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CA 12-12b 01 FEBRUARY 2017 Page 1 of 33

Section/division Accident and Incident Investigation Division Form Number: CA 12-12b

AIRCRAFT SERIOUS INCIDENT REPORT AND EXECUTIVE SUMMARY

Reference: CA18/3/2/1065

Aircraft registration

ZS-SXA Date of incident 17 July 2014 Time of incident 01:10Z

Type of aircraft Airbus A340-300E (Airplane) Type of operation Commercial (Part 121)

Pilot-in-command licence type ATPL Age 56 Licence valid Yes

Pilot-in-command flying experience

Total flying hours

11412.00 Hours on type 5129.20

Last point of departure O.R. Tambo International Airport (FAOR) South Africa

Next point of intended landing Hong Kong International Airport (HKIA)

Location of the incident area: Co-ordinates: 07º16‟32” N & 96º52‟43”S at FL370. Above Andaman Sea

Meteorological information

Malaysia MET reported no significant adverse weather enroute to Hong Kong (HKIA)

Number of people on board

3+10+166 No. of people injured

0+3+18 No. of people killed

0

Synopsis

The Airbus A340-300E departed from O.R. Tambo International Airport on an International Scheduled Flight SA286 with 3 flight deck crew, 10 cabin crew and 166 passengers that included an infant on-board the aircraft to Hong Kong International Airport. The aircraft was cruising at FL370 through Malaysia airspace when the aircraft encountered severe air turbulence and negative G forces at approximately 0110Z (0710B), that caused injuries to three (3) cabin crew-members and eighteen(18) passengers as they were not seated or restrained at the time of the occurrence. The oxygen masks near door 3R dropped out during the incident. Damage was caused to overhead stowage panels when some occupants impacted the overhead panels with their heads. The medical rescue services and station manager at Hong Kong International Airport were alerted of the serious incident that occurred. Upon landing at 0415Z, Hong Kong Civil Aviation Authority (CAD) interviewed some crew members and downloaded the FDR and CVR data, but established that the in-flight occurrence was not in their juristic airspace. The relevant information was forwarded to the RSA as the State of Registry for further investigation.

Probable cause

The sudden severe clear air turbulence followed by negative G forces encountered, during cruise flight, caused 3 cabin crew-members and eighteen passengers being injured as they were not seated nor restrained at the time when the incident occurred.

SRP Date 12 September 2017 Release Date 19 September 2017


Section/division Accident and Incident Investigation Division Form Number: CA 12-12b

AIRCRAFT SERIOUS INCIDENT REPORT

Name of Owner : South African Airways (Pty) Ltd

Name of Operator : South African Airways (Pty) Ltd

Manufacturer : Airbus Company

Model : A340-300E

Nationality : South African

Registration Marks : ZS-SXA

Place : Malaysia Airspace.

Date : 17 July 2014

Time : 01:10Z (0710B)

All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South

African Standard Time is UTC plus 2 hours.

Purpose of the Investigation:

In terms of Regulation 12.03.1 of the Civil Aviation Regulations (2011) this report was compiled in the

interest of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents and

not to establish blame or liability.

Disclaimer:

This report is produced without prejudice to the rights of the CAA, which are reserved.

FACTUAL INFORMATION

1.1 History of flight

1.1.1 On 16 July 2014, the South African Airways Airbus A340-300E, flight SA286, departed from O.R. Tambo International Aerodrome in South Africa with 3 cockpit crew, 10 cabin crew-members and 166 passengers that included one infant on an International Flight to Hong Kong International Airport (HKIA) in China.

1.1.2 The aircraft was cruising at FL370 over the airspace of Malaysia enroute to Hong Kong, when the Senior 1st Officer (P2) pilot flying, left the cockpit to visit the toilet amenity whilst the Captain (Pilot-in-command) was resting on the crew rest bunk.


1.1.3 The 1st Officer (P3) stated that he occupied the left hand seat in the cockpit during this time. The weather radar showed that the weather was clear at the time with no clouds evident when the aircraft suddenly encountered severe clear air turbulence and negative G forces at approximately 01:10Z (0710B) overhead Malaysia airspace. He then immediately activated the cabin seatbelt signs in the cockpit and selected the engine anti-ice to the “ON” position, when he heard a noise that sounded like rain on the airframe. The P3 1st Officer however, did not mention that the auto-pilot did not disconnect which indicated the system robustness. According to the pilot, the speed trend vector increased to the limit that triggered the over-speed warning and that the turbulence lasted for approximately 6 to 8 seconds.

1.1.4 The Captain agreed that the correct decision was to continue to Hong Kong

International Airport rather than to divert, with all the information at his disposal after the crew discussed the risk management model with him. The cockpit crew requested the ATC at Hong Kong International Airport for priority landing at the airport and for the medical services to meet the aircraft after landing. The medical services arranged to come on board and to treat the injured occupants with medical care and attention and to transport the injured to three hospitals in Hong Kong

1.1.5 Three (3) cabin crew-members and 18 passengers sustained minor and serious

injuries during the in-flight incident when some of the passengers that were not seated or fastened with seat belts, struck the overhead panels with their heads. The oxygen masks at 3R dropped out during the incident and damage were caused to overhead panels.

1.1.6 The medical rescue services and station manager at Hong Kong International

Airport were alerted of the incident that occurred.

1.1.7 The 1st officer (P3) resumed his observing role in the cockpit and communicated

with operations center at Hong Kong and required medical services after landing. The medical personnel boarded the aircraft after landing and immediately treated the injured.

1.1.8 The crew-members submitted statements to the Hong Kong Civil Aviation

Department (CAD) in China. The following information is brief summaries of the crew-members statements:

1. The Captain (pilot-in-command) stated that he was sleeping at the crew bunk when the aircraft encountered severe air turbulence. He was woken up by the senior 1st officer and the senior purser and briefed accordingly and immediately went to the cabin to ascertain the extent of the injuries caused to the passengers and cabin crew and damage caused inside the cabin area. He then decided not to divert but rather to continue to Hong Kong International Airport (HKIA) where an uneventful landing was carried out at 0415Z (0815B)..

