Japan Transocean B738 near Naha on Oct 3rd 2022, upset injures flight attendant

Last Update: December 8, 2023 / 17:34:04 GMT/Zulu time

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Incident Facts

Date of incident
Oct 3, 2022

Classification
Accident

Flight number
NU-36

Destination
Komatsu, Japan

Aircraft Registration
JA07RK

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Japan Transocean Boeing 737-800, registration JA07RK performing flight NU-36 from Okinawa to Komatsu (Japan) with 100 passengers and 6 crew, had been enroute at FL410 and was descending through about FL370 when the aircraft experienced an upset causing a flight attendant to receive a serious injury (fracture of the right hallux sesamoid bone). The aircraft continued for a safe landing in Komatsu.

Japan's TSB opened an investigation into the occurrence.

On Dec 8th 2023 the JTSB released their final report concluding the probable causes of the accident were:

The JTSB concludes that the probable cause of this accident was most likely that as the aircraft was shaken violently in lateral direction during cruising, a heavy load was applied on the sole of the right foot of Cabin Crew A who was standing in the aisle in the aft cabin section, resulting in the serious injury to Cabin Crew A.

The reason why the aircraft was shaken laterally was probably because the aircraft flew through the airspace where the wind velocity changed locally, which was not forecast according to the weather data the flight crew members confirmed in advance.

The JTSB analysed:

(1) Injury to Cabin Crew Member

The JTSB concludes that it is probable that while the seat belt sign was turned off and Cabin Crew A was walking in the aisle to attend to passengers, the 2nd Shaking was encountered, when Cabin Crew A, who was about to be thrown to the right. Cabin Crew A stepped hard on her right leg to keep from falling down to the right, but a heavy load added with the vertical acceleration and lateral acceleration caused by the aircraft shaking was momentarily placed on the sole of the right foot, resulting in the injury to Cabin Crew A. From the QAR records, this shaking was caused by a combination of changes in bank angle of the aircraft and nose heading (yaw (heading) movements of the aircraft), and the aft cabin section, where Cabin Crew A had been, was the place that would be significantly affected by lateral inertia caused due to yaw movements of the aircraft as being far from the rotation center of the yaw movements of the aircraft. Therefore, lateral acceleration larger than the recorded acceleration on QAR had probably occurred around the place where Cabin Crew A was.

Cabin Crew A was able to avoid falling down or hitting passenger seats, etc. by grabbing the headrest of a passenger seat quickly was because disseminating information on how to respond to shaking in the regular campaigns and trainings in the Company more likely made a difference to it. It is desirable for the Company to continue to implement the ongoing preventive measures against the injuries due to shaking.

(2) Occurrence of the 2nd Shaking

The JTSB concludes that according to the QAR records, when the 2nd Shaking occurred, the wind velocity temporarily decreased, and at the same time, changes in bank angle and nose heading occurred, therefore, the aircraft shaking at this time was probably caused due to fluctuations in wind velocity.

(3) Predictability about Encountering Turbulence

The JTSB concludes that the flight crew members highly probable failed to predict the 2nd Shaking for the following reasons.

- According to the weather data confirmed before the flight, no weather phenomena that might cause the aircraft to be shaken were forecast around the 2nd Shaking occurrence point.

- Before the accident occurred, there was no report about encountering turbulence from other aircraft flying nearby around the aircraft.

- There were no clouds that could produce turbulence around the 2nd Shaking occurrence point, and no changes in wind direction and velocity, etc. that would be a sign of turbulence were confirmed on the flight instrument in the cockpit.

- In the significant weather analysis and hourly atmospheric analysis charts indicating the weather conditions when the accident occurred, there were no analysis data of weather phenomena that would cause the aircraft to be shaken around the 2nd Shaking occurrence point. Therefore, the temporary decrease in wind velocity at the time of the 2nd Shaking was probably a local weather change that would not be shown in the weather data.
Incident Facts

Date of incident
Oct 3, 2022

Classification
Accident

Flight number
NU-36

Destination
Komatsu, Japan

Aircraft Registration
JA07RK

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

This article is published under license from Avherald.com. © of text by Avherald.com.
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