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Air Crash Investigation: Flight 191

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Air Crash Investigation: Flight 191
24/7/2012

“FLIGHT ENGINE DOWN”

Air Travel
Most effective and safest forms of transport
< 1 for every 2 x 109 personmiles flown

Air crash – One of worst situation
Team Members: Seran Karikalan 1002764 Sivaguru S/O Sivagnanam 1003260 Ng Aiting 1067138 DARE 3B 24

Number of lives it takes with it

Human Error
Manufacturers to Engineers
No one wishes for air crashes

Synopsis
On 25th May 1979, 15:00Hrs
A McDonnell Douglas (MD) DC-10 American Airlines Took-off from Chicago O’Hare Int. airport

Yet, 70% is caused by Human errors “That wouldn’t happen to me”
Is main cause for such errors

Just before lift off
Lost power from No.1 engine

Synopsis
Suddenly rolled heavily to left
Smoke gushing out

Introduction
Air crash do not occur independently Led by ‘chain of errors’
Any one broken link would prevent it

Within 30 seconds
Smashed into nearby trailer park

Analysing
Series of events Maintenance factors Other contributing factors Error preventing strategies

All on-board 271 + 2 other dead

1

24/7/2012

Events
Crash Involved…
On 25th May 1979, American Airlines Flight 191 was en route from Chicago, O’Hare airport to Los Angles, California Had carried 258 passengers and 13 crew members on board

Events
•

Events
•

8 weeks before the crash Flight 191
– Major Maintenance – Spherical Bearings had to

On Crash Day…
– During Take off the left engine

be replaced
– Engine and pylon had to

be removed to gain access
– Came up with own

procedure
– Crack formed in hidden

and pylon ripped off from the left wing – Damaged a meter of leading edge, hydraulic system – Electrical power was disabled as left engine generated electricity

area

Events
•

On Crash Day…
– The loss of hydraulic power

caused Slats to retract due to ram air effect – Stick shaker had failed due to electrical power loss – Plane had loss of lift on the left wing – Plane stalled, rolled left and crashed

2

24/7/2012


References: Earl L. Wiener and David C. Nagel, 1988. Human Factors in Aviation. United States of America: Academic Press. David O’Hare, 1999. Human Performance in General Aviation. Great Britain: Ashgate. Mara E. Vatz, 2004. Knowing When to Stop[online]. Massachusetts Institude of Technology. Available from: http://dspace.mit.edu/bitstream/handle/1721.1/39430/59008054.pdf?sequence=1 [Accessed 20 July 2012]. United States Government, 1979. Aircraft Accident Report[online]. Washington: National Transportation Safety Board. Available from: http://www.airdisaster.com/reports/ntsb/AAR79-17.pdf [Accessed 20 July 2012]. MrCriticOfAll, 2011. Seconds From Disaster-S03E15-Chicago Air Crash(Flight Engine Down) (Chicago Flight 191)[online]. National Geographic. Available from: http://www.youtube.com/watch?v=cPx4aYenWPk [Accessed 15 July 2012] Glam Family, 2012. Air Safety[online]. Seattle: Creative Commons Attribution/Share Alike License. Available from: http://www.enotes.com/topic/Air_safety [Accessed 19 July 2012] Time Magazine U.S., 1979. Nation: The Worst U.S. Air Crash[online]. United States: CNN and CNN Money. Available from: http://www.time.com/time/magazine/article/0,9171,946244-3,00.html [Accessed 21 July 2012] Christopher Kilroy, 1996. Investigation: American Flight 191[online]. AirDisaster.Com. Available from: http://www.airdisaster.com/investigations/aacrash.shtml [Accessed 21July 2012] Aviation Safety Network, 2012. Flight 191 Accident Description[online]. Flight Safety Foundation. Available from: http://aviationsafety.net/database/record.php?id=19790525-2 [Accessed 21 July 2012] Peter B. Ladkin, 1999. Report on the 1979 Chicago Crash[online]. German: National Transportation Safety Board. Available from: http://www.rvs.uni-bielefeld.de/publications/Incidents/DOCS/ComAndRep/OHare/NTSB/COPY/ohare-full.html [Accessed 21 July 2012] 6
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