Forty Years On, Remembering America’s Deadliest Air Disaster.

May 25, 2019

FRIDAY, MAY 25th, 1979, was a sunny day in Boston. I was in seventh grade at the time, and a diehard airplane buff who spent pretty much every weekend planespotting from the old observation deck at Logan airport. I was home that afternoon, sitting in the dining room of the house I grew up in, when at a little past four o’clock the phone rang. It was a friend from school. He told me to turn on the television.

It had been a sunny day in Chicago, too, when at 3:04 p.m. local time, American Airlines flight 191, a McDonnell Douglas DC-10 with 271 people on board, roared down runway 32L at O’Hare International Airport, headed for Los Angeles. Just as the plane lifted off, its left engine broke loose. The entire engine, which weighed about eight thousand pounds, together with its connecting pylon and about three feet of the wing’s leading edge, flipped up over the wing and crashed back onto the runway. As the engine ripped away, it severed hydraulic lines, releasing the hydraulic pressure that held the wing’s leading edge slats, deployed to provide critical lift during takeoff, in place. The slats then retracted, causing the left wing to stall. This forced the jet into a violent roll onto its side, beyond 90 degrees, from which it never recovered.

If the pilots had understood what they were dealing with, they could have avoided catastrophe. Simulations would later show that if the crew had reduced power on the right-side engine, they may have been able to counteract that fatal roll to the left. But this ran counter to everything a pilot is taught to do during an engine failure on takeoff. In addition, the engine separation had caused a cascade of electrical malfunctions, knocking out critical flight instruments and alerting systems, including the stall warning and a slat position indicator.

The cockpit voice recorder also had failed. We’ll never know what Captain Walter Lux and his crew said in those final moments, but presumably the only thing they knew for certain is that they’d lost all power in the left engine. It’s doubtful they had any inkling of the separation, the wing damage, the slat retraction or the stall — the reasons for their sudden, sickening loss of control, or how to stop it. There simply wasn’t time.

Only 50 seconds after liftoff, and now banked at 112 degrees, the DC-10 slammed into a field and trailer park less than a mile from the end of the runway, exploding into a gigantic fireball. All 271 passengers and crew were killed, along with two people on the ground. With 273 fatalities, the crash of flight 191 was, and remains, the deadliest air disaster in U.S. history.

Descriptions of the accident are jarring enough. But we can see the horror, too, quite literally. Because a man named Michael Laughlin captured what might be the most haunting aviation photograph ever taken: the stricken jet literally sideways in the sky, only a few seconds before impact, in the throes of that ghastly twist to the left. And then the explosion.

In the aftermath, the National Transportation Safety Board determined that an unseen crack in the support pylon is what caused the engine to break loose. They put most of the blame on American Airlines for faulty practices, including the use of a crane and forklift to support the engine during routine maintenance. They also cited design flaws in both the pylon the wing slat system, as well as a lack of FAA oversight of air carrier maintenance protocols.

On June 6th, after cracks turned up in several other DC-10 engine pylons, the FAA suspended the plane’s operating certificate. For five weeks, no DC-10s, domestic or foreign, were allowed to operate within the United States.

This was just the latest setback for the DC-10, and not even the worst. Five years earlier, in what is still the world’s fourth-deadliest air disaster of all time, a Turkish Airlines DC-10 crashed after takeoff from Orly Airport outside Paris, killing 346 people. The accident was traced to a faulty cargo door design. (The same door had nearly caused the crash of an American Airlines DC-10 two years earlier.) As later revealed in Samme Chittum’s excellent book, “The Flight 981 Disaster,” McDonnell Douglas had hurriedly designed a plane with a door that it knew was defective; then, in the aftermath of Paris, they’d tried to cover the whole thing up. It was reckless, maybe even criminal.

After the grounding in ’79, the DC-10’s reputation had been so shattered that airlines began removing the “McDonnell Douglas DC-10” decals once proudly affixed to their hulls. At American, where it once said “DC-10 Luxury Liner” in red and blue paint near the nose, it now said, “American Airlines Luxury Liner.”



And so it hardly needs saying that, forty years later, the story of the DC-10 reminds us in no small way of the ongoing drama involving Boeing’s 737 MAX. The similarities are uncanny: Multiple catastrophes, a grounding, a lack of regulatory oversight and an aircraft manufacturer accused of negligence and shoddy design.

And in the end, what?

