Episode 54: American Airlines Flight 191

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Summary:

On May 25, 1979, a routine flight from Chicago to Los Angeles made its way into the history books as the deadliest aviation disaster in US history at the time. In week's episode of Take to the Sky: the Air Disaster Podcast, Stephanie takes us on American Airline's Flight 191's surprising, frustrating, and sorrowful journey to understand what went wrong and how safe travel today is a reflection of the many lessons we learned.



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Who Were the Passengers on American Airlines Flight 191?

258 passengers boarded American Airlines Flight 191 on May 25, 1979, a scheduled flight from Chicago's O'Hare Airport to Los Angeles International Airport. It was a beautiful, clear late spring day; under sunny skies and temperatures right around 60 degrees Fahrenheit, it was about as perfect a day as you could get for a cross country flight.

For some passengers that day, the flight bittersweet. Kathleen Adduci was a nursing student who had just called off her wedding; to get away from the heartbreak and get out of town in advance of June 2nd, which would have been her wedding day, she booked a trip to Hawaii with her friends Gail DeCastro and Rhonda DeYoung. On kind of the opposite side of the spectrum, Bill and Corrinne Borchers were on their way to Hawaii for their honeymoon, which was, frankly, overdue: they had been married for 33 years, had three children, and were looking forward to celebrating the life they had made together.

Itzhak Bentov wasn't heading to California for vacation; a native of the Czech Republic, he was from Boston and worked in several major hospitals in the area as a scientist and inventor; in fact, he invented the cardiac catheter, which is used in interventional cardiology, and he was heading to the west coast to speak at a conference. Ping Chun was 26 years old and was traveling to California for a job interview. Joan Green Fuselier was heading back to LA after attending a workshop; she was Los Angeles director of the U.S. Consumer Product Safety Commission and had been one of Los Angeles' first black female police officers and a senior deputy probation officer for the Los Angeles County Probation Department. And many passengers were planning to spend the weekend at the American Booksellers Association annual meeting; the meeting drew professionals from all over the world, and like many flights headed to LA that weekend, many people on board were looking forward to the same experience. Among them were Stephen Sutton, his wife Carolyn, and their sons- 9-year-old Colin and 7-year-old Christopher. Stephen was a senior editor at Rand McNally, and after the conference the family was looking forward to seeing Carolyn's family and spending some time together at Disneyland.

American Airlines Flight 191 Aircraft

The aircraft that day was a McDonnell Douglas DC-10. The DC-10 was first developed with military service in mind, but the US Air Force passed on the proposal. Instead, it was American Airlines that expressed interest in the aircraft; the airline was looking for a wide-bodied aircraft that could potentially fly the same mid- to long-range routes as the larger Boeing 747 but from shorter runways, which of course could open new possibilities to the airline's network. The first DC-10 entered into service with American in August 1971.

The DC-10 is a tri-engine plane with two of the engines mounted on pylons. A pylon is a structure on a plane's wing designed for an engine to be mounted to it. The third engine was attached to the top of the rear fuselage in what looks a little bit like a bell-shaped encasing; the vertical stabilizer is mounted to the top of the third engine, and the horizontal stabilizer is attached to the sides of the rear fuselage. And as a newer aircraft at the time, it did have some bells and whistles that were probably of special interest to the passengers; one feature on this specific aircraft was the inflight camera. The inflight camera was somewhat new to aviation technology; it's the camera that lets passengers watch takeoffs and landings from the vantage point of a camera installed in the cockpit. It essentially provided passengers with the captain's view of the flight experience, which can be a real thrill.

Who Was the Pilot on American Airlines 191?

Captain Walter Lux was the pilot on American Airlines Flight 191. He was 53 year years old, and he had been flying the DC-10 since its introduction to American Airlines eight years earlier. He had accumulated 3,000 flight hours as a captain on that type of aircraft, which was a good percentage of the 22,000 flight hours he had in his career. Captain Lux was filling in for a colleague that day. He was commissioned as a second lieutenant in the Air Force during World War II, and when his military service ended he entered into his 30-year career with American Airlines.

