Aviation Accident Summaries

Aviation Accident Summary MIA91LA005

CAPE CANAVERAL, FL, USA

Aircraft #1

N8923E

MCDONNELL DOUGLAS DC-9-31

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.

Probable Cause and Findings

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.

 

Source: NTSB Aviation Accident Database

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