In the case of the DC-10, the airplane soldiered on. Fines were paid, lawsuits were settled, technical fixes were put in place. Sure, there would always be a tiny number of travelers who, out of fear or to make a point, would never again set foot on DC-10. But these were a tiny minority, of no consequence to airlines. For everybody else… they forget, they move on. Time works wonders when it comes to restoring trust.

I suspect the same will hold true for the 737 MAX. The other day I read about a poll in which more than half of all Americans said they didn’t know that a crisis involving the 737 MAX even exists. Other surveys reveal that of those who do know, the vast majority will have no qualms about stepping back on board once the jet’s problems are ironed out. As the headlines have it, it’s doom and gloom for Boeing, its customers, and the MAX itself. But love or hate the 737, I’m not buying it. It might take a while for Boeing, the FAA, and the other vested parties to figure this one out, but I’m guessing the planes will be back soon enough, safely, with their cabins full of travelers.

For most airlines, the grounding of the MAX has been an inconvenience with, for now, minimal financial repercussions. There simply aren’t that many of them in existence. For airlines like American and Southwest, we’re talking about a few dozen aircraft out of several hundred. In ’79, with the DC-10, it was different. DC-10s made up the bulk of the widebody fleets at both American and United. At Continental Airlines, the plane represented a quarter of the airline’s total number of seats. At National Airlines it was almost half.

For a thirteen year-old airplane nut in Boston, the most exciting thing about the grounding was a temporary influx of exotic airplanes into Logan. For a month carriers would substitute other types. United’s DC-10 to Chicago became a 747 — the only 747 I’d ever seen in that carrier’s livery. Swissair brought in DC-8s, Lufthansa sent 707s. And so on. New planes, new colors. I couldn’t get to the airport fast enough.

You can always count on a kid, I guess, to find a silver lining in something so awful as a plane crash.



 

The O’Hare disaster also takes us back to a time when plane crashes were disturbingly frequent. In the four-year span from 1977 through 1980 there were twenty major air crashes worldwide, killing over 3,400 people. Five of those occurred in 1977, including the Tenerife catastrophe that left 583 people dead. In ’78 there were four accidents, including the PSA midair collision over San Diego and the crash of an Air India 747. In ’79, in addition to flight 191, was the Western Airlines crash in Mexico City and the Air New Zealand sightseeing disaster in Antarctica (both DC-10s, at it happened). A year later we saw six crashes, including the infamous Saudia L-1011 fire that killed 301.

That’s pretty staggering, until you remember that in 1985, twenty-seven major crashes would kill almost 2,500 people. That’s right, twenty-seven crashes in a twelve month span. Among these were the Japan Airlines crash outside Tokyo with 520 fatalities, the Arrow Air disaster in Newfoundland that killed 240 American servicemen, and the Air India bombing over the North Atlantic with 329 dead. Two of history’s ten worst disasters (JAL and Air India) happened within two months of each other!

1985 was an unusually bad year, but from the dawn of the Jet Age all the way into the 1990s, it wasn’t unusual to see five, six, or eight or more major crashes (or bombings) annually, many of them on U.S. soil. Around the time of the Tenerife collision in ’77, I started keeping newspaper clippings. Whenever there was an accident, anywhere in the world, I would snip the related articles from the paper and put them into a shirt box. By the end of junior high, that box was jammed full.

Nowadays, one or two accidents in a year is big news. The number of commercial aircraft worldwide has more than quadrupled since the 1980s, carrying over five times as many passengers. Yet, per passenger-miles flown, flying is an estimated six times safer. Air crashes get a lot of attention — maybe more than they’ve ever gotten — both because and in spite of how infrequently they occur.

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69 Responses to “Forty Years On, Remembering America’s Deadliest Air Disaster.”
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  1. Dror says:

    Great article. Thanks you.
    I think I was also in seventh grade at the time, and living near Chicago. I remember the locals talking about how they feared that living near such a busy airport they would surely witness a disaster in the future.
    From that day on I had a very bad feeling about the DC-10.
    But I think the 737’s case is different. Boeing is much more established, with a much better track record. Today’s technology allows for less errors, and it’s easier to find a fix when one is needed.
    I also think the MAX will be back in the sky very soon.

  2. Tim says:

    I think the DC-10 crash in Chicago was memorable for me partly because it was local news with all the coverage, and I remember first hearing about it talking to my friend as we sat outside. And there was that picture.

