American Airlines Flight 191

American Airlines Flight 191

Flight 191, its No. 1 engine severed on the runway, in an unrecoverable bank just moments before the crash.
Occurrence
Date	May 25, 1979
Summary	Engine separation
Site	Chicago, Illinois
Aircraft type	McDonnell Douglas DC-10-10
Operator	American Airlines
Registration	N110AAdisaster
Flight origin	O'Hare International Airport
Destination	Los Angeles International Airport
Passengers	258
Crew	13
Fatalities	273 (2 on ground)
Injuries	2 (on ground)
Survivors	0

This article is about the American Airlines flight. For the Delta Air Lines flight of the same number, see Delta Air Lines Flight 191.

American Airlines Flight 191 was a flight originating from O'Hare International Airport in Chicago, Illinois and destined for Los Angeles International Airport in Los Angeles, California, serviced by a McDonnell Douglas DC-10 aircraft. On May 25, 1979, Flight 191 crashed, killing all 271 on board and two on the ground. AA 191 is the deadliest accidental airplane crash on U.S. soil.

Accident

On takeoff from O'Hare the plane carried 258 passengers and 13 crew members. The captain was veteran Walter Lux, his first officer was James Dillard, and the flight engineer was Alfred Udovich. At 15:02 CDT, the aircraft began its takeoff down Runway 32R (Right).

Shortly before the takeoff rotation began, with 6,000 feet of runway covered, tower controllers witnessed the number one engine (left wing) separate from the aircraft and fly up and over the wing to crash onto the runway. The aircraft continued in a normal climb momentarily to around 350 feet (AGL), as fuel and leaking hydraulic fluid spewed in a vapor trail behind the plane. Such an incident is theoretically survivable in a DC-10; the shift in center of gravity and mean aerodynamic chord were within tolerances, and the aircraft could have landed safely if the engine loss had not caused other failures. In subsequent flight simulation testing, only pilots who were aware of Flight 191's specific problems were able to recover successfully from the stall.

Flight 191's final resting place. Damaged mobile homes can be seen to the right. Two occupants of these homes were killed.

The pilots aimed to reduce speed from 165 knots to the recommended engine-out climb speed of 153 knots, but the engine separation had severed the hydraulic lines that controlled the aircraft's leading-edge wing slats (retractable devices that decrease a wing's stall speed during takeoff and landing). Further, the missing engine supplied the electricity to the captain's instruments — notably stall warning, slats disagreement, and stick shaker, which were only available to the captain and not replicated in the first officer's instruments. To reach a backup power switch the flight engineer would have needed to rotate his seat, release his safety belt and stand up, part of the abnormal situation routines, not the take-off emergency procedure. This meant that the pilots were unaware of the aircraft's true configuration. DC-10 aircraft engines are not visible from the cockpit windows and the control tower did not inform the flight crew of what they had seen.

As the hydraulic fluid bled away, the slats retracted on the left wing, raising that wing's stall speed from 124 knots to around 160 knots, resulting in a significant loss of lift. As the pilots slowed the aircraft the left wing stalled, and with the right wing still providing lift the aircraft quickly entered an uncontrollable 112-degree left bank and pitched nose-down from around 325 feet, slamming into an open field approximately 4,600 ft from the end of the runway northwest of the airport at 15:04 CDT after about 31 seconds in the air. The plane struck an abandoned hangar, but the site was mostly an empty field north of Touhy Avenue and just east of a mobile home park. With a full load of fuel, the crash generated a huge fireball causing a plume of smoke so large it could be seen from the Downtown Chicago Loop. The aircraft disintegrated and burned, and all 271 people on board were killed during the impact and explosion. In addition some wreckage was thrown into the nearby mobile home park killing two residents and seriously injuring two others.

