1974 — Sep 11, Eastern Airlines Flight 212 Approach Crash in Fog, Charlotte, NC — 72

–72 Kimura. World Commercial Aircraft Accidents 3rd Ed., 1946-1993, V.1. 4-11-1994, p. 2-16.
–72 NTSB. AAR. Eastern Air Lines… N8984E, Charlotte, NC, Sep 11, 1974. May 23, 1975.

Narrative Information

NTSB: “About 0734 e.d.t., on September 11, 1974, Eastern Air Lines, Inc., Flight 212, crashed 3.3 statute miles short of runway 36 at Douglas Municipal Airport, Charlotte, North Carolina. The flight was conducting a VOR DME nonprecision approach in visibility restricted by patchy dense ground fog. Of the 82 persons aboard the aircraft, 11 survived the accident. One survivor died of injuries 29 days after the accident. The aircraft was destroyed by impact and fire.

“The National Transportation Safety Board determines that the probable cause of the accident was the flightcrew’s lack of altitude awareness at critical points during the approach due to poor cockpit discipline in that the crew did not follow prescribed procedures.” (NTSB-AAR-75-9; from NTIS Abstract)

“…Flight 212…operated as a scheduled passenger flight from Charleston, South Carolina, to Chicago, Illinois, with an en route stop at Charlotte…” (NTSB-AAR-75-9, 2)

“The accident occurred during daylight hours at 35″ 09′ 14″ N. latitude and 80° 55p 34″ W. longitude. Eleven persons who saw the aircraft just before the crash agreed that (1) the aircraft was much lower than those they were accustomed to seeing or hearing on this approach and (2) other than the low altitude and the loud engine noise associated with the flight, there was nothing unusual about the appearance of the aircraft….” (NTSB-AAR-75-9, 5)

“The aircraft struck the ground in an open field. The field was surrounded by dense woods and underbrush. At initial impact, the right wingtip struck and broke tree limbs about 25 feet above the ground. About 16 feet above the ground, the left wing struck and sheared a cluster of pine trees….

“As the aircraft continued 198 feet beyond the initial impact point, the left wingtip contacted the ground and made a m r k 18 feet long. After the aircraft had traveled 550 feet beyond the initial impact point, the left wing contacted other trees and the wing broke in sections; at this point, ground fire began and spread in the direction of travel of the aircraft until the aircraft came to rest. The right wing and right stabilizer were sheared off. The remainder of the aircraft — the fuselage and part of the empennage section — continued through a wooded area. The fuselage breakup was more severe in this area. The aircraft wreckage came to rest in a ravine 995 feet from the initial impact point….” (NTSB-AAR-75-9, 9)

“Of the 71 persons who died as a result of the accident, 31 passengers and 1 crewmember died of impact injuries. Twenty-five passengers died of burns and smoke inhalation; seven passengers died of burns only; one passenger died of smoke inhalation. The remaining five passengers and the flight attendant located in the aft section of the fuselage died because of a combination of factors. The passenger who survived the crash, but who died 29 days later, received impact injuries and severe burns….

“Survivors who had been wearing double-knit garments of manmade fibers reported that these materials melted, adhered to their skin, and could not be removed. One survivor stated that half of his burns were caused by the double-knit material….” (NTSB-AAR-75-9, 11)

“This was a partially survivable accident. Only a small section of the cabin, near the tail of the aircraft, retained its structural integrity. Most of the structure was destroyed and, in most cases, the occupant restraint system failed. Finally, fire occurred in the cabin during the breakup of the aircraft and continued to burn until extinguished by the fire department.

“All survivors in the rear of the aircraft were either thrown out of the wreckage or escaped through holes in the fuselage. The surviving passenger and the two surviving crewmembers in the front of the aircraft escaped through a cockpit window.

“The forward cabin entry door was found partially open but was blocked by a fallen tree. Because of the position of the wreckage, the ground blocked the forward galley door. The center fuselage overwing escape windows were destroyed by fire. The auxiliary exit in the tail of the aircraft was useable; however, it was not used for escape….” (NTSB-AAR-75-9, 12)

“The accident cannot be attributed to malfunctions of ground facilities, the aircraft, or its systems. Although there was a minor air traffic control deficiency concerning acknowledgement of receipt of ATIS information, ATC procedures were not involved i n the accident. Therefore, the Safety Board focused its analysis on the operational, weather, and human-factor aspects of the approach and the survivability of the accident….” (NTSB-AAR-75-9, 14)

“During the descent, until about 2 minutes and 30 seconds prior to the sound of impact, the flightcrew, engaged in conversations not pertinent to the operation of the aircraft. These conversations covered a number of subjects, from politics to used cars, and both crewmembers expressed strong views and mild aggravations concerning the subjects discussed. The Safety Board believes that these conversations were distractive and reflected a casual mood and lax cockpit atmosphere, which continued throughout the remainder of the approach and which contributed to the accident. The overall lack of cockpit discipline was manifested in a number of respects…where the flightcrew failed to adhere to recommended or required procedures….”

