Incident Overview

Date: Wednesday 30 December 2015
Aircraft Type: Boeing 777-333ER
Owner/operator: Air Canada
Registration Number: C-FRAM
Location: 85 NM ENE of Anchorage, Alaska – ÿ Pacific Ocean
Phase of Flight: En route
Status: Unknown
Casualties: Fatalities: 0 / Occupants: 351
Component Affected: Aircraft Communications Addressing and Report System (ACARS) ? specifically, the system’s capacity to provide real-time flight condition data and alerts to the flight crew, particularly regarding turbulence intensity and potential hazards. Additionally, the aircraft?s communication protocols regarding turbulence warnings and advisories. The lack of sufficient information regarding turbulence levels communicated to passengers via announcements and flight deck displays.Aircraft Communications Addressing and Report System (ACARS) ? specifically, the system’s capacity to provide real-time flight condition data and alerts to the flight crew, particularly regarding turbulence intensity and potential hazards. Additionally, the aircraft?s communication protocols regarding turbulence warnings and advisories. The lack of sufficient information regarding turbulence levels communicated to passengers via announcements and flight deck displays.
Investigating Agency: TSBTSB
Category: Accident
On flight AC088, departing Shanghai to Toronto, the flight experienced a sudden and significant increase in turbulence over the southern coastal mountains of Alaska approximately two and a half hours before entering the area of known turbulence. The crew immediately initiated a precautionary measure of stopping the in-flight service and securing the cabin, leading to a series of injuries and a diversion to Calgary. The incident highlights a critical failure in preparedness and communication regarding turbulence, impacting passenger safety and potentially jeopardizing the aircraft’s operational integrity. The flight?s response, while prudent, was insufficient in anticipating and mitigating the potential consequences of the turbulence.On flight AC088, departing Shanghai to Toronto, the flight experienced a sudden and significant increase in turbulence over the southern coastal mountains of Alaska approximately two and a half hours before entering the area of known turbulence. The crew immediately initiated a precautionary measure of stopping the in-flight service and securing the cabin, leading to a series of injuries and a diversion to Calgary. The incident highlights a critical failure in preparedness and communication regarding turbulence, impacting passenger safety and potentially jeopardizing the aircraft’s operational integrity. The flight?s response, while prudent, was insufficient in anticipating and mitigating the potential consequences of the turbulence.

Description

A Boeing 777, operating as flight AC088, departed Shanghai, China at 11:23 UTC, travelling toward Toronto, Canada. The flight was planned for 13 hours and 40 minutes. About five hours into the flight, the flight crew received a meteorological information bulletin that forecasted an area of severe turbulence over the southern coastal mountains of Alaska. Approximately two and a half hours later, 35 minutes before entering the area of known turbulence, the first officer directed that the inflight service be stopped and that the cabin be secured. Seat belt signs were turned on, and several announcements were made in English, French and Mandarin, stating that the flight was approaching an area of turbulence and asking the passengers to fasten their seat belts. Despite these measures, many passengers were not wearing their seat belts when the flight encountered severe turbulence. During the turbulence encounter, 21 passengers were injured, one of whom sustained a serious injury. Once the turbulence subsided, first aid was provided on board the aircraft, as the flight diverted to Calgary, Alberta, Canada. Findings as to causes and contributing factors: – Air Canada flight 088 entered an area of moderate to severe turbulence that was caused by the jet stream traversing the southern coastal mountains of Alaska. – The acceleration forces encountered resulted in passengers who were not wearing seat belts contacting various furnishings and surfaces in the cabin causing a variety of injuries, including 1 serious injury. Findings as to risk: – If training material does not contain complete information pertaining to all of the factors that contribute to turbulence, then there is a risk that the best course of action will not be taken. – If flight crews and dispatchers do not receive all pertinent information relating to flight conditions, optimal decisions on a course of action may not be made, increasing the risk of exposure to adverse conditions. – If systems such as an aircraft communications addressing and report system are not utilized to their full capacity, then there is a risk that more detailed information about flight conditions will not be available. – If cabin lighting is not sufficiently bright, then there is a risk that cabin crew members will miss unfastened seat belts due to the lack of contrast of the seat belt material and concealment by blankets. – If there is no visual or audible indicator associated with not wearing a seat belt, then there is an increased risk of non-conformity with respect to seat belt use. – If seat belt announcements do not contain sufficient detailed information on anticipated turbulence, then there is a risk that passengers will not immediately comply and maintain compliance with an instruction to fasten seat belts. – If safety announcements made by cabin crew do not use language that conveys the expectation of compliance, there is a risk that passengers will perceive these announcements to be less authoritative, which may result in non-compliance. – If passenger safety briefings lack information on the effects turbulence can have on individual passengers, their possessions, and on others, then there is a risk that it will reduce the probability of seat belt use. – If passengers do not expect consequences and enforcement for non-seat belt use, passengers may not perceive the use of seat belts as mandatory, when so directed. – If the approach to improve seat belt use does not include an understanding of the cultural and social norms of passengers, education to increase awareness, improved attitudes and an associated enforcement program to ensure corresponding changes in behaviour, then there is a risk that passengers will not wear their seat belts. – If V-clamps are not installed using the proper procedure and torque, then there is a risk of V-clamp failure and subsequent partial loss of an air conditioning system and cabin pressurization. Other findings: – The Air Canada flight 088 flight crew’s decision to secure the cabin and reduce to turbulence penetration speed contributed to preventing significant numbers of injuries in the cabin and potential damage to the aircraft.

Source of Information

http://www.tsb.gc.ca/eng/rapports-reports/aviation/2015/A15F0165/A15F0165.asp, https://edition.cnn.com/2015/12/30/world/air-canada-flight-turbulence/index.html, https://www.nieuwsblad.be/cnt/dmf20151231_02044288, https://www.luchtvaartnieuws.nl/nieuws/categorie/2/airlines/voorzorgslanding-air-canada-vanwege-turbulentie, https://www.flightradar24.com/data/aircraft/c-fram/http://www.tsb.gc.ca/eng/rapports-reports/aviation/2015/A15F0165/A15F0165.asp, https://edition.cnn.com/2015/12/30/world/air-canada-flight-turbulence/index.html, https://www.nieuwsblad.be/cnt/dmf20151231_02044288, https://www.luchtvaartnieuws.nl/nieuws/categorie/2/airlines/voorzorgslanding-air-canada-vanwege-turbulentie, https://www.flightradar24.com/data/aircraft/c-fram/

Primary Cause

The rapid onset of severe turbulence, triggered by the jet stream traversing the Alaskan mountains, was the primary cause. The acceleration forces experienced by passengers not wearing seat belts, coupled with the insufficient preparation of the aircraft, significantly increased the risk of injury and potential damage to the aircraft.The rapid onset of severe turbulence, triggered by the jet stream traversing the Alaskan mountains, was the primary cause. The acceleration forces experienced by passengers not wearing seat belts, coupled with the insufficient preparation of the aircraft, significantly increased the risk of injury and potential damage to the aircraft.

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