ANA B788 near Beijing on Aug 15th 2019, turbulence injures 4 people

Last Update: March 2, 2021 / 18:27:44 GMT/Zulu time

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Photo of ANA All Nippon Airways JA808A, Boeing 787-8 Dreamliner — ANA All Nippon Airways JA808A, Boeing 787-8 Dreamliner (Photo credit: lkarasawa / Flickr / License: CC by)

Incident Facts

Date of incident
Aug 15, 2019

Classification
Accident

Airline
ANA All Nippon Airways

Flight number
NH-963

Departure
Tokyo Haneda, Japan

Destination
Beijing, China

Aircraft Registration
JA808A

Aircraft Type
Boeing 787-8 Dreamliner

ICAO Type Designator
B788

An ANA All Nippon Airways Boeing 787-8, registration JA808A performing flight NH-963 from Tokyo Haneda (Japan) to Beijing (China) with 214 passengers and 11 crew, was descending through about 5500 meters (FL180) towards Beijing when the crew illuminated the fasten seat belt signs. Shortly afterwards the aircraft encountered turbulence causing injuries to four people on board. The aircraft continued for a safe landing on Beijing's runway 01 about 30 minutes later. The injured were taken to hospitals. It became known a lady (60) was diagnosed with the fracture of her right instep.

Japan's Ministry of Transport reported, the aircraft was descending through 5500 meters about 140km (76nm) northeast of Beijing on Aug 15th 2019 when the aircraft was shaken. Two passengers and two flight attendants received serious injuries.

The airline reported the aircraft was descending through about 5500 meters when the crew illuminated the fasten seat belt sign, the aircraft shortly afterwards jolted causing injuries to 4 people on board.

On Mar 2nd 2021 the JTSB released their final report concluding the probable cause of the accident was:

It is probable that this accident occurred because the aircraft shook violently when flying near the cumulus cloud top, causing two passengers who were not in their seats sustained serious injuries.

The JTSB reported the captain (54, ATPL, 15,432 hours total, 4,523 hours on type) was pilot flying, the first officer (34, CPL, 4,331 hours total, 77 hours on type) was pilot monitoring.

The JTSB described the sequence of events:

While the aircraft was cruising over the Inner Mongolia Autonomous Region of China, the PIC and the FO confirmed with airborne weather radar and visual observation that there were locally developed cumulonimbus and strong echo en route from DABMA to SABEM. The PIC decided to set the heading to 230° around UPNAT after obtaining a clearance from the air traffic control (ATC) and fly avoiding the cumulonimbus to the south side.

After changing its heading, the aircraft was flying in thin clouds spreading to the south of the cumulonimbus, but the airborne weather radar did not display any cloud echo on the course and there was no disturbance, therefore, the PIC flew the aircraft with the fasten seat belt sigh turned off. After that, at 20:18:20, the aircraft started descending after receiving an instruction from the ATC to descend to 3,600 m. At 20:20:59, the aircraft made a right turn while continuing to descend because of having received from the ATC an instruction to change the heading to the right to go straight to GITUM and pass it at an altitude of 3,600 m in order to avoid flight restriction area. When the Aircraft moved beneath the clouds during descent, the airborne weather radar did not display any cloud echo, but cumulus clouds were gathering down below, therefore, the PIC informed the senior cabin crew member in the cockpit that the fasten seat belt sign would be turned on as shaking would be expected. After the senior cabin crew member left the cockpit, the PIC stopped temporarily descending and maintained level flight at an altitude of about 5,500 m between cloud layers in order to fly away from the cumulus clouds gathering down below. However, judging that it would not be able to avoid the towering cloud top, the PIC turned on the fasten seat belt sign at 20:23:33. The aircraft instantaneously shook violently when closely skimming the cumulus cloud top at 20:23:58.

The fasten seat belt sign was turned on in the same time as the senior cabin crew member returned to the forward galley from the cockpit, and very soon the aircraft encountered intense turbulence. For this reason, the senior cabin crew member could neither inform other cabin crew members that the PIC told the fasten seat belt sign would be turned on as shaking was expected, nor make a PA announcement to alert the passengers. In addition, when the Aircraft encountered the turbulence, eight cabin crew members out of nine did not sit down and away from their seats in order to take care of passengers, or take safety actions in accordance with the Company’s operations manual, such as storing and securing articles, and two cabin crew members lost their balance and sustained minor injuries.

