DCA16CA193

NTSB accident investigation · Boeing 737 · New Orleans, LA · June 26, 2016

Accident · Serious injuriesData collectionFinal report
Date
June 26, 2016, 13:00 local (18:00 UTC)
Place
New Orleans, LA
Injuries
1 serious, 177 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N69806Boeing 737
Defining event
Enroute: Cabin safety event
Weather
Not reported
Status
Completed · report June 8, 2020
Report
Approved by Office Director
NTSB office
Major Investigations Division
Lead agency
Other
Case key
93463

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

the improper placement of the coffee pot on the beverage cart and failure to use a safe-pour lid.

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.

Use of equip/infoPersonnel issues › Task performance · Cabin crewBoeing 737-924ER: 1 caseAll aircraft: 111 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

On June 26, 2016, at about 1300 CDT, United Airlines flight 430, a Boeing 737-900ER, N69806, was about 20 minutes into the flight from New Orleans International Airport (KMSY), New Orleans, Louisiana, to Chicago O'Hare International Airport (KORD), Chicago, Illinois, when a coffee pot fell off a galley cart and spilled onto a passenger. Medical personnel were on board and treated the passenger. The flight crew declared a medical emergency and diverted to Little Rock National Airport (KLIT), Little Rock, Arkansas, where the passenger was taken to the hospital and diagnosed with second degree burns from the hot coffee. There were 6 crew and 172 passengers on board. The flight was being operated as a 14 Code of Federal Regulations Part 121 scheduled passenger flight. The flight attendants (FA) stated that the beverage cart pull out trays were not pulled out for the coffee pots but instead, the metal coffee pot was placed on top of the cart in the center. In addition, the FAs stated that they could not find the safe-pour lids in their provisioning supplies so they had placed a plastic cup in the opening of the coffee pot. At the time of the spill, the cart was positioned near seat row 7, with the brakes set. One FA went to retrieve a meal cart and the other FA had turned their head when suddenly screaming was heard. The passenger got up and went to the lavatory and was subsequently examined by a doctor and a nurse. The doctor informed the crew that a diversion was advised. It could not be determined if the coffee pot tipped over or was grabbed by the young passenger causing the coffee to spill. United's flight attendant Galley Guide depicts the proper positioning of the beverage cart pull out trays and where to locate the coffee pots. Coffee pots were to be placed on the pull out trays, not in the center of the cart. In addition, the same guidance had several references throughout the document to, "Use the safe-pour lid on coffee pots anytime they are brought into the aisle."

Factual narrative

On June 26, 2016, at about 1300 CDT, United Airlines flight 430, a Boeing 737-900ER, N69806, was about 20 minutes into the flight from New Orleans International Airport (KMSY), New Orleans, Louisiana, to Chicago O'Hare International Airport (KORD), Chicago, Illinois, when a coffee pot fell off a galley cart and spilled onto a passenger. Medical personnel were on board and treated the passenger. The flight crew declared a medical emergency and diverted to Little Rock National Airport (KLIT), Little Rock, Arkansas, where the passenger was taken to the hospital and diagnosed with second degree burns from the hot coffee. There were 6 crew and 172 passengers on board. The flight was being operated as a 14 Code of Federal Regulations Part 121 scheduled passenger flight. The flight attendants (FA) stated that the beverage cart pull out trays were not pulled out for the coffee pots but instead, the metal coffee pot was placed on top of the cart in the center. In addition, the FAs stated that they could not find the safe-pour lids in their provisioning supplies so they had placed a plastic cup in the opening of the coffee pot. At the time of the spill, the cart was positioned near seat row 7, with the brakes set. One FA went to retrieve a meal cart and the other FA had turned their head when suddenly screaming was heard. The passenger got up and went to the lavatory and was subsequently examined by a doctor and a nurse. The doctor informed the crew that a diversion was advised. It could not be determined if the coffee pot tipped over or was grabbed by the young passenger causing the coffee to spill. United's flight attendant Galley Guide depicts the proper positioning of the beverage cart pull out trays and where to locate the coffee pots. Coffee pots were to be placed on the pull out trays, not in the center of the cart. In addition, the same guidance had several references throughout the document to, "Use the safe-pour lid on coffee pots anytime they are brought into the aisle."

Aircraft

Registration
N69806
Reported as
Boeing 737
Category
Airplane
Serial number
42742
Damage
No damage
Flight
Part 121
Operator
United Air Lines Inc
Registered owner
United
Airworthiness certificate
Standard, Transport
Departed
MSY · New Orleans, LA
Destination
ORD · Chicago, IL

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.

Weather

Conditions
Not reported

Docket · 2

The files NTSB released with the investigation on July 29, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 752 KB in all.