Crash of American Flight 191

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Who can answer THIS trivia question. What happened to the maintenance supervisor who approved the non-standard method of remounting the engines?

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Just saw in the program....
Is he the one that suicided?
Carbon monoxide inhalators? huh?

I may be wrong...I forgot to tune in earlier to the show.

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I didn't get who that person was. He killed himself the day before he was going to answer questions?..............I think the show was sad. Everything that happened could have been prevented if AA took a little more time.
 
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I think this might be a little unfair. First of all American was known for top rate maintneance, back then and thtoughout their history. Secondly, this was a mistake, not a callous act. This method of raising the engine for mounting had been used before. Thirdly, I'm sure this mistake has ruined the lives of everyone involved, including the maintenance people who made it.

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AA used an unapproved method for attaching the engine/pylon (one unit) to the airframe, and it was done as a time-saving measure. This wasn't one of those one-time deals that someone thought up at the moment, it was a maintenance policy by AA that wasn't sanctioned by McDonnell Douglas.

On recovery of the engine/pylon assembly, it was discovered that there was a 10 inch fracture on the rear bulkhead on the pylon. 8 weeks before the accident, the aircraft went through a major check and the self aligning bearings on the bulkhead to wing attachment joints were changed. Normal procedures would involve removing the engine and pylon from the wing separately, by use of a special cradle to lower the engine, but to save on time, a new idea was adapted using a forklift truck to take the whole assembly off as one unit. This did not prove to be a good idea because of down travel on the forks. .
 
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Who can answer THIS trivia question. What happened to the maintenance supervisor who approved the non-standard method of remounting the engines?

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From what I remember, he committed suicide. Went home and shot himself I think. An AA pal told me this guy had watched it go down from the hangar and had a bad feeling about why and was overcome with guilt.

Didn't see then show, but I hear it was less like a good documentary and more like an inflammatory MSNBC reports segemnt.

AAs -10s were not the only ones to have cracks in their pylons waiting to cause this accident. After the DC-10s were grounded, Western & Continental also found fractures in theirs! They were using the same unapproved maintenance technique for removing the engine & pylon as one unit, and not seperately.


This link has some very detailed info on it

http://yarchive.net/air/airliners/dc10_ohare_crash.html
 
American Airlines had the evidence of bad maintenance in hand, yet destroyed a scathing internal report that described in-depth, those procedures.

Not surprising.
 
I saw the documentary, not from seeing this thread, but I was just flipping through channels and happened to catch it on. Pretty good I think, looking at the actual engine coming off the aircraft, and the small, non-engine related things that lead to the aircraft crashing.

United also had a DC-10 with a crack, which I think from the documentary is actually the one that grounded the DC-10 fleet after they found it.
 
Talking of sheared engines, wasn't there an ElAl 747 that lost both engines off 1 wing and ploughed into a tower block whilst being vectored back for an emergency landing at Amsterdam's Schipol?
 
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AA used an unapproved method for attaching the engine/pylon (one unit) to the airframe, and it was done as a time-saving measure. This wasn't one of those one-time deals that someone thought up at the moment, it was a maintenance policy by AA that wasn't sanctioned by McDonnell Douglas.

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"unapproved' by who? This method was not the one that MD recommended, but here's a news flash for you. The manufacturer is not the one that maintains the airplane throughout it's life, which is sometimes for decades. The airlines set the maintenance practices. In many cases practices set by the airlines then become recommended maintenance practices by the manufacturer. That's because so much is learned by having the airplane in service that is not known at the time it is designed and manufactured. The airlines are much more maintenance experts than the manufacturer because they do so much of it. And one of the things they try to do is find cost-effective methods. That's because airlines have to make money.

Continental and United also used this method. MD did not approve or disapprove it, it just wasn't their method. You can bet that FAA maintenance inspectors were aware of it, especially since it had been done by two other major airlines.

