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NTSB Report
October 4, 1990 · Mcdonnell Douglas DC-9-31 · N8923E
Cape Canaveral, FL
Overview
Report Status
Probable Cause
Event Type
Accident
Date
October 4, 1990
Injury Outcomes
26 injuries (1 fatality, 2 serious injuries, 23 minor injuries), 71 uninjured
Location
Cape Canaveral, FL
Aircraft
Mcdonnell Douglas DC-9-31
Tail Number
N8923E
Operator
Eastern Air Lines
Injuries
Fatal
NTSB Number
MIA91LA005
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.
NTSB 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.
Full Narrative
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.
Flight
Event TypeAccident
Event Time20:08 EDT
Nearest Airport0nm N
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo
Aircraft
AircraftMcdonnell Douglas DC-9-31
Tail NumberN8923E
Aircraft CategoryAir
OperatorEastern Air Lines
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsP&W · JT8D-7B · Turbofan · 14000
Seats99
People & Injuries
Injury Summary26 injuries (1 fatality, 2 serious injuries, 23 minor injuries), 71 uninjured
Fatal1
Serious2
Minor23
Uninjured71
Total97
Crew 1Age 49 · First Class
Conditions
ConditionsVMC
LightBright Night
Wind100° @ 10 kt, gusting 18 kt
Visibility3 sm
CeilingBroken clouds 2000 ft
Temperature / Dew Point0 C / 0 C
Altimeter30.10 inHg
Observation Time00:05
Weather SourceWFAC