# NTSB MIA91LA005: Mcdonnell Douglas DC-9-31, N8923E, Cape Canaveral, FL, October 4, 1990

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Limited investigation · Final report
- Date: October 3, 1990, 20:08 local (Oct 4, 1990, 00:08 UTC)
- Place: Cape Canaveral, FL
- Location: 28.3932° N, 80.6048° W: Placed by OpenAirDocs: center of Cape Canaveral, FL, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=28.3932&lon=-80.6048&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal, 2 serious, 23 minor, 71 uninjured
- Status: Completed, report March 31, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 32780
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA91LA005
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32780/pdf
- Page: https://openairdocs.org/ntsb/MIA91LA005

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- In flight encounter with weather, cruise - normal
  - procedures/directives - not followed, pilot in command (cause)
  - procedures/directives - not followed, flight attendant (cause)
  - passenger briefing - not followed, passenger (cause)
  - weather condition - turbulence(thunderstorms) (contributing factor)
  - in-flight planning/decision - improper, pilot in command (cause)

## 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](https://openairdocs.org/deregistered/N8923E-2010-07-28), registration cancelled 2010-07-28, S/N 45838, built 1967 (OpenAirDocs)
- Reported make and model: MCDONNELL DOUGLAS DC-9-31
- Registry model: [Douglas DC-9-31](https://openairdocs.org/model/douglas-dc-9-31) (registry code 3022065) (OpenAirDocs)
- Registry engine: [Pratt & Whitney JT8D-1](https://openairdocs.org/engine/pratt-whitney-jt8d-1) (registry code 52044, turbo-jet) (OpenAirDocs)
- Category: Airplane
- Serial number: DC9-31
- Airframe hours: 48282
- Engines: P&W JT8D-7B 14000 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 49; 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 (OpenAirDocs).

- [Accident 19901003061859A](https://openairdocs.org/incident/19901003061859A), Oct 3, 1990: Doug DC931, Cape Canaveral, FL, 1 fatal. Turbulence near thunderstorm. Passenger hurt died day later. Passengers ignored seat belt sign.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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