DCA14CA035

NTSB accident investigation · Boeing 737 7H4 · Nashville, TN · January 9, 2014

Accident · Serious injuriesData collectionFinal report
Date
January 9, 2014, 18:30 local (23:30 UTC)
Place
Nashville, TN
Injuries
1 serious, 144 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N966WNBoeing 737 7H4
Defining event
Enroute-cruise: Cabin safety event
Weather
Visual (VMC) · Dusk
Status
Completed · report September 1, 2015
Report
Approved by Office Director
NTSB office
Major Investigations Division
Case key
88662

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

A buildup of pressure in the coffee filter package resulting in the release of hot coffee and grounds when the potlocking lever was raised, which resulted in 2nd degree burns.

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.

Equipment/furnishings: buffet/galleysAircraft › Aircraft systems · MalfunctionBoeing 737-7H4: 2 casesAll aircraft: 6 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

While preparing coffee service in the aft galley, the C flight attendant (FA) observed the coffee maker emitting an unusual noise and coffee was pooling on the burner. The FA lifted the potlocking lever on the coffee pot and hot coffee and coffee grounds erupted onto her face, neck, and chest. The flight diverted and landed at Nashville International Airport, Nashville, Tennessee where medical personnel met the flight at the gate. The FA was transported to the hospital and diagnosed with second-degree burns. In January of 2013, the Federal Aviation Administration issued Safety Alert For Operators (SAFO) 13001, which addressed reported cases of coffee filter packages bursting in flight during coffee preparation, resulting in 1st and 2nd degree burns to flight attendants and bystanders. The SAFO encouraged air carriers and operators to add cautionary instructions and procedures to the Flight Attendant Manual (FAM) and training program, warning crew members of the dangers to personnel and equipment.

Factual narrative

While preparing coffee service in the aft galley, the C flight attendant (FA) observed the coffee maker emitting an unusual noise and coffee was pooling on the burner. The FA lifted the potlocking lever on the coffee pot and hot coffee and coffee grounds erupted onto her face, neck, and chest. The flight diverted and landed at Nashville International Airport, Nashville, Tennessee where medical personnel met the flight at the gate. The FA was transported to the hospital and diagnosed with second-degree burns. In January of 2013, the Federal Aviation Administration issued Safety Alert For Operators (SAFO) 13001, which addressed reported cases of coffee filter packages bursting in flight during coffee preparation, resulting in 1st and 2nd degree burns to flight attendants and bystanders. The SAFO encouraged air carriers and operators to add cautionary instructions and procedures to the Flight Attendant Manual (FAM) and training program, warning crew members of the dangers to personnel and equipment.

Aircraft

Registration
N966WN
Reported as
Boeing 737 7H4 (7H4)
Category
Airplane
Serial number
36966
Built
2011
Engines
CFM Intl CFM56-7B24E, turbo fanCFM Intl CFM56-7B24E, turbo fan
Damage
No damage
Flight
Part 121
Operator
Southwest Airlines Co
Registered owner
Southwest Airlines Co
Airworthiness certificate
Standard, Transport
Departed
KIAD · Indianapolis, IN
Destination
KRSW · Fort Meyers, FL
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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Certificates
Airline transport, Private, Flight engineer
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
November 2, 2013
Seat
Left
Flight hours
22,700 total · 11,500 in this make and model
Role
Co-pilot
Age
51
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Seat
Right
Restraint
5-point
Flight hours
11,639 total · 5,612 in this make and model

Weather

Conditions
Visual (VMC) · Dusk
Wind
70° at 3 knots, gusting 23
Visibility
10 statute miles
Lowest ceiling
15,000 ft overcast
Temperature
37 °F, dew point 32 °F
Altimeter
30.31 inHg

Docket · 5

The files NTSB released with the investigation on September 2, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 875 KB in all.