44 Years ago today

fholbert

Mod's - Please don't edit my posts!
Status:Final
Date:Friday 25 May 1979
Time:15:04
Type:
Silhouette image of generic DC10 model; specific model in this crash may look slightly different

McDonnell Douglas DC-10-10
Operator:American Airlines
Registration:N110AA
MSN:46510/22
First flight:1972
Total airframe hrs:19871
Engines:3 General Electric CF6-6D
Crew:Fatalities: 13 / Occupants: 13
Passengers:Fatalities: 258 / Occupants: 258
Total:Fatalities: 271 / Occupants: 271
Ground casualties:Fatalities: 2
Aircraft damage:Destroyed
Aircraft fate:Written off (damaged beyond repair)
Location:Chicago-O'Hare International Airport, IL (ORD) (
N.gif
United States of America)
Crash site elevation:204 m (669 feet) amsl
Phase:Takeoff (TOF)
Nature:Domestic Scheduled Passenger
Departure airport:Chicago-O'Hare International Airport, IL (ORD/KORD), United States of America
Destination airport:Los Angeles International Airport, CA (LAX/KLAX), United States of America
Flightnumber:AA191

1684976052548.png


1684976093884.png



Narrative:
American Airlines Flight 191, a McDonnell-Douglas DC-10-10, crashed on takeoff from Chicago-O'Hare International Airport, Illinois, USA...

On the accident flight, just as the aircraft reached takeoff speed, the number-one engine and its pylon assembly separated from the left wing, ripping away a 3-foot (0.9 m) section of the leading edge with it. The combined unit flipped over the top of the wing and landed on the runway.[1]: 2  Robert Graham, supervisor of maintenance for American Airlines, stated:

As the aircraft got closer, I noticed what appeared to be vapor or smoke of some type coming from the leading edge of the wing and the number-one engine pylon. I noticed that the number-one engine was bouncing up and down quite a bit and just about the time the aircraft got opposite my position and started rotation, the engine came off, went up over the top of the wing, and rolled back down onto the runway... Before going over the wing, the engine went forward and up just as if it had lift and was actually climbing. It didn't strike the top of the wing on its way; rather, it followed the clear path of the airflow of the wing, up and over the top of it, then down below the tail. The aircraft continued a fairly normal climb until it started a turn to the left. And at that point, I thought he was going to come back to the airport.[9]
What was said in the cockpit in the 50 seconds leading up to the final impact is not known, as the cockpit voice recorder (CVR) lost power when the engine detached. The only crash-related audio collected by the recorder is a thumping noise (likely the sound of the engine separating), followed by the first officer exclaiming, "Damn!" at which point the recording ends. This may also explain why air traffic control was unsuccessful in their attempts to radio the crew and inform them that they had lost an engine. This loss of power did, however, prove useful in the investigation, serving as a marker of exactly what circuit in the DC-10's extensive electrical system had failed.[1]: 57 

In addition to the engine's failure, several related systems failed. The number-one hydraulic system, powered by the number-one engine, also failed but continued to operate through motor pumps that mechanically connected it to hydraulic system three. Hydraulic system three was also damaged and began leaking fluid but maintained pressure and operation until impact. Hydraulic system two was undamaged. The number-one electrical bus, whose generator was attached to the number-one engine, failed, as well, causing several electrical systems to go offline, most notably the captain's instruments, his stick shaker, and the slat disagreement sensors. A switch in the overhead panel would have allowed the captain to restore power to his instruments, but it was not used. The flight engineer might have reached the backup power switch (as part of an abnormal situation checklist—not as part of their takeoff emergency procedure) to restore electrical power to the number-one electrical bus. That would have worked only if electrical faults were no longer present in the number-one electrical system. To reach that backup power switch, the flight engineer would have had to rotate his seat, release his safety belt, and stand up. Regardless, the aircraft did not get any higher than 350 feet (110 m) above the ground and was only in the air for 50 seconds between the time the engine separated and the moment it crashed; time was insufficient to perform such an action. In any event, the first officer was flying the airplane, and his instruments continued to function normally.[1]: 52 

