BFO91LA055

NTSB accident investigation · Boeing 747-400 · Philadelphia, PA · June 16, 1991

Accident · Serious injuriesLimited investigationFinal report
Date
June 16, 1991, 15:00 local (19:00 UTC)
Place
Philadelphia, PA
Injuries
1 serious, 5 minor, 272 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
PHBFGBoeing 747-400
Weather
Visual (VMC) · Day
Status
Completed · report August 13, 1993
Report
Approved by Office Director
Case key
11682

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Failure of the pilot to ensure cabin crew members were prepared for an encounter with turbulence.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherDescent - normal
Weather condition - turbulenceFactor
Procedures/directives - not followedPilot in commandCause

Analysis

The flight was on a cruise descent at 20,000 feet MSL when it encountered turbulence, causing injuries to cabin crewmembers including one who was seriously injured. The pilot reported that he was deviating around cumulonimbus clouds when he inadvertently entered one. He said the seat belt sign was on at the time. The flight proceeded to the destination and landed without further incident.

Aircraft

Registration
PHBFG
Reported as
Boeing 747-400
Category
Airplane
Engine
turbo fan
Damage
No damage
Flight
Part 129
Operator
Klm Royal Dutch Airline
Registered owner
Klm Royal Dutch Airline
Airworthiness certificate
Standard, Transport
Last inspection
Unknown · January 2, 2000
Departed
AMS · Amsterdam, OF
Destination
BWI · Baltimore, MD

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Flight hours
15,016 total · 134 in the last 90 days · 65 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 3 knots
Visibility
8 statute miles
Lowest ceiling
7,000 ft broken
Temperature
81 °F, dew point 72 °F
Altimeter
29.00 inHg
Observed at
PHL, 999 nm away