MIA91LA005

NTSB accident investigation · Mcdonnell Douglas DC-9-31 · Cape Canaveral, FL · October 4, 1990

Accident · FatalLimited investigationFinal report
Date
October 3, 1990, 20:08 local (Oct 4, 1990, 00:08 UTC)
Place
Cape Canaveral, FL
Injuries
1 fatal, 2 serious, 23 minor, 71 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N8923EMcdonnell Douglas DC-9-31
Weather
Visual (VMC) · Night/bright
Status
Completed · report March 31, 1993
Report
Approved by Office Director
FAA report
19901003061859A
Case key
32780

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Failure of the captain to follow procedures, his improper in-flight planning/decision by allowing the aircraft to continue into the overhang (anvil) of a thunderstorm, failure of the passengers to abide by procedures/instructions concerning use of seat belts, and failure of the flight attendants to enforce the use of seatbelts. The weather condition (turbulence) was a related factor.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight encounter with weatherCruise - normal
Procedures/directives - not followedPilot in commandCause
Procedures/directives - not followedFlight attendantCause
Passenger briefing - not followedPassengerCause
Weather condition - turbulence(thunderstorms)Factor
In-flight planning/decision - improperPilot in commandCause

Analysis

Eastern airline flt 791 enctrd turbulence while en route at 31,000 ft as it flew thru the overhang of a thunderstorm. Flt thru overhangs was contrary to the company flt opns procedures. Three psgrs rcvd serious injuries & one of these (84 yrs old) died 20 days after the acdnt. The medical examiner listed the cause of death as 'aspiration pneumonia and pneumothorax due to blunt trauma due to commercial airline turbulence encounter.' Contributing to the death was 'occlusive coronary atherosclerosis.' Also, 23 psgrs rcvd minor injuries. According to flt attendants, all injured psgrs were either standing in the aisle or lavaratories or in seats without belts on. The seat belt sign had been on since departure; before departure, flt attendants had briefed the psgrs to remain seated with belts on at all times while the seat belt light was illuminated. Flt attendants indcd that they had not enforced the seat belt instruction.

Aircraft

Registration
N8923E
Reported as
Mcdonnell Douglas DC-9-31
Category
Airplane
Serial number
DC9-31
Airframe hours
48,282
Engine
P&W JT8D-7B, 14,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Eastern Air Lines, doing business as Eastern Air Lines
Registered owner
Eastern Airlines
Airworthiness certificate
Standard, Transport
Last inspection
AAIP · October 1, 1990 · 10 hours before
Departed
DCA · Washington, DC
Destination
PBI · West Palm Beach, FL
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
49
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
12,275 total · 597 in this make and model · 597 as pilot in command · 188 in the last 90 days · 57 in the last 30 days · 7 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/bright
Wind
100° at 10 knots, gusting 18
Visibility
3 statute miles
Lowest ceiling
2,000 ft broken
Altimeter
30.10 inHg
Observed at
X68, 4 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.