FTW03LA195

NTSB accident investigation · Airbus Industrie A340-300 · Walnut Ridge, AR · August 6, 2003

Accident · Serious injuriesLimited investigationFinal report
Date
August 6, 2003, 20:57 UTC
Place
Walnut Ridge, AR
Injuries
2 serious, 43 minor, 213 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
D-AIGKAirbus Industrie A340-300
Weather
Visual (VMC) · Day
Status
Completed · report June 30, 2004
Report
Approved by Office Director
Parties
FAA FSDO, National Transportation Safety Board, Emergency Center-MHH, Deutsche Lufthansa AG, BEA
Case key
57702

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The flight crew's inadequate evaluation of the weather and their decision to continue the along the route of flight resulting in an encouter with severe turbulence. Contributing factors were the captain's instructions to continue food servicing in the cabin, and the passenger's failure to obey the lighted "FASTEN SEAT BELT" sign.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise
Weather condition - turbulenceCause
Weather evaluation - inadequateFlightcrewCause
Flight into adverse weather - continuedFlightcrewCause
Aircraft/equipment inadequateCompany/operator managementFactor
Misc eqpt/furnishings,galley - looseFactor
In-flight planning/decision - initiatedPilot in commandFactor
Misc eqpt/furnishings,seat belt - not securedFactor
Procedures/directives - not complied withPassengerFactor

Analysis

The transport aircraft encountered severe turbulence at flight level 310 while in IMC during an international flight. Convective SIGMETs for an area of thunderstorms with tops to flight level 410 were in effect at the time and location of the accident. The FDR data showed aircraft disturbances in vertical acceleration, lateral acceleration, altitude, magnetic heading, and vertical speed. The autopilot and auto-throttle parameters remained engaged throughout the event. The captain side stick pitch, first officer side stick pitch, and first officer side stick roll parameters showed no movement during the disturbance. The captain side stick roll parameter moved -1 degree during 2057:07 and then returned to 0 degrees. The rudder pedal position and rudder parameters showed less than one degree of movement during the event sequence, and the pitch and elevator parameters registered excursions of less than 1.5 degrees. The altitude reached a minimum value of 30,884 feet msl, the aircraft stabilized at 31,000 feet. The aircraft landed at 2207 at the destination airport, approximately I hour and 10 minutes after the encounter with severe turbulence. Food service was in progress in the cabin, and the "fasten seat belt" light was on at the time of the turbulence encounter. The FA statements revealed that 7 FA's hit the cabin ceiling and then the floor, one FA hit the ceiling then an armrest, and 2 FA's were tossed through a galley. Three food serving carts were lifted from the floor, and numerous food service items were tossed about the cabin. Some of the passengers were out of their seats, and some, who were seated, did not have their seat belts secured per the "Fasten Seat Belt" light. The 18,593-hour captain/check airman with 4,093 hours in the accident aircraft, was the non-flying pilot (PNF) during the event, the 2,759-hour first officer was the pilot flying (PF). Reviews of the flight and duty time records disclosed no evidence of any activities that would have prevented the flight crewmembers from obtaining sufficient rest in the 72 hours before the accident flight. Company interviews revealed that the departure flight was delayed 4 hours and 7 minutes as a result of a change of airplanes. The Flight Crew Manual states in part: every cloud related to a severe thunderstorm represents a serious danger, and AVOID - AVOID - AVOID since weather can exceed the performance capabilities and/or structural limits of the airplane.

Factual narrative

History of flight

On August 6, 2003, approximately 2057 universal time coordinated (UTC), an Airbus A340-300 transport airplane, German registration D-AIGK, operating as Lufthansa Flight 440, sustained minor damage following an encounter with severe turbulence during cruise flight at flight level 310, approximately 029 DME, on the 040 degree radial from the Walnut Ridge Vortac (ARG). The airplane was registered to and operated by Deutsche Lufthansa AG, of Cologne, Germany. Instrument meteorological conditions prevailed, and a instrument flight rules flight plan (IFR) was filed for the Code of Federal Regulations Part 129 scheduled international passenger transport flight. Three cabin crew members and 40 passengers received minor injuries, and two passengers received serious injuries. The three flight crew members, eight cabin crew members, and 202 passengers were not injured. The flight originated from Frankfurt (FRA), Germany, and was destined for the George Bush International Airport (IAH), near Houston, Texas.

According to company personnel and the flight crew, the captain was the non-flying pilot (PNF) during the event, the first officer was the pilot flying (PF), and the senior first officer was in the cockpit crew rest (CCR) area. The airplane was in and out of the clouds, seat belt signs were on, and the weather radar indicated there were several echoes to the southwest, ranging from 40-80 nautical miles. The flight crew considered deviating the flight to the west; however, there were no echoes along the route of flight and the route, and the flight crew elected to continue along the route. Subsequently, flying into a cloud what seemed to be several layers of thin clouds, the flight crew noticed "a chance in density, but did not get any radar echoes." A few seconds later, the flight encountered severe turbulence. The captain stated, "it felt like a hard upward movement, following an extreme downdraft throwing everything in the cockpit up into the air. It stopped abruptly." The flight crew reduced the speed of the aircraft, and assessed the cockpit situation. The senior first officer informed the captain that there were passenger injuries and damage to the cabin area.

