DCA08FA062

NTSB accident investigation · Mcdonnell Douglas DC10 · Pacific Ocean · May 19, 2008

Accident · Serious injuriesField investigationFinal report
Date
May 19, 2008, 13:40 UTC
Place
Pacific Ocean
Injuries
1 serious, 4 minor, 157 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N720AXMcdonnell Douglas DC10
Defining event
Enroute-cruise: Turbulence encounter
Weather
Visual (VMC)
Status
Completed · report June 24, 2009
Report
Approved by Office Director
NTSB office
Major Investigations Division
Parties
FAA Dallas - Ft Worth FSDO
Case key
68154

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 inadvertent in-flight encounter with unforecasted clear air turbulence

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.

Turbulence: clear air turbulenceEnvironmental issues › Conditions/weather/phenomena · Not specifiedMcdonnell-Douglas DC-10-30: 1 caseAll aircraft: 78 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 captain stated that the ride had been smooth at their cruise altitude of 36,000 feet, and the seatbelt sign was off. He further stated that there was some thunderstorm activity, and some towering cumulus in the area, and that the airplane’s radar indicated the presence of a cell about 30 miles south of the airplane’s position, with tops that reached about 28,000 to 30,000 feet. He said they encountered an area of higher clouds, but the radar still did not indicate any activity, and within a few seconds they felt an initial bump, followed by "moderate" turbulence. He said he then turned the seatbelt sign on, and a short while later he was notified that there were some injured passengers and flight attendants. The NTSB’s Recorder Laboratory, Washington DC, read out the DFDR, and the data indicated that at 13:27:22 FDR Recorded GMT, at a pressure altitude of 36,000 feet, the vertical acceleration changed from 0.9 g’s to 1.8 g’s to -0.5 g’s to 1.7 g’s and then back to 0.9 g’s all within 3 seconds, consistent with clear air turbulence. See the NTSB DFDR Factual Report. In addition the NTSB conducted a meteorological study, using data to include synoptic, upper air, and satellite data. See the NTSB Meteorological Factual Report.

Factual narrative

On May 19, 2008, about 1340 UTC, a McDonnell Douglas DC-10-30, N720AX, operated by Omni Air International, as a Title 14 CFR Part 121 supplemental, non-scheduled international passenger flight, reportedly experienced moderate turbulence, over the Pacific Ocean, while in cruise flight at FL360, about 450 nautical miles east of the Territory of Guam, United States of America. The airplane subsequently landed in Guam, uneventfully. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. Of the 150 passengers and 12 crewmembers on board, two passengers and two flight attendants received minor injuries, and one flight attendant received serious injuries. The flight originated at Honolulu International Airport, Honolulu, Hawaii, the same day, about 0745 UTC. According to Omni Air International’s Director of Safety, the accident captain stated in his irregularity report that at approximately 1330z while at 36,000 feet, they encountered moderate turbulence. He said that the ride had been smooth for the whole flight and that the seatbelt sign had been off. There was some thunderstorm activity in the area, and the airplane’s radar indicated the presence of a cell about 30 miles south of the airplane’s position, with tops that reached about 28,000 to 30,000 feet. The pilot said that they saw some towering cumulus clouds in the area, but that the ride still continued to be smooth. The lead flight attendant was on the flight deck, and they encountered an area of higher clouds, but the radar did not indicate any activity. The Captain said that within a few seconds they felt an initial bump, followed by moderate turbulence. The seatbelt sign was then turned on, and the lead flight attendant sat in the observer’s seat. According to the Captain the turbulence lasted only a few seconds, after which the lead flight attendant left the flight deck. A few minutes later the lead flight attendant communicated with the flight deck and informed the Captain of the injured passengers and flight attendants. The lead flight attendant stated that about 1330Z they encountered "bad turbulence", which lasted about 30 seconds. She further stated that she was in the cockpit at the time, and as soon as the turbulence was gone she left the cockpit to check on everyone, at which time another flight attendant informed her that two flight attendants were "down." She then communicated with the flight deck and relayed the information to the captain. Another flight attendant stated that the flight encountered two turbulence events while the cabin crew was making preparations for the second meal service. She said that the turbulence in the first event was slight but the second event was "drastic." She said that the second turbulence event caused her to hit the ceiling and then her entire body descended and slammed to the floor. The accident airplane’s flight data recorder (FDR) was sent to the NTSB’s Recorder Laboratory, Washington DC, for readout,and was found to contain 14 minutes of data pertaining to the accident flight. The data indicated that at 13:27:22 FDR Recorded GMT, at a pressure altitude of 36,000 feet, the vertical acceleration changed from 0.9 g’s to 1.8 g’s to -0.5 g’s to 1.7 g’s and then back to 0.9 g’s all within 3 seconds. The data showed that the airplane’s autopilot had been engaged, and that there was lateral acceleration during the drop in altitude, without corresponding flight or engine control input, consistent with severe clear air turbulence. See the NTSB FDR Factual Report. In addition, the NTSB conducted a meteorological study using data to include synoptic, upper air, and satellite data. See the NTSB Meteorological Factual Report.

Aircraft

Registration
N720AX
Reported as
Mcdonnell Douglas DC10 (30)
Category
Airplane
Serial number
48252
Damage
No damage
Flight
Part 121
Operator
Omni Air International
Registered owner
Omni DC-10 Leasing LLC
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · April 24, 2008 · 248 hours before
Departed
HNO · Hololulu, HI
Destination
GUM · Agana
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
41
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 1, Without waivers/limitations
Last flight review
March 10, 2008
Seat
Left
Flight hours
2,380 in this make and model
Role
Co-pilot
Age
52
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 1, With waivers/limitations
Last flight review
January 24, 2008
Seat
Right
Flight hours
1,959 in this make and model
Role
Flight engineer
Injuries
None
Flight hours
3,469 total

Weather

Conditions
Visual (VMC)
Lowest ceiling
None

Docket · 5

The files NTSB released with the investigation on June 24, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.0 MB in all.