BOEING 737SOUTHWEST AIRLINES CO
Charleston, WV, USA · 2009-07-13·N387SW
What happened
NTSB summary, verbatimFlight data recorder data revealed that the airplane took off and climbed for about 25 minutes to an altitude of approximately 35,000 feet, at which point the cabin altitude warning activated, and the captain disengaged the autopilot. Postincident examination of the airplane revealed fatigue cracking of the fuselage skin near the leading edge of the vertical stabilizer adjacent to the rupture. The fatigue cracking penetrated the fuselage skin and created an approximate 18-inch by 12-inch flap in the skin that depressurized the airplane. The fuselage skin assembly near the leading edge of the vertical stabilizer was manufactured by bonding two full aluminum sheets together, then selectively chemically milling away pockets (bays) of the inner sheet. Continuous fatigue cracks initiated from multiple origins on the inner surface of the skin adjacent to the step formed at the edge of the chemically milled area and propagated outward. Following the Southwest Airlines (SWA) flight 2294 event, on September 3, 2009, Boeing issued Service Bulletin (SB) 737-53A1301, calling for repetitive external inspections to detect cracks in the fuselage skin along the chemically milled step at stringers S-1 and S-2 right and between BS 827 and BS 847. (The hole from the SWA event was within those boundaries.) If cracks are detected, operators are to contact Boeing for repair instructions. On January 12, 2010, the Federal Aviation Administration issued Airworthiness Directive 2010-01-09, which mandated the inspection requirements in SB 737-53A1301.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationFuselage skin failure due to preexisting fatigue at a chemically milled step.
Occurrence sequence
2 stepsNTSB coding · CICTT taxonomy- 1 · Enroute-cruiseEmergency descent initiated
- 2 · Enroute-cruiseAircraft structural failuredefining event
Findings
2 causal · 0 contributing- CAUSEAircraft › Aircraft structures › Fuselage › Plates/skins (aux fuselage) — Fatigue/wear/corrosion
- CAUSEAircraft › Aircraft structures › Fuselage › Plates/skins (aux fuselage) — Failure
Sequence of events
5 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- takeoffclimbp.3Aircraft took off and climbed for about 25 minutes to approximately 34,500 ft
- 17:39:04 EDTcruisep.3Cabin altitude warning indicated a warning and the autopilot turned off (rapid decompression)
- 17:39-17:45 EDTemergency descentp.3Over the next 6 minutes the aircraft descended to approximately 11,000 ft
- about 17:51 EDTdescentp.3Aircraft began to descend again; cabin altitude warning turned off passing through 8,100 ft
- 18:06:29 EDTlandingp.3Aircraft landed uneventfully at Charleston
NTSB analysis
from the final reportFlight data recorder data revealed that the airplane took off and climbed for about 25 minutes to an altitude of approximately 35,000 feet, at which point the cabin altitude warning activated, and the captain disengaged the autopilot. Postincident examination of the airplane revealed fatigue cracking of the fuselage skin near the leading edge of the vertical stabilizer adjacent to the rupture. The fatigue cracking penetrated the fuselage skin and created an approximate 18-inch by 12-inch flap in the skin that depressurized the airplane. The fuselage skin assembly near the leading edge of the vertical stabilizer was manufactured by bonding two full aluminum sheets together, then selectively chemically milling away pockets (bays) of the inner sheet. Continuous fatigue cracks initiated from multiple origins on the inner surface of the skin adjacent to the step formed at the edge of the chemically milled area and propagated outward. Following the Southwest Airlines (SWA) flight 2294 event, on September 3, 2009, Boeing issued Service Bulletin (SB) 737-53A1301, calling for repetitive external inspections to detect cracks in the fuselage skin along the chemically milled step at stringers S-1 and S-2 right and between BS 827 and BS 847. (The hole from the SWA event was within those boundaries.) If cracks are detected, operators are to contact Boeing for repair instructions. On January 12, 2010, the Federal Aviation Administration issued Airworthiness Directive 2010-01-09, which mandated the inspection requirements in SB 737-53A1301.