Captain Lux was joined by 49-year-old first officer James Dillard, who had more than 9,000 flight hours with more than 1,000 of those hours on the DC-10. They were joined by flight engineer Alfred Udovich, who was 56 years old and had worked for American Airlines for more than two decades. He had about 15,000 hours of flight experience with 750 hours on the DC-10; although he originally qualified on the aircraft in September 1971, so just about a month after the first DC-10 was delivered to the airline, he spent most of the decade on other aircraft and had just requalified the year before, in 1978.

What Happened to American Airlines Flight 191?

At 3:02 PM, American Airlines Flight 191 was cleared for takeoff from 32R, and seconds later Captain Lux confirmed it was time to go, saying, "American one-ninety-one under way." As the plane accelerated down the runway, Captain Lux called out V1, which is the speed at which an aircraft must takeoff— it cannot abort at that point— which was followed by rotation. As the wheels lifted off the runway, the cockpit voice recorder captured one word: damn. That was the final sound picked up by the CVR.

What happened next was nothing short of haunting for the flight crew, the passengers, and anyone on the ground who might have had the plane in sight.

The plane took off in a slight left wing down position, reached an altitude of 300 feet before it began to bank to the left. It continued to roll to the left at about 4 degrees per second, until it reached 112 degrees, meaning it was flying on its side. And it was at that angle-- in a left wing down and nose down attitude-- that American Airlines Flight 191 smashed into the ground, slamming into an open field and a trailer park as it disintegrated into fractured parts and flames. It was airborne for about 32 seconds.

What Happened to the Passengers?

Roy Mueller was the manager of the Oasis mobile home park located close to the airport. He said, "We heard a loud rumbling. We went to the door and we saw this airplane flip-flopping in the air. It bellied over and went straight down. One of my superintendents just came back from the field and he said, 'There's bodies scattered all over.'"

A firefighter who was on the scene validated that horrific description, saying, "There wasn't one body intact. Heads, arms, hands were all over the ground. There were shoes with legs in them. Small bodies that I thought were children may just have been people who were badly burned. They were all so badly burned…"

Witnesses on the ground and in the tower immediately knew what happened to the plane. Air traffic controller Edward Rucker knew moments before takeoff that something had gone terribly wrong: he watched as the left engine fell to the ground, smashing into the runway as Flight 191 picked up speed, roared through V1, and took off. He called for emergency backup, and he radioed to the flight crew to ask if they wanted to come back and, if so, to which runway. But they never answered him. And with his colleagues in the tower, he watched as the unthinkable happened: the plane rolled to the left and hurtled toward the ground as Edward said, "There he goes, there he goes." Hospitals were told to be on standby for huge numbers of injured passengers, but by the time rescuers arrived on the scene those requests were cancelled. Instead, a morgue was set up in a nearby American Airlines hangar.

How Many People Died on American Airlines Flight 191?

American Airlines Flight 191 carried 271 people on board: three flight crew members, ten cabin crew members, and 258 passengers. In total, 273 people perished in the accident, which also claimed the lives of two people on the ground, including John Craig, who was 42-years old and died as debris fell onto the truck he was driving. At a nearby auto body shop, 50-year-old Andrew Green was identified after his daughter reported him missing and his body was discovered in his car. At the time, it was the deadliest air disaster in US history.

With the crash, countless lives changed instantly as 273 lives ended. Kathy Aducci was on her way to Hawaii after her engagement ended so that she wouldn't spend June 2nd in Chicago. Her family spent June 2nd in church not for her wedding, but for her funeral. Another passenger, Leonard Stogel, was a well-known music promoter. His death on Flight 191 was preceded by his parents' death 17 years earlier, also on an LA-bound American flight. His brother Stanley said, "It's unbelievable- lightning has struck twice." And I want to share this reflection from Ellen Gemme, whose father Francis was onboard. She said, "May 25, 1979, was a beautiful spring day -- the kind of day when you know winter is really over and the long, lazy days of summer are just ahead. I got home from school and my mom and I started decorating for my eighth birthday party -- a slumber party with eight friends -- that I was having that night. My dad had left a long note for mom on the kitchen counter and whatever was in it made her laugh right out loud. That was the last time I ever heard my mom laugh in just that way. A neighbor called and said there had been a big plane crash. The TV went on, the phone started ringing and, after a few hours, my mom got a call from my dad's office confirming what she had feared -- that my dad had been booked on Flight 191. It was just my mom, a neighbor and myself in the kitchen when she got the news. She was standing at the yellow phone attached to the wall. And when whomever was on the other end of the phone confirmed that my dad's ticket said Flight 191 she fell onto her knees, hugging the phone and wailing."