Although the plane's cockpit voice recorder was powered by the severed number #1 engine, it picked up one of the crew saying "..Damn.." before recording ceased. The control tower radioed the cockpit when they witnessed the engine separation just after take-off, but the crew didn't answer as they were too busy trying to save the aircraft. The clip begins with the controller talking without transmitting on the frequency: "Look at this, look at this, he blew off an engine. Equipment, I need equipment, he blew an engine. Oh, shit." The controller then transmitted, "And American one, uh, ninety-one heavy, you wanna come back and to what runway?" Without keying the mic, the controller can be heard: "He's not talkin' to me ...yeah, he's gonna lose a wing. There he goes, there he goes..."

The disaster and investigation was quickly and thoroughly covered by the media assisted by new news gathering technologies. The public impact of the accident was increased by dramatic amateur photos taken of the incident, which were published on the banner of the Chicago Tribune the following day.

At the time, American Airlines allowed passengers to watch their aircraft takeoffs and landings onboard the aircraft on closed-circuit television. It is not known whether passengers were able thus to see the crash occurring. One Michael Laughlin from Toronto actually filmed the flight and crash through a window at the O'Hare terminal. The destination airport, Los Angeles International, was careful to keep the arriving media away from passenger relatives who were waiting for Flight 191.

NTSB investigation

See also: Joe White

An FAA diagram of the DC-10 engine and pylon assembly indicating the failed aft pylon attach fitting.

The crash of flight 191 brought fierce criticism from the media because it was the fourth fatal accident involving a DC-10 at the time. 622 people had died in DC-10 accidents, including flight 191. As the weather was perfect for flying and there was no indication that a flock of birds or another plane caused the crash, the remains of engine #1 raised serious concerns of the safety of the DC-10. The separated engine was not the only concern, as the public wanted to know whether the detached engine was the only cause of the crash. Investigators wondered if a fire was possibly the cause, as this was backed up by testimony from the air traffic controller who said he saw a 'flash' from the wing. This raised concerns that 191 was the result of a terrorist attack. Sixty witnesses who saw the plane on the runway ruled out a bomb, as they all saw engine #1 swing forward then flip up and over the top of the wing, which pointed to structural failure as the cause. 165454656498465 The findings of the investigation by the National Transportation Safety Board (NTSB) were released on December 21, 1979. It revealed the probable cause to be attributable to damage to the left wing engine pylon that occurred during an earlier engine change at American Airlines's aircraft overhaul facility in Tulsa, Oklahoma. Evidence came from the flange, a critical part of the pylon assembly. It was revealed to be damaged before the crash, and investigators looked at the planes maintenance history and found it was serviced eight weeks before the crash. The pylon was damaged due to an ill thought-out engine removal procedure, conceived of and approved by then AA maintenance director Joe Leonard who is now Chairman, Chief Executive Officer, and President of AirTran Holdings, the parent company of AirTran Airways. The original procedure called for removal of the engine prior to the removal of the engine pylon. To save time and costs, American Airlines, without the approval of McDonnell Douglas, had begun to use a faster procedure. They instructed their mechanics to remove the engine with the pylon all together as one unit. A large forklift was used to support the engine while it was being detached from the wing. This procedure was extremely difficult to execute successfully, due to difficulties with holding the engine assembly straight while it was being removed.

The procedure used for maintenance did not proceed smoothly. If the forklift was in the wrong position the engine would rock like a see-saw and jam against the pylon attachment points. The forklift operator was guided by hand and voice signals the position had to be spot-on or could cause damage, but management was unaware of this. The modification to the aircraft involved in flight 191 didn't go smoothly; engineers started to disconnect the engine and pylon but changed shift halfway through; when work continued, the pylon was jammed on the wing and the forklift had to be re-positioned. This was important evidence because to disconect the pylon from the wing a bolt had to be removed to disconnect it so that the flange could strike the clevis. The procedure used caused an indentation that damaged the clevis pin assembly, and create an indentation in the housing of the self-aligning bearing, which in turn weakened the structure sufficiently to cause a small stress fracture. The fracture went unnoticed for several flights, getting worse with each flight that the plane had taken. During flight 191's takeoff, enough force was generated to finally cause the pylon to fail. At the point of rotation, the engine detached and was flipped over the top of the wing. The Captain proceeded with the take-off, which was standard procedure.

