# NTSB DCA14CA035: Boeing 737 7H4, N966WN, Nashville, TN, January 9, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Data collection · Final report - Date: January 9, 2014, 18:30 local (23:30 UTC) - Place: Nashville, TN - Coordinates: 36.126667, -86.681945 - Nearby events: https://openairdocs.org/map.md?lat=36.1267&lon=-86.6819&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Cabin safety event](https://openairdocs.org/ntsb-events/110) - Highest injury: Serious injuries - Injuries: 1 serious, 144 uninjured - Status: Completed, report September 1, 2015 - Report: Approved by Office Director - NTSB office: Major Investigations Division - NTSB case key (mKey): 88662 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA14CA035 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88662/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88662 - Page: https://openairdocs.org/ntsb/DCA14CA035 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Equipment/furnishings: buffet/galleys](https://openairdocs.org/ntsb-findings/01022530): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Boeing 737-7H4, 2 cases](https://openairdocs.org/ntsb-findings/01022530/cases.md?model=1384404), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01022530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Cabin safety event](https://openairdocs.org/ntsb-events/110) (defining event); cases with it: [Boeing 737-7H4, 5 cases](https://openairdocs.org/ntsb-events/110/sequence.md?model=1384404), [All aircraft, 151 cases](https://openairdocs.org/ntsb-events/110/sequence.md) ## 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](https://openairdocs.org/aircraft/N966WN), registered now, S/N 36966, built 2011 (OpenAirDocs) - Reported make and model: BOEING 737 7H4 (7H4) - Registry model: [Boeing 737-7H4](https://openairdocs.org/model/boeing-737-7h4) (registry code 1384404) (OpenAirDocs) - Registry engine: [CFM International CFM56-7B24E series](https://openairdocs.org/engine/cfm-international-cfm56-7b24e-series) (registry code 13804, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 36966 - Year built: 2011 - Engines: CFM INTL CFM56-7B24E turbo fan; CFM 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; 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 - Co-pilot; age 51; injuries: none; 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 files) The files NTSB released with the investigation on September 2, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88662. 875 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 498 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431316&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Flight Crew Statements (item 2, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431317&FileExtension=.PDF&FileName=Flight%20Crew%20Statements-Master.PDF - FAA safo 13001 (item 3, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431318&FileExtension=.PDF&FileName=FAA%20SAFO%2013001-Master.PDF - Flight Attendant Handbook 12-12-2012 (item 4, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431319&FileExtension=.PDF&FileName=Flight%20Attendant%20Handbook%2012-12-2012-Master.PDF - Flight Attendant Handbook 01-31-2014 (item 5, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431320&FileExtension=.PDF&FileName=Flight%20Attendant%20Handbook%2001-31-2014-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.