Emirates A388 near Salt Lake City on Feb 1st 2020, turbulence injures passenger
Last Update: October 1, 2020 / 19:09:33 GMT/Zulu time
On Oct 1st 2020 the UAE GCAA released their final report concluding the probable cause of the accident was:
The Air Accident Investigation Sector determines that the cause of the Accident was the acceleration forces imposed on the Aircraft as it flew through an area of clear air turbulence, which resulted in an unsecured passenger forcefully impacting cabin furnishings in the lavatory.
Lack of placarded instructions and inaccessibility of the handholds within the lavatory for use in case of turbulence.
The GCAA analysed:
Upon hearing that other Aircraft were reporting to air traffic control (ATC) that there was light turbulence below FL290, the flight crew were aware that the OFP indicated insignificant shear rates of either ‘zero’ or ‘one’ for any turbulence between FL330 and FL350 over the Rocky Mountains, Wyoming. In addition, ATC had not communicated to UAE216 any pilot reports or turbulence beyond FL290. Thus, the flight crew did not believe that there was any threat to the Aircraft as it followed the planned route.
The Investigation concludes that the turbulence encounter was not associated with wake vortices as there was no other aircraft close to the flight level of UAE216. Because there was no active weather system over the ridges of the Absaroka Range, it is possible that the unanticipated clear air turbulence encountered by the Aircraft was related to the formation of mountain waves.
Within a few seconds of the onset of the turbulence, the flight crew reacted appropriately by immediately turning the seatbelt sign ON and directing the cabin crew to be seated. The Operator’s standard operating procedures for a turbulence encounter were followed, including reporting the turbulence to ATC and communicating with the Operator’s medical support team to determine whether to continue the flight to OMDB, taking into consideration the passenger injury.
In case of unanticipated turbulence, for a person occupying a lavatory, except for lavatories specifically equipped for use by people of determination, there was no standardization of handholds in terms of number and orientation. Some lavatories had one handhold and others had two with the handholds oriented either horizontally or vertically. For a person standing and facing the sink, there was no handhold within easy reach in case of turbulence.
Similar to the turbulence occurrence of 19 July 2019 (AIFN/0009/2019), the injury was sustained by a passenger in the aft cabin. Thus, without placarded instructions and sufficient handholds or other means for occupants to secure themselves during unanticipated significant turbulence, injuries will most likely reoccur.
The Investigation could not determine whether the deficiencies related to the lavatory handholds contributed to this Accident as it was not possible to interview the injured passenger.
However, the description by the passenger of being “forced up in the air” during the turbulence indicates that, most likely, the passenger was unable to make use of the single handhold in the lavatory to secure themselves.
Handholds should be located such that in case of unanticipated turbulence, they are easily accessible when the person is seated or standing and when using the lavatory sink. The Investigation believes that the repeated injuries to persons occupying the lavatory may suggest that the placement of the handhold are insufficient and not easily reachable.
The Investigation recommends that the Operator standardize and improve the
accessibility of the lavatory handholds, having regard to optimum ergonomic design requirements, and also include simple placarded instructions on the use of the handholds in case of turbulence.
This article is published under license from Avherald.com. © of text by Avherald.com.
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