The loss of the engine by itself should not have been enough to cause the accident. During an interview on seconds from disaster, an investigator mentioned there were other incidents where the engine fell off, yet they landed without incident. Flight 191 would have been perfectly capable of returning to the airport using its remaining two engines as the DC-10 is capable of staying airborn with any two engines out of operation. Unfortunately, several other factors combined to cause a catastrophic loss of control.

The separation of the engine severed electrical wiring and hydraulic lines which were routed through the leading edge of the wing. The damage to the lines caused a loss of hydraulic pressure, which in turn led to uncommanded retraction of the outboard slats in the port wing. The DC-10 design included a back-up hydrolic system which should have been enough to keep the slats in place, however both lines are kept too close together, a design used on the DC-9. There was still enough fluid to keep the slats normal nevertheless, so investigators wanted to know why the pilot never re-extended them, the answer came from the ending of the CVR, the number 1 engine powered the recorder and the Slat Warning System which left Dillard with no idea of the slats position. Investigators explored the FDR to see what he did after the engine came off, the procedure called to go to V2 which he did perfectly, but investigators find it said nothing about if the speed was already above V2 as was in this case, so he had to reduce speed, simulator tests were done to see if this made a difference, 13 pilots followed the procedure 70 times and not one saved the aircraft, the NTSB concluded reducing speed when the slats are back is the worst thing to do. However one more mystery was to be solved even if there were flaws in the procedure there was one more device which should have saved the plane, when a DC-10 is about to stall it makes a dual-warning the first is the stick-shaker which causes the yolk to vibrate in addition a light flashes, this combined warning should have alerted the pilots to increase speed immediately. But because when American Airlines chose to only have the sick-shaker on the pilots side only Captain Lux had one which wasn't working, there was a back-up supply for engineer Alfred Udovich to turn on, but for him to do it during take-off was impossible because he was belted to his seat.

The DC-10 hit the ground with a bank of 112°, and at a nose down attitude of 21°. The NTSB concluded that given the circumstances of the situation, the pilots could not be reasonably blamed for the resulting accident.

This method of engine-pylon removal saved man hours and was encouraged despite the manufacturer issuing bulletins that specified how the procedure should have taken place. These were not binding. The accident investigation also concluded that the design of the pylon and adjacent surfaces made the parts difficult to service and prone to damage by maintenance crews. According to the History Channel programme "Crash of Flight 191", United Airlines and Continental Airlines were also using a one-step procedure. After the accident, cracks were found in the bulkheads of DC-10s in both fleets.

In his book Blind Trust, John J. Nance argues that the 1978 Airline Deregulation Act caused havoc and induced cost-cutting in the industry producing a serious erosion of the margin of safety for passengers. Nance argues that the industry "reverted from an industry under partial surveillance to an industry running on the honor system..".

Aftermath

First responders survey the Flight 191 crash site in Des Plaines, Illinois.

Problems with DC-10s were discovered as a cause of the accident, including deficiencies in both design specifications and maintenance procedures which made damage very likely. Since this tragedy happened just before a Western Airlines DC-10 crashed in Mexico City and six years after a Turkish Airlines DC-10 crashed in Paris, the FAA quickly ordered all DC-10s to be grounded until all problems were solved. The result of the problem-solving was an arguably more efficient and safe DC-10.

The US government fined American Airlines $500,000 for improper maintenance procedures, but the insurance settlement for the replacement of the aircraft gave American Airlines $25,000,000 beyond the fine amount..

Although the company's employees participated in an "I'm proud of the DC-10" campaign, McDonnell Douglas shares fell more than 20% following the crash of Flight 191. Several decades later, the company was taken over by its rival, Boeing.

Despite the safety concerns, the DC-10 went on to outsell its closest competitor, the Lockheed L-1011, by nearly 2 to 1. This was because the DC-10 went into service earlier and had a greater choice of engines (the L-1011 was only available with Rolls-Royce engines, while the DC-10 could be ordered with General Electric or Pratt & Whitney engines).

