11/11/2016 LessonsLearned

AmericanAirlinesDC10atChicago
AccidentOverview
AccidentBoardFindings
AccidentBoardRecommendations
RelevantRegulations
PrevailingCultural/OrganizationalFactors
KeySafetyIssue(s)
SafetyAssumptions
Precursors
ResultingSafetyInitiatives
AirworthinessDirectives(ADs)Issued
CommonThemes
RelatedAccidents/Incidents
LessonsLearned

AccidentOverview

PhotoofAmericanAirlinesFlight191,DC10

PhotoofChicagoDC10crashsite

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AmericanAirlinesFlight191,aDC10,experiencedanumber1(leftwing)engine/strutfailure,andsubsequentengineand
strutseparation,ontakeofffromChicago,O'HareAirportonMay25,1979.Duringrotation,theleftengineandstrut
assembly,andaboutthreefeetofwingleadingedge,separatedfromthewingasasingleunit,wentoverthetopofthewing,
andfelltotherunway.Thetakeoffcontinued,thepilotsassumingthattheyhadexperiencedanenginefailure,unawarethatthe
leftengineandpylonassemblyhadseparatedandfallenofftheairplane.Compoundingthedevelopingproblems,thepylon
separationalsoseveredhydrauliclines,causingalossofassociatedhydraulicpressureandretractionofallslatsoutboardof
theleftengine.

Theseparationoftheleftenginealsocausedthelossofelectricalpowerprovidedbythatengine'selectricalgenerator.This
resultedinthelossofmanyaircraftsystemsandinstruments,includingthecaptain'sflightinstruments,theleftstallwarning
computer,thestickshaker(stallwarning)motor,number1engineinstruments,theslatdisagreewarningsystem,andpartsof
theflightcontrolindicatingsystem.

Theairplaneclimbedtoapproximately300feetwithwingslevel,thenbegantoturnandrollleft,withbankangleincreasingto
approximately90degrees.Duringtheroll,thenosealsopitcheddown,andtheairplanebegantodescend.Theairplane
continuedtoroll(112degreesofrollatimpact)andcrashedinatrailerparkneartheairport.All271passengersandflight
crewandtwopersonsonthegroundwerekilled.Additionally,twopersonsonthegroundreceivedseriousinjuries.

FlightPath

Approximatelyonesecondpriortoliftoff,theleftengineandstrutassemblyseparatedfromtheairplane.Theairplanehad
acceleratedthroughtheengineoutclimbspeed,V2,aspeednormallyachievedatapproximately35feetabovetheground,
whilestillontheground,andliftedoffatV2+6knots.Theairplaneliftedoffslightlyleftwingdown,andwascorrectedback
towingslevelflightviaappropriateflightcontrolinputs.Theairplanecontinuedtoclimbwingslevel,andaboutnineseconds
afterliftoff,theairplanehadacceleratedto172knotsandreached140feetofaltitude.Astheclimbcontinued,theairplane
begantodecelerateatarateofaboutoneknotpersecond,andat20secondsafterliftoff,andanaltitudeof325feet,airspeed
hadbeenreducedto159knots.Atthispoint,theairplanebegantorolltotheleft,counteredbyrudderandaileroninputs.The
airplanecontinuedtorolluntilimpact,31secondsafterliftoff,andina112degreeleftroll,and21degreenosedownpitch
attitude.

ClickonthislinktoviewanaerialphotographofO'HareAirportandsurroundingareas.Thecrashsiteisintheupperright
portionofthephotograph,betweenthegreenareanorthoftherunwayandthefueltankfarmatuppercenter.

PhotoofChicagoDC10crash
TheNTSBconcludedthattheairplanewasbeingflowninaccordancewithAmericanAirline'senginefailureprocedures.
Immediatelyafterliftoff,apitchattitudeof14degreeswasattainedandmaintained,indicatinguseoftheflightdirectorfor
pitchguidance.Itwasalsosubsequentlydeterminedthatthecaptain'sflightdirectorwasinoperative,implyingthatthefirst
officerwasflyingthetakeoff.AmericanAirlinesproceduresrequiredthat,followinganenginefailure,theairplaneshouldbe
acceleratedtoV2,andclimbedto800feetatthatspeed.Nodifferencesintheprocedurewerespecifiedifanenginefailure
occurredafterreachingV2,andinfact,thespecificscenariowasnotaddressedbytheairline'sprocedures.Followingthe
accident,AmericanAirlinesmodifiedthisproceduretoeithermaintainthespeedatthetimeofenginefailure,ifbetweenV2

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andV2+10,andtomaintainnotlessthanV2+10ifthefailureoccurredafterreachingV2+10.Therevisedprocedurealso
instructedcrewstodisregardtheflightdirectorpitchcommand(whichprovidedguidancetoachieveV2)andtomaintainat
leastV2+10.

