LAX99LA212

NTSB accident investigation · Boeing 747-422 · Pacific Ocean (Pacific Ocean) · June 9, 1999

Accident · Serious injuriesLimited investigationFinal report
Date
June 9, 1999
Place
Pacific Ocean (Pacific Ocean)
Injuries
1 serious, 325 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N198UABoeing 747-422
Weather
Visual (VMC) · Day
Status
Completed · report November 22, 2000
Report
Approved by Office Director
FAA report
19990609041989A
Case key
46501

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

intentional tampering/altering of a galley lift interlock microswitch by unknown persons.

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.

Miscellaneous/otherCruise - normal
Misc eqpt/furnishings,galley/personnel lift - fouledCause
Equipment,other - improper use ofUnknownCause

Analysis

While en route from Singapore to Narita, Japan, a flight attendant proceeded to transfer a serving cart from the main deck to the upper deck. As the flight attendant pushed the cart into the lift, the lift began to move. The lift continued to raise, catching the edge of the cart and lifting it off the ground, trapping the flight attendant between the other end of the cart and the galley counter opposite the lift. As the cart was raised off the floor, the flight attendant was lifted off her feet and her body was pushed on top of the galley counter. The cart continued to rise, pinning the flight attendant's face between the cart and the bins above the galley counter. An inspection of the galley lift after landing revealed a piece of cardboard had been inserted into the interlock safety switch, disabling it, and by doing so, the galley lift can be operated without closing the galley lift door. This condition is known to have been caused, in other incidents, by food service personnel to expedite loading of food service aboard the aircraft.

Factual narrative

On June 9, 1999, about 0245 hours coordinated universal time, a Boeing 747-422, N198UA, operating as United Airlines Flight 890, experienced a serious cabin attendant injury while en route from Singapore to Narita, Japan. The flight over international waters had departed Singapore at 2341 on June 8, 1999, destined for Narita. The flight was operated by United Airlines, Inc., of Chicago, Illinois, as a scheduled international passenger flight under 14 CFR Part 121 of the Federal Aviation Regulations. Neither the airline transport pilot captain and first officer, the remaining 17 cabin attendants or 306 passengers were injured.

At 0245, the captain contacted dispatch and reported a diversion to Hong Kong due to an accident in the galley involving a flight attendant. According to a United Airlines report, the flight attendant was injured in the main deck galley while using the lift to move carts to the upper deck.

The flight attendant was in the process of placing a cart in the lift when it began to move, having been called from the upper deck. The upward movement of the lift caused the cart to roll out of the lift, striking and pinning the flight attendant against the galley wall. The lift continued to raise, catching the edge of the cart, and lifting it off the floor, trapping the flight attendant between the other end of the cart and the galley counter opposite the lift. As the cart was raised off the floor, the flight attendant was lifted off her feet and her body was pushed on top of the galley counter. The cart continued to rise, pinning the flight attendant's face between the cart and the bins above the galley counter.

An inspection of the galley lift at Hong Kong revealed a piece of cardboard had been inserted into the interlock safety switch, disabling it, and by doing so, the galley lift can be operated without closing the galley lift door.

As a result of other similar upper deck cart accidents/incidents Boeing has issued a Service Bulletin 747-25-3187 to modify the control panel to allow only the person working on the cart lift to send it.

Aircraft

Registration
N198UA
Reported as
Boeing 747-422
Category
Airplane
Serial number
28716
Airframe hours
8,439
Engine
P&W P&W4056, 56,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
United Airlines
Registered owner
United Airlines Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · August 17, 1998 · 4,002 hours before
Departed
SIN · Singapore, OF
Destination
NRT · Narita, OF
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
Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
19,127 total · 603 in this make and model

Weather

Conditions
Visual (VMC) · Day

FAA reports on this event · 1

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