Pilot Debrief

BOEING 737-7H4 near Oakland, CA — 2011-12-02

Final reportWPR12LA053
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Date
2011-12-02
Location
Oakland, CA, USA
Airport
OAK
Aircraft
BOEING 737-7H4
Registration
N261WN
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Descent

Probable cause

The flight crew’s flight into known severe turbulence associated with mountain wave activity.

NTSB narrative

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.

Analysis

Primary failure mode
Human factors
First missed decision gate
Flight attendants should have been seated earlier due to expected turbulence.

NTSB coding

Evidence available

  • CVR
  • FDR / data
  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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