What Was It Like for Passengers on American Airlines 191?

There is a lot we don't know for sure about Flight 191's final moments, and a big part of that is because even though the CVR and the FDR, or the flight data recorder, were found at the crash site, they didn't provide the kind of helpful information we're used to hearing about. We know that the last thing the CVR picked up was one of the pilots saying the word damn, and then it went silent. The FDR continued to record data, but it was almost nonsensical when investigators reviewed it; the plane was flying erratically, and so the data captured erratic data. We really don't know what was going on in the cockpit during that time. One of the most frightening considerations stems from the very feature that would have excited me the most as a passenger on the plane: the cockpit camera that was broadcasting live images of the flight to the passengers in the cabin. It would have given them a front row seat to their fate as it unfolded, which means the final seconds of their lives may have been horrifically clear to them as the plane banked into an unsavable dive.

Was American Airlines Flight 191 the First DC-10 Crash?

American Airlines Flight 191 was not the first DC-10 crash. The first major incident was American Airlines Flight 96, which in June 1972 lost its cargo door midflight. There were no fatalities on that flight, which highlighted a major issue with the cargo door design on the DC-10. That was a precursor to a flight shared in Take to the Sky Episode 022: Turkish Airlines Flight 981, which in 1974 met an almost identical fate with a much more tragic ending, when 346 people died in France because of the same issue. The FAA issued an airworthiness directive for all DC-10s, and every aircraft had modifications made to the cargo doors to prevent similar issues from happening again. But the crash of American Airlines Flight 191 was just five years after the Turkish Airlines crash. It was for a seemingly different reason; in this case, we know an engine fell off the aircraft during the takeoff sequence. Still, it was one more catastrophic issue with the DC-10— and the traveling public began to question whether the DC-10 was safe.

American Airlines Flight 191 Investigation

To start to answer the question as to whether the DC-10 was safe, let's talk about the investigation. Led by the NTSB, it was clear from the start that there would not be a lot of physical evidence to go on. There was very little left of the plane to use as evidence, although the NTSB did have some reliable witness accounts that confirmed the left engine had broken off the wing before takeoff. Before long, a good deal of information began to come into focus, and it started with a broken bolt discovered close to the crash site. The bolt was identified as part of the DC-10 and was used as part of the pylon, which is the structural component that connected the engine to the wing. The NTSB had to determine whether the bolt had broken before or after the engine separation;mdash; did it break before the accident, or did it break during the accident?

Investigators were interested in metal fatigue. It's not uncommon in aviation, but it's something maintenance teams are trained to watch for and stay on top of to ensure they don't cause problems for aircraft at any phase of flight. And as the investigation continued, it seemed possible that metal fatigue could have been involved: sure enough, there was a crack in the metal of the pylon bulkhead on the left, or aft, side of the plane. The crack that investigators observed ran along the top edge of the pylon, which provided evidence that the crack had started there and spread, which is a sign of metal fatigue and also a sign that the damage had existed before the accident occurred. Even more concerning, though, was a dent that investigators noticed in the spot where the crack started. The dent was suspicious; it also didn't seem to be related to the accident. So what would cause the metal pylon to develop a visible dent?

American Airlines Flight 191 Maintenance Records

The NTSB decided to take a look at the DC-10's maintenance records, which they hoped would tell more of the aircraft's story than the accident scene was able to do. Sure enough, there was a bit of evidence that struck them as concerning: eight weeks before the accident, the DC-10 was removed from flight scheduled so it could undergo service on the left engine.