It was a mistake. And if there had not also been a design flaw in the DC-10 it would have only been a spectacular mistake instead of a deadly one.
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Talking of sheared engines, wasn't there an ElAl 747 that lost both engines off 1 wing and ploughed into a tower block whilst being vectored back for an emergency landing at Amsterdam's Schipol?

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As one of the guys on the documentary pointed out, separated engines is not that uncommon. I can remember an American 707 with only three engines hanging coming into STL for a fairly routine landing. DC-8s, DC-9s, 747s, 727s, 737s. I know of separated engine incidents on all these types that not only were not a problem, but in many cases the crew didn't know the engine was "gone" until they got on the ground.

Again, if the lift devices had stayed out on AA 191 they would have had a fairly routine return to ORD.
 
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[It was a mistake. And if there had not also been a design flaw in the DC-10 it would have only been a spectacular mistake instead of a deadly one.
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Disagree. Huge difference between a mistake and blatent cutting of corners. MD knew about the practice and let American know they didn't agree with it. AA decided to do it anyways and that's their perogative; there was nothing MD could do about that other than inform the FAA PMI at American. Now that they made that call, AA should live with the consequences and the responsibility that goes with creating your own procedures that were counter to the manufacturer's reccomendation. Period.

A mistake would be following the manufacturer reccommended procedure, but a mech forgets to hook up a bolt correctly, or something akin to that.

AA screwed up, plain and simple. The mistake was the pylon attach fitting getting broken during maintenance (mistake as in not intentionally broken), the situation that allowed this mistake to occur were faulty maintenance procedures devised as a corner-cutting idea in order to save maintenance time, and ultimately, save money.

As it always is, the almighty corporate buck came ahead of doing the right thing.
 
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I know of separated engine incidents on all these types that not only were not a problem, but in many cases the crew didn't know the engine was "gone" until they got on the ground.

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Okay, I'm not sure what you mean by "gone", but if an engine falls off of your airplane, I think you are going to notice it.
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I think Mike is hitting the nail on the head! It is all about the green backs! There are a lot of companies who have kept things quite, even unsafe things, in order to save money.
 
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As one of the guys on the documentary pointed out, separated engines is not that uncommon. I can remember an American 707 with only three engines hanging coming into STL for a fairly routine landing. DC-8s, DC-9s, 747s, 727s, 737s. I know of separated engine incidents on all these types that not only were not a problem, but in many cases the crew didn't know the engine was "gone" until they got on the ground.

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Had AA not been cutting corners with their maintenance, it's unlikely that the DC-10 in question would've had the damage it had. THAT damage caused a weak area that eventualy failed. When it did, the engine sheared away in an unbalanced manner that, IMO, wouldn't have occurred had this jet NOT had the maintenance-incurred damage it did. Without the damage, IMO, had the jet encountered a situation (say, heavy turbulance, for example) while airborne that was severe enough to cause the engine to separate, the engine would've separated as advertised, and not in the manner it did with 191.

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Again, if the lift devices had stayed out on AA 191 they would have had a fairly routine return to ORD.

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Agree. Crew was following established procedures for engine out and had no way of knowing the extent of the damage to the aircraft, or knowing that by following the established procedures, they were inadverently putting the aircraft in a bad position.

Tragic.
 
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I know of separated engine incidents on all these types that not only were not a problem, but in many cases the crew didn't know the engine was "gone" until they got on the ground.

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Okay, I'm not sure what you mean by "gone", but if an engine falls off of your airplane, I think you are going to notice it.
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I believe he means "gone" in the sense of performance. IE- the jet's flying capabilities and performance weren't extensively different that with 3 engines (on a 4 engine aircraft, for example).

Of course you'll know if you have a failed engine, or otherwise, but I do see his point.
 
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I know of separated engine incidents on all these types that not only were not a problem, but in many cases the crew didn't know the engine was "gone" until they got on the ground.

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Okay, I'm not sure what you mean by "gone", but if an engine falls off of your airplane, I think you are going to notice it.
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Obviously they knew they had an engine "out". I'm talking about the 727 and DC-9 where you can't really see the engine unless someone goes back and looks for it.

