- Date
- March 21, 2023, 15:23 local (22:23 UTC)
- Place
- Sacramento, CA
- Injuries
- 1 serious, 191 uninjured
- Damage
- No damage
- Phase of flight
- Enroute
- Aircraft
- N79011Boeing 777-224
- Defining event
- Enroute-climb to cruise: Turbulence encounter
- Weather
- Visual (VMC) · Day
- Status
- Completed
- Report
- Approved by Office Director
- Investigation class
- Class 4 - Basic report with no Prelim publish
- NTSB office
- Major Investigations Division
- Case key
- 106933
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
An encounter with forecast convective turbulence during climb.
Findings · 2
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
United Airlines flight 194 encountered convective turbulence while climbing through 19,000 ft after departure from San Francisco International Airport (SFO), San Francisco, CA, and a flight attendant was seriously injured. Upon being notified of the injury, the flight crew declared an emergency and diverted to Denver, Colorado for medical assistance. The flight crew reported that before departure, the purser (lead flight attendant) was asked to have the flight attendants remain seated until the 10,000 ft signal due to weather conditions at the departure airport. After departure, airspeed fluctuations and turbulence were encountered with a smooth ride once the airplane was above a cloud layer. About 12,000 ft the captain gave the 10,000 ft signal that it was safe for the flight attendants to begin the initial service. When the flight was about 32 miles northeast of SFO the flight crew established communication with Oakland Air Route Traffic Control Center (ARTCC) while climbing through flight level (FL) 175 [17,500 ft]. The controller advised them to expect occasional light turbulence up to FL 260 and instructed them to climb to FL350. Shortly thereafter, as the airplane climbed through 19,000 ft, the flight encountered unexpected turbulence for about 5 seconds. The flight crew then received a call from the cabin advising them that a flight attendant had fractured her leg. At the time of the turbulence event, one of the flight attendants was in the aft galley preparing her cart for the initial service when she felt “violent up and down jolting turbulence”. She attempted to move towards the nearest jump seat when another “intense bump” occurred. She was thrown into the air and impacted the floor fracturing her leg. Airmen’s Meteorological Information (AIRMETs) were in effect at the time of the accident for moderate turbulence below 12,000 ft and moderate turbulence from FL220 to FL360. A convective Significant Meteorological Information (SIGMET) was issued at 1455 PDT and in effect at the time of the accident for the area with areas of thunderstorms forecast with tops to FL290. A convective SIGMET implies severe or greater turbulence, severe icing, and low-level windshear. Numerous pilot reports (PIREPs) reporting moderate or greater turbulence were issued for central California (including the accident area) within two hours of the accident time.
Aircraft
- Registration
- N79011
- Reported as
- Boeing 777-224
- Category
- Airplane
- Serial number
- 29859
- Built
- 1999
- Airframe hours
- 101,792
- Engines
- GE GE90-90B, 94,000 lbs thrust, turbo fanGE GE90-90B, 94,000 lbs thrust, turbo fan
- Damage
- No damage
- Flight
- Part 121
- Operator
- United Airlines Inc
- Registered owner
- United Airlines Inc
- Airworthiness certificate
- Standard, Transport
- Last inspection
- Continuous airworthiness · September 14, 2021
- Destination
- Munich, OF
- Flight plan
- IFR
- Equipment
- Stall warning system, ADS-B, Satellite tracking device, Onboard weather, Angle of attack indicator, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display
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 · 2
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 62
- Injuries
- None
- Certificates
- Airline transport, Flight instructor, Commercial
- Airplane ratings
- Single-engine sea, Multi-engine land, Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, With waivers/limitations
- Last flight review
- December 12, 2022
- Seat
- Left
- Restraint
- 5-point
- Flight hours
- 28,800 total · 183 in this make and model · 10,600 as pilot in command · 183 in the last 90 days · 88 in the last 30 days
- Role
- Co-pilot
- Age
- 56
- Injuries
- None
- Certificates
- Commercial, Airline transport
- Airplane ratings
- Single-engine sea, Multi-engine land, Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, With waivers/limitations
- Last flight review
- September 30, 2022
- Seat
- Right
- Restraint
- 5-point
- Flight hours
- 21,900 total · 1,560 in this make and model · 3,850 as pilot in command · 77 in the last 90 days · 25 in the last 30 days
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 140° at 25 knots, gusting 38
- Visibility
- 10 statute miles
- Lowest ceiling
- 6,000 ft broken
- Temperature
- 61 °F, dew point 46 °F
- Altimeter
- 29.34 inHg
- Observed at
- KSMF, 17 nm away
- METAR
- SPECI KSMF 212227Z 14025G38KT 10SM SCT044 BKN060 16/08 A2934 RMK AO2 PK WND 14038/2227 WSHFT 2207 LTG DSNT SW AND W RAE00 TSE2157 P0000 T01560083
Docket · 3
The files NTSB released with the investigation on June 20, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.1 MB in all.