ERA09LA488

The flight crew's encounter with convective turbulence. Contributing to the accident was the failure of the operator's dispatch department to provide the flightcrew with current adverse weather information along the planned route of flight. Also contributing was the failure of the flightcrew to provide relevant forecast information to the cabin crew, and their failure to detect and avoid the existing convective conditions.

The scheduled passenger flight was climbing through 25,000 feet when it encountered convective turbulence in daytime instrument meteorological conditions. A flight attendant, who was servicing the aft cabin, sustained leg and ankle fractures when her service cart became airborne and struck her in the leg. Both the flight and cabin crew members stated that the turbulence was unexpected. The National Weather Service (NWS) had issued multiple, sequential warnings of significant meteorological activity (SIGMETs) regarding the potential for thunderstorms and turbulence along the flight's planned route. The operator's dispatch department provided the flightcrew with a SIGMET that was valid until about one hour before the scheduled departure time. Contrary to operator and regulatory requirements, the dispatch department did not provide the flight crew with updated, current information, which included two new SIGMETs, one of which was issued an hour before the scheduled departure time, and all of which were similar in content and coverage area. The flight crew did not check with dispatch to determine whether any SIGMETS were current for the planned departure time. None of the air traffic controllers who handled the flight prior to the event relayed any hazardous weather information to the flight, despite their requirement to do so. Correlation of meteorological and flight path data indicated that the turbulence encounter occurred when the airplane penetrated a continuous line of thunderstorms that was present in the SIGMET coverage area. Strong radar echoes, indicative of potential turbulence, were detected below the airplane's altitude by ground-based weather radar. Review of the operator's flight and cabin crew guidance revealed that the procedures incorporated some of the latest industry strategies for mitigating turbulence hazards, but did not provide the flight attendants with the recommended level of autonomy when it came to decisions about when to provide service, or how to prioritize tasks, in the event of turbulence. Although hindered by the failure of the dispatch department to provide them with current SIGMETs, given the previous SIGMET and forecast for significant thunderstorms along the route, and atmospheric activity that was likely readily detectable by the airplane's onboard weather radar, the flightcrew could have anticipated the turbulence, and the flight attendants could have either been instructed to remain seated, or been provided with sufficient information to decide on their own, until the airplane was clear of the hazard area.

