WPR11LA139

NTSB accident investigation · Boeing 767-300 · Ni'ihau, HI · February 10, 2011

Accident · Serious injuriesLimited investigationFinal report
Date
February 10, 2011, 08:30 local (18:30 UTC)
Place
Ni'ihau, HI
Injuries
1 serious, 6 minor, 243 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
JA603JBoeing 767-300
Defining event
Enroute-descent: Turbulence encounter
Weather
Visual (VMC) · Day
Status
Completed · report March 20, 2012
Report
Approved by Office Director
NTSB office
Western Pacific Region
Lead agency
Other
Parties
Federal Aviation Administration, Japan Transport Safety Board
Case key
78383

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 encounter with unanticipated convectively induced windshear and turbulence during descent.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Turbulence: convective turbulenceEnvironmental issues › Conditions/weather/phenomena · Effect on personnelAll aircraft: 145 casesProbable cause
Wind: windshearEnvironmental issues › Conditions/weather/phenomena · Effect on operationAll aircraft: 90 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Turbulence encounterEnroute-descentAll aircraft: 423 casesDefining event

Analysis

As the airplane descended from about 38,000 feet, the flight crew observed that they had a tailwind of between 60 and 70 knots and that cumulonimbus clouds were ahead of the airplane. Descending through 34,668 feet, the tailwind suddenly decreased and the indicated speed of the airplane quickly increased. The captain activated the speed brakes and disengaged the autopilot. Subsequently, the airplane began to slow. As the captain was slowly retarding the speed brakes, the airplane started to climb and the captain slowly lowered the nose of the airplane. The digital flight data recorder revealed that over a 30-second period the airplane’s vertical acceleration decreased to 0.75 g, then increased to 2.33 g, decreased to 0.05 g, then stabilized at 0.9 g (normal). During the event, one passenger broke her femur; two cabin attendants and four passengers received minor injuries. The airplane was not damaged. Convective activity was located immediately west of where the event occurred, likely blocking the wind flow and causing a wave-like disturbance downstream of the storms, which would result in unanticipated convectively induced turbulence. Since the event occurred in clear air downstream of the cumulonimbus clouds, the airplane likely encountered an undulating turbulence under a strong temperature inversion and strong windshear. The turbulence was not predicted by weather forecasters.

Factual narrative

On February 10, 2011, at 0830 Hawaiian standard time (HST), a Boeing 767-300, Japan registry JA603J, while descending through 34,668 feet mean sea level (msl), experienced a turbulence event 4 miles south of Ni'ihau, Hawaii. Japan Airlines International Co, Ltd., operated the airplane as a commercial passenger flight, JAL074, under the provisions of Title 14 Code of Federal Regulations Part 129. The flight crew was not injured. One passenger was seriously injured; two cabin attendants and four passengers received minor injuries. The airplane was not damaged. Visual meteorological conditions prevailed, and an instrument flight plan had been filed. The flight originated from Narita, Japan. The flight crew reported that after starting the descent from 38,000 feet, they observed the tailwind increase from about 60 knots to about 65-70 knots, along with cumulonimbus clouds located in front of the airplane. As the airplane descended through about 34,668 feet, they observed the tailwind suddenly drop and the airplane’s speed quickly accelerated. The captain pulled the speed brake, disengaged the autopilot, and the airplane gradually began to slow. As the captain slowly retarded the speed brake, the co-pilot stated that the airplane was starting to climb. Subsequently, the captain slowly started to pitch the nose of the airplane down. During the event, one passenger received a broken femur. The passenger was located outside of the aft lavatory when she felt her body sink and she fell onto the floor; she collided with cabin objects throughout the turbulence event. A cabin attendant was located in the aft galley when she felt her body float halfway up to the ceiling and then she fell onto her knees. Her body floated up a second time and she struck her head on the ceiling; subsequently, she fell onto the right side of her body, striking her face and elbow on the floor but was not seriously injured. The Japan Transport Safety Board (JTSB) downloaded the data from the airplane’s digital flight data recorder (DFDR) and provided it to the National Transportation Safety Board’s (NTSB) Vehicle Recorder Laboratory. According to the DFDR data, the event occurred at 18:30.05 UTC (0830 HST); at this time, the airplane was descending through 34,964 feet mean sea level (msl). The vertical acceleration decreased from approximately 1 g to 0.76 g’s in less than 1 second, approximately 6 seconds later at 8:30:11, the vertical acceleration peaked at 2.33 g’s while the pressure altitude leveled at approximately 34,634 feet msl. About 2 seconds later at 8:30:13, the vertical acceleration decreased to 0.05 g’s and approximately 22 seconds later at 8:30:35, the vertical acceleration settled back to approximately 0.9g. A weather synopsis produced by a NTSB meteorologist revealed convective activity approximately 20-40 miles west of where the event occurred. Satellite imagery indicated several high level cirrus cloud bands moving eastward towards where the event occurred. TheLihue sounding revealed a level of maximum wind from 280° at 71 knots at 38,000 feet. At 34,000 feet the wind was estimated from 294° at 49 knots with a temperature of -46° Celsius (C). The event occurred in clear air, downstream of cumulonimbus clouds, within a strong temperature inversion and wind shear. No turbulence was predicted by weather forecasters where the event occurred.

Aircraft

Registration
JA603J
Reported as
Boeing 767-300
Category
Airplane
Serial number
32888
Airframe hours
31,822
Engines
turbo jetGE CF6-80C2B7F, 60,000 lbs thrust, turbo jet
Damage
No damage
Flight
Part 129
Operator
Japan Airlines International
Registered owner
Dia Lavender Ltd, SMBCL Cassiopeia Co., Ltd
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 27, 2011
Departed
NRT · Narita
Destination
HNL · Honolulu, HI
Flight plan
IFR
Airport
PHNL · Honolulu International Airport

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
49
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Flight hours
9,968 total · 8,397 in this make and model · 145 in the last 90 days · 40 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
29
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land, Multi-engine sea
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
1,933 total · 1,634 in this make and model · 172 in the last 90 days · 43 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 5 knots
Visibility
10 statute miles
Lowest ceiling
2,800 ft broken
Temperature
72 °F, dew point 70 °F
Altimeter
29.95 inHg
Observed at
PHLI, 32 nm away

Docket · 12

The files NTSB released with the investigation on February 1, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.8 MB in all.