LAX99LA050

NTSB accident investigation · Boeing 737-300 · Sacramento, CA · December 14, 1998

Accident · Serious injuriesLimited investigationFinal report
Date
December 13, 1998, 18:40 local (Dec 14, 1998, 02:40 UTC)
Place
Sacramento, CA
Injuries
1 serious, 74 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N328AWBoeing 737-300
Weather
Visual (VMC) · Night/dark
Status
Completed · report June 21, 2000
Report
Approved by Office Director
FAA report
19981213041989A
Case key
45466

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 failure of the second and third flight attendants to comply with instructions to remain seated in anticipation 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
Weather condition - turbulence
Miscellaneous/otherDescent
Procedures/directives - not followedOther crewmemberCause

Analysis

Prior to descent from cruise, the cockpit crew advised the second flight attendant, who was later injured, and the third flight attendant by intercom that turbulence was anticipated during descent for landing and for them to secure the cabin and be seated. The second attendant notified the first attendant who directed her attention toward securing first class. The second flight attendant proceeded through the cabin from front to rear, with a trash bag, picking up service items and ensuring that passenger's seat belts were fastened. As she reached the rear of the cabin, turbulence was encountered and both she and the third flight attendant, who was working in the rear galley, took their seats and fastened their seat belts. After 1 or 2 minutes of moderate turbulence, the turbulence ceased and the second and third flight attendants got up to finish their work in the aft galley. Additional turbulence was then encountered which caused the second flight attendant to fall to the floor of the galley. The third flight attendant also fell but landed on the foot of the second attendant, which broke the second attendant's ankle. The fight data recorder output showed that, at one point in the descent, vertical acceleration values varied from 0.65 g's to 2.02 g's over a 1-second period.

Factual narrative

On December 13, 1998, at 1840 hours Pacific standard time, a Boeing 737-300, N328AW, encountered turbulence during descent for landing at Sacramento, California. One flight attendant was seriously injured. The other 4 crewmembers and 70 passengers were not injured, and the aircraft was not damaged. Visual meteorological conditions prevailed for the regularly scheduled domestic passenger flight. The flight was operated on an instrument flight rules flight plan under 14 CFR Part 121 by America West Airlines as flight 378. The flight departed Santa Ana, California at 1750.

According to statements provided by America West Airlines, prior to descent from cruise, the cockpit crew advised the second flight attendant, who was later injured, and the third flight attendant by intercom that turbulence was anticipated during descent for landing and for them to secure the cabin and be seated. The second attendant notified the first attendant who directed her attention toward securing first class. The second flight attendant proceeded through the cabin from front to rear, with a trash bag, picking up service items and ensuring that passenger's seat belts were fastened. As she reached the rear of the cabin, turbulence was encountered and both she and the third flight attendant, who was working in the rear galley, took seats and fastened their seatbelts. After 1 or 2 minutes of moderate turbulence, the turbulence ceased and the second and third flight attendants got up to finish their work in the aft galley. Additional turbulence was then encountered which caused the second flight attendant to fall to the floor of the galley. The third flight attendant also fell but landed on the foot of the second attendant, which broke the second attendant's ankle.

The Safety Board investigator reviewed the aircraft's flight data recorder output. As the aircraft descended from flight level 310 (approximately 31,000 feet) the vertical acceleration values recorded remained between 0.85 and 1.06 g's until descending through flight level 200 (approximately 20,000 feet). Between flight level 200 and 7,500 feet mean sea level (msl) in the descent, vertical acceleration values ranged from a low of 0.53 to a high of 2.02 g's. The peak values occurred 5 seconds from one another while the aircraft was descending through 19,832 feet at time 33:41. The vertical acceleration dropped to 0.65 g's and 1 second later increased to 2.02 g's. In the next 4 seconds, values of 1.23, 1.16, 1.45 and 0.53 g's were recorded. Below 7,500 feet the vertical acceleration values returned to the 0.85 to 1.19 range.

Aircraft

Registration
N328AW
Reported as
Boeing 737-300
Category
Airplane
Serial number
23377
Airframe hours
41,558
Engine
GE CFM56-3B2, 22,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
America West Airlines, Inc.
Registered owner
First Security Bank
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 14, 1998 · 1,098 hours before
Departed
SNA · Santa Ana, CA
Destination
SMF
Flight plan
IFR

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Certificates
Airline transport, Flight engineer, Flight instructor
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
11,000 total · 135 in the last 90 days · 45 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
180° at 8 knots
Visibility
10 statute miles
Lowest ceiling
3,800 ft overcast
Temperature
48 °F, dew point 46 °F
Altimeter
30.00 inHg
Observed at
SMF

FAA reports on this event · 1

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