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1 Severe turbulence is described as conditions in which abrupt changes in aircraft attitude and/or altitude occur,
aircraft may be out of control for short periods and usually with large variation in airspeed. Changes in
accelerometer reading greater than 1.0 ‘G’ at the aircraft’s centre of gravity. Occupants are forced violently
against seat belts. Loose objects are tossed about. (Ref. ICAO PANS-ATM Doc 4444)
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passengers were seated with their seat belts fastened. However, as the cabin crew were
serving meals along the aisles and galley areas they were not strapped in. Based on the
Digital Flight Data Recorder (DFDR) data, during the turbulence encounter, the cruising level
varied between FL 408 and FL 416. The aircraft experienced a rapid sequence of jolts that
resulted in various degrees of injuries to all twelve cabin crew members. Of the 236
passengers on board, three sustained minor injuries.
The accident occurred within the Manila Flight Information Region (FIR) where a tropical
depression had just moved to an area over the sea to the west of the Philippines, moving on a
track of west-northwest and was forecast to intensify over water. At the time of the accident,
the aircraft was deviating 6 NM to the right of Route M754 northbound at a position
approximately 160 NM to the west-northwest of the centre of the tropical depression.
After the accident, the aircraft was promptly accorded priority landing at Hong Kong. It
subsequently landed safely at Hong Kong International Airport (HKIA).
As the occurrence resulted in serious injuries, in the form of bone fractures, to persons on
board, it was classified as an aircraft accident. The Chief Inspector of Accidents therefore
ordered an Inspector’s Investigation be carried out in accordance with the Hong Kong Civil
Aviation (Investigation of Accidents) Regulations 1983.
The investigation concluded that the aircraft inadvertently flew into an area of turbulent
weather caused by strong convective activity associated with the tropical depression. Based
on the evidence as to the way in which the weather radar was operated, it was highly probable
that the flight crew were not presented with the optimum weather radar picture that would
have enabled a full appreciation of the intensity and extent of the weather in the vicinity of
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the aircraft. As a result, the deviation around weather was not initiated early enough, nor was
the deviation large enough to avoid the weather.
1. FACTUAL INFORMATION
1.1. History of the Flight
1.1.1. On 18 July 2003, a Hong Kong Dragon Airlines Airbus A330-342
aircraft Registration B-HYA, was operated on a flight from Hong
Kong to Kota Kinabalu and returned on the same day. The flight
crew reported for duty at 2245 UTC on 17 July 2003 at the HKIA.
After an uneventful flight to Kota Kinabalu, the aircraft, together
with the same crew, departed Kota Kinabalu at 0412 for Hong
Kong with a flight number of HDA060.
1.1.2. The weather conditions at the time were influenced by a Tropical
Depression ‘Koni’ situated over the sea 170 NM southwest of
Manila, moving west-northwest at 10 knots. Isolated and
embedded cumulonimbus clouds (CB) with cloud tops of FL 450,
associated with moderate or severe turbulence, were forecast
within 200 NM of the centre of the Tropical Depression. The
aircraft was tracking along Route M754 north bound (Area Route
Chart is given in Appendix 1) and would route through the
extensive cloud area associated with the Tropical Depression.
1.1.3. The aircraft was initially cleared to cruise at FL 370. Later on, the
flight crew requested and received approval to cruise at FL 410.
4
Prior to NOBEN, with yellow and green weather returns observed
on the radar, they requested permission from Manila ATC to
deviate 10 NM to the right of track for weather avoidance. At 0510,
shortly after commencing track deviation, the aircraft encountered
severe turbulence. (Appendix 2 depicts the aircraft track at around
the time of the turbulence encounter.)
1.1.4. The DFDR data showed that immediately before the turbulence
encounter, the aircraft was cruising at an indicated Mach Number
(M) 0.81. During the turbulence encounter, the speed increased
beyond M 0.86. The Maximum Operating Speed/Maximum
Operating Mach Number (Vmo/Mmo) overspeed warning was
triggered and the Autopilot disconnected. The flight level recorded
by the DFDR varied between FL 408 and FL 416.
1.1.5. At the time of the turbulence encounter, the cabin attendants were
serving meals to the passengers. They were thrown into the air,
some hitting their heads on the ceiling panels before falling back
onto the cabin floor, causing various degrees of injuries to all
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