ItwascleartotheNTSBthattheairplanewasbeingdeceleratedfrom172knotstowardV2inanattempttofollowtheengine
outclimbprocedure(andreacquireV2)whentheleftwingstalledat159knots.Thestallresultedintheleftrollandensuing
lossofcontrol.

Astheengine/pylonassemblyseparatedfromtheairplane,fourhydrauliclinesinthevicinityoftheenginepylonweresevered,
resultinginthelossofhydraulicpressuretotheslatactuatorsoutboardoftheenginelocation.Thislossofpressureallowed
severalleftwingleadingedgeslatstoretract.Thehydraulicactuatorsdidnotincludeanalternatelockingsystemtoprevent
inadvertentslatretractionintheeventofhydraulicsystempressureloss.Theslatsystemwasdesignedsuchthatwhentheslats
achievethecommandedposition,thehydraulicsystemprovidesa"lock"thatuseshydraulicpressuretomaintainslatposition.
(viewdiagramoftheslatactuationsystemPDF:272KB)Whentheengine/pylonassemblyseparatedfromthewing,hydraulic
fluidwaspumpedthroughthebrokenlines,drainingthesystemanddepletingthehydrauliclockingpressure.Uponlossofthis
pressure,aerodynamicloadscausedtheretractionoftheslatsontheoutboardportionoftheleftwing.Withtheslatsretracted,
thestallspeedforthewingishigherthanwithslatsextended.ViewAnimationoftheengineseparationsequenceduringthe
takeoffroll,andseeanillustrationoftheeffectsofslatretractiononthewing'sabilitytogenerateliftandthecrew'scapability
tocontroltheairplane.

StrutFailureandAssociatedMaintenanceProcedures

Detailofaftattachsphericalbearing,andlocationinenginepylon
(ViewLargeImage)

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Detailofforwardattachfitting
(ViewLargeImage)

Strutfailurewasdeterminedtohavebeencausedbyunintendedstructuraldamagewhichoccurredduringengine/pylon
reinstallationusingaforklift.Theengine/pylonremovalandreinstallationwerebeingconductedtoimplementtwoDC10
ServiceBulletins,oneofwhichcalledforreplacementoftheaftattachsphericalbearingsonengines1and3(McDonnell
DouglasServiceBulletin5448),andtheothercalledforlubrication/replacementoftheforwardattachmonoballbearingsfor
engines1and3(McDonnellDouglasServiceBulletin5459).

ServiceBulletin5448supersededbutdidnotcancelanearlierServiceBulletin(5445),whichrequiredinspection/replacement
oftheaftattachbearing.BothServiceBulletins5448and5459requiredthatthepylonsberemoved,andrecommendedthat
thisbeaccomplishedwiththeenginesremoved.TheServiceBulletininstructionsassumedthatenginesandpylonswouldbe
removedseparately,anddidnotprovideinstructionstoremovetheengineandpylonasaunit.Additionally,removalofthe
enginesandpylonsasaunitwasnotanapprovedMaintenanceManualprocedure.

PhotoofCF6engineonenginestand
PhotoCopyrightJulioCastillousedwithpermission
TheDC10enginestrutandpylonaccessdoorsareillustratedbelow.Thisfigureidentifiestheinspectionpanelsandaccess
points.Ifinspectionpertheservicebulletin(s)revealeddamagedparts,thenremovaloftheengineandpylonwasnecessary.

Forremovaloftheengineandpylon,theillustratedattachmentpointswouldbesuccessivelyaccessedanddetachedper
maintenancemanualinstructions,firstremovingtheengineandthenthepylon.

TheMaintenanceManualdidnotprovideinstructionsforremovaloftheengineandpylonasanintegralunit.Tofacilitatethe
timerequiredforbearingreplacement,AmericanAirlinesdevelopedaprocedureusingaforklifttoremove,support,and
replacetheengine/pylonassembly.