The aircraft climbed to about 325 feet (100 m) above ground level while spewing a white mist trail of fuel and hydraulic fluid from the left wing. The first officer followed the flight director and raised the nose to 14°, which reduced the airspeed from 165 knots (190 mph; 306 km/h) to the takeoff safety airspeed (V2) of 153 knots (176 mph; 283 km/h), the speed at which the aircraft could safely climb after sustaining an engine failure.[1]: 53–54 

The engine separation severed the hydraulic fluid lines that controlled the leading-edge slats on the left wing and locked them in place, causing the outboard slats (immediately left of the number-one engine) to retract under air load. The retraction of the slats raised the stall speed of the left wing to about 159 knots (183 mph; 294 km/h), 6 knots (6.9 mph; 11 km/h) higher than the prescribed takeoff safety airspeed (V2) of 153 knots. As a result, the left wing entered a full aerodynamic stall. With the left wing stalled, the aircraft began banking to the left, rolling over onto its side until it was partially inverted at a 112° bank angle (as seen in the Laughlin photograph) with its right wing over its left wing.

Since the cockpit had been equipped with a closed-circuit television camera positioned behind the captain's shoulder and connected to view screens in the passenger cabin, the passengers may have witnessed these events from the viewpoint of the cockpit as the aircraft dove towards the ground.[10][11]

The No.1 engine pylon failure during takeoff was determined to have been caused by unintended structural damage which occurred during engine/pylon reinstallation using a forklift. The engine/pylon removal and reinstallation were being conducted to implement two DC-10 Service Bulletins. Both required that the pylons be removed, and recommended that this be accomplished with the engines removed. The Service Bulletin instructions assumed that engines and pylons would be removed separately, and did not provide instructions to remove the engine and pylon as a unit. Additionally, removal of the engines and pylons as a unit was not an approved Maintenance Manual procedure.
The lack of precision associated with the use of the forklift, essentially an inability to perform the fine manipulations necessary to accomplish reinstallation of the engine/strut assembly, in combination with the tight clearances between the pylon flange and the wing clevis resulted in damage to the same part that had just been inspected.
Inspections of other DC-10 pylon mounts following the accident resulted in nine additional cracked mounts being identified.


Probable Cause:

PROBABLE CAUSE: "The asymmetrical stall and the ensuing roll of the aircraft because of the uncommanded retraction of the left wing outboard leading edge slats and the loss of stall warning and slat disagreement indication systems resulting from maintenance-induced damage leading to the separation of the no.1 engine and pylon assembly procedures which led to failure of the pylon structure.
Contributing to the cause of the accident were the vulnerability of the design of the pylon attach points to maintenance damage; the vulnerability of the design of the leading edge slat system to the damage which produced asymmetry; deficiencies in FAA surveillance and reporting systems which failed to detect and prevent the use of improper maintenance procedures; deficiencies in the practices and communications among the operators, the manufacturer, and the FAA which failed to determine and disseminate the particulars regarding previous maintenance damage incidents; and the intolerance of prescribed operational procedures to this unique emergency."
 
Last edited:
My dad was on 355 north bound and witnessed it, ironically he was heading to a meeting which lead to a party, where my parents met…
 
You don't know what you don't know until you know it.
Oh, that wasn't meant in a judgey sense. Just more like we can learn from their totally SOP-compliant mistake. Thing isn't flying? Reduce the AOA.

They did exactly what they were trained to do, almost millimetrically, and I honor them for it. I probably would have done the same, given the training of the time. Thing is, though, no matter how well you engineer the thing, someone has to fly it, And the only real reason we're still up there is to...fly it.
 
Oh, that wasn't meant in a judgey sense. Just more like we can learn from their totally SOP-compliant mistake. Thing isn't flying? Reduce the AOA.
Yeah. I guess this accident is the reason why no longer fly V2, we fly V2 or whatever speed we've attained or whatever the verbiage is.
They did exactly what they were trained to do, almost millimetrically, and I honor them for it. I probably would have done the same, given the training of the time. Thing is, though, no matter how well you engineer the thing, someone has to fly it, And the only real reason we're still up there is to...fly it.
This.
 