2. A cabin crew-member stated that she and another cabin crew-member were checking the toilets in the cabin and the galley when they experienced some moderate turbulence for a few seconds. The other cabin crew-member with her then sat down at 4AFT R jump seat and secured herself with the safety belt, but as she also sat down at seat 4 AFT L jump seat to secure herself with the safety belt, she was flung out of the jump seat by severe air turbulence and struck the ceiling with her head and fell down onto the floor. The seat belt signs illuminated


immediately at that time. A male passenger exited 4 AFT L toilet and was very confused and scared. A cabin crew member walking towards the front of the cabin to render assistance to a passenger got injured and some oxygen masks were dropping out of the PSU panels. All the cabin crew-members then attended to several passengers that were injured. One passenger that was seated at 3L with neck injuries was treated by paramedics on board the aircraft.

3. Another cabin crew-member stated that she was sleeping at the crew rest at the time when the aircraft encountered severe turbulence. She was woken up by another crew-member and noted that several oxygen masks were hanging out of the PSU panels. All the passengers that were injured were attended to by the rest of the cabin crew-members. Breakfast was then served to the passengers.

4. One of the five cabin crew-members that was on duty at the time of the incident stated that he was busy at the galley when a passenger seated at 15H came to the galley and asked for something to drink. As the turbulence started, he advised the passenger to go back to his seat and to fasten his seatbelt. As he also attempted to go back to his jump seat, severe turbulence suddenly started and he was forced to hold onto the galley storage handles. After the turbulence stopped within a few seconds, he opened the window shutter at his jump seat and noted that it was sunny outside.

1.1.9 The in-flight incident occurred at 01:10Z (0710B) during daylight conditions in Kuala Lumpur Malaysia airspace at co-ordinates 07º16‟32”North & 96º52‟43”East en-route to Hong Kong International Airport in China. The aircraft landed safely at Hong Kong International Airport at 0415Z (0815B).

1.2 Injuries to persons

Injuries Pilot Crew Pass. Other

Fatal - - - -

Serious - 2 2 -

Minor - 1 16 -

None 3 7 148 -

1.2.1 7 South Africans and 14 Chinese passengers were injured during the in-flight incident that occurred.

1.3 Damage to aircraft

1.3.1 The aircraft did not sustain any damage except that the cabin area overhead panels were damaged when the occupants impacted the overhead panels with their heads.

1.4 Other damage

1.4.1 None.


1.5 Personnel information

1.5.1 Pilot-in-command (PIC)

Nationality South African Gender Male Age 56

Licence number 0270065501 Licence type Airline Transport

Licence valid Yes Type endorsed Yes

Ratings Instrument rating, Flight test rating multi engine piston

Medical expiry date 31 March 2015

Restrictions Corrective lenses

Previous accidents None

Flying experience:

1.5.2 Senior First officer (SFO) (Pilot Flying)


Licence number 0270160104 Licence type Airline Transport


Ratings Instrument rating, Flight test rating Instructor Grade 2

Medical expiry date 31 March 2015

Restrictions None

Previous accidents None

Flying experience:

Total hours 13 285,0

Total past 90-days 262,0

Total on type past 90-days 262,0

Total on type 2 331,0

Total hours 11412.00

Total past 90-days 193.35

Total on type past 90-days 131.15

Total on type 5129.20


1.5.3 First Officer (1st Officer) (Observer)


Licence number

Piston 0272383340 Licence type Airline Transport


Ratings .Test Pilot Rating Class 2. Multi Engine Piston Night Flt

Medical expiry 14 June 2022

Restrictions None

Flying Experience

Total hours 2000,0

Total past 90-days 170,0

Total on type past 90-days 170,0

Total on type 170.0

1.5.4 Senior Cabin Crew Member (SCCM - Injured)


Licence number 0274004092 Licence type Cabin crew


Ratings Safety, Emergency, Live Fire Fighting, Dangerous Goods,

Wet Ditching, Av-Med.

Medical expiry date 30 April 2015

Restrictions None

1.5.5 Cabin Crew Member (CCM - Injured)

Nationality South African Gender Female Age 51

Licence number 0274005370 Licence type Cabin crew


Ratings Safety, Emergency, Live Fire Fighting, Dangerous

Goods, Wet Ditching, Av-Med.

Medical expiry date 30 April 2015

Restrictions None


1.6 Aircraft information

Airframe:

Type Airbus A340-300E

Serial number 544

Manufacturer Airbus Company

Year of manufacture 2005

Total airframe hours (At time of accident) 49532.53

Last inspection C-check (hours & date) 49455.50 10 July 2014

Hours since last inspection 77.03

C of A (Issue date) 3 August 2007

C of A (Expiry date) 2 August 2014

C of R (Issue date) (Present owner) 27 July 2007

Operating categories Standard Part 121

Maximum certified take-off mass 275 000 kg

1.6.1 The Airbus A340-300E ZS-SXA was certified and maintained in accordance with

existing regulation and approved procedures. There were no pre-existing defects or conditions that contributed to the in-flight occurrence. The aircraft was airworthy at the time that the serious incident occurred.

Engine No. 1:

Type CFM International CFM56 5C4/P

Serial number 567264

Hours since new 43010.0

Cycles since new 5140

Engine No. 2:





Engine No. 3:






Engine No. 4:





1.7 Meteorological information:

1.7.1 An official weather report was obtained from Malaysian Weather Service (MWS) for 16 July 2014, between 0000UTC and 0200UTC. The analysis of the weather situation was based on product issued by the World Area Forecast Centre (WAFC), satellite pictures and local significant weather chart 0000-0200UTC on 16 July 2014.

