NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C.

Forwarded to:

Honorable Donald 0. Engen

Administrator

SAFETY RECOMMENDAT I ON (S)

A-85-133

through -137

On August 1 2 , 1985, Japan Air Lines, Flight 123, a Boeing 747SR-100, en

route from Tokyo's Haneda Airport t o Osaka, crashed i n t o a mountain ridge a t
an elevation of 1,600 meters about 55 nmi northwest of Haneda. The Government
of Japan i s continuing i t s investigation i n t o the f a c t s and circumstances of
t h i s accident. However, the investigation has revealed t h a t the airplane
experienced a decompression near 24,000 f e e t and subsequently l o s t a large
portion of the vertical f i n and the use of a l l four hydraulic systems.
Preliminary evidence indicates t h a t the a f t pressure bulkhead ruptured in
f l i g h t while the airplane was over water allowing pressurized cabin a i r t o
vent into the unpressurized empennage. As a r e s u l t , the empennage was
subjected t o an excessive buildup i n pressure d i f f e r e n t i a l which damaged the
vertical s t a b i l i z e r . Portions of the upper and lower rudders, the auxiliary
power u n i t (APU), t h e APU firewall, and the a f t torque box o f the v e r t i c a l
s t a b i l i z e r are presumed t o have f a l l e n into the sea and have not been
recovered.
The Boeing 747 empennage section i s designed so t h a t , i n the event of
exposure t o an excessive pressure d i f f e r e n t i a l , a vent door will open t o
relieve the internal pressure before structural damage is incurred. However,
preliminary analysis conducted by the airplane manufacturer indicates t h a t the
s i z e of the vent door would be inadequate t o relieve the high pressure
produced when a large area of the bulkhead suddenly opened. Thus, the high
pressure d i f f e r e n t i a l will cause a structural f a i l u r e . The a f t torque box of
the vertical s t a b i l i z e r was determined t o be the f i r s t element t o f a i l under
such a condition. Since the a f t torque box provided the primary structural

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support f o r the vertical s t a b i l i z e r t o which the rudders were attached,

s t r u c t u r a l damage t o the torque box jeopardized the directional s t a b i l i t y and
control of the airplane. Because of the potential f o r similar occurrences,
the Safety Board believes t h a t design changes should be developed and
incorporated i n t o the empennage s t r u c t u r e t o protect i t against catastrophlc
f a i l u r e in the event of exposure t o a pressure buildup a f t e r a bulkhead
structural failure.
The loss of a l l four hydraulic systems apparently occurred because t h e
hydraulic f l u i d l i n e s located i n the empennage were severed when the a f t
torque box and rudders of the v e r t i c a l s t a b i l i z e r separated. The l i n e s of a l l
four systems are routed through t h i s area t o hydraulic actuators f o r the upper
rudder and lower rudder, b o t h of which were separated from t h e v e r t i c a l
stabilizer.
The incorporation of four separate and independent hydraulic systems < s
intended t o provide f o r redundancy necessary t o ensure the continued s a f e
f l i g h t and landing of the airplane i n the event of hydraulic f a i l u r e s .
However, the circumstances of t h i s accident have raised concerns about the
adequacy of the redundant design because of the collocation of the l i n e s of
a l l four hydraulic systems < n the a f t torque box, and the vulnerability of the
v e r t i c a l s t a b i l i z e r s t o damage in the event the empennage i s exposed t o an
excessive pressure d i f f e r e n t i a l . The Safety Board believes t h a t the design of
the hydraulic system i n the empennage should be modified t o ensure the
redundancy intended and t o eliminate the v u l n e r a b i l i t y t o f a i l u r e of a l l four
systems.
The dome-shaped a f t pressure bulkhead i s a f a i l - s a f e design which
incorporates four circumferential t e a r straps around the pressure dome t h a t
are riveted t o 18 p5e-shaped bulkhead sheets with radial s t l f f e n e r s . The
areas of the bulkhead between these t e a r s t r a p s and s t i f f e n e r s a r e c a l l e d
bays. The manufacturer indicated t h a t in the event of cracking in the
bulkhead sheets, t h e t e a r straps are designed t o confine the crack propagation
t o a single bay. 'The t e a r s t r a p s are supposed t o redirect progressive
cracking and/or overstress f r a c t u r e so t h a t the individual sheet metal of a
bay panel will f l a p open allowing f o r a controlled release of cabin pressure
instead of sudden separation across t h e e n t i r e dome and subsequent exposure of
the area a f t of the bulkhead t o an excessive pressure d i f f e r e n t i a l .

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The " f l a p p + n g " of one bay i s the basis f o r the " f a i l - s a f e " design concept
for the Boeing 747 pressure dome. The pressure r e l i e f door, which i s located
on the a f t lower fuselage, i s designed t o l i m i t the pressure d j f f e r e n t i a l
a f t e r such a f a i l u r e .
To date, the investigation has disclosed t h a t the rupture of the bulkhead
may have stemmed from numerous f a t i g u e cracks i n t h e upper dome sheet i n an
area of an improperly i n s t a l l e d s p l i c e made d u r i n g a r e p a i r of the bulkhead
a f t e r a previous landing accident i n 1978. During t h i s repair, t h e damaged,