Servicing engines on airplanes is considered routine maintenance, and between March 29 and 30, 1979, that is exactly what happened: the engine underwent routine maintenance. However, what the NTSB uncovered is that the way in which the engine was serviced was not quite the routine process that was expected. The plane's manufacturer, McDonnell-Douglas, provided an engine removal procedure to ensure the engine could be safely removed. During that process, the engine would be detached from the pylon, and then the pylon would be detached from the wing. It was an extensive process— and maintenance workers discovered there was an easier way to do it. To follow McDonnell-Douglas's procedure required 79 different disconnects that impacted electrical wiring, hydraulics, and fuel lines. But maintenance workers realized that if they skipped a step and removed the engine and pylon from the wing as one connected unit instead of removing each part separately, they could reduce the number of disconnects and reconnects from 79 to 27. In addition to reducing some human error that could arise from incorrectly disconnecting or reconnecting any component, they also saved a total of 200 manhours with every single routine maintenance procedure they completed. From that perspective, the choice to adapt the maintenance procedure made a lot of sense and might even seem like a rational, responsible way to save time and money and potentially improve safety while returning aircraft to the air as quickly as possible.

There was a true downfall to this plan: reattaching the engine and pylon as a single unit required the use of a forklift. Forklifts are not well-suited for use in situations where precision is needed. During the reinstallation process, maintenance teams would attach the engine and pylon to a forklift and use it to carefully maneuver it back into place, which required guiding it into very specific attachment points so it could be secured. The forklift operators could not see this process; they relied on other workers to call out directional positioning to help them find exactly the right spot. Sometimes that process worked out, and sometimes it didn't; when it didn't, the forklift operator might hit the pylon, which could lead to structural damage— including dents.

Investigators interviewed maintenance teams in Tulsa, Oklahoma, where the DC-10 had been serviced two months before. Sure enough, they had followed their own, improvised procedure to remove and reinstall the engine: they removed the engine and pylon as a single unit, and they used a forklift when it was reattached. With that initial dent and crack in place, every single time that plane took off over the next eight weeks it put more and more pressure on the pylon's structure. Finally, on May 25, 1979, the attachment failed. The pylon and the engine broke away from the plane.

What Happened to the Engine on American Airlines Flight 191?

The DC-10 had three engines, and even though one fell off, two of them were still intact. And two engines would provide plenty of power for the aircraft even if the third engine was completely offline. But Flight 191 crashed anyway. Why did the plane crash when it should have had enough engine power to fly?

Investigators started to question whether or not the flaps and ailerons were properly configured for takeoff; if, for some reason, they were not, that would very quickly help to solve the puzzle regarding why the plane couldn't sustain flight. There are some photos that exist of the plane's final moments, including a very famous amateur photo that investigators used to answer some of their questions. Working with a digital analysis laboratory in California, investigators were able to confirm that the flaps were properly extended for takeoff on the right side of the plane, but they appeared to be retracted on the left side. And what they could deduce from that analysis was that, when the engine separated from the plane, it hit the wing of the plane with enough force to sever the hydraulic line in the wing, which caused some of the slats to retract and hydraulic fluid to drain from the lines. That imbalance between the left and right sides of the plane led the plane to bank 112 degrees to the left and sent it crashing to the ground. In effect, the plane stalled; it never had a chance.

Or did it?

DC-10 Power Issues

There was one more piece of information that the NTSB was able to discern from the evidence they had available to them, and that was the fact that part of the plane lost power when the left engine separated from the aircraft. The left engine powered the left side of the plane; that means Captain Lux had nothing to go by as far as warning lights or indicators to confirm that the plane was stalling. Pilots are trained for how they can fly out of a stall. To do that, Captain Lux would have needed to lower the plane's nose, which would decrease the angle of climb and increase the speed of the air flow over the wings. But he didn't know he was stalling because there was no power to his side of the plane; when a plane starts to stall, an indicator known as the stick shaker will activate to alert the pilot to the problem. With no power, the stick shaker never activated. On First Officer Dillard's side of the plane, there was power from the engines that were online, but there was no stick shaker on that side, which means he likely did not know the plane was stalling, either. And he didn't have the altitude at that point to do much of anything; they weren't even 400 feet of the ground.

American Airlines 191 Simulator Tests

In July 1979, investigators put their theory that power issues were responsible for muting the warning signals to the test: they programmed a flight simulator to duplicate the damage and watched as 13 test pilots recreated the exact sequence of events that devastated Flight 191. In the simulator, without the knowledge provided by warning signals and indicators, the pilots were left to fly the aircraft with only their training to support them— and not a single pilot was able to prevent the simulator from crashing. They proved that for Captain Lux and First Officer Dillard, the training they received on operating the DC-10 after engine loss was at odds with what they should have done when the plane was stalling. They should have increased their speed when the plane started to roll instead of following their training protocol, which called for them to slow the aircraft after engine loss. According to one pilot who contributed to a Washington Post article about the accident, he said, "His instrument was telling him he had extra airspeed [a condition that was true only for the right wing], so he was trading it for altitude. That is exactly what he was trained to do and what his flight controls told him to do."

