Pilot Debrief

BOEING 737 near Yuma, AZ — 2011-04-01

Final reportDCA11MA039
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Date
2011-04-01
Location
Yuma, AZ, USA
Airport
NYL
Aircraft
BOEING 737
Registration
N632SW
Category
Airplane
Highest injury
Minor
Fatalities
0

Probable cause

the improper installation of the fuselage crown skin panel at the S-4L lap joint during the manufacturing process, which resulted in multiple site damage fatigue cracking and eventual failure of the lower skin panel. Contributing to the injuries was flight attendant A's incorrect assessment of his time of useful consciousness, which led to his failure to follow procedures requiring immediate donning of an oxygen mask when cabin pressure is lost.

NTSB narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/reports_aviation.html. The Aircraft Accident Brief number is NTSB/AAB-13/02. On April 1, 2011, about 1558 mountain standard time (MST), a Boeing 737-3H4, N632SW, operating as Southwest Airlines flight 812 experienced a rapid decompression while climbing through flight level 340. The flight crew conducted an emergency descent and diverted to Yuma International Airport (NYL), Yuma, Arizona. Of the 5 crewmembers and 117 passengers on board, one crewmember and one nonrevenue off-duty airline employee passenger sustained minor injuries. The airplane sustained substantial damage; postaccident inspection revealed that a section of fuselage skin about 60 inches long by 8 inches wide had fractured and flapped open on the upper left side above the wing. The flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a regularly scheduled domestic passenger flight from Phoenix Sky Harbor International Airport, Phoenix, Arizona, to Sacramento International Airport, Sacramento, California.

NTSB coding

Evidence available

  • CVR
  • FDR / data
  • Photos
  • 30 docket documents
View NTSB final reportView NTSB docket

Docket documents30

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