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lower half of the bulkhead was replaced, and a 36-inch-long s p l i c e p l a t e was

installed because the upper and lower domes f a i l e d t o mate. The splice plate,
which spanned 2 of the 10 bays along the j o i n t , was improperly installed. As
installed, only one l i n e of r i v e t s e f f e c t i v e l y carried the load i n t o the upper
dome sheet instead of two, as intended in the r e p a i r engineering. In
addition, "doubler sheets were i n s t a l l e d i n the two bays above the splice t o
correct f o r oil-can wrinkling of the domed sheet metal material. I t was
within t h i s area of the improperly installed s p l i c e t h a t the rupture
initiated.
Preliminary examination of the bulkhead f r a c t u r e has shown t h a t the
bulkhead t e a r straps d i d not r e d i r e c t the cracking and overstress progression
of the sheet metal separation as o r i g i n a l l y intended. Multiple cracks were
developing i n adjacent bays without the f a i l u r e of a single bay by the
"flapping" concept, and numerous small fatigue cracks were found i n the sheet
which would n o t have been detected d u r i n g normal visual inspection.
Although the Safety Board believes t h a t the improper i n s t a l l a t i o n of the
designed repair and doubler reinforcement influenced the cracking in t h i s
bulkhead, the Safety Board i s concerned about the basic "fail-safe" design
even i n a properly constructed bulkhead. Thus, the Safety Board believes t h a t
the basic design, which also was used on the Boeing 767, should be analyzed
and tested t o assure t h a t the "flapping" concept i s valid. Furthermore,
approved repairs t o this bulkhead design should be examined t o ascertain
whether the i n s t a l l a t i o n of doublers or splices invalidates the "fail-safe"
concept.
The Safety Board also i s concerned about the approved visual inspection
procedures for the a f t pressure bulkhead. Visual inspection will n o t detect
small fatigue cracks beneath r i v e t heads. Furthermore, both the design and
inspection procedures should be such t h a t any cracking will be detected before
a crack reaches a c r i t i c a l length. The "fail-safe" concept which provides an
additional level of safety by limiting the progression of an undetected crack
t o the f a i l u r e of one bay w i t h limited pressure change may be invalid if
multiple small cracks can progress undetected, thus weakening the e n t i r e
bulkhead structure. Consequently, the Safety Board believes t h a t the FAA
should require Boeing t o establish an inspection interval f o r the bulkhead
t h a t includes a more thorough inspection t o determine the extent of fatigue,
i f any.
I t appears t h a t the consequences of this accident may have been the
r e s u l t of an isolated and extremely remote occurrence; however, the Safety
Board i s concerned t h a t certain features of the design of the Boeing 747
empennage make i t susceptible t o catastrophic damage and loss of
c o n t r o l l a b i l i t y in the event of a large cabin depressurization a t the a f t
pressure bulkhead. Therefore, t o preclude the p o s s i b i l i t y of f u t u r e
occurrences of such conditions, the National Transportation Safety Board
recommends t h a t the Federal Aviation Administration:

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Require the manufacturer t o modify t h e design o f t h e Boeing 747

empennage so t h a t i n t h e event t h a t a s i g n i f i c a n t pressure b u i l d u p
occurs i n t h e n o r m a l l y unpressurized empennage, t h e s t r u c t u r a l
i n t e g r i t y o f t h e s t a b i l i z e r s and t h e i r r e s p e c t i v e c o n t r o l surfaces
w i l l be p r o t e c t e d against c a t a s t r o p h i c f a i l u r e , and t o i n c o r p o r a t e
associated m o d i f i c a t i o n s on a l l Boeing 747 airplanes.
(Class XI,
P r i o r i t y Action) (A-85-133)
Require t h e manufacturer t o modify t h e design o f t h e Boeing 747
h y d r a u l i c systems so t h a t i n t h e event a s i g n i f i c a n t pressure
b u i l d u p occurs i n t h e n o r m a l l y unpressurized empennage, t h e
i n t e g r i t y o f a l l f o u r h y d r a u l i c systems w i l l not be impaired, and
t o i n c o r p o r a t e associated m o d i f i c a t i o n s on a l l Boeing 747
airplanes. (Class 11, P r i o r i t y Action) (A-85-134)
Reevaluate t h e design o f t h e Eoeing 747 and 767 a f t pressure
bulkheads by r e q u i r i n g Eoeing t o analyze and t e s t f u r t h e r t h e
bulkhead t o demonstrate t h e v a l i d i t y o f t h e f a i l - s a f e " f l a p p i n g "
f a i l u r e mode. (Class 11, P r i o r i t y Action) (A-85-135)
Evaluate any procedures approved t o r e p a i r 8-747 and E-767 a f t
pressure bulkheads t o assure t h a t t h e r e p a i r s do not a f f e c t t h e
" f a i l - s a f e " concept of t h e bulkhead design which i s intended t o
l i m i t t h e area o f presssure r e l i e f i n the event o f a s t r u c t u r a l
f a i l u r e . (Class 11, P r i o r i t y A c t i o n ) (A-85-136)
Revise t h e i n s p e c t i o n program f o r t h e 8-747 r e a r pressure bulkhead,
t o e s t a b l i s h an i n s p e c t i o n i n t e r v a l wherein i n s p e c t i o n s beyond t h e
r o u t i n e v i s u a l i n s o e c t i o n would be oerformed t o d e t e c t t h e e x t e n t
of p o s s i b l e m u l t i p l e s i t e f a t i g u e cracking. (Class 11, P r i o r i t y
Act ion) (A-85-137)

EURNETT, Chairman, GOLDMAN, Vice Chairman,

concurred i n these recommendations

and LAUEER,

Member,

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