Victims

Itzhak Bentov, the celebrated biomedical inventor (the cardiac catheter), New Age author (Stalking the Wild Pendulum and A Cosmic Book) and kundalini-researcher was one of the crash victims.

Another victim was author Judith Wax, who perished along with her husband, Sheldon Wax. Judith was a frequent contributor to Playboy magazine (of which Sheldon was managing editor), notably the annual "Christmas cards" piece that "presented" short satirical poems to various public figures. It was reported at the time that in her 1979 book Starting in the Middle, she had talked about her fear of flying and that her comments appeared on Page 191. The magazine's fiction editor Vicki Haider also lost her life in the crash.

Several victims were members of the American Booksellers Association on their way to its annual convention at the Los Angeles Convention Center where they were to have a joint party organised by Playboy founder Hugh Hefner.

Actress Cyd Charisse's daughter-in-law, Sheila Charisse, was also a victim of the crash.

Close calls and premonitions

Actress Lindsay Wagner, TV's Bionic Woman, was scheduled to fly on the ill-fated plane, but she felt uneasy about it just prior to boarding. As a result, Wagner decided to skip the flight and catch a later one instead, a decision that saved her life.[1]

Power-pop band Shoes were also scheduled to be on the flight, but at the last minute switched to another flight scheduled for the following Tuesday. [2]

Arthur C. Clarke's World of Strange Powers reports the case of David Booth. In 1979, he had a series of recurring premonitory dreams that tormented him for ten consecutive nights. He saw a plane take off from an airport, bank steeply and then crash. On 22 May he called the FAA at Greater Cincinnati International Airport, American Airlines, and a psychiatrist at University of Cincinnati. The authorities took him seriously — the FAA had guessed from Booth's description that the plane was a DC-10 — but they could do nothing about it. The accident occurred three days after Booth's dreams in almost exactly the way Booth envisioned. Leonard Nimoy's documentary TV series In Search Of... featured an episode entitled Air Disaster Predictions which covered the case of Flight 191 and its possible prediction by Booth.

History and media

The crash in Chicago remains the most deadly single-aircraft accident in United States history. Another flight with the same number, Delta Air Lines Flight 191, crashed at Dallas/Fort Worth International Airport in 1985. Most recently, Delta Air Lines Flight 5191, operated by Comair as Flight 191, crashed in 2006 killing 49 people. All three carriers have since retired the flight number 191, as is currently customary after major accidents on most airlines. In addition, Puerto Rican airline Prinair also had a fatal flight numbered Flight 191. The only fatal X-15 crash was also Flight No. 191.

The cable/satellite TV channel The History Channel produced a documentary on the crash..

The Bible & Literature Missionary Foundation issued a 1979 pamphlet by Kenny McComas titled The Sad Fate of Flight 191.

This crash was mentioned by the character Casey Singleton in Michael Crichton's Airframe.

An episode of Cold Case Files also featured the crash of Flight 191. The episode concerned a man who blamed a woman's death on this plane crash, but she was never listed to be on the plane.

The episode from Seconds From Disaster titled "Chicago Plane Crash" (also known as "Flight Engine Down") detailed the crash of Flight 191.

Following the crash and the media attention towards the DC-10, American Airlines replaced all "DC-10 LuxuryLiner" titles with a more generic "American Airlines LuxuryLiner".

See also

• List of accidents and incidents on commercial airliners

References

• Nance, John J., Blind Trust, William Morrow & Co, 1987. ISBN 0-688-05360-2
• Seconds From Disaster: "Flight Engine Down" on National Geographic Channel.

External links

• Aviation-Safety.net report on the disaster
• NTSB (National Transportation Safety Board) Report (pdf)
• FAA "Public Lessons Learned from Accidents -American Airlines Flight 191"
• Article on a journalist's investigation of DC-10 aircraft and the Flight 191 crash
• Ghost of the Prairie - Lingering Spirits of Flight 191
• PlaneCrashInfo.Com - American Airlines Flight 191
• Chicago Public Library article on Flight 191
• Flight 191 Remembered (FOX Chicago website)
• Google Maps image of the crash site

42°0′35″N 87°55′48″W