    Eighteen months later I was on my way from Chicago to boot camp in San Diego on a DC-10. I wasn’t the least bit worried about the plane. More worried about what was waiting for me in San Diego and talking with the other Chicago guys headed to boot camp.

  3. Patrick says:

    All right, enough back-and-forth about the 737. That means you, Rod. This is a post about the DC-10 and the legacy of flight 191.

    • Rod says:

      True. But if the rug is broad and thick enough, maybe it will be OK.
      And if it’s true that American has had only one runaway trim in its last 750,000 737 flights, the problem is looking a wee bit less acute.

      I mean, they should DO something about these mini-trim-wheels. And honestly, even IF all aircraft were flawlessly stable platforms, all pilots should still have second-nature stick-and-rudder skills, which I don’t see such low-time FOs possibly possessing. Because there’s always that freaky-fluky chance of an upset out there. With Everybody at All Levels shedding costs wherever possible, chickens are bound to come home to roost at some point. (Will the 797 be single-pilot? Will Michael O’Leary be revered as a visionary?)

      But if Boeing is really that confident that the MAX can go considerable millions of accident-free hours now, well they’re betting their company on it.

      And I guess they’ll just have to say their prayers for the 787.

  4. Rod says:

    Jeez, you sure don’t have to stir very hard. Boeing does most of the pushing and pulling for you.

    It’s hard to decide which link to post first. (Flips coin.)
    https://www.nytimes.com/2019/06/01/business/boeing-737-max-crash.html#commentsContainer?register=google

    I mean, just consider the negligent manner in which MCAS was conjured into the final product. (Yet it isn’t final — it will supposedly, one day, have a new iteration, which keeps not happening.)

    As we see below (BTW I recommend Moon of Alabama all-around), Boeing had already installed smaller manual trim-wheels on the 737NG, which Naturally make it more difficult to deal with a runaway trim. Great. (A crew in a simulator lost 7,000 feet retrimming the aircraft. Moral: Don’t have a runaway in an NG under 10,000 ft.).

    Now there’s this.
    https://www.cnbc.com/2019/06/02/boeing-notifies-faa-of-737-max-parts-that-may-be-susceptible-to-failure.html

    I still think that Patrick MAY be right and that in a few months Boeing will introduce its freaking patch, the MAX will go back into service, and everybody will live happily ever after.

    However, the more all this goes on, the less I’d be surprised if Boeing isn’t digging its own grave. And then consider the 787 (see documentary that both Jennifer Moore and I have posted below). Boeing has sacrificed quality-control in favour of non-union, drug-addled employees building planes under deadline pressure. (plumb outta space ayGIN)

  5. Rod says:

    Are the NG and 787 flying timebombs? (The MAX has already blown up in Boeing’s face.)

    From what I understand, Boeing does have the cash to simply close the MAX programme, cut its losses, buy back the MAXes, do Whatever is needed to deal with the NG slat’n’trim trouble and come clean on the 787. Though it surely does not have the reserves to truly address that last elephant in its living room. (When a 32-year-veteran Boeing aeronautical engineer says she won’t fly on a 787, that has to mean Something. I’d fly on a 787 or a MAX, simply because your chances have to be excellent. But WHAT is she telling us?)

    This is the can of worms that keeps on giving. Capitalism has concentrated things into an Airbus/Boeing duopoly. We’re certainly better off with that than an Airbus monopoly.

    https://live.staticflickr.com/65535/47992783852_c067937a79_m.jpg

    • Thomas says:

      Now they have to retrofit a second, independent (redundant) electric trim-motor on the NG and MAX, in case there is a runaway on the primary trim-motor.

      If Patrick had a type-rating on the 737, it would be interesting to find out if he would refuse further flights, since a runaway-trim below 7,000′ AGL would probably be fatal on the NG or MAX.

      • Rod says:

        Those guys went into the simulator knowing exactly what was going to go wrong, and having rehearsed in their heads how to get out of it. Real life would be different — a total surprise. So I’m sure we can add a further 3,000 ft and conclude that the moral of the story is: don’t have a runaway-trim on the NG below 10,000′ AGL.

        Curiouser and curiouser, eh?

        • Thomas says:

          Excellent point — about the additional 3000′ altitude loss.

          I doubt that Boeing will spend 1 billion+ dollars to retrofit the 1300+ NGs, with secondary (redundant), trim-motors.

          Imagine the lawsuits against Boeing when one of the NGs goes down, due to a runaway trim below 10000′ AGL.