1.7.2 Below and on the next page, is the flight information region with the coordinate

location of the turbulence encountered by Flight SAA286.The full weather report (both enroute and Malaysian) are attached to this report as Annexure A. Observed weather conditions in the vicinity of the occurrence according to satellite images.

1.7.3 Satellite picture on 16 July 2014

According to the satellite images, (infrared channel) for the period concerned, within the highlighted area, only non-significant high clouds were present. Moreover, there were no cumulonimbus clouds present. The images below, shows the weather at the time of the incident.

Figure 1 Shows Malaysian Meteorolgical chart.


Figure 2 shows the meteorological image

Figure 3: Red dot shows aircraft position in Malaysia Airspace at Co-ordinates: 07º16‟32” N & 96º52‟43”S (Above Andaman Sea)


Figure 4: Indicate where the in-flight incident occurred in Malaysia airspace

1.7.4 Conclusion on the analysis of the meteorological information: In accordance to the weather information, no significant adverse weather was expected for the en-route flight within the area concerned. It could be relevant to indicate if Pilot Reports (PIREP) were available in this area concerning any clear air turbulence-phenomenon.

1.7.5 No request for weather deviation, or any other report, by pilot to ATC was recorded.

There was also no other aircraft flying in same route or within the vicinity of the incident aircraft.

1.8 Aids to navigation

1.8.1 The aircraft was equipped with standard navigational equipment for the aircraft type as approved by the regulating authority.

1.8.2 The below image shows, Flight SAA286 observed on ATC Radar Display to be approaching position LEKIR – pilot reported LEKIR a minute later, maintaining FL370.


Figure 5 : Red circle indication Aircraft approaching LEKIR

Note: The above image on the radar display shows SAA286 approaching position LEKIR. The pilot reported LEKIR a minute later whilst maintaining FL370. The pilot did not request a weather deviation or any other report according to the ATC recordings. There was also no other aircraft flying along the same route or in vicinity of the incident aircraft.

1.9 Communication

1.9.1 The following information was provided by the Malaysian ATC:

1) SAA 286 transited KUALA LUMPUR FIR at FIR BDRY entry point POVUS and FIR BDRY exit point RUSET at 0046 UTC and 0117 UTC respectively, for a duration of 31 minutes on Airways P627 in eastbound direction.

2) At 0046 UTC, SAA 286 established contact with Lumpur Control on

frequency 133.4 MHz after being transferred by Jakarta control and reported maintaining FL370 at POVUS [FIR BDRY 060000N 0943958E].

3) At 0109 UTC, SAA 286 reported over position LEKIR (071632N 0965243E)

maintaining FL370. As reflected on the ATC radar display at that time, there was no aircraft along same route or within the vicinity of SAA286. In addition no request for weather deviation by the pilot to the ATC was reported. Lumpur ATC instructed SAA 286 to report at RUSET.

4) At 0117 UTC, SAA 286 was transferred to Bangkok Control (frequency 125.7

MHz) at RUSET. 5) There was a total of three (3) radio telephony transmissions between SAA

286 and Lumpur ATC during the duration of SAA 286 through Malaysian airspace, namely at times UTC 0046, 0109 and 0117.

6) No significant adverse weather for the enroute flight for SAA 286 within the area concerned.

1.9.2 The pilot-in-command of the incident aircraft communicated with Hong Kong ATC and requested a priority landing as 3 cabin crew members and 18 passengers were injured during the severe turbulence that was encountered. The priority landing was granted, and the cockpit crew performed an uneventful landing at Hong Kong International Airport.


1.10 Aerodrome information (Destination)

1.10.1 The aircraft continued to Hong Kong International Airport passed the Malaysia airspace to Hong Kong International Airport where an uneventful landing was performed at 0415Z (0815B). The Hong Kong Medical Services were on standby to meet the aircraft upon landing.

ICAO designation HKIA (Hong Kong International Airport)

Aerodrome co-ordinates N2218.50 E11354.9

Aerodrome elevation 28ft above mean sea level (AMSL)

Runway designations 07L / 25R 07R / 25L

Runway dimensions 3800 x 60 m 3800 x 60 m

Runway used 07L

Runway surface Asphalt

Approach facilities ILS, VOR, DME, PAPI‟s, runway lights

Aerodrome status Licensed Airport

1.10.2 The closest International Airport at the time that the incident occurred in the Malaysia airspace was Phuket International Airport (HKT) at co-ordinates of 8º06‟44.24” North & 98º18‟27.16” East at 10m AMSL 71.5 NM heading 60º from the plane location. Phuket International Airport (HKT) is an International Airport that serves Phuket Province of Thailand and it is located north of Phuket Island, 32 km from the centre of Phuket city. The Airport accommodates domestic flights and also major Asian and European flights.

1.11 Flight recorders

1.11.1 The Flight Data Recorder was downloaded by the Hong Kong Civil Aviation Department. The raw data was then transferred to the BUREAU D‟ENQUETES ET D‟ANALYSES POUR LA SECURITE DE L‟AVIATION CIVILE (BEA), who decoded them as they had the capability to decode the raw data of the Flight Data Recorder (FDR).

The FDR was downloaded and decoded to provide the history of the eventful flight

and a trajectory list of engineering values on a relevant set of parameters.

The decoding of the parameters was done with the assistance of the data frame reference “k256fact”, provided by the manufacturer of the plane, allowing the decoding of more than 1.300 parameters.

The flight of the event was identified inside the recorded data as the synchronized zone 2, based on the variation of the recorded normal acceleration found in this flight.

1.11.2 History of flight as recorded by the FDR:

1. The Airbus A340-300E, registered ZS-SXA, took off on 16 July 2014 at 15 hour 10

minutes 16 seconds, from OR Tambo International Airport (Johannesburg-South Africa) runway 03L. Auto-throttle (A/THR) was engaged and active and A/P2 engaged shortly after take-off.


