLOR FOR AIRCRAFT RESCUE AND FIREFIGHTING VEHICLES THAT OPERATE AT HONOLULU INTERNATIONAL AIRPORT. (Closed - Acceptable Action)
Issued: 28-AUG-1991	To: FAA	A-91-083
ISSUE AN AIRWORTHINESS DIRECTIVE APPLICABLE TO ALL BOEING 747 AIRPLANES WITH A FLEXIBLE CONDUIT PROTECTING THE WIRING BUNDLE BETWEEN THE FUSELAGE AND AFT CARGO DOOR TO REQUIRE AN EXPEDITED INSPECTION OF (Closed - Reconsidered)
Issued: 28-AUG-1991	To: FAA	A-91-084
EVALUATE THE DESIGN, INSTALLATION, AND OPERATION OF THE FORWARD CARGO DOOR FLEXIBLE CONDUITS ON BOEING 747 AIRPLANES SO EQUIPPED AND ISSUE, IF WARRANTED, AN AIRWORTHINESS DIRECTIVE FOR INSPECTION AND REPAIR OF THE FLEXIBLE CONDUIT AND UNDERLYING WIRING BUNDLE, SIMILAR TO THE PROVISIONS RECOMMENDED IN A-91-83. (Closed - Reconsidered)
Issued: 09-APR-1992	To: FAA	A-92-021
REQUIRE THAT THE ELECTRICAL ACTUATING SYSTEMS FOR NONPLUG CARGO DOORS ON TRANSPORT-CATEGORY AIRCRAFT PROVIDE FOR THE REMOVAL OF ALL ELECTRICAL POWER FROM CIRCUITS ON THE DOOR AFTER CLOSURE (EXCEPT FOR ANY INDICATING CIRCUIT POWER NECESSARY TO PROVIDE POSITIVE INDICATION THAT THE DOOR IS PROPERLY LATCHED AND LOCKED) TO ELIMINATE THE POSSIBILITY OF UNCOMMANDED ACTUATOR MOVEMENTS CAUSED BY WIRING SHORT CIRCUITS. (Closed - Acceptable Alternate Action)

Show all AD's and Safety Recommendations

Foto's

Kaart

Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Honolulu International Airport, HI en Auckland International Airport bedraagt 7046 km (4404 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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