Incident Overview

Date: Sunday 27 July 1952
Aircraft Type: Boeing 377 Stratocruiser 10-26
Owner/operator: Pan American World Airways (Pan Am)
Registration Number: N1030V
Location: off Rio de Janeiro, RJ – ÿ Atlantic Ocean
Phase of Flight: En route
Status: Minor, repaired
Casualties: Fatalities: 1 / Occupants: 27
Component Affected: Cabin DoorCabin Door
Investigating Agency: CABCAB
Category: Accident
On flight from New York to Buenos Aires, an aircraft experienced a rapid depressurization due to a door opening and subsequent leakage. The purser initially reported a hissing noise and instructed the flight engineer to depressurize, leading to the door being opened. The engineer’s assessment of the door’s condition ? near being unlocked ? triggered the purser to deploy wet towels to mitigate the leak. The door blew open, causing a passenger to be blown out of the cabin. The rapid depressurization, combined with condensation, resulted in significant damage to the cabin, including ceiling panel damage, upholstery tearing, and a temporary fogging of the cabin. The aircraft was immediately returned to Rio de Janeiro, landing safely.On flight from New York to Buenos Aires, an aircraft experienced a rapid depressurization due to a door opening and subsequent leakage. The purser initially reported a hissing noise and instructed the flight engineer to depressurize, leading to the door being opened. The engineer’s assessment of the door’s condition ? near being unlocked ? triggered the purser to deploy wet towels to mitigate the leak. The door blew open, causing a passenger to be blown out of the cabin. The rapid depressurization, combined with condensation, resulted in significant damage to the cabin, including ceiling panel damage, upholstery tearing, and a temporary fogging of the cabin. The aircraft was immediately returned to Rio de Janeiro, landing safely.

Description

The aircraft, on a flight from New York to Buenos Aires left the airport of Rio de Janeiro at 11:28 following an intermediate stop. A climb was started, as was cabin pressurization. At an altitude of about 12,000 feet and with a cabin pressure differential of 4.1 pounds per square inch, corresponding to a cabin altitude of about 2.000 feet, the purser heard a loud hissing noise at the cabin door. He went to the flight deck and stated to the captain, “We should depressurize because I think the door is open.” With the door warning light still on the flight engineer accompanied the purser to inspect the door. The flight engineer did not make a visual inspection through the door windows but placed his hand along the top edge of the door, whereupon the noise decreased. He then instructed the purser to place wet towels in that area to reduce the air leak and the noise. At this time the door handle was still not in the locked position, the flight engineer estimating that it was still about 25 degree from being in the horizontal position and the purser estimating it to be only about 19 degree from the vertical, or fully unlocked position. The purser then went aft in the cabin to procure towels. The flight engineer returned to his station and reported to the captain that the door seal was leaking but everything seemed normal. The captain elected to continue. The door warning light was still on. Within a minute or two the cabin door blew open. A woman passenger in seat No. 33, nearest the door, was blown out. The depressurization, of an explosive violence, caused damage throughout ‘the cabin, blowing loose ceiling panels and many sections of soundproofing and upholstery and tearing off the door of the ladies’ lavatory. Fog, caused by condensation at the lower pressure, temporarily filled the cabin. The aircraft was immediately turned back to Rio de Janeiro where it landed uneventfully at 12:13. PROBABLE CAUSE: “(a) The flight engineer’s failure to recognize an unsafe condition of the cabin door despite three completely separate warnings of that condition; and (b) the captain’s action in continuing flight while pressurized despite the several warnings that the main cabin door was not properly locked.”

Primary Cause

Failure to recognize an unsafe condition of the cabin door despite three separate warnings of that condition, compounded by the captain’s decision to continue flight while pressurized despite multiple warnings.Failure to recognize an unsafe condition of the cabin door despite three separate warnings of that condition, compounded by the captain’s decision to continue flight while pressurized despite multiple warnings.

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