UNITED STATES OF AMERICA

TATION SAFETY
WASHINGTON, D.C.

ISSUED: . J u l y 6, 1 9 7 2

Adopted by t h e NATIONAL TRANSPORTATION SAFETY BOARD

a t i t s o f f i c e i n Washington, D . C .
on t h e 23rd d a y o f June 1972.

....................................
FORWARDED TO: )
Honorable John H. S h a f f e r 1
Administrator 1
F e d e r a l A v i a t i o n Administration 1
Washington, D. C. 20591 1
1

SAFETY RECOMMENDATIONS A-72-97 & 98

The National T r a n s p o r t a t i o n S a f e t y Board i s i n v e s t i g a t i n g a n a c c i d e n t

i n v o l v i n g a n American A i r l i n e s McDonnell Douglas DC-10-10, N103AA, which
occurred s h o r t l y a f t e r t a k e o f f from D e t r o i t Metropolitan-Wayne County
A i r p o r t on June 12, 1972.

The a f t l e f t - h a n d cargo door opened w h i l e t h e a i r c r a f t was a t approx-

i m a t e l y 12,000 f e e t . The cabin f l o o r over t h i s cargo compartment then f a i l e d
as a r e s u l t of d e p r e s s u r i z a t i o n loading, and t h e f l o o r dropped p a r t i a l l y
i n t o t h e cargo compartment. This displacement of t h e f l o o r caused s e r i o u s
d i s r u p t i o n of t h e c o n t r o l c a b l e s which a r e routed through t h e f l o o r beams
t o t h e empennage c o n t r o l systems a n d the e n g i n e c o n t r o l s . With t h e exception
o f t h e r i g h t rudder pedal c a b l e , a l l of t h e c a b l e s on t h e l e f t s i d e of t h e
f u s e l a g e broke. The c a b l e runs on t h e r i g h t s i d e were a l s o damaged the--
c a b l e guides t o r e from t h e i r attachments t o the f l o o r beams, and t h e c a b l e s
were d e f l e c t e d downward by t h e f l o o r s t r u c t u r e .

Preliminary i n v e s t i g a t i o n has revealed t h a t t h e door l a t c h e s were not

d r i v e n f u l l y c l o s e d , and t h e lock-pins which should have prevented t h e
l a t c h e s from opening were n o t i n place. The reason t h e s e door l a t c h e s were
not d r i v e n o v e r c e n t e r t o t h e f u l l y closed p o s i t i o n has n o t y e t been d e t e r -
mined. However, although t h e S a f e t y Board b e l i e v e s t h i s was relevant and a
c o n t r i b u t i n g f a c t o r , w e a r e more concerned over t h e f a i l u r e of t h e door
s a f e t y f e a t u r e s t o preclude d i s p a t c h with a n unlocked door. The design of
t h e door should have precluded t h e d i s p a t c h of t h e a i r c r a f t w i t h t h i s door
Honorable John H. Shaffer - 2 ..
improperly closed. With t h e lock-pins n o t engaged, a small vent door on
t h e cargo door should have remained open, preventing normal p r e s s u r i z a t i o n
of t h e a i r c r a f t . Also, t h e v e n t door handle should n o t have stowed.

However, t e s t s conducted a t Douglas A i r c r a f t Company have demonstrated

t h a t t h e v e n t door can be closed, and the handle stowed, without t h e lock-
pins engaged. Apparently, some combination o f d e f l e c t i o n o f t h e o p e r a t i n g
mechanisms and t o l e r a n c e s permitted such o p e r a t i o n when a f o r c e of approx-
i m a t e l y 120 pounds WAS a p p l i e d t o t h e o p e r a t i n g handle. During t h e s e t e s t s
our i n v e s t i g a t o r observed bending of t h e s l i d i n g lock-tube which caused
t h e cap end of the tube to make c o n t a c t w i t h t h e p i l o t i n d i c a t o r s w i t c h
actuating arm. This arm moves through a very s m a l l a r c t o a c t u a t e t h e switch,
and t h e Board b e l i e v e s t h a t a similar c o n t a c t on t h e a c c i d e n t a i r c r a f t door
probably a c t u a t e d t h e switch and gave t h e p i l o t s a door s a f e i n d i c a t i o n on
the annunciator l i g h t panel.

F i n a l l y , t h e Board b e l i e v e s t h a t sudden l o s s of p r e s s u r e i n t h i s cargo

compartment f o r any reason should n o t j e o p a r d i z e the s a f e t y of the f l i g h t .
I n t h i s case, t h e l o s s of the door and r e s u l t a n t cabin f l o o r f a i l u r e caused
an unwanted rudder i n p u t , s e v e r e l y r e s t r i c t e d t h e e l e v a t o r c o n t r o l a v a i l a b l e
t o the crew and d i s r u p t e d the No. 2 engine c o n t r o l s .

We a r e aware of t h e i n s p e c t i o n procedures c u r r e n t l y i n e f f e c t t o e n s u r e
s a f e t y of o p e r a t i o n s of t h e I)C-10 as w e l l as t h e e x i s t i n g s a f e t y f e a t u r e s of
the door design. Nevertheless, i n o r d e r t o preclude the r e c u r r e n c e of s i m i l a r
a c c i d e n t s , ~h~ Safi;Ly Board rccommends t h a t t h e F e d e r a l Aviation Administration:

1. Require a m o d i f i c a t i o n t o t h e DC-10 cargo door l o c k i n g system

t o make i t p h y s i c a l l y impossible t o p o s i t i o n t h e e x t e r n a l
l o c k i n g handle and v e n t door t o t h e i r normal door locked
p o s i t i o n s u n l e s s t h e locking p i n s a r e f u l l y engaged.

2. Require t h e i n s t a l l a t i o n of r e l i e f vents between t h e c a b i n

and a f t cargo compartment t o minimize the p r e s s u r e l o a d i n g
on t h e c a b i n f l o o r i n g i n the event of sudden d e p r e s s u r i z a t i o n
of t h e cargo compartment.

Members of o u r Bureau of Aviation S a f e t y w i l l be a v a i l a b l e f o r c o n s u l -

t a t i o n i n t h e above m a t t e r i f d e s i r e d .

These recommendations w i l l be r e l e a s e d to t h e p u b l i c on t h e i s s u e d a t e
shown above. No p u b l i c d i s s e m i n a t i o n of t h e c o n t e n t s of t h i s document should
be made p r i o r t o t h a t d a t e .
Honorable John H. S h a f f e r - 3 -

Reed, Chairman, McAdams, Thayer, Burgess and Haley, Members, concurred

in the above recommendations.

By: Reed
Chairman