What Was the Probable Cause of the Crash of American Airlines Flight 191?

In the weeks after the crash of American Airlines Flight 191, every single one of the 138 DC-10s in the USA was grounded. Additionally, DC-10s operating outside of the USA were banned from flying in US airspace. And a few disturbing truths emerged, especially with regard to how engines were serviced: as it turned out, most airlines were cutting similar corners to save time and money. Investigators identified eight other DC-10s with similarly damaged pylons from the same maintenance techniques. 

On December 21, 1979, the NTSB released their accident report and the probable cause for the crash of Flight 191: "The National Transportation Safety Board determines that the probable cause of this accident was 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 at a critical point during takeoff. The separation resulted from damage by improper maintenance 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 Federal Aviation Administration 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.”

What Safety Recommendations Came from the Crash of American Airlines Flight 191?

The resulting safety recommendations included issuing an airworthiness directive to inspect the pylon attach points, a maintenance service bulletin to discontinue the practice of detaching the engine and pylon using any method other than that recommended by the manufacturer; and the revision of operational procedures to increase stall margins. Ultimately, recommendations and directives were swiftly implemented, and DC-10s were returned to service within two months. But for the traveling public, the damage was done. Orders for the aircraft dropped off steeply, and although DC-10s continued to fly travelers for 30 years after the accident, they have not been manufactured since 1988. Today they are largely used as cargo planes; American Airlines has not flown the DC-10 since the year 2000.

What Happened to the DC-10 After the Crash of American Airlines 191?

The DC-10 fell out of favor with the traveling public after the crash of American Airlines Flight 191. Interestingly, one other contributor to the demise of the DC-10 was Air New Zealand Flight 901, which was known as the Mount Erebus crash in Antarctica— a crash we covered in Take to the Sky Episode 004. The crash had absolutely nothing to do with the aircraft in service that day; it was a human error and environmental conditions crash, not a mechanical or maintenance one. Still, that crash did not help the DC-10's reputation, and it gave travelers one more reason to avoid DC-10s whenever possible.

What Is the Legacy of American Airlines 191?

More than anything, the legacy of American Airlines Flight 191 is about safety. This accident called into focus how planes are maintained and serviced and forced all airlines- not just American- to recognize that there is no amount of time or money saved that can compete with safe travel. Building a culture of training and safety became essential throughout the industry, and that is a legacy that remains and benefits every one of us to this day.

It took more than 30 years before the families of Flight 191 had a memorial in honor of the 273 people who perished with the plane. Lake Park in Des Plaines features a concave brick wall the bears the names of every person who lost their life on May 25, 1979. The memorial was paid for by American Airlines and is the result of efforts spearheaded by the children of passengers Bill and Corrinne Borchers, who never made it to their Hawaiian honeymoon. Casey Binstadt, the daughter of passenger James Adams, said, "It feels like his body died over there [at the crash site] and his spirit floated over here."

Show Notes:

In addition to sending a BIG thank you to everyone who has joined our Patreon community, we talked about inspirational quotes- and Stephanie finally got her harp! Don't expect a concert anytime soon— unless you like the Jurassic Park theme song!

Credits:

Written and produced by: Shelly Price and Stephanie Hubka
Directed and engineered at: Snow Monster Studios
Sound editor: Stephanie Hubka
Producer: Adam Hubka
Music by: Mike Dunn
American Airlines Flight 191

The moment of impact for American Airlines Flight 191. Source: LA Times

American Airlines Flight 191

Aerial view of the American Airlines Flight 191 crash scene. Source: LA Times

American Airlines Flight 191

Fallen engine rests on the grass near the runway. Source: LA Times

American Airlines Flight 191

Wreckage of American Airlines Flight 191. Source: LA Times

American Airlines Flight 191

An investigator holds up a broken bolt found at the crash site. Source: LA Times

American Airlines Flight 191

A now famous photo captured as American Airlines Flight 191 banked to the left moments before impact. Source: LA Times