# NTSB DCA14CA120: Boeing 737 7H4, N968WN, Dallas, TX, June 17, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Data collection · Final report - Date: June 17, 2014, 09:30 local (14:30 UTC) - Place: Dallas, TX - Coordinates: 32.505279, -97.156669 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.5053&lon=-97.1567&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Cabin safety event](https://openairdocs.org/ntsb-events/110) - Highest injury: Serious injuries - Injuries: 1 serious, 143 uninjured - Status: Completed, report September 1, 2015 - Report: Approved by Office Director - NTSB office: Major Investigations Division - NTSB case key (mKey): 89484 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA14CA120 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89484/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89484 - Page: https://openairdocs.org/ntsb/DCA14CA120 ## 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 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: 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 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](https://openairdocs.org/aircraft/N968WN), registered now, S/N 36679, 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: 36679 - Year built: 2011 - Engines: CFM INTL CFM56-7B24E; CFM 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: none; 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 files) The files NTSB released with the investigation on September 2, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89484. 4.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431357&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Flight Attendant Statement (item 2, .PDF, 496 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431358&FileExtension=.PDF&FileName=Flight%20Attendant%20Statement-Redacted.PDF - Safo 13001 (item 3, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431359&FileExtension=.PDF&FileName=SAFO%2013001-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.