# NTSB SEA08LA050: Mcdonnell Douglas DC-9-83, N943AS, Ontario, CA, December 25, 2007 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 25, 2007, 09:18 local (17:18 UTC) - Place: Ontario, CA - Coordinates: 34.05611, -117.601112 - Nearby events: https://openairdocs.org/map.md?lat=34.0561&lon=-117.6011&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious, 112 uninjured - Status: Completed, report January 14, 2009 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 67295 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA08LA050 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67295/pdf - Page: https://openairdocs.org/ntsb/SEA08LA050 ## Probable cause The lack of turbulence forecasts available to the flight crew, which resulted in the flight attendants not being seated when the flight encountered severe terrain-induced turbulence. Contributing to the accident were the terrain-induced turbulence, the failure of the company that provided the flight's weather briefing to forecast severe turbulence, and the failure of the dispatcher to provide the National Weather Service severe turbulence forecast to the flight. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, descent - weather forecast - inadequate, other institution (contributing factor) - weather condition - turbulence,terrain induced (contributing factor) - in-flight weather advisories - not relayed, dispatcher (contributing factor) - hazardous weather advisory - not available, flightcrew (cause) ## Analysis Two flight attendants were seriously injured when the airplane encountered severe turbulence while descending for landing. The turbulence was likely the result of strong easterly winds interacting with the rough terrain in the area (mechanical turbulence). The flight data recorder data indicates that the airplane experienced a vertical acceleration of +0.4 G to +1.9 G, or 1.5 G total change, which corresponds to severe turbulence. The National Weather Service forecast the severe turbulence in Significant Meteorological Advisory (SIGMET) Victor 2, which was issued before the flight departed. The weather company that provides weather information to the operator did not forecast severe turbulence for the area. The content of SIGMET Victor 2 was available to the flight's dispatcher. However, this information was not provided to the flight crew. The two flight attendants who sustained injuries were both standing, completing final cabin duties in preparation for landing, and were knocked to the floor during the turbulence encounter. ## Factual narrative On December 25, 2007, about 0918 Pacific standard time, a McDonnell Douglas DC-9-83, N943AS, encountered severe turbulence during descent for landing at Ontario International Airport (ONT), Ontario, California. The airplane, which was being operated under 14 Code of Federal Regulations Part 121 by Alaska Airlines as flight 464, was not damaged. Two flight attendants sustained serious injuries. The third flight attendant, the two flight crewmembers and the 109 passengers were not injured. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the regularly scheduled domestic passenger flight. The flight departed from Seattle, Washington, about 0703, and the intended destination was Ontario. Following the turbulence encounter, the airplane landed at ONT without further incident at 0925. According to information provided by Alaska Airlines, the flight was descending on the ONT ZIGGY 4 arrival in the vicinity of ZIGGY intersection at an altitude of 8,300 to 8,500 feet above mean sea level (msl) when it encountered severe turbulence. The two flight attendants who sustained injuries were both standing, completing final cabin duties in preparation for landing, and were knocked to the floor during the turbulence encounter. One of the flight attendants sustained multiple fractures to one ankle, and the other flight attendant suffered a head injury with loss of consciousness and concussion. In a written statement, the captain reported, "there was no turbulence listed in the hazard section of the preflight paperwork, but the Enroute section showed a couple of "5's" for the Tropopause [vertical windshear number] in California." (The vertical windshear numbers in the paperwork ranged from 00 to 06, with higher numbers indicating a greater chance of turbulence.) During a briefing with the first officer and the flight attendants, the captain told them, "the ride didn't look good for the climb, cruise, and descent into ONT." He also discussed the Santa Ana wind conditions expected on arrival at ONT. (Santa Ana winds are dry, warm, downslope winds in the Southern California area that blow in from the desert. They tend to be channeled through passes and canyons, locally increasing their speed.) The captain was the flying pilot. Although he anticipated turbulence, the departure, cruise, and initial descent into ONT were "smooth" and uneventful. At 13,000 feet msl on descent, he "chimed the flight attendants early," indicating they were to prepare the cabin for landing and then be seated. According to the captain, "a violent jolt" occurred with no warning as the airplane was descending through about 8,300 feet msl. In a written statement, the first officer reported