2. After climbing phase, the plane started its cruising phase at FL 330 and then

climbed to FL 350 and FL 370.

3. At approximately 01:10Z at FL 370 and at the co-ordinates of 07º16‟32”North & 096º52‟43”East enroute to Hong Kong International Airport, the normal acceleration value oscillated. During 12.6 first seconds, the oscillations were limited in the range (between 0.74G and 1.31G) at a frequency of around one oscillation per second. The rhythm of the oscillations then decreased (around 4 seconds per oscillation while its range increased between -0.5 and 1.6G.

4. The plane was then flying at FL 370, at GPS coordinates of 7 29 21 N and 97 16 42 E closest airport: Phuket International Airport – Runway 09 threshold at 71 5 NM, heading 60 from the plane location

5. During the event, the aircraft experienced small changes in roll, between 6º left wing down and then 8º right wing down. Meanwhile, the pitch value decreased from 3º nose up to -2º nose down (elevators oscillated, within a small range [-1.3-2.2], with a slightly positive average value of 0.13), standard altitude increased (+400 ft) and CAS decreased (min at 250 kt for a cruise speed of 265 kt). The Table below indicates the values recorded during the event:

Key Values During The Event Min Max

Normal acceleration -0.489 G 1.594 G

Longitudinal acceleration -0.102 G 0.035 G

Lateral acceleration -0.102 G 0.09 G

Altitude 37.020 ft 37.416 ft

Computed Airspeed 249 kt 267 kt

Roll -6 8

Pitch -2 3

6 No side stick input was recorded during this period of time, neither for the Captain side nor the first officer side. The end of the flight was uneventful, with a landing on Hong Kong International Airport onto RWY 07 R at 0428Z

7 No Over-speed warning was recorded by the FDR during the severe turbulence

that was encountered.


Figure 6: The graph showing the Auto-pilot information

8. The Auto-pilot did not disconnect during the incident when the aircraft experienced the severe air turbulent condition at FL370. During the cruise, A/P lateral mode was set to NAV and A/P longitudinal mode was set to ALTCRZ-except during the FL changes (CLIMB mode then). When the turbulences occurred, A/P remained engaged and no change to A/P settings was detected. The graph indicated that the aircraft did not descend or ascended more than 200ft during cruise at FL370 for the auto plot to disconnect.

1.11.3 Engines settings:

The engines operated within the specified parameters and settings during the event:

The A/THR was engaged and active in the MACH mode. No disconnection of the A/THR was recorded. Engines behaved as expected and followed the engine thrust target N1

value. Just after the end of the event, N1 target increased and then decreased to adjust the speed.


The anti-ice valve fault triggered for the engines #2, #3, and #4 for 1 second (around 01 hour 12 minutes 46 seconds). Two minutes thirty seconds later, the same fault triggered for all the engines for 1 second, and then the parameters read normally for the rest of the flight.

Figure 7: Shows the Engine parameters


Figure 8: shows: FDR Engine parameters

1.11.4 Displays/Radar:

1.11.4.1 The ND for both Captain and F/O sides were set to Arc mode. During the event, the range for the captain side was set to 160 NM while the range on the F/O side was set to 80 NM As far as the radar was concerned, the setting was “weather only” during the cruise phase, and especially during the event. The plot is provided below (see A2.6).


Figure 9: Radar Displays

1.11.5 FMS trajectory of the flight of the event:

The FDR recorded the latitude and longitude positions of the plane. From these recorded values, the following trajectories were drawn:

A complete trajectory (see appendices A1.1). A zoom around the time of the event as reflected on the Figure below:

Figure 10: Zoom on the trajectory

Flight Path Trajectory


1.11.6 Full or complete FMS trajectory flight of the event

The aircraft was fitted with a flight data recorder (FDR), a cockpit voice recorder (CVR) and a quick access recorder (QAR). Both the FDR and the CVR were downloaded by the Civil Aviation Department (CAD) of Hong Kong after the incident aircraft landed at Hong Kong International Airport and the Data later sent to the SACAA for investigation purposes. The CAD informed the SACAA of the incident shortly after the CAD completed a preliminary assessment of the incident aircraft that landed at Hong Kong International Airport. (The regulatory requirement for the reporting of an accident is at least within 24-hours as stipulated in Part 12.02.1(1) of the Civil Aviation Regulations of 2011 as amended).

The downloaded data showed that the aircraft encountered severe air turbulence

and vertical accelerations with peak values of + 1.6G and -0.5G as reflected on the graph below. The air turbulence lasted approximately 8 seconds while the aircraft was flying at 37 000 feet AMSL. During 22 second time frame, substantial vertical acceleration was observed. According the Cockpit crew the air turbulence lasted also between 6 to 8 seconds.

Figure 11. The graph displays the Vertical acceleration & Air turbulence encountered.

Note: The blue line represents the altitude of the aircraft during the incident.

+1.6 G

-0.5 G


Figure 12. The graph displays vertical acceleration during the severe air turbulence

1.12 Wreckage and impact information

1.12.1 None.

1.13 Medical and pathological information

1.13.1 Three (3) cabin crew-members and (18) eighteen passengers that were injured during the serious incident were transported to different hospitals in Hong Kong for medical treatment. Most of the injured were discharged during the day, except that one injured passenger was discharged the next day and the other passenger two days later.

1.13.2 The crew continued to Hong Kong when they had injuries on board instead of landing at Puket-Malaysia.

1.14 Fire

1.14.1 There was no evidence of pre- or post-impact fire.

1.15 Survival aspects

1.15.1 The incident was considered to be survivable as there was no structural damage

that could have caused fatal injuries to the occupants

1.16 Tests and research

1.16.1 None.

+1.6 G

-0.5 G


1.17 Organizational and management information:

1.17.1 The Operator was in possession of a valid Air Service License that was issued by the National Department of Transport as well as a valid Air Operating Certificate AOC) No‟s S552D, N553D, G554D that was issued by the regulating authority

1.17.2 The International flight was conducted under the provisions of Part 121 of the Civil Aviation Regulations of 2011, as amended and the operator was in possession of a valid Air Service Licence as well as an Air Operating Certificate (AOC) at the time of the incident flight.