At 2058;04, the captain informed the controller that the flight had encountered severe turbulence. The captain requested and was cleared to divert to the west for approximately 30 nautical miles. Subsequently, the controller cleared the flight direct to Little Rock, Arkansas, at flight level 200 (20,000 feet msl). At 2102:48, the captain informed the controller of the injuries on board the aircraft. Subsequently, the senior first officer informed the captain that the cabin attendants were assisting the passengers, and medical assistance was given by several physicians with no assessment of life-threatening injuries. The captain requested and was cleared by the controller to continue the flight to the IAH. At 2107;08, the controller cleared the airplane to climb to flight level 280 (28,000 feet msl), and issued a direct route via radar vectors for the ILS approach to runway 27 at IAH. At 2207, the airplane landed on runway 27 at IAH, and proceeded without delay to terminal D, gate 12. Immediate medical assistance was received by the injured, and they were transported to local area hospitals.

A review of the fight attendant (FA) statements, about the turbulence encounter, revealed the following: seven FA's hit the cabin ceiling and then the floor, one FA hit the ceiling then an armrest, and two FA's were tossed through a galley. The trolleys (food serving carts) were lifted from the floor. Numerous food service items were tossed and broken throughout the cabin.

Personnel information

The captain's last duty before the accident flight was a ground refresher, which ended at 1500, on August 5, 2003; therefore, the captain's rest time before the flight was 15:35 hours. The senior first officer's last duty before the flight was a duty/office day which ended at 1515 on August 4, 2003; therefore, the first officer's rest time before the flight was 39:20 hours. The first officer's last duty before the flight was a flight that ended at 0516 on July 30, 2003; therefore, the first officer's rest time before the flight was 169:19 hours. Review of the flight and duty time records and company interviews disclosed no evidence of any activities that would have prevented the flight crewmembers from obtaining sufficient rest in the 72-hours before the flight. However, according to company personnel, the original flight departed FRA at 0635, and returned to the ramp at 0839 following a maintenance discrepancy. Thus the FRA departure flight was delayed 4 hours 7 minutes resulting from the change of airplanes.

The captain's initial employment date with Lufthansa was May 1, 1967. The captain, an airline transport rated pilot, with an A340 type rating, who transitioned to the A340 on December 30, 1992, had accumulated a total flight time of 18,593.02 hours (4,093.39 hours as captain in the A340). The captain (check airman for the A340 since February 26, 1993) accumulated 120:48 hours in the A340 and 56:00 hours in the A340 simulator in the last 90 days prior to the flight, and 58:14 hours in the A340 and 4:00 hours in the A340 simulator in the last 30 days prior to the flight. The captain's last check was the operator proficiency check (OPC), satisfactorily performed on Jun 17, 2003. The captain's most recent first-class medical certificate was issued on August 5, 2003.

The senior first officer's (SFO) initial employment date was May 24, 1995. The SFO, an airline transport rated pilot with an A340 type rating who transitioned to the A340 on April 21, 2000, had accumulated a total flight time of 5,398.29 hours (1,843.33 hours as first officer and 459.27 as SO in the A340). The SFO accumulated 142.35 hours in the A340 and 4:00 hours in the A340 simulator in the last 90 days prior to the flight, and 75:46 hours in the A340 in the last 30 days prior to the flight. The SFO's last check was the Standard Refresher Session (REF) performed on June 10, 2003. The SFO's most recent first-class medial certificate was issued on November 7, 2002, with no limitations stated.

The first officer's (FO) initial employment date was December 1, 1998. The FO, an airline transport rated pilot with an A340 type rating, had accumulated a total flight time of 2,759.12-hours (47 hours as FO in the A340 simulator). The FO had accumulated 66.24 flight hours in the last 30 days prior to the flight. The FO's licensing flight check was satisfactorily completed on performed on Jun 6, 2003, in the A340 simulator, and the final check for the A340 airplane remained open at the time of the flight. The flight DLH 440 of August 8, 2003, was dedicated as the final line check for the FO after the transition to the A340, and the entitled check captain was the type rating instructor and type rating examiner for the FO. The FO's most recent medical certificate was issued on November 11, 2002, with the limitation "wear corrective lenses and bring an extra pair of glasses along."

The Lufthansa Operations Manual Part D Paragraph 2.12.5. Line Training and Checking states in part: Line flying under supervision may only take place after the type rating was issued. The list of topics for line training include: use of weather radar and high level cumulous (CB) scanning.

The 11 cabin FA's training for emergency first aid had been satisfactorily performed prior to the flight. Four of the FA's completed the training in October of 2002, two FA's completed the training in November of 2002, two FA's completed the training in January of 2003, two FA's completed the training in July of 2003, and one FA completed the training in May of 2003.

The flight crewmember Training Information Manual weather training (turbulence) includes in part: a review of previous events and turbulence

Aircraft

Registration
D-AIGK
Reported as
Airbus Industrie A340-300
Category
Airplane
Serial number
056
Airframe hours
45,114.49
Engine
CFM International CFM56-56C, 31,200 lbs thrust, turbo fan
Damage
Minor damage
Flight
Part 129
Registered owner
Deutsche Lufthansa AG
Airworthiness certificate
Standard, Transport
Departed
EDDF · Frankfurt
Destination
KIAH · Houston, TX
Flight plan
IFR

Flight crew · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
July 17, 2003
Seat
Left
Flight hours
18,593 total · 4,093 in this make and model · 176 in the last 90 days · 62 in the last 30 days
Role
Pilot
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
June 6, 2003
Seat
Right
Flight hours
2,759 total · 66 in the last 90 days · 37 in the last 30 days
Role
Pilot
Injuries
None
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
June 10, 2003
Flight hours
5,398 total · 142 in the last 90 days · 75 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 77 °F
Altimeter
29.86 inHg
Observed at
ARG, 29 nm away

Docket · 16

The files NTSB released with the investigation on May 4, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 25.3 MB in all.