that they "encountered previously unreported severe turbulence at approximately 8,500 feet msl." The preflight weather information in the briefing packet provided to the flight crew contained the actual and forecast weather for the departure, destination and alternate destination airports. The ONT Terminal Area Forecast (TAF) included in the document indicated the expected weather conditions for the flight's arrival were winds from 060 at 30 knots with gusts to 45 knots, visibility greater than 6 miles, and clear sky. The weather information provided also included a Pilot Report (PIREP) summary by state; no PIREPs were listed for the state of California. The document noted "no WSI hazardous weather" for the northwest U.S. as of 0600:24 and for the southwest U.S. as of 0600:25. (WSI Corporation provides weather information to Alaska Airlines.) The following National Weather Service (NWS) Significant Meteorological Advisories (SIGMETs) included the Ontario area and were issued before the flight's departure: SIGMET Victor 1 for Occasional Severe Turbulence below 12,000 feet was issued at 0200 and was valid until 0600. The turbulence encounter occurred within the area of this SIGMET. SIGMET Victor 2 for Occasional Severe Turbulence below 12,000 feet was issued at 0600 and was valid until 1000. The turbulence encounter occurred within the area of this SIGMET. These advisories were not included in the briefing packet. In response to written questions, the flight's dispatcher stated that as the airplane was nearing ONT, "a WSI sigmet for MOD TURB [moderate turbulence] was issued for the SOCAL [Southern California] region. This was not unusual, considering the Santa Ana wind conditions reflected in the TAF." He further stated that the "WSI sigmet was transmitted to several aircraft approaching the SOCAL region, but apparently [the accident aircraft] was not one of them." For further weather information, see the Meteorology Factual Report in the public docket for this accident. Review of 14 Code of Federal Regulations section 121.601 revealed that it requires an aircraft dispatcher, before beginning a flight, to provide the pilot in command with all available weather reports and forecasts of weather phenomena that may affect the safety of flight. This includes adverse weather phenomena, such as clear air turbulence, thunderstorms, and low altitude wind shear for each route flown and each airport used during flight. During the flight, the aircraft dispatcher must also provide the pilot in command any additional available information of meteorological conditions, and irregularities of facilities and services that may affect safety of flight. The airplane was equipped with a flight data recorder (FDR), which was sent to the Safety Board's laboratory in Washington, DC, for readout. The FDR data indicates that the airplane experienced a vertical acceleration of +0.4 G to +1.9 G, or 1.5 G total change. The NWS uses the following changes in vertical acceleration to quantify the intensity of turbulence: Less than 0.5 G, light turbulence; 0.5 to 1.0 G, moderate turbulence; 1.0 to 2.0 G, severe turbulence; greater than 2.0 G, extreme turbulence. For further details of the data recorded by the FDR, see the public docket for this accident. ## Aircraft - Registration: [N943AS](https://openairdocs.org/deregistered/N943AS-2008-06-12), registration cancelled 2008-06-12, S/N 53018, built 1990 (OpenAirDocs) - Reported make and model: MCDONNELL DOUGLAS DC-9-83 - Registry model: [Mcdonnell Douglas DC-9-83(MD-83)](https://openairdocs.org/model/mcdonnell-douglas-dc-9-83-md-83) (registry code 3022083) (OpenAirDocs) - Registry engine: [Pratt & Whitney JT8D series](https://openairdocs.org/engine/pratt-whitney-jt8d-series) (registry code 52053, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 53018 - Airframe hours: 55606 - Engines: Pratt & Whitney JT8D 20850 lbs thrust turbo fan; Pratt & Whitney JT8D 20850 lbs thrust turbo fan - Damage: No damage - Flight: Part 121 - Operator: Alaska Airlines, Inc. - Registered owner: Wells Fargo Bank Northwest - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, August 17, 2007 - Departed: SEA, Seattle, WA - Destination: ONT, Ontario, CA - Flight plan: IFR - Airport: ONT, Ontario International ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: none; airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review August 18, 2007; seat: left; flight hours: 7,833 total, 461 in this make and model, 92 in the last 90 days - Co-pilot; age 47; injuries: none; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 11, 2007; seat: right; flight hours: 12,284 total, 9,674 in this make and model, 220 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 50° at 23 knots, gusting 37 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point -4 °F - Altimeter: 30.15 inHg - Observed at: ONT ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20071225830739A](https://openairdocs.org/incident/20071225830739A), Dec 25, 2007: Doug MD83, Ontario, CA, Minor damage. (-23) Alaska flight asa 464 encountered moderate/severe turbulence during descent to Ontario, CA. Turbulence was encountered at 8,300 feet and resulted in… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.