FlarePath
Cases › DCA09FA065 · Part 121 airline

BOEING 737SOUTHWEST AIRLINES CO

Charleston, WV, USA · 2009-07-13·N387SW

0
fatal
0
serious
No injury
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

Flight 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 found
The aircraft before the accident
N387SW - Boeing 737-3H4 - Southwest Airlines (36944952421)
Colin Brown from St Ann, MO, USA · CC BY 2.0 · Wikimedia Commons

Probable cause

the Board's determination
Fuselage skin failure due to preexisting fatigue at a chemically milled step.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy
  1. 1 · Enroute-cruise
    Emergency descent initiated
  2. 2 · Enroute-cruise
    Aircraft structural failure
    defining event

Findings

2 causal · 0 contributing
  • CAUSE
    Aircraft › Aircraft structures › Fuselage › Plates/skins (aux fuselage) — Fatigue/wear/corrosion
  • CAUSE
    Aircraft › Aircraft structures › Fuselage › Plates/skins (aux fuselage) — Failure

Sequence of events

5 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)
  1. takeoffclimbp.3
    Aircraft took off and climbed for about 25 minutes to approximately 34,500 ft
  2. 17:39:04 EDTcruisep.3
    Cabin altitude warning indicated a warning and the autopilot turned off (rapid decompression)
  3. 17:39-17:45 EDTemergency descentp.3
    Over the next 6 minutes the aircraft descended to approximately 11,000 ft
  4. about 17:51 EDTdescentp.3
    Aircraft began to descend again; cabin altitude warning turned off passing through 8,100 ft
  5. 18:06:29 EDTlandingp.3
    Aircraft landed uneventfully at Charleston

NTSB analysis

from the final report

Flight 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.