ERA09LA224

NTSB accident investigation · Mcdonnell Douglas MD88 · Atlanta, GA · March 28, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
March 28, 2009, 13:00 local (17:00 UTC)
Place
Atlanta, GA
Injuries
1 serious, 136 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N941DLMcdonnell Douglas MD88
Defining event
Enroute-descent: Turbulence encounter
Weather
Instrument (IMC) · Day
Status
Completed · report December 20, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20090328007969A
Case key
73579

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

The flight attendant’s failure to properly restrain herself after taking her jumpseat.

Findings · 3

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.

Action: delayed actionPersonnel issues › Action/decision · Cabin crewMcdonnell Douglas MD-88: 1 caseAll aircraft: 894 casesProbable cause
TurbulenceEnvironmental issues › Conditions/weather/phenomena · Not specifiedMcdonnell Douglas MD-88: 1 caseAll aircraft: 92 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

While on initial approach, the flight crew announced over the public address system for passengers and flight attendants to take their seats. According to one of the flight attendants, it took about 1 minute to get everything put away in the galley, then he and another attendant went to the aft jumpseat to be seated. Neither fastened their restraints. Shortly thereafter, there was a "jolt of turbulence" that lasted between 2 to 3 seconds. Both flight attendants came off the aft jumpseat and it retracted into the stowed position, and one fell onto her side and incurred injuries to her elbow, shoulder, and head. As a result of the event, the operator clarified its turbulence training and guidance to emphasize that flight attendants "must be seated with seat belts and shoulder harness secured during moderate/severe turbulence or when directed by the captain."

Factual narrative

On March 28, 2009, at 1300 eastern daylight time, a McDonnell Douglas MD-88, N941DL, operating as Delta flight 1966, experienced inflight turbulence while on approach to Hartsfield Jackson Atlanta International Airport (ATL), Atlanta, Georgia. The captain, first officer, 2 flight attendants, and 132 passengers reported no injuries. One flight attendant received serious injuries, and the airplane sustained minor damage. The flight was operated as a commercial transport flight under the provisions of 14 Code of Federal Regulations Part 121 under instrument flight rules with a company flight plan in effect. Instrument meteorological conditions prevailed at the time of the accident. The flight originated from El Paso International Airport (ELP), El Paso, Texas, at 0941 EDT. According to the two non-injured flight attendants (FA), the flight crew had turned on the fasten seat belt sign and announced over the public address (PA) system that all passengers and all flight attendants were to be seated because they were getting ready to go through some "rough air." One FA was located in the first-class galley; she secured all loose items then sat down and strapped in. She stated that within a few minutes the airplane "dropped severely." The second FA stated that they were on initial approach to ATL when the flight crew announced over the PA for passengers and FAs to take their seats. The FA stated that it took about 1 minute to get everything put away in the galley. Then he and the third FA went to the aft jumpseat to be seated. Neither FA fastened their restraints. According to the second FA, a passenger was getting up to use the lavatory and "I told him to return to his seat. I also made a PA for all passengers to remain seated. A child in row 28 tried to get up and I got up and told his father and the child to remain seated. The child was up several times during the flight." Then he returned to the jumpseat next to the third FA. Within a minute or so there was a "jolt of turbulence." It lasted between 2 to 3 seconds. We both came off the aft jumpseat and it retracted into the stowed position. The third FA fell on her side and hit her elbow, shoulder, and head on the lavatory door. "It all happened so quickly. I got her on the jumpseat and buckled her in." I asked her if she was okay. The captain called back and asked us if we were all right. I told him that the third FA had hit her head and had a cut on her arm. The captain said that he would have paramedics meet the flight. According to the Delta Flight Safety representative, damage to the airplane was isolated to ceiling panels above the injured flight attendant's jumpseat. The panels were replaced and the airplane was returned to service. Prior to the accident, turbulence guidance in the Delta Airlines Onboard Manual (flight attendant manual), included, “flight attendants should be seated immediately when directed by the captain to take their seats due to moderate or severe turbulence.” As a resultof the accident, Onboard Manual turbulence guidance was changed to include, “flight attendants must be seated with seat belts and shoulder harness secured during moderate/severe turbulence or when directed by the captain.”

Aircraft

Registration
N941DL
Reported as
Mcdonnell Douglas MD88 (88)
Category
Airplane
Serial number
49814
Airframe hours
53,061
Engines
Pratt & Whitney JT8D, 21,900 lbs thrust, turbo jetPratt & Whitney JT8D, turbo jet
Damage
Minor damage
Flight
Part 121
Operator
Delta Air Lines Inc
Registered owner
Delta Air Lines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 25, 2009
Departed
ELP · El Paso, TX
Destination
ATL · Atlanta, GA
Flight plan
IFR
Airport
ATL · Hartsfield Jackson Int. Arpt

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
49
Injuries
None
Certificates
Flight engineer, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
November 24, 2009
Seat
Left
Flight hours
11,844 total · 1,745 in this make and model
Role
Co-pilot
Age
40
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 11, 2009
Seat
Right
Flight hours
3,300 total · 836 in this make and model

Weather

Conditions
Instrument (IMC) · Day
Wind
110° at 24 knots, gusting 33
Visibility
2 statute miles
Lowest ceiling
2,700 ft overcast
Temperature
59 °F, dew point 57 °F
Altimeter
29.92 inHg
Observed at
ATL, 20 nm away

Docket · 8

The files NTSB released with the investigation on August 17, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.