          Can you say bank-rupt-cy ?

          • Rod says:

            Months ago (which shows how long this business has been going downhill) I read an interview somewhere with a 12,000-hr 737 pilot who would say only that he lives at 55°N and is an instructor on the NG. So I’m guessing it’s Edmonton, Alberta and Westjet. He said: “The 737 will kill again, and I don’t just mean the MAX.”

            Then there’s the 787. Maybe all those construction faults simply don’t matter and nothing bad will ever happen. But then maybe it’s a time-bomb too. Who knows?

            You would think that, as a pure survival strategy, Boeing would go the humility / openness route now, yea unto backing out of the MAX.

            Meantime, Icelandair has simply fired its MAX pilots. That’s a measure of the company’s confidence.
            https://simpleflying.com/icelandair-lets-go-of-its-boeing-737-max-pilots/

  6. Carol says:

    Yes, I was thinking the other day about how plane crashes and plane hijackings were so much part of my youth. Kids would talk about whether they’d take a flight. Some would quote a statistic that driving was more dangerous than flying. When I got on a plane, I’d ask myself “will this be the one?” Now, I don’t. It seems flight safety has been improved?

  7. Pete says:

    “That’s pretty staggering, until you remember that in 1987, twenty-seven major crashes would kill almost 2,500 people.”

    The crashes you mention — JAL, Air India, Arrow Air — were all in 1985. You didn’t mention the Delta Air Lines crash due to windsheer in a thunderstorm at DFW.

    Air India and Delta in particular struck a chord with me because I was abroad in the U.K. that summer, having moved to the U.S. with my family as a kid a few years earlier. Also noteworthy that summer was the British Airtours incident at Manchester that killed 55 people after an uncontained engine failure and fire.

    I think those, and the Challenger disaster that followed a few months later, contributed to my fascination with aerospace that continues to this day. It’s strange how kids latch on to the morbid aspects.

    • Patrick says:

      Yes, 1985. I’ve cited the crash statistics from ’85 many times, so I’m not sure why I typed 1987 instead. Thanks for the catch. It’s been fixed.

      There were so many crashes that I couldn’t list them all. I went with the three worst.

  8. Tom says:

    I was a bit younger in the late 70’s, seven years old when the accident in Chicago occurred. Those formative years, though, left me with a fear of flying from which I’ve never recovered. It wasn’t a major accident, but on August 2nd of 1979, after watching 2 years of TV news coverage of major disasters, I watched reports detailing the accidental death of NY Yankees star Thurman Munson. Each time I fly now, and it’s not frequently, I tend to go through a ritual of getting my affairs in order. Thanks to your blog, I can at least allay some of the fears through understanding the technical details a bit better.

    • Rod says:

      Each of us has irrational fears. None of us is in a position to laugh at anyone else. Putting your affairs in order is probably a kind of superstitious gesture (I’m not making fun), superstition being a way of trying to influence the uncontrollable (“Well, it worked last time”).

      You’re right to read this blog. Just remember that if all this awful stuff weren’t Incredibly Infrequent, nobody would fly.

  9. Ben says:

    This piece speaks volumes to how fatally flawed Boeing’s current safety culture is:
    https://www.forbes.com/sites/laurarittenhouse/2019/05/19/can-boeing-be-safe-profitable-and-wise/

    Quote: “To evaluate Boeing’s culture, we searched their 2018 annual report to see how many times the word “safe” and its derivations – “safety,” “safest,” “safer” and “safely,” etc. – were used in this public document. Then we did the same search in Airbus’ 2018 annual report, the other global airplane manufacturer.

    We compared these search results and found that Boeing’s 154-page annual report had only 17 words related to “safe.” In contrast, Airbus’ 324-page annual report had 155 words related to “safe.”

    We found the same trend when we searched for these words in company annual reports over the past five years. Boeing used “safe” words a total of 76 times and Airbus used them a total of 397 times.

    We also calculated the ratio of the number of times words about “profits” were found in each annual report compared to words about safety. In its 2018 annual report, Boeing used two profit words for every safety word, while Airbus’ ratio was one profit word for every safety word.” End Quote.

  10. Marty U. says:

    Like Patrick, I, too was in 7th grade on 5/25/79. At 3:04pm I was standing in line to board the school bus home from my suburban Chicago junior high school. Directly above the roof of the bus, on the horizon, was a horrible smoke plume which I can still remember.

