DCA23LA213

NTSB accident investigation · Boeing 777-224 · Sacramento, CA · March 21, 2023

Accident · Serious injuriesClass 4 · LimitedFinal report
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.

Turbulence: convective turbulenceEnvironmental issues › Conditions/weather/phenomena · Effect on personnelBoeing 777-224: 1 caseAll aircraft: 145 casesProbable cause
Turbulence: convective turbulenceEnvironmental issues › Conditions/weather/phenomena · Effect on operationBoeing 777-224: 1 caseAll aircraft: 145 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

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.