# NTSB DCA16CA193: Boeing 737, N69806, New Orleans, LA, June 26, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Data collection · Final report - Date: June 26, 2016, 13:00 local (18:00 UTC) - Place: New Orleans, LA - Coordinates: 29.59361, -90.152778 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.5936&lon=-90.1528&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, 177 uninjured - Status: Completed, report June 8, 2020 - Report: Approved by Office Director - NTSB office: Major Investigations Division - Lead agency: Other - NTSB case key (mKey): 93463 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA16CA193 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93463/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93463 - Page: https://openairdocs.org/ntsb/DCA16CA193 ## Probable cause the improper placement of the coffee pot on the beverage cart and failure to use a safe-pour lid. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info](https://openairdocs.org/ntsb-findings/02063000): Personnel issues › Task performance · Cabin crew (probable cause); cases with it: [Boeing 737-924ER, 1 case](https://openairdocs.org/ntsb-findings/02063000/cases.md?model=13848A3), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02063000/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 737-924ER, 2 cases](https://openairdocs.org/ntsb-events/110/sequence.md?model=13848A3), [All aircraft, 151 cases](https://openairdocs.org/ntsb-events/110/sequence.md) ## 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](https://openairdocs.org/aircraft/N69806), registered now, S/N 42742, built 2013 (OpenAirDocs) - Reported make and model: BOEING 737 - Registry model: [Boeing 737-924ER](https://openairdocs.org/model/boeing-737-924er) (registry code 13848A3) (OpenAirDocs) - Registry engine: [CFM International CFM56-7B27E series](https://openairdocs.org/engine/cfm-international-cfm56-7b27e-series) (registry code 13078, turbo-fan) (OpenAirDocs) - 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 ## Weather - Conditions: Not reported ## Docket (2 files) The files NTSB released with the investigation on July 29, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93463. 752 KB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 705 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12483223&FileExtension=pdf&FileName=6120%20Flight%20430%20JUN%2026%202016-Rel.pdf - Cabin crew statements (item 2, PDF, 2 pages, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12483955&FileExtension=pdf&FileName=Cabin%20Crew%20Statements%20Flight%20430%20June%2026%202016-Rel.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.