1.17.3 Hong Kong ATC was informed by the HKIA Apron Control that SA286 had encountered turbulence with several passengers and crew members injured. Medical assistance was required after landing. Hong Kong ATC facilitated SA286's arrival to HKIA expeditiously. The aircraft landed at HKIA uneventfully at approximately 0428Z where after 18 passengers and three crew members were transported to three hospitals in Hong Kong for medical treatment. Most of the injured were discharged the same day, except that two injured passengers were later discharged during the following two days.

1.17.4 The Hong Kong Civil Aviation Department (CAD) investigators were waiting for the aircraft at the gate for preliminary crew interviews and information gathering. The Flight Data Recorder and Cockpit Voice Recorder were removed and the data was downloaded after coordination with the SACAA, South Africa, the operator and the latter's representatives in Hong Kong. The Recorders were returned to the operator after the downloading was completed. The aircraft returned to South Africa on a ferry flight on 17 July 2014.

1.17.5 The User‟s Quick Reference Guide was provided to the SACAA in the e-mail dated 21 July 2014 while the recorders data was sent through the CAD secure website. The Guide was to facilitate SACAA assessing the CAD secure website and was not relevant to the subject matter. Since the event did not occur within Hong Kong, Hong Kong CAD was not in the capacity to conduct the investigation as per ICAO Annex 13 provisions. Nevertheless, the CAD investigation authority where the aircraft has landed in Hong Kong, assisted in gathering as much information as possible and share with the State of Registry and the State of the Operator.

1.17.6 Hong Kong Civil Aviation Department (CAD) requested that they would welcome a copy of the final Incident report by SACAA when released.

1.17.7 Following the event SITA performed a rapid screen of TURB in the area, and there was no reported CAT or CB TURB evident.

1) With SITA TURB predictor was developed which uplinks to the MCDU screen, for printing when requested. Crew type TURB, in the same fashion as UPDATE and the turbulence predictor is generated by SITA for all ensuing waypoints. This predictor runs off the WAFC TURB predictor, and is presented for all waypoints requested. SITA provide CAT and CB determined TURB. Crew make the request as and when required. This request had not been made on this particular flight.


2) With a TURB function available on the weather radar, it needs to be selected to WX +TURB, which is only selected when required, as stated by the manufacturer. This function only works up to 40 Nm. If it is on permanently it doubles the scan cycle rate. The weather radar generally does not pick up these needle type clouds, as it is returning a water content.

The shear rate value has little or no value on the flight plan and with the uplink winds into the FMS. SITA, can modified that field and replace it with the WAFC determined TURB value for CAT.

1.17.8 Hong Kong Civil Aviation Authority commenced with the investigation, but established that the in-flight occurrence was not in their juristic airspace. Hong Kong Authorities contacted South Africa advising them of the occurrence and that they could not get hold of Malaysian Authorities. RSA requested assistance from ICAO in Canada to contact the Malaysia authorities. Malaysian Authorities advised South Africa that they are not going to investigate due to resources allocated to MH370 and MH17 accidents. The state of registry and operator conducted the investigation and was assisted by BEA, Malaysian DCA and Hong Kong CAD. The relevant information was forwarded to the RSA as a State of Registry and Operator for investigation.

1.17.9 The following France, China and Malaysia states participated in the investigations

and the final draft report was send to them for comments. All their comments were considered. AIID however did not receive comments from Malaysia.

1.18 Additional information

1.18.1 The South African Airways (SAA) Cabin Crew Member Manual (Standard Operating Procedures) states the following information during Flight:

1. After take-off all cabin crew members (CCMs) shall remain seated with seat belt

and shoulder harnesses fastened until the „Fasten Seat Belt‟ signs have been switched off. All occurrences which may affect the safety of the operation and the well-being of the passengers shall be immediately reported to the flight deck crew members (FDCMs). Safety-related situations that requires notification to the flight deck include, but are not limited to: Unruly behaviour by passengers; Injury to passengers or cabin crew members; Medical emergencies and/or use of first aid or medical equipment; Fire, smoke or toxic fumes in the cabin; Failure of any emergency system and/or equipment.

1.18.2 South African Airways Final Aviation Investigation Report:

Several of the CCM reports included words which would indicate they experienced an increased level of anxiety and decreased level of resilience. In such a situation a period of anxiety would be normal however, should normalize following an assessment of the situation dependent on the level of the persons resilience.

There are however several indicators of stress factors impacting on decisions made, such as by passing all injured passengers in economy class to assist the CCM at 2R to give medical assistance to a passenger with a minor injury in business class.


Crew not called from the crew rest to assist. Strong smell of something burning at 3R the CCM returns door 4L to make the alert call. PA direct not used to make the alert call.

The passengers were not informed prior to landing that door 3L was a blocked exit. The effects of stress are also noted in the feedback to the Cockpit crew where it is stressed how bad the situation was and that they (the cabin crew) needed emergency medical help for the passengers however, this is contradicted by the statement that nobody‟s life was in serious danger One passenger was suspected to have broken his neck and was immobilized on the floor with pillows at the number 3L door.

It would have been difficult for the flight deck crew to accurately establish the risk to aircraft and passengers without factual information such as the number of injured passengers, the type of injuries and the damage to the aircraft etc. Only one wound dressing was used from the First Aid kit for the injury which the CCM describes as a “scratch” that indicated that the cuts sustained by the passengers were minor in nature.

The Majority of passenger‟s appeared to have injuries consistent with blunt force impact such as bumps, bruises and sprains from knocking their heads against overhead storages. It was less impact injury to the passenger.