    Let’s pray that Boeing, the FAA and others involved have learned from the lessons of AA191.

    Marty

    • Kurt says:

      Let me add my recollection, I was a 5th grader on the south end of Mt. Prospect, IL, about 3 miles from the crash site. I was looking out my bedroom window and saw the plume of smoke rising in the sky. I called my Mom to come look and she replied, ‘oh, I knew one of those aviation oil tanks would blow up one of these days!’. Then we turned on the TV and saw the horror. I was scheduled to fly for the first time to my aunt’s house in Connecticut the following week. I refused to get on the plane, my aunt had to come out and pick me up, fly back with me. Nightmares following and for years afterwards I could never look out the car window when we drove past the site. It still affects me when the 25th, 30th, now 40th anniversary of the crash rolls around. Now I’m a one million mile flyer with United and have lost my fear of flying completely, even in turbulence. You’re right Patrick. Time does work wonders to help people move on.

  11. Rod says:

    The documentary recommended below by Jennifer Moore (https://www.youtube.com/watch?v=rvkEpstd9os) is definitely food for thought about the Boeing company of recent years.

    It was published almost five years ago — years before the MAX started being delivered. It’s actually about negligent construction of the 787. But REALLY it’s about Boeing itself.

    Many people involved in building the 787 say here that they wouldn’t want to fly on it. An aeronautical engineer who logged 32 years with Boeing says the same.

    But this documentary is now five years old, and (unlike the MAX) no 787 has fallen from the sky. So should we conclude that Boeing has just been luckier with the 787 than with the MAX? Or, rather, that faulty construction will Become a problem as the airframes begin to age, i.e. that them 787 chickens will come home to roost later rather than sooner? Will even the best maintenance correct for a shoddily built airplane? (damn, done run outta space)

    • Ben says:

      Honestly with the 787, Boeing just got plain lucky that the 787 batteries caught fire when the planes were parked on the tarmac. If they caught on fire while in flight over the ocean hours from any diversion airport, it would have been very different story very similar to what is happening to the 737 MAX now.

    • Ben says:

      As for the 787’s construction, regardless of it being shoddy or not, the 787 is in completely uncharted territory for an airliner when it was the first airliner ever made primarily out of carbon fiber rather than metal. To protect against lightning strikes, the 787 used a metal-mesh over the entire carbon fiber fuselage. The 787 is basically writing the book as it goes given that fundamental fact of being the first mainly carbon fiber airliner.

      • Rod says:

        OK, that’s one thing (Rockaway nightmares). Even if the most scrupulous manufacturer in the world had undertaken that project, it would still be as you say.

        HOWEVER, if harassed employees high on drugs have been hammering stuff home any old way (as described in the documentary), would even a D-check necessarily discover this?

        And if not, might it survive intact for a few dozen thousand hours, and only THEN fall apart?

        In other words, are we suddenly going to see, in future, a spate of 787 structural failures?
        I personally have no idea, but am mighty impressed by the words of that engineer.

        • Ben says:

          Yikes! Given this new knowledge, the 787s that really need to be checked are the oldest and/or ones that under go a heavy number of cycles compared to others after this. Many passengers refuse to the fly the 787 already due to how extremely cramped the plane is in 9 abreast layout that is now the main economy layout for the 787 even without this knowledge of its consistently shoddy construction.

        • Ben says:

          I know that Boeing had to make new equipment to check for cracks in the mostly composite 787 as conventional metal fatigue checks did not work for it. Now I wonder how effective that equipment truly is.

          • Rod says:

            I know stuff like water somehow working its way in than freezing and expanding and whatnot was at least considered after the 2001 Rockaway crash (which I don’t understand because I thought the fin was pinned on). Though the ultimate finding blamed the pilot flying and airline training. Still, it shows they initially wondered whether they weren’t back with the Comet in a way: How does this stuff behave, maybe very far down the line?

            Anyway, the documentary (published, remember, five years ago) says it’s rumoured at least one airline has refused to accept 787s built at the good-ol’-boy, union-bustin’ South Carolina plant and insists on Everett-built aircraft.

    • Simon says:

      Yikes!

      Patrick, have you watched this Al Jazeera documentary on the 787? Any comments?

