LAX96LA013

NTSB accident investigation · Boeing 747-422 · Pacific Ocean (Pacific Ocean) · October 17, 1995

Accident · Serious injuriesLimited investigationFinal report
Date
October 17, 1995
Place
Pacific Ocean (Pacific Ocean)
Injuries
1 serious, 5 minor, 331 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N191UABoeing 747-422
Weather
Visual (VMC) · Night/dark
Status
Completed · report September 9, 1996
Report
Approved by Office Director
FAA report
19951017047939A
Case key
29311

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

an inadvertent encounter with unreported and unforecasted severe turbulence. A factor in the accident was the passengers' non-use of seat belts during cruise flight.

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 forecast - inaccurate
Weather condition - turbulence,clear airCause
Seat belt - not usedPassengerFactor

Analysis

Six passengers were injured during a severe turbulence encounter over the Pacific Ocean while the aircraft was in cruise at flight level FL330. The accident occurred in international waters near latitude 40 degrees north, longitude 152 degrees east. Review of the forecasts and pilot reports of the dispatch/weather package given to the flight crew prior to departure disclosed that an area of light to moderate turbulence was forecast along the aircraft's planned track from 151 to 162 degrees east longitude. Pilot reports available at the time of departure consistently reported smooth conditions in the area of the forecast turbulence. At the time of the encounter the aircraft was in clear air above a cirrus cloud deck. The crew saw no convective activity ahead either visually or on radar. In the process of preparing for a position report to air traffic control, the flight crew overheard another airline flight ahead of them reporting an encounter with moderate to severe turbulence. The captain decided to secure the cabin as a precaution. The purser was notified of the decision and the captain was in the process of reaching for the seat belt sign when the turbulence was encountered. All of the injured passengers were located aft of row 50, with the majority aft of row 58. None of the injured were secured by seat belts.

Factual narrative

On October 17, 1995, at 0944 UTC (1944 local meridian time), six passengers were injured onboard United Airlines Flight 806, during a severe turbulence encounter over the Pacific Ocean. The aircraft, a Boeing 747-422, N191UA, was operated by United Airlines, Inc., as a regularly scheduled non-stop international passenger flight from Hong Kong to San Francisco. The accident occurred in international waters near latitude 40 degrees north, longitude 152 degrees east, while the aircraft was in cruise at flight level FL330. The aircraft was not damaged. One passenger sustained serious injuries and five additional passengers incurred minor injuries. The remainder of the 309 passengers, 18 cabin attendants, and flight deck crew of four were not injured. The flight originated from Hong Kong at 0516 UTC.

Copies of the original dispatch package given to the flight crew prior to departure was obtained and examined. Weather data and forecasts given to the crew were included as part of the package. Examination of the forecasts and pilot reports disclosed that an area of light to moderate turbulence was forecast along the aircraft's planned track from 151 to 162 degrees east longitude. Pilot reports available at the time of departure consistently reported smooth conditions in the area of the forecast turbulence.

According to flight and cabin crew statements, the aircraft was in level cruise flight at FL330 in clear air above a cirrus cloud deck. The crew saw no convective activity ahead either visually or on radar. In the process of preparing for a position report to air traffic control, the flight crew overheard a Delta Airlines flight, which was ahead of them on their assigned track at FL350, reporting an encounter with moderate to severe turbulence. The captain decided to secure the cabin as a precaution. The purser was notified of the decision and the captain was in the process of reaching for the seat belt sign when the turbulence was encountered.

The crew described the encounter as "one sudden heavy jolt," accompanied by airspeed and altitude excursions of plus and minus 20 knots and 200 feet from the respective cruise target values. Moderate turbulence then continued for about 20 minutes thereafter.

All of the injured passengers were located aft of row 50, with the majority aft of row 58. None of the injured were secured by seat belts. The 62-year-old female passenger who was seriously injured was in the 5R lavatory at the rear of the aircraft at the time of the encounter. Her injuries consisted of compression fractures of several lumbar vertebrae. A table is appended to this report which denotes the exact location and activities of the injured passengers at the time of the encounter.

Aircraft

Registration
N191UA
Reported as
Boeing 747-422
Category
Airplane
Serial number
26880
Airframe hours
11,793
Engine
P&W PW4056, 56,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
United Airlines, Inc.
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · September 10, 1994 · 5,596 hours before
Departed
VHHH · Hong Kong, OF
Destination
KSFO · San Francisco, CA
Flight plan
IFR

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Certificates
Flight engineer, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
7,857 total · 66 in this make and model · 66 in the last 90 days · 66 in the last 30 days

Weather

Conditions
Visual (VMC) · Night/dark
Visibility
100 statute miles
Lowest ceiling
None
Temperature
-47 °F
Altimeter
29.00 inHg

FAA reports on this event · 1

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