DCA23LA421

NTSB accident investigation · Boeing 777-222 · Over the (Atlantic Ocean) · August 18, 2023

Accident · Serious injuriesClass 4 · LimitedFinal report
Date
August 18, 2023, 19:11 local (14:11 UTC)
Place
Over the (Atlantic Ocean)
Injuries
1 serious, 8 minor, 247 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N209UABoeing 777-222
Defining event
Enroute-cruise: Turbulence encounter
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Major Investigations Division
Parties
FAA AVP100, United
Case key
192927

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 inadvertent encounter with clear air turbulence during cruise flight.

Findings · 5

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: clear air turbulenceEnvironmental issues › Conditions/weather/phenomena · Effect on personnelBoeing 777-222: 2 casesAll aircraft: 78 cases
Turbulence: clear air turbulenceEnvironmental issues › Conditions/weather/phenomena · Awareness of conditionBoeing 777-222: 2 casesAll aircraft: 78 cases

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 918 encountered clear air turbulence during cruise flight, while en route to the London Heathrow International Airport (LHR), London, United Kingdom resulting in one flight attendant (FA) sustaining a serious injury. The flight originated at Dulles International Airport (IAD), Dulles, Virginia. The flight crew reported that their preflight weather briefing revealed no significant areas of weather or turbulence over their planned route to LHR. During their preflight checks an open status message “PASS ADDRESS SYSTEM” displayed on their engine indication and crew alerting system (EICAS) display and maintenance was called. A technician responded who reinitialized the entire passenger address (PA) system and cleared the status message. The flight crew reported that prior to the JOBOC intersection, there was minimal light turbulence, and the seatbelt sign had been on and off sporadically as required. They also indicated that no turbulence was identified in their immediate vicinity from their inflight weather resources. About 80 nm east of JOBOC, the flight encountered very light turbulence and the first officer (FO), who was the pilot flying, made the PA announcement: “Flight Attendants take your seats.” In a postaccident statement, the captain reported that while in the forward lavatory, the flight encountered very light turbulence and he heard through the lavatory wall, the FO make the PA announcement: “Flight Attendants take your seats.” However, because he did not hear the PA announcement over the lavatory speaker he didn’t know if the rest of the crew or passengers heard this announcement. The in-flight service manager (ISM), who was in the cockpit at the time also heard the FO make the announcement “Flight Attendants take your jumpseats.” As the captain attempted to take his seat (left seat) the flight encountered a moderate turbulence spike that made his knees buckle and threw him back down into the 1st observer’s seat. He indicated that he was able to flash the seatbelt sign on and off three times rapidly. The flight crew then executed all the steps of the TURBULENCE IMMEDIATE ACTION GUIDE. The turbulence ended as abruptly as it had begun. The captain then made a PA announcement “Flight attendants check in.” The ISM advised the captain that all the flight attendants had been knocked to the floor and one was seriously injured. The flight crew contacted dispatch and advised of the clear air turbulence encounter. The dispatcher had no reports of turbulence from any other United flights in the area. According to the cabin crew, they did not hear the PA announcement “Flight Attendants take your seats” and therefore they were completing their normal duties when, without warning, the airplane encountered turbulence. One FA, who was delivering meals at the time of the turbulence encounter, was thrown down, impacted the floor, and was injured. According to the ISM, shortly after the encounter, the captain came on the PA and said“Flight Attendants, Check In.” The cabin crew heard that announcement and the ISM reported to the flight crew that one FA was on the floor and was unable to get up. Upon being notified of the injured FA, the flight crew declared a medical emergency and requested paramedics meet the aircraft at the gate in LHR. The injured FA was moved to an unoccupied passenger seat, given ice, and was assisted by an onboard medical doctor for the rest of the flight. After landing the FA was transported to a local hospital where she was diagnosed with a fractured left fibula. A postaccident functional check of the passenger address system revealed no malfunctions or anomalies with the system.

Aircraft

Registration
N209UA
Reported as
Boeing 777-222
Category
Airplane
Serial number
30215
Built
1999
Airframe hours
92,517
Engines
P&W PW4000 SER, 60,000 lbs thrust, turbo fanP&W PW4000 SER, 60,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
United Airlines Inc
Registered owner
United Airlines Inc
Airworthiness certificate
Standard, Transport; Standard, Normal
Last inspection
Continuous airworthiness · September 22, 2023
Departed
KIAD · Dulles, VA
Destination
LHR · London, OF
Flight plan
IFR
Equipment
Angle of attack indicator, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Onboard weather, Satellite tracking device, Stall warning system, ADS-B

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 · 7

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
None
Certificates
Flight engineer, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Medical
Class 1, Waiver time limited special
Seat
Left
Restraint
5-point
Flight hours
21,000 total · 3,441 in this make and model · 18,307 as pilot in command · 214 in the last 90 days · 73 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
48
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right
Restraint
5-point
Flight hours
15,000 total · 1,575 in this make and model · 10,000 as pilot in command · 245 in the last 90 days · 88 in the last 30 days · 0 in the last 24 hours
Role
Flight instructor
Injuries
None
Seat
Rear
Restraint
5-point
Flight hours
0 total · 0 in this make and model
Role
Cabin crew
Injuries
None
Restraint
4-point
Role
Cabin crew
Injuries
Serious
Restraint
4-point
Role
Cabin crew
Injuries
None
Restraint
4-point
Role
Cabin crew
Injuries
None
Restraint
4-point

Weather

Conditions
Visual (VMC) · Night
Wind
65 knots
Visibility
10 statute miles
Lowest ceiling
None
Observed at
CYQX

Other investigations on N209UA · 1

Matched to the same aircraft by N-number and date.