      I liked the Dreamliner concept and the initial idea of long and thin, 8-abreast Y class, etc. I say this a somebody who doesn’t just like it because it’s Boeing (big fan of the A330 and A350 too). I flew the Dreamliner first on JAL and ANA and loved it. Lately with United on a -9, not so much. But I never felt unsafe, even after the two battery incidents which I was willing to believe were teething issues. But having seen now how the FAA has systematically neglected to truly regulate Boeing (MAX-8) and after watching this documentary, I honestly don’t think I’ll feel that safe next time I board a Dreamliner.

  12. Rod says:

    And now my own memory of the Chicago crash. I was at university in West Germany. A friend came over to visit on the cheap, flying Laker Skytrain from Toronto to London. Then ferry over the Channel. Then hitchhiking (yep, those were the days). The DC-10 had JUST been returned to the air after its grounding and was still very much in the news. John was quite nervous about flying on the thing. We were listening to BBC World Service on short-wave at my place and there was a news item on the DC-10. At the end, the plummy-voiced announcer paused before going on to the next item. My friend, an excellent mimic, broke in with the news-reader’s voice but in a much more confidential tone: “Would you fly on a DC-10? I sure wouldn’t!”

  13. Lee Taplinger says:

    I might easily be missing something here but it seems like if Boeing had just done one thing differently there wouldn’t have been the 2 MAX crashes: just made the entire MCAS safety suite standard. There are already 2 or 3 AOA sensors on each MAX anyway, just included tying them together with disagree software. Then neither plane would have activated MCAS on takeoff no matter if an AOA was defected or suffered a bird strike.

    • Thomas says:

      Don’t forget the proclivity of the MAX to STALL.

      Curiously, there has been no dissemination of statistical data regarding stall-frequency of the airplane.

      Perhaps the MAX is approaching a stall, and the AOA sensors disagree enough that the MCAS is not activated. If the stall occurs at “low” altitude, I wouldn’t want to be on that flight.

      • Rod says:

        Right. The whole Point of MCAS is to prevent the plane from stalling (in situations where previous versions of the 737 remain inherently stall-safe).

        Let’s say that MCAS is a symptom of a deeper problem. (But there are pathologies where it’s the symptom that kills you, not the pathology itself.)

        As Thomas says, however, stall too low to recover and you’ll be dead alright.

        • Thomas says:

          Rod makes an astute point, that previous 737 versions didn’t need MCAS.

          So, as Rod points out, neither the disease, nor the therapy, is there, to kill you, in previous 737 versions.

      • Lee Taplinger says:

        It’s hard to forget the proclivity of the MAX to stall since that’s the reason MCAS was added. Designers can’t prevent every possible series of problems but it would be rare that disagree software shuts off MCAS because of a sensor problem AND the plane stalls. If Boeing has 3 AOA sensors on each plane then 2 would have to fail to shut off MCAS and that would really be rare. Since all pilots are trained to handle stalls wouldn’t it be enough if when MCAS shuts itself off because of 2 sensor problems then software alerts the pilots that they’re going to handle a stall the old fashioned way?

  14. Peter says:

    Sadly I remember this well but for reasons a little different to many of the other posters. I was working for Air New Zealand at the time and tragically we had our own disaster to deal with in November 1979 when our DC-10 crashed in Antartica. When we saw the AA191 disaster I remember a discussion with some of my colleagues that if there was one more DC-10 disaster, Air NZ would really struggle. Little could we imagine it would be our own aircraft. During the 5 week shutdown we leased 747’s from PAA (I think there were others) and I remember specifically going on to a PAA 747 serving our night flight from AKL to LAX and thinking, “what a tub”. I loved the DC-10 and have great memories of some excellent flights during my time with (then) TE.

  15. Cheapside says:

    When remembering American Airlines Flight 191, can we just take a moment to look at the roles of the people who maintain these aircrafts? If they fail in their duty to properly maintain a plane, it’s the passengers and pilots who must pay the price. While looking online, I found a list of major accidents caused by improper maintenance:

    Alaska Airlines 261: MD-83, improper jackscrew maintenance
    Japan Airlines 123: 747, improper repair after earlier tailstrike
    Aeroperú Flight 603: 757, maintenance worker’s failure to remove protective tape from static port
    British Airways 5390: BAC 1-11, improperly installed windscreen

    It is important to understand that aviation disasters can be caused by flaws in the aircraft’s inherent design (ET302 being one example), or pilot error (much like the infamous crash of TransAsia Airways 235). However, in looking at the past, I still believe it is important not to forget the role of the aircraft maintannence worker in protecting lives, as one mistake or faulty decision can lead to disaster and death.

