Ryanair B738 enroute on Jun 23rd 2014, turbulence injures 5 occupants

Last Update: June 28, 2016 / 15:31:27 GMT/Zulu time

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Incident Facts

Date of incident
Jun 23, 2014

Classification
Accident

Cause
Turbulence

Airline
Ryanair

Flight number
FR-4398

Departure
Dublin, Ireland

Destination
Reus, Spain

Aircraft Registration
EI-ENB

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Ryanair Boeing 737-800, registration EI-ENB performing flight FR-4398 from Dublin (Ireland) to Reus,SP (Spain) with 163 passengers and 6 crew, was on approach to Reus' runway 25 when the crew requested an ambulance and medical services to meet the aircraft upon landing reporting severe turbulence along the route had caused bleeding injuries to two passengers, three cabin crew were injured as well. The aircraft landed safely on runway 25.

On Jun 24th 2014 the airline reported the aircraft experienced severe turbulence on approach to Reus causing minor injuries (minor cuts and bruises) to two customers and three cabin crew.

The occurrence aircraft was able to depart for the return flight with a delay of 4 hours.

On Aug 25th 2014 Spain's CIAIAC reported one passenger received a serious, another passenger and 3 cabin crew minor injuries when the aircraft flew through a zone of severe turbulence just as it started the descent towards Reus. The five injured were taken to a hospital in two ambulances.

On Mar 13th 2015 Spain's CIAIAC reported the aircraft was enroute at FL370 at 0.766 mach and 133,400 lbs of weight with the autopilot in NAV mode about 7nm north of Toulouse (France) when the crew started to deviate to the right due to a storm cell building over Toulouse. The CIAIAC reported: "The evasive manoeuvre could not avoid the aircraft penetrated in the edge of the storm, so it was affected by the characteristic turbulences of these atmospheric phenomena, which lasted about 29 seconds, beginning at 16:38:11 and finishing at 16:38:42."

On Jun 27th 2016 the CIAIAC released their final report concluding the probable cause of the accident was:

The accident was caused when the aircraft entered a developing convective cloud that had not been detected by the crew. The severe turbulence associated with the cloud affected the aircraft, causing injuries to several passengers and crew who had not been alerted to the turbulence.

The CIAIAC analysed: "The weather information did not mention the presence of any significant turbulence along the route, especially in the area where the accident occurred. With this information, then, the flight crew concluded that they would not encounter any significant phenomena along the route, and mentioned as much to the cabin crew during their departure briefing" and continued: "Images from weather satellites detected the presence of a convective cumulonimbus cloud developing above the city of Toulouse. Although their planned route did not pass over that position, subsequent instructions from ATC resulted in a deviation from their route that led them to fly over the storm cell. Although they heard other crews on the frequency requesting to divert due to storm activity, they did not receive any information in this regard from ATC informing them of the presence of similar phenomena along their route."

With respect to the use of weather radar the CIAIAC analysed:

The company’s procedures require the captain to have the radar weather on his navigation display, and this was in fact the mode that was active, selected to a range of 80 NM at the time of the accident.

The operator recommends a long range at first to monitor areas where convective activity is anticipated. Then, as the aircraft approaches the cumulonimbus cloud, the range is lowered to improve the definition and the display scale so the most problematic areas can be detected. The fact that the captain had such a long range selected could indicate that their monitoring and surveillance of the weather situation was improper, since with such a long range and the cloud scale displayed it is impossible to see in detail how the situation is evolving and where the areas of greatest risk are.

The first officer had the terrain mode selected on his navigation display, set to a range of 160 NM, as required by the company’s procedures. The company also permits, at the captain’s discretion and depending on the situation, for both pilots to select the weather display so as to make it easier to study it and analyze a possible course change to avoid flying through storms. The mode and range that were active on the first officer’s display did not provide information that they could use to avoid the stormy area. The use of this mode indicates that the crew were not concerned about the possibility of being affected by the adverse phenomena associated with developing cloud formations.

The crew adhered to the requirements of the operations manual regarding holding the relevant briefing far enough ahead of the calculated descent point (TOD). The piloting functions were swapped so the first officer could prepare and present the briefing. This activity could have distracted the crew, preventing them from detecting the presence of the convective cloud. The operator recommends cross checking the radar display with visual observations to better assess the conditions.

Ten seconds before the course change to the southwest was recorded, the recorded wind data started to change. This indicates the proximity of a turbulent region. From this we can conclude that the maneuver to avoid the active cell was started late, with the aircraft already close to the cloud, instead of clearing the cloud formation by 20 NM, as recommended by the operator. Since the cumulonimbus was not detected ahead of time, the seatbelt sign was not turned on until the evasive maneuver was started.

The decision to turn off the seatbelt sign after the takeoff and/or landing phases and to bring out the service cart is always the captain’s to make, regardless of whether he is the pilot flying or not. This decision is made based on the weather conditions that exist during the flight.

In the event of turbulence and in the absence of instructions from the flight crew, the Cabin Supervisor can decide to interrupt any activity not related to safety and inform the captain of the level of turbulence being experienced, and recommend turning on the seatbelt sign.

It was during the turning maneuver that they experienced the most severe turbulence, causing the speed to increase in excess of the MMO. Although the crew made a corrective input to the throttles, they did not disengage the autothrottle, contrary to the manufacturer’s recommendations for flying in severe turbulence.

The aircraft experienced an increase in vertical acceleration (maximum value of 1.89515 g) and lateral acceleration (maximum value of 0.244 g). The turbulent movements typical of these atmospheric phenomena that affected the aircraft lasted about 29 s. Due to its effects, the turbulence is believed to have been severe.

The CIAIAC analysed with respect to CRM and crew coordination:

The encounter with this turbulence was not reported to ATC, contrary to the requirements of the operator’s Operations Manual. The crew explained this omission by arguing that they were busy evaluating the injuries sustained in the passenger cabin.

The captain established contact with the flight attendants, who informed him of the injuries sustained by the FAs themselves and by the passengers. Although he was told about the injuries, he did not report the need for medical assistance until he was in contact with controllers at the Reus Airport. He also did not think it necessary to declare a medical emergency (PAN PAN Medical) to ATS.

The statements by the cabin supervisor and the flight crew seem to indicate that communications between them were not good, since the former stated that when the captain called to ask about the situation in the cabin, she told him there were several injuries that would require medical attention. In contrast, the flight crew stated that it was their understanding that there were two injured passengers whose condition did not seem serious. In any event, the flight crew were aware that two injured individuals were being treated by two passengers who were healthcare professionals. Had the captain been better informed of the situation in the cockpit, that should have prompted him to request help from ATS by declaring a medical emergency. This would have given them a certain priority and minimized the length of time the injured were left unattended.

The Cabin Supervisor did not tell the flight crew that she was unable to move the more seriously injured passenger, and of her decision to land with a passenger blocking access to the aft doors. This information is essential to the captain, as it affects how a potential evacuation will be conducted. Likewise, the Cabin Supervisor must take into account any obstacles (injured passenger and damaged service cart) that could affect the availability of an emergency exit and give instructions to the rest of the crew so that, in the event of an evacuation, the obstruction can be avoided. This investigation has thus detected a fault involving crew resource management (CRM); in particular, faulty communications and threat assessment. A safety recommendation was considered to be issued to the operator in this regard.

The CIAIAC stated in the analysis: "Nevertheless, during the investigation term, the operator showed that they had improved
its training regarding the detected deficiency ..."