CEN11LA085

NTSB accident investigation · Embraer EMB-135LR · Milwaukee, WI · November 30, 2010

Accident · Serious injuriesLimited investigationFinal report
Date
November 30, 2010, 09:35 local (15:35 UTC)
Place
Milwaukee, WI
Injuries
1 serious, 9 minor, 19 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N12530Embraer EMB-135LR
Defining event
Enroute: Turbulence encounter
Weather
Instrument (IMC) · Day
Status
Completed · report October 17, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Embraer Aircraft Holding, Inc, CENIPA, Chautauqua Airlines
FAA report
20101130053649A
Case key
77907

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

On this page

Probable cause

An in-flight encounter with turbulence during cruise flight, which resulted in a serious injury to a flight attendant.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

TurbulenceEnvironmental issues › Conditions/weather/phenomena · Effect on personnelAll aircraft: 92 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The flight's dispatch package included a current significant meteorological warning for occasional severe turbulence between 14,000 and 24,000 feet mean sea level (msl). The warning indicated that turbulence was reported by other flightcrews. The flight was dispatched with a cruise altitude of 13,000 feet msl due to the turbulence. According to the operator, based on a discussion with an air traffic controller the captain then changed the flight's cruise altitude to 15,000 feet msl to avoid turbulence. The seat belt sign was illuminated during the entire flight. During the beginning of the flight attendant's service, the aircraft experienced light turbulence. Halfway through the service, the aircraft experienced moderate turbulence. The flight attendant locked the cart and took a seat. The moderate turbulence dissipated after about a minute and the flight attendant completed the service. Following the service, the flight attendant was standing by the forward wardrobe closet and was thrown up into the ceiling and back to the floor. She sustained serious injury when she broke her nose and fractured her left wrist. A seated five foot nine inch passenger was observed to have a six-inch gap between the overhead passenger service unit and the passenger's head. Three of the passenger service units sustained damage consistent with the passenger's head impacting those units. Nine passengers reported minor injuries. However, all passengers had their seat belts fastened. A review of the flight data recorder data confirmed the upset.

Factual narrative

On November 30, 2010, about 0935 central standard time, an Embraer EMB-135LR, N12530, operated by Chautauqua Airlines Inc., as flight 1146, encountered turbulence while in cruise about 60 miles south of Milwaukee, Wisconsin. The 2 pilots and 17 passengers were uninjured. The flight attendant sustained a serious injury and nine passengers sustained minor injuries. The airplane sustained no damage. The scheduled domestic passenger flight was conducted under 14 Code of Federal Regulations Part 121. Instrument meteorological conditions prevailed and an activated instrument flight rules flight plan was on file. The flight departed from the Lambert-St Louis International Airport (STL), near St Louis, Missouri, about 0902, and landed at the General Mitchell International Airport, near Milwaukee, Wisconsin, about 1002. Flight 1146's dispatch package included remarks for significant meteorological information (SIGMET) VICTOR 1, valid until 1130 on November 30, 2010, to include parts of Iowa, Wisconsin, Michigan, Illinois, and Indiana bounded by a line from Marquette, Michigan, to 40 miles south southwest of Sault Ste Marie, Michigan, to Fort Wayne, Indiana, to 50 miles east of St Louis, Missouri, to Quincy, Illinois, to Iowa City, Iowa, to Marquette, Michigan, for occasional severe turbulence between 14,000 feet above mean sea level (MSL) and 24,000 feet. The SIGMET indicated that turbulence was reported by other flightcrews. Remarks indicated that turbulence conditions would continue beyond 1130. The dispatcher issued the dispatch for this flight with a cruise altitude of 13,000 feet MSL and a remark of LOWER [FLIGHT] LEVEL DUE TO TURBURLENCE. According to the operator, air traffic control (ATC) in STL discussed the potential of turbulence with the flightcrew and stated that an altitude of 15,000 feet MSL would a better option to avoid turbulence than 13,000 feet MSL. ATC briefed that there still could be some turbulence at 15,000 feet MSL. The captain changed the flight's cruise altitude to 15,000 feet MSL. The crew announced the seat belt sign would remain on during the flight due to any potential encounter of turbulence. The seat belt sign was illuminated during the entire flight. During the beginning of the flight attendant's service, the aircraft experienced light turbulence. Halfway through the service, the aircraft experienced moderate turbulence. The flight attendant locked the cart and took a seat. The moderate turbulence dissipated after about one minute and the flight attendant completed the service. Following the completed service, the flight attendant was standing by the forward wardrobe closet and was thrown up into the ceiling and back to the floor. She broke her nose and fractured her left wrist. After that turbulence encounter, the flightcrew called the flight attendant and asked her about her condition and the passenger's condition. She informed the flightcrew of three passengers whom had bumped their heads on the overhead passengerservice units and advised the flightcrew of her injuries. Medical personnel were requested who later met the aircraft at the gate. According to flight data recorder data, approximately 0935, while cruising at a pressure altitude of approximately 15,230 feet and with an indicated airspeed of 317 knots, the airplane's vertical acceleration increased from 1 g to 1.3 g's. The closest recorded latitude and longitude at that time of the upset was 41 degrees 55 minutes 05 seconds north and 088 degrees 18 minutes 46 seconds west. About 0.25 seconds later, the vertical acceleration decreased to -1.2 g's. About 0.63 seconds later, the vertical acceleration increased to 1.8 g's. About one second later, the vertical acceleration decreased to 0.4 g's. During the upset, the pressure altitude increased to a maximum of 15,407 feet and the indicated airspeed increased to 329 knots. Approximately 15 seconds later, the vertical acceleration settled back to 1 g. A Federal Aviation Administration (FAA) inspector confirmed that all passenger seat belts were fastened. A seated five foot nine inch passenger was observed to have a six-inch gap between the overhead passenger service unit and the passenger's head. Three of the passenger service units sustained damage consistent with the passenger's head impacting the units. None of the passenger lap belt restraints had failed. According to the operator, nine passengers reported minor injuries. Subsequent to the accident, the operator published an article on turbulence in the airline's quarterly safety newsletter for all employees. In reference to the accident, the operator produced a memorandum on turbulence and the accident event, which was focused on their flight operations personnel.

Aircraft

Registration
N12530
Reported as
Embraer EMB-135LR
Category
Airplane
Serial number
145533
Airframe hours
17,224
Engines
Rolls-Royce AE 3007A1P, 8,338 lbs thrust, turbo fanRolls-Royce AE 3007A1P, 8,338 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Chautauqua Airlines Inc
Registered owner
Wells Fargo Bank Northwest Na Trustee
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · November 24, 2010
Departed
STL · St Louis, MO
Destination
MKE · Milwaukee, WI
Flight plan
IFR
Airport
MKE · General Mitchell IAP, runway 25L, 7,761 × 150 ft, concrete

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
October 22, 2010
Seat
Left
Flight hours
5,427 total · 2,950 in this make and model · 185 in the last 90 days · 61 in the last 30 days · 5 in the last 24 hours
Role
Co-pilot
Age
30
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
April 23, 2010
Seat
Right
Flight hours
5,602 total · 3,401 in this make and model · 244 in the last 90 days · 76 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
240° at 17 knots, gusting 23
Visibility
5 statute miles
Lowest ceiling
700 ft overcast
Temperature
36 °F, dew point 32 °F
Altimeter
29.59 inHg
Observed at
MKE, 65 nm away

Docket · 4

The files NTSB released with the investigation on September 7, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.