# NTSB DCA23LA465: Boeing 787-8, N804AN, Lake Erie Beach, NY, September 28, 2023

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Class 4 · Limited · Final report
- Date: September 28, 2023, 08:57 UTC
- Place: Lake Erie Beach, NY
- Coordinates: 42.616667, -79.083333 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=42.6167&lon=-79.0833&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-cruise: Turbulence encounter](https://openairdocs.org/ntsb-events/360)
- Highest injury: Serious injuries
- Injuries: 1 serious, 239 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 4 - Basic report with no Prelim publish
- NTSB office: Major Investigations Division
- Parties: American Airlines, FAA
- NTSB case key (mKey): 193179
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DCA23LA465
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193179/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193179
- Page: https://openairdocs.org/ntsb/DCA23LA465

## Probable cause

Malfunctioning brakes on a service cart.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Enforcement: operational procedures](https://openairdocs.org/ntsb-findings/04034015): Organizational issues › Support/oversight/monitoring · Maintenance provider; cases with it: [Boeing 787-8, 1 case](https://openairdocs.org/ntsb-findings/04034015/cases.md?model=1388002), [All aircraft, 2 cases](https://openairdocs.org/ntsb-findings/04034015/cases.md)
- [Resources: adequacy of equipment](https://openairdocs.org/ntsb-findings/04022025): Organizational issues › Management · Maintenance provider; cases with it: [Boeing 787-8, 1 case](https://openairdocs.org/ntsb-findings/04022025/cases.md?model=1388002), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/04022025/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-cruise: Turbulence encounter](https://openairdocs.org/ntsb-events/360) (defining event); cases with it: [Boeing 787-8, 1 case](https://openairdocs.org/ntsb-events/360/sequence.md?model=1388002), [All aircraft, 423 cases](https://openairdocs.org/ntsb-events/360/sequence.md)
- [Enroute: Cabin safety event](https://openairdocs.org/ntsb-events/110); cases with it: [Boeing 787-8, 3 cases](https://openairdocs.org/ntsb-events/110/sequence.md?model=1388002), [All aircraft, 151 cases](https://openairdocs.org/ntsb-events/110/sequence.md)

## Analysis

American Airlines flight 160 encountered turbulence during climb to cruise while enroute to Athens International Airport (ATH), Spata, Greece from O’Hare International Airport (ORD), Chicago, Illinois resulting in a flight attendant (FA) being seriously injured. The captain reported having completed a briefing with the cabin crew prior to the flight where he discussed turbulence precautions and pointed out areas specifically where they expected the flight would encounter turbulence. During climb to the cruise altitude of flight level (FL) 370 [37,000 feet], the flight crew reported that air traffic control (ATC) assigned an intermediate level off at FL 330. The captain and first officer stated that while at FL 330 they discussed the continual light chop that the flight was experiencing and decided to keep the fasten seat belt sign on. The flight was then cleared to climb to FL 350 and the crew stated that during the climb the ride was smooth. Soon after reaching FL 350, the flight crew reported answering a cabin call informing them that a service cart had injured a flight attendant (FA2). The flight crew then informed flight dispatch and diverted to Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, where they made an overweight landing and were met by paramedics at the gate. The cabin crew reported that FA2 was standing in the back galley preparing the flight meals when the pilot announced on the public address (PA) system that they were going to experience some turbulence. When the turbulence was encountered, the flight had started to climb, and FA2 reported that in a matter of seconds she was pinned between the cart and the back galley wall. She added that the cart then began to fall, knocking her to the floor. She said the cart fell on her before she could get up and the back of her right ankle was impacted, causing a large tear in the skin and subsequent bleeding. An onboard passenger who was an acute care registered nurse practitioner assisted FA2. Upon landing, FA2 was removed from the aircraft on a stretcher and taken to a hospital where she was diagnosed with an Achilles tendon injury, as well as other injuries. The cabin crew stated that the cart’s brakes had been applied but thought it had malfunctioned causing the food cart to move and injure FA2. According to American Airlines, the vendor who maintains and repairs the carts was unable to identify the event cart nor locate its maintenance and repair history.

## Aircraft

- Registration: [N804AN](https://openairdocs.org/aircraft/N804AN), registered now, S/N 40622, built 2015 (OpenAirDocs)
- Reported make and model: BOEING 787-8
- Registry model: [Boeing 787-8](https://openairdocs.org/model/boeing-787-8) (registry code 1388002) (OpenAirDocs)
- Registry engine: [GE GENX-1B70/P2](https://openairdocs.org/engine/ge-genx-1b70-p2) (registry code 30228, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 40622
- Year built: 2015
- Airframe hours: 30418.64
- Engines: GE GENX-1B70/P2 72300 lbs thrust turbo fan; GE GENX-1B70/P2 72300 lbs thrust turbo fan
- Damage: No damage
- Flight: Part 121
- Operator: American Airlines Inc, doing business as American Airlines
- Registered owner: American Airlines Inc
- Airworthiness certificate: Standard, Transport
- Last inspection: Continuous airworthiness, September 27, 2023
- Departed: KORD, Chicago, IL
- Destination: ATH, Spata, OF
- Flight plan: IFR
- Equipment: ADS-B, Stall warning system, Onboard weather, Electronic primary flight display, Electronic multifunction display, Electronic flight bag or handheld device, Data recorder, Angle of attack indicator, Auto-pilot

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 626; injuries: none; flight engineer, airline transport, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review September 17, 2023; seat: left; restraint: 5-point; flight hours: 600 in this make and model
- Co-pilot; age 62; injuries: none; flight instructor, airline transport, flight engineer; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review April 23, 2023; seat: right; restraint: 5-point; flight hours: 2,882 in this make and model
- Other flight crew; injuries: none; airline transport; seat: center; restraint: 5-point; flight hours: 632 in this make and model
- Cabin crew; injuries: serious; seat: none; restraint: none

## Weather

- Conditions: Visual (VMC), Day
- Lowest ceiling: 25,000 ft broken
- Observed at: KBUF, 50 nm away

## Docket (3 files)

The files NTSB released with the investigation on October 29, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193179. 2.5 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17448811&FileExtension=pdf&FileName=AA160%2028SEP%206120%20-%20signed-Rel.pdf
- Employee statements - crew statements (item 2, PDF, 2 pages, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17448643&FileExtension=pdf&FileName=FLIGHT%20CREW%20STATEMENTS%20AAL%20160%20copy-Rel.pdf
- Employee statements - FA2'S statement (item 3, PDF, 1 page, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17448821&FileExtension=pdf&FileName=F160%2028SEP23%20FA2%20NTSB%20Statement-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.

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