Event Details

Title:Structural failure, Aloha Airlines, Flight 243, Boeing 737-200, N73711, Near Maui, Hawaii, April 28, 1988
Micro summary:This Boeing 737 experienced massive structural failure and explosive decrompression in cruise.
Event Time:1988-04-28 at 1345 HDT
File Name:1988-04-28-US.pdf
Publishing Agency:National Transportation Safety Board (NTSB)
Publishing Country:USA
Report number:NTSB-AAR-89-03
Diversion Airport:Kahului Airport, Kahului, Maui, Hawaii
Site of event:Cruise FL240
Departure:Hilo International Airport, Hilo, Hawaii, USA
Airplane Type(s):Boeing 737-200
Flight Phase:Cruise
Operator(s):Aloha Airlines
Type of flight:Revenue
Serious Injuries:65
Other Injuries:0
Diverted to:Kahului Airport, Kahului, Maui, Hawaii
Executive Summary:On April 28, 1988, at 1346, a Boeing 737-200, N73711, operated by Aloha Airlines Inc., as flight 243, experienced an explosive decompression and structural failure at 24,000 feet, while en route from Hilo, to Honolulu, Hawaii. Approximately 18 feet from the cabin skin and structure aft of the cabin entrance door and above the passenger floorline separated from the airplane during flight. There were 89 passengers and 6 crewmembers on board. One flight attendant was swept overboard during the decompression and is presumed to have been fatally injured; 7 passengers and 1 flight attendant received serious injuries. The fl ight crew performed an emergency descent and landing at Kahului Airport on the Island of Maui.

The National Transportation Safety Board determines that the probable cause of this accident was the failure of the Aloha Airlines maintenance program to detect the presence of significant disbonding and fatigue damage which ultimately led to failure of the lap joint at S-10L and the separation of the fuselage upper lobe. Contributing to the accident were the failure of Aloha Airlines management to supervise properly its maintenance force; the failure of the FAA to evaluate properly the Aloha Airlines maintenace program and to assess the airline's inspection and quality control deficiencies; the failure of the FAA to require Airworthiness Directive 87-21-08 inspection of all the lap joints proposed by Boeing Alert Service Bulletin SB 737-53A1039; and the lack of a complete terminating action (neither generated by Boeing nor required by the FAA) after the discovery of early production difficulties in the B-737 cold bond lap joint which resulted in low bond durability, corrosion, and premature fatigue cracking.

The safety issues raised in this report include:

o The quality of air carrier maintenance programs and the FAA surveillance of those programs.

o The engineering design, certification, and continuing airworthiness of the B-737 with particular emphasis on multiple site fatigue cracking of the fuselage lap joints.

o The human factors aspects of air carrier maintenance and inspection for the continuing airworthiness of transport category airplanes, to include repair procedures and the training, certification and qualification of mechanics and inspectors.

Recommendations concerning these issues were addressed to the Federal Aviation Administration, Aloha Airlines, and the Air Transport Association.
Learning Keywords:Operations - Maintenance
Other - Regulatory Oversight
Consequence - Damage - Airframe or fuselage
Consequence - Hull Loss


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