# NTSB ERA09LA224: Mcdonnell Douglas MD88, N941DL, Atlanta, GA, March 28, 2009

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: March 28, 2009, 13:00 local (17:00 UTC)
- Place: Atlanta, GA
- Coordinates: 33.640556, -84.42694
- Nearby events: https://openairdocs.org/map.md?lat=33.6406&lon=-84.4269&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-descent: Turbulence encounter](https://openairdocs.org/ntsb-events/360)
- Highest injury: Serious injuries
- Injuries: 1 serious, 136 uninjured
- Status: Completed, report December 20, 2010
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 73579
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA224
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73579/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73579
- Page: https://openairdocs.org/ntsb/ERA09LA224

## Probable cause

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

## Findings

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

- [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Cabin crew (probable cause); cases with it: [Mcdonnell Douglas MD-88, 1 case](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=3023688), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md)
- [Policy/procedure: adequacy of policy/proc](https://openairdocs.org/ntsb-findings/04021015): Organizational issues › Management · Operator; cases with it: [Mcdonnell Douglas MD-88, 1 case](https://openairdocs.org/ntsb-findings/04021015/cases.md?model=3023688), [All aircraft, 106 cases](https://openairdocs.org/ntsb-findings/04021015/cases.md)
- [Turbulence](https://openairdocs.org/ntsb-findings/03032000): Environmental issues › Conditions/weather/phenomena · Not specified (probable cause); cases with it: [Mcdonnell Douglas MD-88, 1 case](https://openairdocs.org/ntsb-findings/03032000/cases.md?model=3023688), [All aircraft, 92 cases](https://openairdocs.org/ntsb-findings/03032000/cases.md)

## Sequence of events

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

- [Enroute-descent: Turbulence encounter](https://openairdocs.org/ntsb-events/360) (defining event); cases with it: [Mcdonnell Douglas MD-88, 4 cases](https://openairdocs.org/ntsb-events/360/sequence.md?model=3023688), [All aircraft, 423 cases](https://openairdocs.org/ntsb-events/360/sequence.md)

## 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](https://openairdocs.org/deregistered/N941DL-2020-05-04), registration cancelled 2020-05-04, S/N 49814, built 1989 (OpenAirDocs)
- Reported make and model: MCDONNELL DOUGLAS MD88 (88)
- Registry model: [Mcdonnell Douglas MD-88](https://openairdocs.org/model/mcdonnell-douglas-md-88) (registry code 3023688) (OpenAirDocs)
- Registry engine: [Pratt & Whitney JT8D series](https://openairdocs.org/engine/pratt-whitney-jt8d-series) (registry code 52053, turbo-jet) (OpenAirDocs)
- Category: Airplane
- Serial number: 49814
- Airframe hours: 53061
- Engines: Pratt & Whitney JT8D 21900 lbs thrust turbo jet; Pratt & 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 49; injuries: none; 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
- Co-pilot; age 40; injuries: none; 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

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20090328007969A](https://openairdocs.org/incident/20090328007969A), Mar 28, 2009: Doug MD88, Atlanta, GA, No damage. (-23) On March 28, 2009 delta flight 1966 departed el paso, TX for Atlanta, GA. As the flight started its descent on the honie arrival the crew observed rain…

## Docket (8 files)

The files NTSB released with the investigation on August 17, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73579.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 572 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329309&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Captains Statement (item 2, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329310&FileExtension=.PDF&FileName=Captains%20Statement-Redacted.PDF
- FO Statement (item 3, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329311&FileExtension=.PDF&FileName=FO%20Statement-Redacted.PDF
- Cabin Crew Statements (item 4, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329312&FileExtension=.PDF&FileName=Cabin%20Crew%20Statements-Redacted.PDF
- Honie 5 RNAV Arrival (item 5, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329313&FileExtension=.PDF&FileName=Honie%205%20RNAV%20Arrival-Master.PDF
- Other Pertinent Forms and Reports; Delta Bulletin 04/02/2009 (item 6, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329489&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports;%20Delta%20Bulletin%2004%2F02%2F2009-Master.PDF
- Other Pertinent Forms and Reports Delta IFS OBM Excerpt (Post Jan 1 2010) (item 7, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329490&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20Delta%20IFS%20OBM%20Excerpt%20(Post%20Jan%201%202010)-Master.PDF
- Other Pertinent Forms and Reports Delta IFS OBM Excerpt (Pre Jan 1 2010) (item 8, .PDF): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40329491&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20Delta%20IFS%20OBM%20Excerpt%20(Pre%20Jan%201%202010)-Master.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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