Theairline'senginechangeprocedureremovedtheengineandpylonasaunit.Aforkliftwithanattachedenginestandwas
usedtosupporttheenginewhiletheforwardandrearpylon/wingattachmentswereremoved.AmericanAirlinesdevelopedthe
forkliftprocedureforremovingtheenginewithoutconcurrencefromMcDonnellDouglas.Theairlinehadevaluatedand
validatedportionsoftheprocedure,buttheNTSBconcludedthattheprocedurehadnotbeensufficientlyevaluated,and
appropriateconsiderationhadnotbeengiventothepotentialforinducingdamage.

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Pylonaccesspanelsandinspectionpoints

Engineandwingattachmentpoints

Thelackofprecisionassociatedwiththeuseoftheforklift,essentiallyaninabilitytoperformthefinemanipulationsnecessary
toaccomplishreinstallationoftheengine/strutassembly,incombinationwiththetightclearancesbetweenthepylonflangeand
thewingclevisresultedindamagetothesamepartthathadjustbeeninspected.Viewanimationillustratinghowthedamageto
aftpylonattachfittingoccurred.

Shownisanillustrationofthepylon/wingattachments.InAmericanAirlines'procedure,theforwardandaftfittingswerethe
onlyfittingsthatweredetachedinordertoseparatetheengineandpylonfromthewingasaunit.Thefailure,whichallowed
theengineandpylontoseparatefromthewingandcausetheaccident,occurredattheaftattachmentpoint,thepylonaft
bulkhead.

DiagramofWing/pylonattachmenthardware
Adetailedcutawayviewofthepylonattachmentstructureillustratesthecomplexityofthesurroundingareaandrelative
difficultyininspectingand/orworkingintheareawithoutremovingthepylonfromthewing.

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DiagramofPylonstructureandwing/pylonattachments
(ViewLargeImage)
Duringreinstallationoftheengine/pylonassembly,replacementoftheforwardpylon/wingfittingbolt(priortoreplacementof
theaftfitting)allowedtheengine/pylonassemblytopivotaroundtheforwardpylonbulkheadfitting.Thisrotationofthe
engine/pylonassemblyaroundtheforwardfittingresultedinrearmountcontactwiththewingclevis.Theforcesimpartedby
thiscontactresultedincrackingofthepylonaftbulkheadandthesubsequentfailureofthefittingduringatakeoff.

InspectionsofotherDC10pylonmountsfollowingtheaccidentresultedinnineadditionalcrackedmountsbeingidentified.
Asaresult,citingthepossibilitythattheDC10"...maynotmeettherequirementsofSection603(a)oftheFederalAviation
ActforaTypeCertificate..."FAAAdministratorBondrevokedtheDC10typecertificatefor37dayswhiletheinvestigation
proceeded.

TheNTSBwashighlycriticaloftheFAA'slackofinvolvementinoverseeingandapprovingimportantmaintenancetaskssuch
asenginechangeprocedures.Asaresultofthisaccident,TypeCertificationProcessesnowformallyaddresscertain"vital"
maintenancetasks.Priortothis,aircraftcertificationandmaintenanceweretreatedasseparate,somewhatunrelatedissues.

Duringtheinvestigation,AviationWeek&SpaceTechnologypublishedaseriesofarticlesconcerningvariousaspectsofthis
accidentandtheearlyinvestigation.Thesearticlescanbeviewedbyclickingonthetitles:

CrashtoBoostFAAScrutiny,AW&ST,June4,1979,Page12
DC10typeCertificateLifted,AW&ST,June11,1979,Page47
PylonRelatedBulletinsIssuedEarlier,AW&STJune11,1979,Page57
FAAProbeTurnstoDC10SlatSystem,AW&STJuly9,1979,Page30

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PhotoofAmericanAirlinesFlight191Memorial
PhotocopyrightJasonRiceusedwithpermission

AccidentMemorial
InOctober2011,amemorialwasdedicatedtothepassengersandcrewofFlight191.Thememorialisnearthecrashsite,and
consistsofadecorativegarden,borderedbyabrickwall.Thebricksinthewallareengravedwiththenamesofpersonswho
perishedintheaccident.

Backtotop

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