Ryanair B738 at Barcelona on Jul 31st 2021, severe turbulence injures cabin crew and passengers
Last Update: June 21, 2022 / 22:25:01 GMT/Zulu time
The Spanish CIAIAC reported one flight attendant as well as one passenger received serious injuries, 3 flight attendants minor injuries, all these were taken to a hospital. In addition a number of passengers required medical assistance at the airport.
The aircraft returned to service about 3:20 hours after landing.
ON Jun 21st 2022 the CIAIAC released their final report concluding the probable cause was:
The investigation has concluded that the probable cause of the accident was the series of actions taken by the PF to prevent the aircraft from exceeding the VMO while it was flying through an area of turbulence. This resulted in vertical acceleration that caused severe injuries to a passenger and two cabin crew members.
The CIAIAC analysed:
Analysis of the meteorological factors related to the accident.
Analysis of the meteorological information supplied to the flight crew
The meteorological forecasts supplied to the flight crew prior to beginning the flight predicted storms in both the Barcelona area and in the vicinity of the airport. Additionally, the operational flight plan between Fez and Barcelona airports indicated wind shear of between 3 and 4 units at the STAR points, which meant it was likely that the aircraft’s descent and approach would take place within an area of turbulence.
The captain concurred with the assessment, and he informed the cabin crew accordingly.
Analysis of the meteorological conditions in the area of the accident
The flight crew were following the MATEX 2E STAR, and had the weather radar connected, when they detected a storm formation in the section between MATEX and BL028 points. In order to avoid entering the storm, they asked ATC to divert them 14º to the left. According to the captain, this gave them a sufficient margin of separation from the cloud. He also stated that they were in VMC and the air was stable.
There had been no reports of turbulence; however, requests for track deviations from aircraft to avoid storm clouds were heard on the frequency.
According to the flight crew, a few moments later the aircraft began to pass through an area of turbulence. The crew’s statement concurs with the data obtained from the QAR, which show significant changes in vertical acceleration as well as variations in outside temperature and wind intensity, direction and speed. From the moment the aircraft entered the area of turbulence to the moment the autopilot was disengaged, the level of turbulence varied from light to moderate, with variations in vertical acceleration that, on occasion, reached 0.7 g within the space of one second. During this same period, the aircraft’s speed underwent fluctuations that reached a maximum of 12 kt within the space of one second, moments before the disengagement of the autopilot.
With regard to the period after the disengagement of the autopilot, it has not been possible to determine the level of turbulence, as the actions applied to the control column contributed to the variations in vertical acceleration that occurred while the autopilot was disengaged. During this period, changes in vertical acceleration reaching 3.2 g were recorded within the space of one second, coinciding with changes to the pitch angle and the level of force exerted on the control column.
During the period after the autopilot was re-engaged, the level of turbulence was light, with variations in vertical acceleration that, on occasion, reached 0.4 g within the space of one second.
Analysis of the coordination between the flight crew and cabin crew regarding the turbulence.
During the pre-flight briefing, the flight crew informed the cabin crew of the likelihood of encountering turbulence during the descent into Barcelona. According to the statements of both the pilots and the cabin crew, the captain also informed the passengers of this likelihood in his passenger announcement.
Once the aircraft had begun to descend, and after deviating in order to avoid entering a storm cloud, the captain called the cabin crew to inform them that they might encounter turbulence during the approach and that they should start to secure the cabin. During this call, the captain did not specify the level of turbulence (light/moderate/severe), nor did he indicate how much time the cabin crew would have to secure the cabin.
At the time of the captain’s call, the estimated remaining flight time was approximately 25 minutes. In other words, he asked the cabin crew to start preparing to secure the cabin earlier than usual (normally the request is made 15 minutes before landing), as he anticipated having to cross an area of cloud - whose associated turbulence might affect the passengers and cabin crew - during the approach. The message did not communicate a sense of urgency with regard to securing the cabin; however, the request to begin preparations was issued early, as a precaution, so that the cabin would be secure for the approach.
Barely two minutes after the captain called to inform the cabin crew of the likelihood of encountering turbulence during the approach, the aircraft entered an area of turbulence that had not been detected by the flight crew. According to the TCP, they were starting to secure the cabin when they were suddenly thrown against various parts of the galley and cabin, and then fell to the floor. From their perspective, it was a sudden encounter with severe turbulence in which they did not have enough time to sit down or even grab onto any elements within the cabin.
Analysis of the actions of the flight crew
Because ATC had delayed the aircraft’s descent, the PF increased the speed selected in the MCP as the aircraft descended, to increase the rate of descent. Subsequently, the flight crew was authorised to proceed to ASTEK, which shortened the route to the touchdown area and kept the aircraft positioned above the descent profile. The tailwind component was 58 kt. The PF extended the speed brakes to continue increasing the rate of descent.
According to the pilots, they had managed to avoid the storm cloud and were under VMC.
Thus, the aircraft entered an area of undetected turbulence with its speed brakes extended and at a CAS of 325 kt.
The PF reduced the speed selected to 308 kt; however, the area of turbulence caused changes in the aircraft’s calibrated speed, which fluctuated between 306 kt and 329 kt.
Some 30 seconds after entering the area of turbulence, the aircraft’s speed suddenly increased from 322 kt to 334 kt. According to the PF, the speed trend vector was showing large oscillations and he saw that the autopilot was not correcting the changes in speed.
The PF disengaged the autopilot and pitched nose up, to reduce speed. During this manoeuvre, vertical acceleration of +3.09 g was reached. One second later, the pilot performed the opposite action, lowering the aircraft’s nose. This resulted in vertical acceleration of -0.18 g, representing a change of 3.2 g within the space of one second.
Although the VMO was not exceeded in this instance, the manufacturer recommends that in the event of unexpected overspeed, the flight crew should keep the autopilot engaged, unless it is clear that the autopilot is not correcting the overspeed event. It also warns that disengaging the autopilot to prevent or reduce the severity of an unexpected overspeed event can result in abrupt changes to the pitch angle.
The PF explained that, in his opinion, the turbulence had become severe. Under such conditions, the manufacturer recommends reducing speed to 280 kt. The aircraft reached speeds near to 280 kt during the period in which the autopilot was disengaged.
After carrying out an internal safety investigation into the accident, the operator reinforced the flight crew’s training on the subject of turbulence and overspeed. Additionally, among other measures, it proposed to publish the lessons learnt from this event in its operational safety publications, and to include the event as a case study in its crew training activities. All of these measures are considered appropriate, and no safety recommendations are proposed.
Aircraft Registration Data
This article is published under license from Avherald.com. © of text by Avherald.com.
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