HISTORY OF FLIGHT On August 27, 2009, about 1603 eastern daylight time (EDT), a Boeing 717-200, N994AT, operated by Airtran Airways as flight 163, encountered convective turbulence while climbing through flight level 250 near Inverness, Florida. One flight attendant sustained serious injuries. The other two flight attendants, the two airline transport pilots, and the 81 passengers were not injured, and the airplane was not damaged. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan had been filed for the flight that departed Tampa International Airport (TPA), Tampa, Florida, destined for Hartsfield-Jackson Atlanta International Airport (ATL), Atlanta, Georgia. The scheduled passenger flight was conducted under Title 14 Code of Federal Regulations (CFR) Part 121. According to the flight crew, after departure, the airplane was assigned a heading of 350 degrees, and was cleared to climb to its cruise altitude. The flight then entered instrument meteorological conditions (IMC), and encountered "very mild light chop." There were "no reports of turbulence from PIREPS or ATC and no cells were displayed on the radar." The seat belt sign was illuminated. After the airplane passed through 10,000 feet, the flight attendants began their cabin service. As the airplane passed through flight level 250, still in IMC, it encountered turbulence for approximately 15 seconds. The non-flying pilot checked the airborne radar, and changed the range settings to see if the airplane had "hit a cell." He saw "nothing" on the radar. The turbulence encounter occurred approximately 60 miles north of TPA. According to the lead flight attendant, the cabin crew consisted of three flight attendants, designated as Lead, R1, and L2. The lead attendant was working business class at the front of the cabin, and the R1 and L2 attendants were working the service cart in the aisle at the rear of the airplane. The R1 attendant was forward of the cart, and the L2 attendant was aft of the cart. At the time of the turbulence encounter, the lead attendant was in the galley, and he "came off the floor about a foot." He reported that the turbulence lasted about 15 to 20 seconds, that coffee was "splashing out of the pots," and that beverage cans were turning over. According to the operator's incident report, during the turbulence encounter the L2 flight attendant and the service cart "came off the floor," and the cart struck the flight attendant's leg. The turbulence subsided, and the L2 flight attendant was observed to be lying on the floor, and complaining of "intense pain" in her right leg. The flight attendant's leg was immobilized and a passenger who was a nurse helped her to an unused row of seats. The flight crew was notified of the injury, and informed that the injured attendant could not perform her duties. The flight crew and the dispatch department arranged for medical personnel to meet the flight in ATL. Cabin service was discontinued, and the R1 flight attendant occupied the L2 station at the tailcone door for the landing. The injuries were subsequently diagnosed as a fractured tibia and a crushed ankle. PERSONNEL INFORMATION Captain According to records provided by the operator, the captain held an airline transport pilot certificate with multiple ratings including airplane multi-engine land, and a type rating for the Boeing 717. His most recent Federal Aviation Administration (FAA) first-class medical certificate was issued May 2009. The captain reported 18,700 total hours of flight experience, including 5,000 hours in the accident airplane make and model. The captain's length of employment with the operator was not determined. First Officer The first officer held an airline transport pilot certificate with ratings for airplane multi-engine land, and multiple type ratings. His most recent FAA first-class medical certificate was issued in February, 2009. The first officer reported 10,000 total hours of flight experience, including 3,000 hours in the accident airplane make and model. The first officer's length of employment with the operator was not determined. Cabin Personnel The lead flight attendant was employed by the operator as a flight attendant for nearly 5 years. The L2 (injured) flight attendant was employed by the operator as a flight attendant for 2 1/2 years. The R1 flight attendant's length of employment with the operator was not determined. AIRCRAFT INFORMATION The airplane was a variant of the Douglas Aircraft DC-9, and was manufactured in 2002. It was powered by two Rolls-Royce BR 715 series turbofan engines, and at the time of the turbulence encounter, the airplane gross weight was approximately 99,000 pounds. According to the operator, the airplane was configured for 2 flight crew, 4 cabin crew, and 117 passengers. METEOROLOGICAL INFORMATION General Forecast Detailed meteorological information regarding the flight conditions was documented in a separate report by a National Transportation Safety Board (NTSB) meteorologist. That and other information is summarized briefly in this section. The National Weather Service (NWS) data issued at 0800 depicted conditions which supported widespread upward vertical motion over the region of the flight track. The 1230 NWS Convective Outlook indicated that only general airmass-type convective activity was expected, and did not forecast any organized severe weather for the region. The 1345 area forecast for northern Florida called for scattered clouds at 1,500 and 4,500 feet, broken cloud layer at 12,000 feet, with tops to 17,000 feet, broken cirrus clouds above, with scattered thunderstorms and light rain. Cumulonimbus cloud tops were forecast to reach 45,000 feet. The same forecast stated that after 2000, scattered clouds at 2,000 feet, a broken cloud layer at 12,000 feet, with widely scattered thunderstorms and light rain, were expected. NWS information issued at 1400 depicted conditions in the immediate vicinity of the turbulence encounter that provided additional support for the generation of convective activity, including moderate to strong multicellular-type thunderstorms in lines and clusters. AIRMETs and SIGMETs The NWS website stated that "AIRMETs (AIRman's METeorological information) are issued by the Aviation Weather Center to advise of weather potentially hazardous to all aircraft but that does not meet SIGMET criteria." The NWS stated that "moderate turbulence" was one of the conditions that would result in the issuance of an AIRMET, and that "AIRMETS are also amended as necessary due to changing weather conditions or issuance/cancellation of a SIGMET." AIRMETs are routinely issued for 6-hour periods beginning at 2245 EDT. The NWS website stated that a "SIGMET (SIGnificant METeorological information) advises of weather potentially hazardous to all aircraft other than convective activity," and are issued for several reasons, including "severe or extreme turbulence." SIGMETs are typically issued for 4-hour periods. According to the NWS, "if conditions persist beyond the forecast period, the SIGMET is updated and reissued." Convective SIGMETs are issued for "severe surface weather," including "embedded thunderstorms, lines of thunderstorms, and thunderstorms greater than or equal to video integrator and processor (VIP) intensity level 4 affecting 40% or more of an area at least 3000 square miles." The NWS stated that "any convective SIGMET implies severe or greater turbulence," that they are issued hourly at 55 minutes past each hour, and are valid for up to 2 hours. Between 1255 and 1555, the NWS issued three convective SIGMETs that overlaid the planned flight track in the vicinity of the turbulence encounter, and which forecast embedded thunderstorms, with tops above flight level 450, moving approximately south to north. At 1255, the NWS issued convective SIGMET 37E. That convective SIGMET was vali