Accident at Charlotte, North Carolina, 11 Sept 1974

Accident narrative

On September 11, 1974, at about 0734 eastern daylight time, Eastern Air Lines Flight 212 crashed 3.3 statute miles short of runway 36 at Douglas Municipal Airport in Charlotte, North Carolina. The Douglas DC-9-31 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 later. The aircraft was destroyed by impact and fire.

### The flight

Flight 212 was a scheduled passenger flight from Charleston, South Carolina, to Chicago, Illinois, with an en route stop at Charlotte. The flight departed Charleston at 0700 with 78 passengers and four crewmembers on board.

The crew was certificated and qualified for the flight. Captain James E. Reeves had accumulated 8,876 flight-hours as pilot-in-command, including 3,856 hours in the DC-9. First Officer James M. Daniels, Jr., who was flying the aircraft, had 3,016 flight-hours, including 2,693 hours in the DC-9.

### The approach

Between 0721 and 0725, the cockpit voice recorder (CVR) recorded the Charlotte Airport Terminal Information Service (ATIS) broadcast. The weather information included a partial obscuration, an estimated ceiling of 4,000 broken, and visibility of 1.5 miles in ground fog.

At 0725:18, Charlotte Approach Control provided vectors to the final approach course for runway 36 and cleared the flight to descend to 6,000 feet. The captain acknowledged the clearance and completed the in-range checklist. From shortly after this checklist until 0731:07, the flightcrew engaged in conversations on several nonoperational subjects, interrupted only by radio calls and sounds similar to the pitch trim.

At 0731:09, the final controller cleared the flight for the VOR 36 approach. An altitude alert sounded as the flight data recorder (FDR) showed the aircraft approaching 3,000 feet. Five seconds later, the captain pointed out Carowinds Tower, an amusement park observation tower located near the approach path.

The captain stated, "Ross, five point five, eighteen hundred. Ross Intersection was the final approach fix, located 5.5 nautical miles from the Charlotte VOR, with a minimum crossing altitude of 1,800 feet above sea level (1,074 feet above the touchdown zone).

The captain again mentioned Carowinds Tower, initiating a 35-second discussion about it. During this conversation, at 0732:41, the steady tone of the terrain warning sounded, indicating the aircraft was 1,000 feet or less above the ground. The aural warning was silenced.

At 0733:12, one crewmember said, "Three ninety-four," which corresponded to the minimum descent altitude above touchdown elevation for the approach. The captain said, "There's ah, Ross. Now we can go down." The first officer requested 50 degrees of flaps. At that time, the FDR showed the aircraft's altitude was about 1,480 feet.

At 0733:36, the captain advised Charlotte Tower they were by Ross Intersection, and the local controller cleared the flight to land. The captain said, "All we got to do is find the airport. The first officer answered "Yeah". About one-half second later, both pilots shouted, and the CVR recorded the initial impact.

### What the investigation found

The aircraft struck small trees and impacted a cornfield about 100 feet below the airport elevation. It then struck larger trees, broke up, and burst into flames. The wreckage came to rest in a ravine 995 feet from the initial impact point.

The Board found no evidence of an in-flight fire, explosion, or bird strike. The aircraft's powerplants, airframe, flight controls, and systems were not factors in the accident. Both engines showed evidence of rotation at impact, and all observed fractures were typical of overload. Postaccident flight checks of the VORTAC facility showed no malfunctions.

The investigation focused on the operational and human-factor aspects of the approach. The Board noted that the nonoperational conversations during the descent reflected a casual mood and lax cockpit atmosphere. This lack of discipline continued throughout the approach, during which the crew failed to adhere to prescribed procedures.

The 35-second discussion of Carowinds Tower occurred as the aircraft descended through 1,800 feet. The Board noted that the crew's attention was directed outside the cockpit, and they did not heed the terrain warning alert that sounded during this period. The aircraft passed over the final approach fix at an altitude of 1,350 feet—450 feet below the prescribed crossing altitude—and at an airspeed of 168 knots, well above the recommended speed of 122 knots. The captain did not make required callouts at the final approach fix, at 500 feet above field elevation, or at 100 feet above the minimum descent altitude.

The Board analyzed the crew's altimeter setting procedures. Eastern Air Lines procedures required the primary altimeters to be set to QFE (height above field elevation), while the captain's secondary altimeter was set to QNH (height above sea level). When the captain briefed the final approach fix crossing altitude as "eighteen hundred," he used the mean sea level figure rather than the QFE figure of 1,074 feet. The Board believed it was possible the first officer accepted the 1,800 feet as a QFE figure, leading him to believe the aircraft was higher above the field elevation than it actually was. However, the Board stated that the crew was well equipped to accomplish the approach safely, and there was no causal factor beyond the flightcrew itself.

The Board determined this was a partially survivable accident. The occupiable area of the cabin was compromised, the occupant restraint system failed in many instances, and an intense postimpact fire consumed much of the cabin. The Board also noted that survivors wearing double-knit garments of manmade fibers reported that the materials melted and adhered to their skin, increasing the severity of their burns.

### Probable cause

The National Transportation Safety Board determined 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."