IAD01LA102

NTSB accident investigation · Embraer ERJ-135ER · Richmond, VA · August 30, 2001

Accident · Serious injuriesLimited investigationFinal report
Date
August 30, 2001, 15:55 local (19:55 UTC)
Place
Richmond, VA
Injuries
1 serious, 28 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N25504Embraer ERJ-135ER
Weather
Visual (VMC) · Day
Status
Completed · report May 13, 2003
Report
Approved by Office Director
Parties
FAA
FAA report
20010830026339A
Case key
53157

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

Inadequate company procedures/directives, which resulted in the flight attendant leaving her seat prematurely, while the airplane was still in an area of turbulence.

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 weatherDescent - normal
Procedures/directives - inadequateCompany/operator managementCause
Weather condition - turbulence in clouds
Seat belt - discontinuedFlight attendant

Analysis

The airplane was on autopilot in instrument meteorological conditions, descending through 17,000 feet at 280 knots. It was being operated in an area of convective activity, with cells about 20 nautical miles on either side of the flight path. There were no radar echoes in the path of flight. The captain notified the flight attendant that the "ride may be bumpy," and had her sit down. The seat belt sign was illuminated, and a general announcement about potential turbulence was made. Approximately 10 minutes after the announcement, severe turbulence was encountered. The flight attendant, who had gotten up after thinking the area of turbulence had passed, was then seriously injured. There was no specific guidance in the company's flight operations manual about seating cabin crewmembers in anticipation of turbulence. As a result of the investigation, and after coordination with the senior manager of flight safety for the airline, guidance was published that included a requirement that cabin crewmembers remain seated until advised by the captain.

Factual narrative

On August 30, 2001, at 1555 eastern daylight time, an Embraer ERJ-135ER, N25504, operating as Continental Express flight 3608, was undamaged during a turbulence encounter near Richmond, Virginia. The captain, first officer, and 26 passengers were not injured. One flight attendant was seriously injured. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the flight that originated at Cleveland-Hopkins International Airport (CLE), Cleveland, Ohio. The scheduled passenger flight was destined for Richmond International Airport (RIC), Richmond, Virginia, and conducted under 14 CFR Part 121.

According to the airline's senior manager of flight safety, the airplane was on autopilot, descending through 17,000 feet, at 280 knots. It was being operated in an area of convective activity, with cells about 20 nautical miles on either side of the flight path. There were no radar echoes in the path of flight. The captain notified the flight attendant that the "ride may be bumpy," and had her sit down. The seat belt sign was illuminated, and a general announcement about potential turbulence was made. Approximately 10 minutes after the announcement, severe turbulence was encountered. The flight attendant, who had been standing near row 12 at the time, was then seriously injured.

The senior manager of flight safety for Continental Express interviewed the pilots and the flight attendant by telephone, and prepared summaries of each interview. All three crewmembers gave a similar accounting of events. The first officer said that when the severe turbulence was encountered, it caused his hands and feet to come off the controls. He also said that the autopilot disconnected and the airplane banked about 15 degrees.

According to the flight attendant, the captain called and advised her that he expected to encounter turbulence within 5 to 10 minutes, and that she was to secure the galley and sit down. She closed the galley and took her seat. A few minutes later, she felt the airplane bounce a few times.

"I thought we were through the turbulence and got up to complete cabin preparations for landing. As I got to the back of the aircraft, we hit severe turbulence that knocked me to the floor. It felt like we went down-up-down. My leg and ankle folded under me and I immediately knew that I had broken my leg."

When the flight attendant was asked why she got out of her seat before the captain advised her, she said:

"After we encountered the [first] bumps, it got smooth. Normally the crews do not advise us when we are over the turbulence."

All three crewmembers were asked if there was any specific guidance in the company's flight operations manual about seating cabin crewmembers in anticipation of turbulence. None of the three was aware of any. When the captain was asked if he told the flight attendant how long to stay seated, he stated:

"Not that I recall. I thought she would stay seated until I told her otherwise."

A review of information from the flight data recorder (FDR) revealed that the airplane encountered an area of turbulence, about 1547. The turbulence lasted approximately 3 minutes and varied in magnitude from a positive 1.25g to a negative .25g.

The airplane resumed relatively smooth flight for about 4 minutes. At that point, there was a vertical acceleration to over 3g's. There was also roll divergence of about 20 degrees both left and right.

As a result of the investigation, and after coordination with the senior manager of flight safety for Continental Express, the airline published a Cabin Information Letter for cabin crews, and a Flight Information Letter for flight crews with the following guidance regarding turbulence:

Flight Crew:

· Ensure the Seatbelt sign is ON

· Slow the aircraft to turbulence penetration speed

· If required, Notify the FA to be seated and remain seated until further advised by the PIC

· Make a PA (public address) as appropriate

· Advise the FA when normal duties may be resumed

Flight Attendants:

· Remain seated until further advised by the PIC

· Make a PA as appropriate to passengers (if Flight crew has not)

· Resume normal duties when advised by the PIC only

Aircraft

Registration
N25504
Reported as
Embraer ERJ-135ER
Category
Airplane
Serial number
145-186
Airframe hours
4,225
Engines
oravia AE3001A1/3, 7,057 lbs thrust, turbo fanoravia AE3001A1/3, 7,057 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
Continental Express Inc
Airworthiness certificate
Standard, Transport
Departed
CLE · Cleveland, OH
Destination
RIC · Richmond, VA
Flight plan
IFR
Airport
RIC · Richmond International

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
30
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
April 8, 2001
Seat
Left
Flight hours
5,319 total · 3,086 in this make and model
Role
Co-pilot
Age
37
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
July 22, 2001
Seat
Right
Flight hours
1,900 total

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 13 knots
Visibility
8 statute miles
Lowest ceiling
25,000 ft broken
Temperature
86 °F, dew point 73 °F
Altimeter
29.96 inHg
Observed at
RIC, 24 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.