“It is noteworthy that at 0732:41, during the latter part of the discussion regarding Carowinds Tower, the terrain warning alert sounded in the cockpit, signifying that the aircraft was 1,000 feet above the ground. This warning should have been particularly significant to the flightcrew, if heeded, since it would have made them aware that the aircraft had pre-maturely descended through the FAF crossing altitude of 1,074 feet above touchdown elevation. Obviously, the crew was not so alerted, since the descent continued.. Based on pilot testimony taken at the hearing, it appears that the crew’s disregard of the terrain warning signal in this instance may be indicative of the attitudes of many other pilots who regard the signal as more of a nuisance than a warning. If this is indeed the case, the Board believes that airline pilots should reexamine their attitudes toward the terrain warning alert, lest the purpose for which the device vas installed be defeated. Although the repetitious sounding of the alarm may have a tendency to undermine its effectiveness, this accident points up the importance of devices designed to enhance altitude awareness at critical points in an instrument approach….

“The Board has been unable to determine the precise reason for the almost total lack of altitude awareness on the part of the crew throughout the approach….The most likely explanation of why Flight 212 was unable to establish visual contact with the runway environment, whereas other flights were able to do so and thereby complete the approach, is that Flight 212, flying at a lower altitude, initially entered the fog bank at a point farther from the runway threshold and thus had a greater slant-range distance through which to sight the runway markings through the fog….” (NTSB-AAR-75-9, 15-17)

“By virtue of training, experience, cockpit instrumentation, navigational aids, and approach plates, this crew was well equipped to accomplish the approach to Charlotte safely, and there is no causal factor beyond the flightcrew itself which would account for their failure to do so. This accident exemplifies the. absolute necessity of strict adherence to prescribed procedures, particularly those pertaining to altitude awareness, during an instrument approach….” (NTSB-AAR-75-9, 18)

“The weather in the Charlotte area was characterized by shallow, patchy ground fog such that VMC existed above the fog bank, but that visibility was drastically reduced within the fog….” (NTSB-AAR-75-9, 20)

Baron: In 1981 the FAA publishes the “Sterile Cockpit Rule:”

“The sterile cockpit rule was implemented to eliminate non-essential chatter between the pilots during critical phases of flight. A 1974 accident investigation by the NTSB revealed that distractions and discussions of non-relevant flight issues were causal factors leading to the crash of Eastern Airlines Flight 212 in Charlotte, North Carolina (NTSB, 1974). In that crash, 71 of 82 people lost their lives because the pilots were discussing politics rather than the plans for their approach to Charlotte Douglas Airport in bad weather. The new rule was to prevent this type of non-essential chatter below 10,000 feet and reads as follows:

Sec. 121.542 Flight crewmember duties.

(a) No certificate holder shall require, nor may any flight crewmember perform, any duties during a critical phase of flight except those duties required for the safe operation of the aircraft. Duties such as company required calls made for such nonsafety related purposes as ordering galley supplies and confirming passenger connections, announcements made to passengers promoting the air carrier or pointing out sights of interest, and filling out company payroll and related records are not required for the safe operation of the aircraft.

(b) No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft.

(c) For the purposes of this section, critical phases of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet, except cruise flight. [Note: Taxi is defined as “movement of an airplane under its own power on the surface of an airport.”]

[Doc. No. 20661, 46 FR 5502, Jan. 19, 1981]
(Source: U.S. Government Printing Office via GPO Access, 2004, 14CFR121.542).” (Baron, Robert. “The Cockpit, the Cabin, and Social Psychology,” AirlineSafety.com.)

Sources

Baron, Robert. “Cockpit Discipline,” Aero Safety World, December 2007, pp. 47-48. Accessed at: http://www.flightsafety.org/asw/dec07/asw_dec07_p47-48.pdf

Baron, Robert. “The Cockpit, the Cabin, and Social Psychology,” AirlineSafety.com. Accessed 4-9-2020 at: https://web.archive.org/web/20131204222509/https://airlinesafety.com/editorials/CockpitCabinPsychology.htm

Kimura, Chris Y. World Commercial Aircraft Accidents 3rd Edition, 1946-1993, Volume 1: Jet and Turboprop Aircrafts. Livermore, CA: Lawrence Livermore National Laboratory, Risk Assessment and Nuclear Engineering Group. 4-11-1994.

National Transportation Safety Board. Aircraft Accident Report. Eastern Air Lines, Inc., Douglas DC-9-31, N8984E, Charlotte, North Carolina, September 11, 1974. Washington, DC: NTSB, adopted May 21, 1975. Accessed 4-9-2020 at: https://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR75-09.pdf