Severe turbulence is not a desired state however, the conditions in the cabin after such an event were normal and to be expected. The amount of injuries and damage along with the mess in the galley and cabin was not found to be unusual for the amount variations in the G-forces that were experienced. See Conclusions & Findings later in this report.

. 1.18.3 Airbus Final Aviation Cabin Crew Safety Investigation Report:

The CCM 4LA was not strapped in and was dislodged from her feet and landed on the floor after hitting her head against the ceiling and her back against the jump seat. After the turbulence have passed, the Purser proceeded to check the condition of the passengers and called the CCM 1LA to come with her. The CCM1LA grabbed a piece of paper and pen to write down the names of the injured down and proceeded to assist injured passengers.

The CCM 2R noted that the passenger at 15A had a scratch on his forehead and called CCM 4LA to assist her with the passenger whilst she cleaned up the broken glass in the galley. She assisted passengers with ice for swellings and sprains as well as responded to the alert call for the SCCM to report to door 3R. The CCM 4LA then assisted CCM 2R with the injured passenger in 15A and with the injured passenger at the rear of the aircraft. As she noted the smell of smoke in the vicinity of doors 3L she raised the alarm and proceeded with locating the fire. CCM4R attended to injured passengers communicated with Chinese passengers‟

The Senior Purser was woken up by the turbulence and returned to the cabin area about 5 minutes after the incident and concluded that the smell of fire was result of chemical reaction in the oxygen concentrator. The baggage and passengers were then moved away from the area in the interest of safety.

The Senior Purse liaised with the Flight Deck crew and reported that passengers were seriously injured. The passenger with a suspected broken neck was immobilised and monitored as per the cabin crew training at 3L cabin exit door.


Breakfast was served not only to feed the passengers but as a means to revert back to normal operations and everything under control.

Several of the CCM reports included words which indicated that they experienced an increased level of anxiety and a decreased of resilience. In such situation, a period of anxiety would be normal, however, should normalize following an assessment of the situation dependent on the level of the persons resilience.

There are several indications of stress factors evident on decision making noted such as by passing all injured in the economy class to assist the CCM at 2 R to tend to a passenger with minor injury in business class.

Crew not called from the crew rest to assist. Strong smell of something burning at 3R, the CCM returns to door 4L to make the alert call. PA direct not used to make the alert call.

Not informing the passengers prior to landing that door 3L was a blocked exit. The defects of stress are also noted in the feedback to the 2nd Pilot where it is stressed how bad the situation was and that the cabin crew needed emergency medical assistance for the passengers however, this is contradicted by the statement that nobody‟s life was in serious danger. One passenger was suspected to have broken his neck and was immobilized on the floor with pillows at the number 3L door.

It would have been difficult for the flight deck crew to accurately establish the risk to aircraft and passengers without factual information such as the number of injured passengers, the type of injuries and the damage to the aircraft etc. Only one wound dressing was used from the First Aid kit for the injury which the CCM describes as a “scratch” this would indicate that the cuts sustained by the passengers were minor in nature. Majority of passenger‟s injuries were consistent with blunt force impacts from knocking their heads against overhead storages.

1.18.4 Adverse Weather Conditions during flight Turbulence experienced during flight is the motion of air that is haphazard in all directions but especially vertically. The cells within storms, the shear associated with transition into a jet-stream, or the disruption to the even flow of strong winds by surface irregularities area causes of turbulence. The intensity of turbulence can be classified into three areas – Light, Moderate, and Severe:

Light Occupants may feel a slight strain against seat belts and/or shoulder harness. Unsecured objects may be displaced slightly and food and beverage service may be conducted and little or difficulty is encountered in walking.

Moderate Occupants feel definite strain against seat belt and shoulder harness. Unsecured objects will also be dislodged. Food and beverage service and walking are difficult.

Severe Occupants are forced violently against their seats-belts and shoulder harness and unsecured objects are tossed about such as food and beverages. In flight service and walking are impossible. „Fasten-Seat-Belt’ When this sign illuminates in-flight due to turbulence, the passengers must be advised via the PA to return to their seats and fasten their seat belts. Ideally the FDCMs should make an announcement, however if the sign is illuminated and there is no announcement forthcoming from the flight deck (possibly busy with radio calls,


etc.), the senior cabin crew member (SSCM) must take the announcement. The CCMs must then ensure:

1. All passengers are seated with their seat belts secured. 2. All lavatories are vacated; 3. Overhead stowage compartments are closed; 4. Hot beverage service is suspended. 5. It is the responsibility of the CCMs to ensure passengers comply with the „Return to

Seat‟ and „Fasten Seat Belt‟ light instruction. 6. If the FDCMs determine that the service must be suspended, the following

additional procedures will apply: The food and beverage service must be suspended immediately; All trolleys must be restrained and latched in the galley; CCMs be seated with the seat belt and shoulder harness fastened. If no announcement has been made from the flight deck to suspend the service, but the SCCM finds it necessary to do so, the Commander must be informed via the interphone.

7. Clear air turbulence is undetectable on radar and is associated with jet streams at high altitude. The major deflections of air upwards and downwards may result in sudden turbulence without warning. In this event CCMs must: Suspend the in-flight service immediately; Restrain and latch all trollies (if in use) in the galley; Ensure all passengers are seated with their seat belts fastened; All lavatories are vacated; Be seated with both the seat belts and shoulder harness fastened; If need be, via the interphone, request that the Commander switch on the

„Fasten Seat Belt‟ light.”

1.18.5 The announcement for the passengers to keep their seatbelts fastened during the night was made in English and Mandarin prior to the cabin lights being switched off to allow passengers to sleep. Approximately 01: 10 Zulu the aircraft experienced light turbulence buffeting which progressively became more severe. The 3rd Pilot switched on the seatbelt signs.

