ERA09LA396

NTSB accident investigation · Airbus A320-232 · Fort Myers, FL · July 10, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
July 10, 2009, 16:08 local (20:08 UTC)
Place
Fort Myers, FL
Injuries
2 serious, 2 minor, 149 uninjured
Damage
No damage
Phase of flight
Approach
Aircraft
N606JBAirbus A320-232
Defining event
Approach: Turbulence encounter
Weather
Visual (VMC) · Day
Status
Completed · report November 9, 2009
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Case key
74250

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 in-flight encounter with turbulence during approach. Contributing to the accident was the passengers' failure to follow the instructions of the illuminated seatbelt sign.

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.

TurbulenceEnvironmental issues › Conditions/weather/phenomena · Not specifiedAirbus A320-232: 2 casesAll aircraft: 92 casesProbable cause
Communication (personnel): following instructionsPersonnel issues › Task performance · PassengerAirbus A320-232: 1 caseAll aircraft: 31 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

The airplane was descending through 12,500 feet on approach to the airport. The airplane was jolted as it flew through a small cumulus cloud. Specifically, the airplane dropped about 20 feet instantaneously, experiencing a positive g-load of 1.98, followed by a negative g-load of -0.43, less than 1 second later. During that time, a seated passenger did not have her seatbelt fastened. She fell forward into the stowed tray table in front of her, fracturing two ribs. A second passenger was in an aft lavatory and suffered two spinal fractures. The captain had made a passenger announcement during initial descent and prior to the turbulence encounter, emphasizing the need for passengers to take their seats and fasten their seatbelts when the seatbelt sign was illuminated. Additionally, a flight attendant made a public announcement when the seatbelt sign was illuminated. The seatbelt sign had been illuminated since 19,000 feet (about 4 minutes prior) and the airplane was not flying through any precipitation. The captain had also instructed the flight attendants via intercom to sit down a few minutes prior to the turbulence encounter.

Factual narrative

On July 10, 2009, at 1608 eastern daylight time, an Airbus A320-232, N606JB, operated by JetBlue Airways Corporation as flight 133, encountered turbulence while on approach to Southwest Florida International Airport (RSW), Fort Myers, Florida. The 2 certificated airline transport pilots, 3 flight attendants, and 144 passengers were not injured; while 2 passengers received serious injuries and 2 passengers received minor injuries. The airplane was not damaged. Visual meteorological conditions prevailed at RSW and an instrument flight rules flight plan was filed for the air carrier flight conducted under the provisions of 14 Code of Federal Regulations Part 121. The flight originated from John F Kennedy International Airport (JFK), New York, New York, at 1403. According to the captain's written statement, the airplane was jolted as it descended through 12,000 feet and went through a small cumulus cloud (top approximately 14,000 feet). Specifically, the airplane dropped about 20 feet instantaneously. The seatbelt sign had been illuminated since 19,000 feet (about 5 minutes prior) and there were no returns on the weather radar within 20 miles of the airplane's position. The captain had instructed the flight attendants via intercom to sit down a few minutes prior to the turbulence encounter. Within 15 seconds of encountering the jolt, the airplane was in clear air and the captain called the flight attendants to tell them it was safe to get up. He was then notified that a female passenger in seat 24C did not have her seatbelt fastened, and had fallen forward into the stowed tray table in front of her. Shortly thereafter, the captain was notified that another female passenger (seat 22C) was in an aft lavatory during the turbulence and was complaining of back pain. The flight landed uneventfully and emergency medical services (EMS) personnel, who had been requested by the flightcrew, boarded the airplane at the gate. At that time, two additional passengers (seats 21E and 24E) informed EMS that they were injured. All four passengers were transported to local hospitals. The first officer and flight attendants reported that the captain had made a passenger announcement during initial descent and prior to the turbulence encounter, emphasizing the need for passengers to take their seats and fasten their seatbelts when the seatbelt sign was illuminated. Additionally, a flight attendant made a public announcement when the seatbelt sign was illuminated. According to a Senior Air Safety Investigator at JetBlue, the passengers in seats 21E and 24E were released from the hospital with no fractures reported. The passenger in the lavatory suffered two spinal fractures and the passenger in 24C suffered fractures of two ribs. The Senior Air Safety Investigator at JetBlue further stated that review of the airplane's quick access recorder (QAR) data revealed that approximately 4 minutes elapsed from the time the airplane descended through 19,000 feet, until the time ofthe turbulence encounter. He added that the company's standard operating procedure is for the seatbelt sign to be activated when descending through 18,000 feet. Further review of the QAR revealed that at 1608, the airplane experienced a positive g-load of 1.98, followed by a negative g-load of -0.43 less than 1 second later. At that time, it was at an altitude of approximately 12,500 feet, near the MAZZY waypoint. Review of Nexrad and Doppler weather radar revealed light to moderate intensity echoes east of the airplane's position, which the captain noted in his written statement. There were no Significant Meteorological Information (SIGMET)s or convective SIGMETs in effect at the time and location of the turbulence encounter. The recorded weather at RSW, at 1553, was: wind from 090 degrees at 6 know; sky clear; visibility 10 miles; temperature 32 degrees Celsius; dew point 21 degrees Celsius; altimeter 30.10 inches of mercury.

Aircraft

Registration
N606JB
Reported as
Airbus A320-232
Category
Airplane
Serial number
2384
Airframe hours
18,703
Engines
IAE V2527-A5, 26,500 lbs thrust, turbo fanIAE V2527-A5, 26,500 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Jetblue Airways Corp
Registered owner
Jetblue Airways Corp
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 10, 2009
Departed
JFK · New York, NY
Destination
RSW · Fort Myers, FL
Flight plan
IFR
Airport
RSW · Southwest Florida Internationa

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
48
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 10, 2009
Seat
Left
Flight hours
12,384 total · 4,246 in this make and model · 11,363 as pilot in command · 194 in the last 90 days · 64 in the last 30 days · 10 in the last 24 hours
Role
Co-pilot
Age
40
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 24, 2009
Seat
Right
Flight hours
7,847 total · 1,659 in this make and model · 3,361 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 70 °F
Altimeter
30.10 inHg
Observed at
RSW

Docket · 10

The files NTSB released with the investigation on September 22, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.6 MB in all.