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Cases › WPR12LA053 · Part 121 airline

BOEING 737-7H4SOUTHWEST AIRLINES CO

Oakland, CA, USA · 2011-12-02·N261WN

0
fatal
1
serious
Serious injury
highest injury
—
damage

What happened

NTSB summary, verbatim

The flight was transitioning through an area of known severe turbulence. One of the flight attendants reported that the flight crew asked the cabin crew to secure the cabin early as they expected to encounter turbulence during the descent. Shortly thereafter, the airplane encountered severe turbulence and the flight attendants were thrown about the galley; one sustained a serious injury. The cockpit voice recorder contained audio that was not relevant to the flight (it was likely recorded over by subsequent events), thus it could not be conclusively determined when the flight crew asked the flight attendants to be seated because they could not recall. It is likely that the flight crew’s request for the cabin to be secured was close to the time of the turbulence encounter, since none of the flight attendants had completed securing the service items when the encounter occurred. Synoptic conditions were favorable for mountain wave activity and a significant meteorological information (SIGMET) advisory and airmen’s meteorological information advisories had been issued for turbulence over the region. The flight crew also had an advisory issued from their enhanced weather information systems for severe turbulence. The event occurred in the region that the SIGMET and the advisory for severe turbulence had been issued. According to the filed flight plan, the flight was to descend before entering the advisory area for weather avoidance; however, the planned descent was not followed.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
N261WN - Boeing 737-7H4 - Southwest Airlines (36384312781)
Colin Brown from St Ann, MO, USA · CC BY 2.0 · Wikimedia Commons

Probable cause

the Board's determination
The flight crew’s flight into known severe turbulence associated with mountain wave activity.

Occurrence sequence

1 stepsNTSB coding · CICTT taxonomy
  1. 1 · Enroute
    Turbulence encounter
    defining event

Findings

2 causal · 0 contributing
  • CAUSE
    Environmental issues › Conditions/weather/phenomena › Turbulence › Clear air turbulence — Effect on personnel
  • CAUSE
    Personnel issues › Action/decision › Action — Pilot

Sequence of events

4 timed eventsfrom the FDR factual report · claude-sonnet-5
  1. 1931cruisep.2
    the aircraft was in level flight at 40,000 feet and was experiencing vertical accelerations of about +/- 0.1g
  2. 1943:05descentp.2
    the aircraft descended to 30,000 feet
  3. 1953:21cruisep.2
    aircraft level at 30,000 feet, began experiencing vertical accelerations for about 13 seconds
  4. 1953cruisep.1
    flight 1489 encountered turbulence at flight level 30,000 feet (FL300), over Yosemite National Park

NTSB analysis

from the final report

The flight was transitioning through an area of known severe turbulence. One of the flight attendants reported that the flight crew asked the cabin crew to secure the cabin early as they expected to encounter turbulence during the descent. Shortly thereafter, the airplane encountered severe turbulence and the flight attendants were thrown about the galley; one sustained a serious injury. The cockpit voice recorder contained audio that was not relevant to the flight (it was likely recorded over by subsequent events), thus it could not be conclusively determined when the flight crew asked the flight attendants to be seated because they could not recall. It is likely that the flight crew’s request for the cabin to be secured was close to the time of the turbulence encounter, since none of the flight attendants had completed securing the service items when the encounter occurred. Synoptic conditions were favorable for mountain wave activity and a significant meteorological information (SIGMET) advisory and airmen’s meteorological information advisories had been issued for turbulence over the region. The flight crew also had an advisory issued from their enhanced weather information systems for severe turbulence. The event occurred in the region that the SIGMET and the advisory for severe turbulence had been issued. According to the filed flight plan, the flight was to descend before entering the advisory area for weather avoidance; however, the planned descent was not followed.