When the fasten seat belt sign was turned on, Passenger A, who was in line for the restroom waiting and standing in front of the lavatory (L3), encountered shaking, then, lost the balance, fell to the floor, and injured the right foot. In addition, when the fasten seat belt sign was turned on, the other Passenger B was sitting down in the lavatory (R4) and encountered shaking, and suffered an injury to the loin as the upper body was strongly squeezed longitudinally.

The aircraft continued to fly, and landed at Beijing Capital International Airport at about 20:52.

The JTSB analysed:

(1) Weather

It is highly probable that because the meteorological satellite image displayed that there were vertically developed tall cumulus with low brightness temperature and high cloud top in the vicinity where the aircraft shook, these clouds were associated with vigorous convective activity. It is probable that strong disturbance relating to the convective activity occurred near the cloud top of the cumulus where the aircraft closely skimmed.

(2) The shaking of the aircraft

According to the EAFR records, the vertical acceleration was greatly fluctuated between +2.16 G and +0.37 G instantaneously for about two seconds from 20:23:58, and it is probable that at this time, the aircraft skimmed the cumulus cloud top and shook violently due to strong disturbance. It is highly probable that because of this shaking, two passengers and two cabin crew members were injured.

(3) Turning on the fasten seat belt sign

The aircraft changed its heading to fly avoiding the cumulonimbus; however, it is probable that because unexpectedly the aircraft received an instruction from the ATC to change the heading in order to avoid flight restriction area, it was not able to fly far enough away from the significant weather area. For this reason, the PIC turned on the fasten seat belt sign without being able to give the cabin crew members and passengers ample notice about the expected shaking.

It is probable that in case of making requests to the ATC to coordinate significant weather avoidance route, pilots should confirm whether it is flyable route by providing the ATC with information as much detail as possible, such as the heading, the deviation from the planned route (distance to offset) and the expected distance to proceed after the deviation required to avoid the significant weather area, which is useful to judge pre-emptively the timing or the necessity of whether to turn on the fasten seat belt sign and provide safety information to people in the cabin.

Metars:
COR ZBAA 151500Z 02005MPS 350V060 9999 TS FEW040CB 21/18 Q0997 BECMG TL1540 NSW=
ZBAA 151430Z 02004G10MPS 340V040 9999 -TSRA SCT033CB SCT040 24/18 Q0998 NOSIG=
ZBAA 151400Z 29007G13MPS 9999 FEW033CB BKN040 27/16 Q0998 BECMG AT1430 TS=
ZBAA 151330Z 35005MPS 9999 FEW050CB 25/20 Q0996 NOSIG=
ZBAA 151300Z VRB01MPS 9999 FEW050CB 27/21 Q0994 BECMG AT1430 33009G15MPS TS=
ZBAA 151230Z 36002MPS 9999 FEW050CB 27/22 Q0994 NOSIG=
ZBAA 151200Z 36003MPS 330V030 9999 FEW050CB 27/22 Q0994 NOSIG=
ZBAA 151130Z VRB01MPS 9999 FEW050TCU 27/22 Q0994 NOSIG=
ZBAA 151100Z 18003MPS 130V250 CAVOK 30/21 Q0994 RETS NOSIG=
ZBAA 151030Z 21004G10MPS 180V250 9999 TS FEW040CB 31/21 Q0994 NOSIG=
ZBAA 151000Z 18004MPS 150V230 9999 FEW050CB 31/21 Q0994 BECMG AT1040 29005MPS TS=
ZBAA 150930Z 17004MPS 130V210 CAVOK 31/22 Q0995 NOSIG=
ZBAA 150900Z 14004MPS CAVOK 31/21 Q0994 NOSIG=
ZBAA 150830Z 15004MPS 110V170 CAVOK 32/22 Q0994 NOSIG=
ZBAA 150800Z 14004MPS CAVOK 32/21 Q0995 NOSIG=