- Date
- June 17, 2014, 09:30 local (14:30 UTC)
- Place
- Dallas, TX
- Injuries
- 1 serious, 143 uninjured
- Damage
- No damage
- Phase of flight
- Enroute
- Aircraft
- N968WNBoeing 737 7H4
- Defining event
- Enroute: Cabin safety event
- Weather
- Day
- Status
- Completed · report September 1, 2015
- Report
- Approved by Office Director
- NTSB office
- Major Investigations Division
- Case key
- 89484
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 handle was raised, which resulted in 2nd and 3rd 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.
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 working in the forward galley, the flight attendant noticed that the coffee pot was leaking onto the counter and proceeded to turn it off and cleaned up the spill. Then while lifting the coffee maker's potlocking lever, hot coffee grounds and hot water erupted onto her face, neck, upper chest and hands. The flight crew elected to divert to Dallas Love Field (DAL), Dallas, Texas, and landed without incident. Medical personnel met the flight and the flight attendant was treated for 1st and 2nd degree burns. Approximately 18 months before the accident, the Federal Aviation Administration (FAA) had issued Safety Alert for Operators (SAFO) 13001, which addressed reported cases of coffee filter packages bursting in-flight during coffee preparation, causing 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. At the time of the accident the following warning was present in the operator's FAM: WARNING: To avoid injury from bursting coffee filters, step to the side, turn off power to the coffeemaker, and do not raise the potlocking lever until the unit has cooled. Following the accident the warning was changed to the following: WARNING: Water overflowing and/or a hissing noise coming from the coffeemaker could result in injury from bursting coffee packets. Step to the side, turn off power to the coffeemaker, and DO NOT raise the potlocking lever.
Factual narrative
While working in the forward galley, the flight attendant noticed that the coffee pot was leaking onto the counter and proceeded to turn it off and cleaned up the spill. Then while lifting the coffee maker's potlocking lever, hot coffee grounds and hot water erupted onto her face, neck, upper chest and hands. The flight crew elected to divert to Dallas Love Field (DAL), Dallas, Texas, and landed without incident. Medical personnel met the flight and the flight attendant was treated for 1st and 2nd degree burns. Approximately 18 months before the accident, the Federal Aviation Administration (FAA) had issued Safety Alert for Operators (SAFO) 13001, which addressed reported cases of coffee filter packages bursting in-flight during coffee preparation, causing 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. At the time of the accident the following warning was present in the operator's FAM: WARNING: To avoid injury from bursting coffee filters, step to the side, turn off power to the coffeemaker, and do not raise the potlocking lever until the unit has cooled. Following the accident the warning was changed to the following: WARNING: Water overflowing and/or a hissing noise coming from the coffeemaker could result in injury from bursting coffee packets. Step to the side, turn off power to the coffeemaker, and DO NOT raise the potlocking lever.
Aircraft
- Registration
- N968WN
- Reported as
- Boeing 737 7H4 (7H4)
- Category
- Airplane
- Serial number
- 36679
- Built
- 2011
- Engines
- CFM Intl CFM56-7B24ECFM Intl CFM56-7B24E
- Damage
- No damage
- Flight
- Part 121
- Operator
- Southwest Airlines
- Registered owner
- Southwest Airlines Co
- Airworthiness certificate
- Standard, Transport
- Last inspection
- Continuous airworthiness · June 16, 2014 · 8,816 hours before
- Departed
- LAS · Las Vegas, NV
- Destination
- ATL · Atlanta, GA
- 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
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 59
- Injuries
- None
- Certificates
- Commercial, Airline transport
- Airplane ratings
- Single-engine land, Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, With waivers/limitations
- Last flight review
- May 17, 2014
- Seat
- Left
- Restraint
- 4-point
- Flight hours
- 21,000 total · 14,000 in this make and model · 1,700 as pilot in command · 150 in the last 90 days
Weather
- Conditions
- Day
- Wind
- 170° at 18 knots, gusting 23
- Visibility
- 10 statute miles
- Lowest ceiling
- 30,000 ft broken
- Temperature
- 79 °F, dew point 72 °F
- Altimeter
- 29.95 inHg
- Observed at
- KDFW, 25 nm away
Docket · 3
The files NTSB released with the investigation on September 2, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.2 MB in all.