Yup. Their own trained profile killed them. The jet was flying, under control. Until they slowed down to meet the profile.

The excessive public transparency was bothersome too, and had detrimental unintended effects. It was a colossal screw-up when NTSB vice chair Elwood Driver gave a press briefing where he held up a broken engine pylon mount bolt that had been found on the runway where the engine had separated, thus implying that there was a structural deficiency of the DC-10 aircraft itself, rather than preserving that evidence integrity and following the evidentiary trail to where the true cause was found: a maintenance error in both operation as well as maintenance policy that resulted in the bolt fracture. Driver's extremely irresponsible action in front of the media with a singular piece of unanalyzed and uncorroborated evidence that was entirely inconclusive in and of itself as a stand-alone item, a seemingly minor action, had major implications to the DC-10 aircraft which were wholly unwarranted, and which severely damaged the reputation of that aircraft to such a degree from which it never was able to recover.

So yes, I have my own concerns with things I see the NTSB do. Things that the premier accident investigative body, Britain’s AAIB, or Air Accident Investigation Board, would never do.
 
Way too many victims of this crash.
The Chicago Tribune ran a story last year’s anniversary for 2022:


One story that really stood out was this poor woman. Her circumstances, her reason for the journey, her death, and the deaths of her family members that followed hers. Truly tragic, all around…



LD3TGMMZE5FBTLZWVBGRASTDIA.jpg






Kathleen Adduci (Homewood)​



From Michael Adduci, brother:

“Kathy was supposed to get married and the date was set for June 2 of that year, but it was called off. To take her mind off the wedding, my mom talked her into going to Hawaii with two other friends. They were Gail DeCastro and Rhonda DeYoung, who also perished. We ended up in church on the 2nd of June for Kathy — for her funeral.

She was a sweet and beautiful sister who had many friends. She was studying to be a nurse at South Suburban College at the time of the accident and needed a break from school and the heartbreak of the wedding being called off. I remember she had just bought a new Pontiac Firebird and I went with her to sign the papers and bring it home. She was so proud of it.

The devastation of the accident affected my family way beyond 1979. My mom was in remission from breast cancer and three months after the accident her cancer came back and she passed away in 1981. My father was heartbroken over losing two loved ones and committed suicide in 1997.

What I didn’t realize until the (memorial’s) dedication was there were families there who lost up to five family members at once. Now, that’s devastation, isn’t it?”
 
Last edited:
Way too many victims of this crash.
The Chicago Tribune ran a story last year’s anniversary for 2022:


One story that really stood out was this poor woman. Her circumstances, her reason for the journey, her death, and the deaths of her family members that followed hers. Truly tragic, all around…



LD3TGMMZE5FBTLZWVBGRASTDIA.jpg






Kathleen Adduci (Homewood)​



From Michael Adduci, brother:

“Kathy was supposed to get married and the date was set for June 2 of that year, but it was called off. To take her mind off the wedding, my mom talked her into going to Hawaii with two other friends. They were Gail DeCastro and Rhonda DeYoung, who also perished. We ended up in church on the 2nd of June for Kathy — for her funeral.

She was a sweet and beautiful sister who had many friends. She was studying to be a nurse at South Suburban College at the time of the accident and needed a break from school and the heartbreak of the wedding being called off. I remember she had just bought a new Pontiac Firebird and I went with her to sign the papers and bring it home. She was so proud of it.

The devastation of the accident affected my family way beyond 1979. My mom was in remission from breast cancer and three months after the accident her cancer came back and she passed away in 1981. My father was heartbroken over losing two loved ones and committed suicide in 1997.

What I didn’t realize until the (memorial’s) dedication was there were families there who lost up to five family members at once. Now, that’s devastation, isn’t it?”

One thing I have learned as I have gotten older is some people are cursed with incredibly bad luck... One of the passengers Leonard Stogel a music producer had also lost both his parents on American Airlines flight 1 in 1962 it was also bound for Los Angeles . What are the odds of that?

 
Back
Top