When you think about it losing the engine completely is the best scenario (if it doesn't hit anyone) Less weight and much less drag to contend with. Of course in single engine planes it's always fatal as the CG shifts to an uncontrollable point. So try to avoid that if possible.
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I believe he means "gone" in the sense of performance. IE- the jet's flying capabilities and performance weren't extensively different that with 3 engines (on a 4 engine aircraft, for example).

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Okay, I can see that... just sounded like they did not notice a failed engine until they landed.

"Hey Joe, wern't there four engines on this thing when we left L.A.?"
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[quoteAs it always is, the almighty corporate buck came ahead of doing the right thing.

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Well, at least you can feel better now that very few of the airlines are making any bucks.

Just so you know: In the industry for the last 7 or 8 decades the airlines establish their own maintenance practices. They probably differ from the manufactureres recommendations more than they agree with them. The airlines have their own engineers who evaluate the practices and approve or disapprove them, as happened in this case. That whole setup is approved by the FAA.

The practices often are much better than what the manufacturer reccomends. And they are often more efficient. This is because the manufacturer makes money selling airplanes. The airlines "try" to make money operating them. Different perspective.

It's easy to second-guess after the fact. But it appears almost every operator thought this practice was sound. Obviously it wasn't. If you don't want to fly or fly on airplanes that aren't being maintained exactly by the manufacturer's recommendations you'll need to stay away from US airlines. You could try to only fly airplanes that are new enough that they haven't had much maintenace yet.
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Just so you know: In the industry for the last 7 or 8 decades the airlines establish their own maintenance practices. They probably differ from the manufactureres recommendations more than they agree with them. The airlines have their own engineers who evaluate the practices and approve or disapprove them, as happened in this case. That whole setup is approved by the FAA.



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Fully agree. However when they do that (deviate) they open themselves up for the liability when nearly anything happens that can be related to that practice. AAs practice began the chain, so to speak, in this particular instance. In no way am I saying that AA knew what would happen to DC-10s, or even knew that their practice for engine changes could result in any damage, or could have any unforseen consequences; or that they were doing anything particulary wrong procedure-wise. All I'm saying is that they took the gamble by devising their own methods counter to manufacturer recommendations (which everyone does, and is perfectly lega), but when you do this, IMO, you just open yourself up, so to speak, to intense scrutiny, increased responsibility, and increased liability.
 
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All I'm saying is that they took the gamble by devising their own methods counter to manufacturer recommendations (which everyone does, and is perfectly lega), but when you do this, IMO, you just open yourself up, so to speak, to intense scrutiny, increased responsibility, and increased liability.

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Absolutely. Fortunately the majors have shouldered that responsibility pretty well, evidenced by the record. Honestly, it's a wonder to methat anyone ever goes in the business. The men that started the airlines were true giants.

That's why I fly for an airline, not own one. I'll take my responsibility one flight at a time.
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BTW, while the focus of the documentary was on the "faulty maintenace practices" and only looked at the design flaw at the end of the program, it took both factors to bring this plane down. I guarantee you that at the time pilots were more concerned about the asymmetric wing condition. Maintenance procedures are easy to correct. Design flaws are a little more expensive and involved. If not this incident with the engine, then some other deal would have come up to expose this engineering mistake. Then the full weight might have fallen on MD and not an AA maintenance supervisor.
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Maintenance procedures are easy to correct. Design flaws are a little more expensive and involved. If not this incident with the engine, then some other deal would have come up to expose this engineering mistake. Then the full weight might have fallen on MD and not an AA maintenance supervisor.
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Agree. IMO, the Mx supervisor shouldn't have shouldered the full responsibility for the maintenance practice. I can understand tremendous guilt he may have felt, but at his level, it was simply a mistake that happened. He didn't devise the company maintenance procedure, he and his crew were simply following it. His death was an additional and needless tragedy that came out of this accident.
 
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