Accident Boeing 737-330 (SF) N301KH,
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ASN Wikibase Occurrence # 320426
 
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Date:Thursday 16 October 2014
Time:14:47
Type:Silhouette image of generic B733 model; specific model in this crash may look slightly different    
Boeing 737-330 (SF)
Owner/operator:Aloha Air Cargo
Registration: N301KH
MSN: 27904/2691
Year of manufacture:1995
Total airframe hrs:41163 hours
Engine model:CFMI CFM56-3C1
Fatalities:Fatalities: 0 / Occupants: 3
Aircraft damage: Substantial, repaired
Category:Accident
Location:Lanai Airport, HI (LNY) -   United States of America
Phase: Take off
Nature:Cargo
Departure airport:Lanai Airport, HI (LNY/PHNY)
Destination airport:Honolulu-Daniel K. Inouye International Airport, HI (HNL/PHNL)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Aloha Air Cargo flight 601, a Boeing 737-330, experienced a cargo shift shortly after takeoff from Lanai Airport (LNY), Hawaii, causing substantial damage to the aft pressure bulkhead and the airplane was not able to pressurize. The flight continued to its destination and was towed to a hanger. Upon further examination it was found that a stack of cargo "cookie sheets" came free of their cargo locks in position 9 and shifted rearward. There were no injuries to the two flight pilots and one onboard mechanic.
Aloha Air Cargo was chartered by Hawaii Island Air to fly round trip from Honolulu (HNL) to LNY to deliver lumber for an impeding hurricane. LNY was not a station Aloha Air Cargo normally flew to, nor did they have employees there. In addition to the flight crew, a flight mechanic and a load planner were scheduled to fly with the aircraft to provide support. Just prior to the flight's departure, dispatch noted that due to weight and balance concerns on the return trip only one of the additional employees could ride with the aircraft. The choice was made to leave the load planner behind and take the aircraft mechanic as the Additional Crew Member (ACM). This was contrary to company guidance.
Flight 600, departed HNL at 12:40 local time and arrived in LNY at 12:53. After arriving in LNY, the aircraft was off loaded and then the, now empty, cargo pallet cookie sheets were loaded for the return flight.
The mechanic, first officer (FO), and Island Air employees helped to load the aircraft and verified that the locks were up and locked in all positions. There were a total of 8 empty pallet cookie sheets. Of these sheets 7 were strapped down and secured to the 8th sheet. The 8th sheet was then locked down in position 9 (the aircraft was equipped with 9 cargo positions on the main deck with the ninth position being the most aft and turned lengthwise). This was done per dispatch's request for center of gravity (CG) consideration, even though before departure from HNL the load planner had discussed with the mechanic that each pallet should go back in their original position and locked down.
Flight 601, departed LNY at 14:49 and arrived in HNL at 15:14. Nothing out of the ordinary was noticed by the crew in the feel of the aircraft nor did they hear anything unusual.
The auto fail light came on during climb and the quick reference handbook (QRH) was then followed. No door lights illuminated and the outflow valve indicated "Closed." However, upon reaching 10,000 ft. the altitude alert horn came on so the crew leveled at 10,000 ft. No emergency was declared. The aircraft landed uneventfully.

A post-flight check revealed that all of the pallets were loaded into position 9, that none of the locks between position 8 and 9 were up, and the straps holding the sheets had allowed the sheets to shift aft making contact with the aft pressure bulkhead. The bulkhead had substantial damage.

Probable Cause: the improper loading and securing of the cargo pallets, which shifted on departure, resulting in substantial damage to the aft pressure bulkhead.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: DCA15LA011
Status: Investigation completed
Duration: 5 years and 5 months
Download report: Final report

Sources:


Location

Images:


photo (c) NTSB; Honolulu-Daniel K. Inouye International Airport, HI (HNL); 16 October 2014; (publicdomain)

Revision history:

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