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Cases › DCA11FA004 · Part 121 airline

BOEING 757-223AMERICAN AIRLINES INC

Miami, FL, USA · 2010-10-27·N626AA

0
fatal
0
serious
No injury
highest injury
Substantial
damage

What happened

NTSB summary, verbatim

Flight data recorder data revealed that, after takeoff from Miami International Airport (MIA), Miami, Florida, the airplane climbed for about 16 minutes and was passing through an altitude of approximately 32,000 feet when the rapid decompression occurred. The flight crew declared an emergency (the first officer was the pilot flying) and returned to MIA. Post accident examination of the airplane revealed fatigue cracking of the upper fuselage skin above the forward left passenger (L1) door. The fatigue cracking penetrated the fuselage skin, leading to a rupture and an approximate 18-inch-by-7-inch hole that depressurized the airplane. NTSB examinations of a section of the fuselage crown skin (from body station 374 to body station 439) where the rupture occurred revealed fatigue cracking along the lower longitudinal step of the chemically milled pocket just above the stringer S-4L (left) lap joint. The fatigue cracking initiated on the interior surface of the skin at multiple locations and propagated through the skin thickness. The skin thickness at the base of the chemically milled step measured 0.035 to 0.037 inch—which is less than the 0.039-inch minimum thickness specified by Boeing. Calculations from an NTSB study of the fatigue striation density and propagation in the fatigue region indicate that it would take an average of 3,709 total cycles for a crack to grow through skin with 0.035-inch thickness and an average interval of 917 cycles for a crack to grow from a minimally detectable size and penetrate a 0.035-inch skin thickness. The area of cracking and rupture on the accident airplane was not subject to any specific inspections, service bulletins (SB), or airworthiness directives (AD) at the time of the accident. Following the accident, on November 22, 2010, Boeing issued SB 757-53-0097, which called for repetitive external inspections (every 30, 200 cycles, or 300 hours depending on the inspection method) to detect cracks in the fuselage skin along the chemically milled step at stringers S-4L (left) and S 4R (right) between body station 297 and body station 439. On January 10, 2011, the Federal Aviation Administration issued AD 2011-01-15 (effective January 25, 2011) mandating the inspections recommended in SB 757-53-0097. During its investigation, the NTSB learned of a United Airlines 757 and a second American Airlines 757 that exhibited cracking in the fuselage skin similar to the accident airplane; both had nonconforming thickness at the base of the chemically milled step at the stringer location specified in the SB. Records of manufacture for the skin panels on the accident airplane and the other airplanes with fuselage skin cracking were not retained, and were not required to be retained; therefore, a cause for the manufacturing nonconformance could not be identified.

Photographs

1the aircraft, and what the investigators found
Wreckage and site documentation · 1 photographs from the docket

Photographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.

Probable cause

the Board's determination
Fatigue failure of the fuselage crown skin due to incorrect manufacturing of the crown skin panel that resulted in a skin thickness less than the manufacturer-specified thickness.

Occurrence sequence

1 stepsNTSB coding · CICTT taxonomy
  1. 1 · Enroute
    Aircraft structural failure
    defining event

Findings

2 causal · 0 contributing
  • CAUSE
    Aircraft › Aircraft structures › Fuselage › Plates/skins (aux fuselage) — Fatigue/wear/corrosion
  • CAUSE
    Organizational issues › Development › Manufacture/production › Equipment manufacture — Manufacturer

Sequence of events

6 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)
  1. 21:13:20 EDTtakeoffp.3
    Takeoff from Miami
  2. 21:28:47 EDTclimbp.3
    'CABIN ALT > 10kft' parameter set along with left and right master warnings; aircraft at 31,993 ft with pitch attitude decreasing (rapid decompression)
  3. 21:28:55 EDTemergency descentp.3
    Passenger oxygen discrete set to ON
  4. 21:29:00 EDTemergency descentp.3
    Descent began
  5. 21:35:10 EDTdescentp.3
    Aircraft leveled at approximately 10,000 ft
  6. 21:57:00 EDTlandingp.3
    Aircraft landed at Miami

NTSB analysis

from the final report

Flight data recorder data revealed that, after takeoff from Miami International Airport (MIA), Miami, Florida, the airplane climbed for about 16 minutes and was passing through an altitude of approximately 32,000 feet when the rapid decompression occurred. The flight crew declared an emergency (the first officer was the pilot flying) and returned to MIA. Post accident examination of the airplane revealed fatigue cracking of the upper fuselage skin above the forward left passenger (L1) door. The fatigue cracking penetrated the fuselage skin, leading to a rupture and an approximate 18-inch-by-7-inch hole that depressurized the airplane. NTSB examinations of a section of the fuselage crown skin (from body station 374 to body station 439) where the rupture occurred revealed fatigue cracking along the lower longitudinal step of the chemically milled pocket just above the stringer S-4L (left) lap joint. The fatigue cracking initiated on the interior surface of the skin at multiple locations and propagated through the skin thickness. The skin thickness at the base of the chemically milled step measured 0.035 to 0.037 inch—which is less than the 0.039-inch minimum thickness specified by Boeing. Calculations from an NTSB study of the fatigue striation density and propagation in the fatigue region indicate that it would take an average of 3,709 total cycles for a crack to grow through skin with 0.035-inch thickness and an average interval of 917 cycles for a crack to grow from a minimally detectable size and penetrate a 0.035-inch skin thickness. The area of cracking and rupture on the accident airplane was not subject to any specific inspections, service bulletins (SB), or airworthiness directives (AD) at the time of the accident. Following the accident, on November 22, 2010, Boeing issued SB 757-53-0097, which called for repetitive external inspections (every 30, 200 cycles, or 300 hours depending on the inspection method) to detect cracks in the fuselage skin along the chemically milled step at stringers S-4L (left) and S 4R (right) between body station 297 and body station 439. On January 10, 2011, the Federal Aviation Administration issued AD 2011-01-15 (effective January 25, 2011) mandating the inspections recommended in SB 757-53-0097. During its investigation, the NTSB learned of a United Airlines 757 and a second American Airlines 757 that exhibited cracking in the fuselage skin similar to the accident airplane; both had nonconforming thickness at the base of the chemically milled step at the stringer location specified in the SB. Records of manufacture for the skin panels on the accident airplane and the other airplanes with fuselage skin cracking were not retained, and were not required to be retained; therefore, a cause for the manufacturing nonconformance could not be identified.