The Purser entered the galley area at doors 1L after doing her rounds at this time CCM 1LA had taken up her seat and secured the lap strap and shoulder harness due to the initial turbulence and mentioned to the Purser she should do the same. The Purser took up the jump seat at doors 1L however, did not have time to secure the shoulder harness and lap strap. The 2nd Pilot was exiting the toilet at doors 1L. The turbulence displaced the 2nd Pilot and the Purser landing on her back. CCM 1LA stated the 2nd Pilot landed on his arms and legs in the crouching position. CCM 4R had partially strapped herself in when the turbulence hit however, she was sitting at an angle as she attempted to shout to CCM 4LA to strap herself in. CCM 4LA was not strapped in and was dislodged from her feet and landed on the floor after hitting her head against the ceiling and her back against the jump seat .

Once the turbulence had passed and it was deemed safe to move around the Purser proceeded to check the condition of the passengers returning to the first galley to call the CCM 1LA to come with her. CCM 1LA grabbed a piece of paper and pen to write the names of the injured pax down. They proceeded to assist by


attending to passengers. CCM 2R noted that the passenger seated 15A had a scratch on his forehead and called CCM 4LA to assist her with the passenger while she cleaned up the broken glass in the galley. She assisted passengers with ice for swellings and sprains as well as responded to the alert call for the SCCM to report to doors 3 right.

CCM 4LA after the event assisted CCM 2R with the injured passenger in 15A and then assisted with injured passenger in the rear of the aircraft. She noted that there was a smell of smoke in the vicinity of doors 3L and raised the alarm and proceeded with locating the fire.

CCM 4R attended to injured passengers and a Chinese language crew member communicated to with the Chinese passengers. The Senior Purser was woken up by the turbulence returned to the cabin approximately five minutes after the event and confirmed that the fire smell was as a result of the chemical reaction in the oxygen concentrator. The passengers and baggage had been moved away from this area and in the interest of safety the area was monitored.

The Purser and Senior Purser liaised with the Flight Deck and the Commander (2nd Pilot) was informed that the passengers were seriously injured but that it would not be necessary to divert as medical attention in Hong Kong on arrival would suffice. The passenger with a suspected broken neck was immobilized as per the crew training at door 3L and monitored.

Breakfast was served, this served not only to feed the passenger but as a means to revert back to normal ops and as confirmation that the Crew had everything under control.

1.19 Useful or effective investigation techniques

1.19.1 None.

2. ANALYSIS

2.1 Crew

2.1.1 The flight deck crew which consisted of the pilot-in-command, the senior 1st officer and the 1st officer were appropriately qualified to conduct the flight. The 1st Officer that occupied the left-hand seat in the cockpit activated the „Fasten Seat Belt‟ sign when clear air turbulence was encountered during cruise at FL370 over Kuala Lumpur Malaysia airspace. However, shortly thereafter, sudden negative G forces caused 3 cabin crew-members and 18 passengers that were not restrained by the safety belts to be flung upwards and impacted the overhead panels with their heads. According to the (P3) 1st officer ( PF) at the time, he did not deem it necessary to advise the cabin crew to take up their seats and secure their harnesses as the weather radar data did not indicate turbulence or moisture from the clouds to render such a decision.

2.1.2 The Cabin Crew Member Standard Operating Procedure Manual specifies that the

flight deck crew will make all announcements concerning the flight and any irregularities such as sudden heavy turbulence, they will also inform cabin crew to stop any service they might be busy with and to take up their seats and fastened


their harnesses. 2.1.3 It is not clear why the crew continued to Hong Kong when they had injuries on board

instead of landing at Puket-Malaysia.

2.2 Aircraft

2.2.1 Both the FDR and the CVR were removed and the data subsequently downloaded after coordination with the AIID in South Africa, the operator and the latter's representatives in Hong Kong. The Recorders were returned to the operator after the downloading was completed. The aircraft returned to South Africa on a ferry flight on 17 July 2014.

2.2.2 Flight data that was obtained from the FDR indicated that the aircraft was adversely affected by the clear air turbulence with vertical accelerations that reached peaks of +1.6g and – 0.5g over a period of eight (8) seconds. The energy was sufficient to initiate a significant attitude change in the vertical plane that resulted in the displacement of the two cabin crew members at the rear galley. According to an interview with the pilot flying, it would appear that the turbulence had much more profound effect in the aft section of the aircraft as they did not find it to be anything out of the norm in the cockpit at the time.

2.2.3 The 1st officer (P3) concluded that as he switched on the engine anti-ice, the over-speed warning sounded. He then pulled the speed knob to select the speed which was still normal. The speed trend vector increased to the limit which triggered the warning, and then the turbulence stopped. This is not consistent with facts, and in particular with the flight data recordings, since the speed did not exceed MMO 0.86, no red warning, no master caution, no master warning were recorded. It is likely that the audio-alert reported by the crew was actually a c-chord that was indicating a deviation in altitude from the flight path. Indeed, the alert triggers when the aircraft deviates for more than 200ft of the selected altitude. The A/C was flying at FL370, therefore the deviation would correspond to an altitude of 37200ft. Such a deviation occurred between GMT 01.12.46 and 01.12.57. An extract of the alert description and of the flight data recordings is provided in attachment. The altitude alert is not recorded in the flight data recordings which confirms the consistency of this hypothesis that may be confirmed by the crew.

2.2.4 The 1st Officer reported that the over-speed warning triggered. This is not consistent with facts, and in particular with the flight data recordings, since no red warning, no master caution, no master warning were recorded. It is likely that the audio-alert reported by the crew was actually a chord that was indicating a deviation in altitude from the flight path. An extract of the alert description and of the flight data recordings is provided in attachment. The altitude alert is not recorded in the flight data recordings which confirm the consistency of this hypothesis.

2.2.5 The damaged caused on the furnishings inside the aircraft is within the limits or specifics as required by the manufacturer. These furnishings are designed to resist to a vertical load of 20DaN on a surface of 80mm*80mm.Combination of high vertical acceleration, high weight, and limited surface contact, this figure was exceeded.


