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Aviation safety reports, made easier to study

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NTSB Report

October 17, 1995 · Boeing 747-422 · N191UA

Pacific Ocean, PO

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
October 17, 1995
Injury Outcomes
6 injuries (1 serious injury, 5 minor injuries), 331 uninjured
Location
Pacific Ocean, PO
Aircraft
Boeing 747-422
Tail Number
N191UA
Injuries
Serious
NTSB Number
LAX96LA013

Six passengers were injured during a severe turbulence encounter over the Pacific Ocean while the aircraft was in cruise at flight level FL330. The accident occurred in international waters near latitude 40 degrees north, longitude 152 degrees east. Review of the forecasts and pilot reports of the dispatch/weather package given to the flight crew prior to departure disclosed that an area of light to moderate turbulence was forecast along the aircraft's planned track from 151 to 162 degrees east longitude. Pilot reports available at the time of departure consistently reported smooth conditions in the area of the forecast turbulence. At the time of the encounter the aircraft was in clear air above a cirrus cloud deck. The crew saw no convective activity ahead either visually or on radar. In the process of preparing for a position report to air traffic control, the flight crew overheard another airline flight ahead of them reporting an encounter with moderate to severe turbulence. The captain decided to secure the cabin as a precaution. The purser was notified of the decision and the captain was in the process of reaching for the seat belt sign when the turbulence was encountered. All of the injured passengers were located aft of row 50, with the majority aft of row 58. None of the injured were secured by seat belts.

NTSB Probable Cause

an inadvertent encounter with unreported and unforecasted severe turbulence. A factor in the accident was the passengers' non-use of seat belts during cruise flight.

Full Narrative

On October 17, 1995, at 0944 UTC (1944 local meridian time), six passengers were injured onboard United Airlines Flight 806, during a severe turbulence encounter over the Pacific Ocean. The aircraft, a Boeing 747-422, N191UA, was operated by United Airlines, Inc., as a regularly scheduled non-stop international passenger flight from Hong Kong to San Francisco. The accident occurred in international waters near latitude 40 degrees north, longitude 152 degrees east, while the aircraft was in cruise at flight level FL330. The aircraft was not damaged. One passenger sustained serious injuries and five additional passengers incurred minor injuries. The remainder of the 309 passengers, 18 cabin attendants, and flight deck crew of four were not injured. The flight originated from Hong Kong at 0516 UTC. Copies of the original dispatch package given to the flight crew prior to departure was obtained and examined. Weather data and forecasts given to the crew were included as part of the package. Examination of the forecasts and pilot reports disclosed that an area of light to moderate turbulence was forecast along the aircraft's planned track from 151 to 162 degrees east longitude. Pilot reports available at the time of departure consistently reported smooth conditions in the area of the forecast turbulence. According to flight and cabin crew statements, the aircraft was in level cruise flight at FL330 in clear air above a cirrus cloud deck. The crew saw no convective activity ahead either visually or on radar. In the process of preparing for a position report to air traffic control, the flight crew overheard a Delta Airlines flight, which was ahead of them on their assigned track at FL350, reporting an encounter with moderate to severe turbulence. The captain decided to secure the cabin as a precaution. The purser was notified of the decision and the captain was in the process of reaching for the seat belt sign when the turbulence was encountered. The crew described the encounter as "one sudden heavy jolt," accompanied by airspeed and altitude excursions of plus and minus 20 knots and 200 feet from the respective cruise target values. Moderate turbulence then continued for about 20 minutes thereafter. All of the injured passengers were located aft of row 50, with the majority aft of row 58. None of the injured were secured by seat belts. The 62-year-old female passenger who was seriously injured was in the 5R lavatory at the rear of the aircraft at the time of the encounter. Her injuries consisted of compression fractures of several lumbar vertebrae. A table is appended to this report which denotes the exact location and activities of the injured passengers at the time of the encounter.

Flight

Event TypeAccident
Nearest Airport0nm
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBoeing 747-422
Tail NumberN191UA
Aircraft CategoryAir
Operating RulePart 121
Engines4
Engine TypeTurbofan
Engine DetailsP&W · PW4056 · Turbofan · 56000
Seats441

People & Injuries

Injury Summary6 injuries (1 serious injury, 5 minor injuries), 331 uninjured
Fatal0
Serious1
Minor5
Uninjured331
Total337
Crew 1Age 58 · First Class

Conditions

ConditionsVMC
LightDark Night
Wind260°
Visibility100 sm
CeilingNone
Temperature / Dew Point-47 / 0 C
Altimeter29.00 inHg
Weather SourcePILO

Appendix: Source Data