2.3 Environment

From the weather data obtained it is evident that clear weather conditions prevailed along the flight path within the Malaysian airspace, It was therefore concluded from the above statement and the enroute weather filed by the operator, that no significant adverse weather conditions was expected for the en-route flight within the area concerned. The „Fasten Seat Belt‟ sign was switched off by the flight deck crew at the time of the incident. In the absence of previous pilot reports, SIGMET reports, clear air turbulences are difficult or impossible to anticipate. The sudden increase of the turbulences did not leave sufficient time to all the crew members to restrain themselves.

3. CONCLUSION

3.1 Findings

3.1.1 The pilot-in-command was in possession of a valid Airline Transport Pilot Licence and had the aircraft type endorsed in his logbook.

3.1.2 The senior first officer, who was the PF this sector was in possession of a valid Airline Transport Pilot Licence and had the aircraft type endorsed in his logbook.

3.1.3 The first officer, who was the PNF this sector was in possession of a valid Airline

Transport Pilot Licence and had the aircraft type endorsed in his logbook. 3.1.4 The cabin crew members that sustained injury during the flight were in possession

of valid cabin crew licenses.

3.1.5 Neither of the three cabin crew members injured were seated nor restrained at the time the aircraft encountered the severe air turbulence as they were busy securing trolleys and bins in the rear galley area of the aircraft.

3.1.6 The CCM failed use the PA system direct to make the alert call in the cabin and did

not informed the passengers prior to landing that 3L door was a blocked exit. The cabin crew in the crew rest were also not called to come and assist with the occupants injured.

3.1.7 The CCM also failed to inform the cockpit of the burning smell in the cabin. 3.1.8 The aircraft was certified and maintained in accordance with existing regulation and

approved procedures. There were no pre-existing faults or conditions that contributed to the occurrence.

3.1.9 The flight data obtained from the Flight Data Recorder (FDR) indicated that, during the sequence of severe air turbulence‟ the vertical acceleration reached peak values of +1.6g and -0.5g over a period of; eight (8) seconds.

3.1.10 Recorded data indicate that the autopilot remained engaged and was kept engaged

by the pilot, as per SOP. 3.1.11 The flight deck crew indicated that at the time of the incident, the „Fasten Seat Belt‟

sign was switched off as they were cruising for more than 10 hours before they encountered the sudden severe air turbulence that resulted in injury to the cabin


crew members. 3.1.12 The flight deck crew and weather report from Malaysia indicated that it was clear

sky during the incident; the weather radar did not indicate turbulence or moisture in the clouds that deemed it necessary to instruct the cabin crew to take up their seats and fastened their harnesses.

3.1.13 The fact that the (P3) 1st Officer concluded that the over-speed warning was

triggered, is however, not consistent the with the facts, and in particular with the flight data recordings, since no red warning and no master caution or warning were recorded and that the airspeed did not approach the maximum operational VMO/ MMO. It is likely that the auto alert reported by the crew was actually a c-cord that was indicating a deviation in altitude from the flight path. An extract from the alert description and of the flight data recordings is provided as per attachment. The altitude alert is not recorded in the flight data recordings which confirm the consistency of this hypothesis that may be confirmed by the flight crew.

3.1.14 The crew continued to Hong Kong when they had injuries on board instead of

landing at Puket-Malaysia. 3.2 Probable cause:

3.2.1 The sudden severe clear air turbulence followed by negative G forces encountered, during cruise flight, caused 3 cabin crew-members and eighteen passengers being injured as they were not seated nor restrained at the time when the incident occurred.

4. SAFETY RECOMMENDATIONS

4.1 Action by operator: Now in dealing with the SOP, with SITA we have a developed TURB predictor which uplinks to the MCDU screen, for printing when requested. Crew type TURB, in the same fashion as UPDATE and the turbulence predictor is generated by SITA for all ensuing waypoints. This predictor runs off the WAFC TURB predictor, and is presented for all waypoints requested. SITA provide CAT and CB determined TURB. Crew make the request as and when required.

5. APPENDICES

5.1 Appendix 1 - Flight Plan.

5.2 Appendix 2 - Comments from state of manufacture (Airbus)

5.3 Appendix 3 – Actions by the operator


Appendix 1


Appendix 2




Appendix 3

Dear all,

If I recall this particular incident was a turbulence event experienced when the aircraft flew through

a 'needle' of towering cloud when eastbound to HKG.

Following the event SITA did a rapid screen of TURB in the area, and there was no reported CAT

or CB TURB evident.

Now in dealing with the SOP,

1) With SITA we have a developed TURB predictor which uplinks to the MCDU screen, for

printing when requested. Crew type TURB, in the same fashion as UPDATE and the turbulence

predictor is generated by SITA for all ensuing waypoints. This predictor runs off the WAFC TURB

predictor , and is presented for all waypoints requested. SITA provide CAT and CB determined

TURB. Crew make the request as and when required. This request had not been made on this

particular flight.

Manny Hetzler through the check Captain forum on A320's went through an education drive about

six months ago.

2) We have a TURB function on the weather radar, however it needs to be selected to WX +TURB,

which is only selected when required, as stated by the manufacturer. This function only works up to

40 Nm. If we have it on permanently it doubles the scan cycle rate. The weather radar generally

does not pick up these needle type clouds, as it is returning a water content.

My input, I think the shear rate value has little or no value on the flight plan, now that we uplink

winds into the FMS. SITA can modify that field and replace it with the WAFC determined TURB

value for CAT.

Documents

Section/division Form Number AIRCRAFT SERIOUS …caa.co.za/Accidents and Incidents Reports/1065.pdf · AIRCRAFT SERIOUS INCIDENT REPORT AND EXECUTIVE SUMMARY ... airspace when the