    • Rod says:

      Very true, and lousy maintenance played a prominent role in the Chicago crash (indeed I seem to remember the head of the maintenance crew committed suicide over it).

      EasyJet founder Sir Stelios Haji-Ioannou once said something like “If you think good maintenance is expensive, just try having a crash.” Well said.

      Your examples all concern negligence, but not deliberate negligence, except in the Alaska Airlines case as far as I know (outrageous!). In the BAC-111, not only did they not lose the aircraft, they didn’t even lose the captain. Miraculous.

      Another case of deliberately negligent maintenance was the “Azores Glider”, news of which was eclipsed by 911.
      An interesting sidenote to this case is that the captain, Robert Piché, had once served 16 months in a US federal prison for flying dope into the country. It has been suggested that this sort of experience (also lots of bush-flying in northern Quebec) prepared him mentally to face reality and Deal with it.
      For some reason Canada keeps leading the world in airline gliding records. There oughta be an event at the Olympics.

      Anyway, no lousy maintenance on the MAX, I think. Just lousy concept.

      • Ben says:

        The 737 MAX also has been only in service since 2017 before it was grounded. At that age, there is very little time in many cases for maintenance to be an issue. The Jakarta crash in October 2018 happened to involve literally a plane that had been delivered extremely recently too.

    • Ben says:

      On average, most plane crashes involve pilot error by a wide majority, with the remainder being mainly improper maintenance. It is pretty unusual for a plane crash to be the result entirely of bad weather and/or design flaws in the plane itself now, but the two 737MAX crashes fit into that rare entirely design flaws in the plane itself category.

      • Peter says:

        Some years ago I was acquainted with an American Eagle pilot. His view was that he hoped a probable cause of any crash was pilot error, because that was the one thing he could actually learn from and do something about.

        I remember the AA 191 crash vividly, both from those eyewitness photos, and because relatives who lived near Chicago lost some good friends aboard that plane, gone because of shoddy cost-cutting maintenance.

  16. Derek McCabrey says:

    When the photo of the DC10 flying at a 90° angle to the ground was published, I remember staring at the photo for quite some time in the realisation that what I was looking at were the last moments of people’s lives on earth. I could feel the utter panic, the diminishing hope that the pilots could recover the plane and get it on the ground safely and the sickening despair that gripped the passengers and crew as they realised that they were about to die and that there was no possible way out, trapped in a metal tube that was inexorably plummeting to the ground.

    When an aircrash occurs, I think that many thoughts begin and end with photos of blackened, burnt, twisted piles of wreckage. But in that wreckage are the remains of passengers that minutes previously might have been heading to a happy destination.

    There has, of course, been comprehensive coverage of the two recent 737-Max crashes, with claim and counter claim being made, politics being played, and face-saving being attempted by those reckoned to be responsible. But as with the Flight 191 disaster, the human cost is often forgotten except, of course, by those that lost their loved ones.

    That is the true cost and no amount of dollars can bring back those that perished.

  17. Thomas says:

    I can understand how Patrick can infer that past history would suggest, that with a technology fix, and additional training, this will “blow over,” as with the DC-10, Comet, 787, etc… The odds are that history will repeat, and Patrick will be correct.

    But, how dangerous would an aircraft design have to be, so that no technology fix, and additional training would be sufficient, to enable the aircraft to be flown safely ? Can an aircraft design be dangerous enough, that it would be different this time ?

    • Rod says:

      A rhetorical question I take it. Many pretty knowledgeable people have said, in so many words, that — for the purposes of the first years of a return to service — the MAX has now lived eight of its nine lives. Meaning that another big crash for Whatever Reason could be a deathblow to public confidence. The media could be relied upon to Remind people that, yes, This is The One — Remember?

      As for a fundamentally flawed design, well who am I? But it does seem to me that they took a sound design and went too far, making it a trifle stall-happy. For which they had to apply a cyber-bandaid. Then Jakarta and Addis.

      By definition we all use computers, so we all know how plumb Weird the cyberworld can be. I mean, even IF the angle-of-attack system and not the software itself was at fault — Who Cares? Boeing has gratuitously introduced an extra layer of complexity and people have died as a result.

      Will their Superduper New’n’Improved Stallproof-o-Rama system be flawless?
      It had damn well better be. And I guess that’s the answer to your question: There must Never Again be Even a Serious Incident involving MCAS&Co. Because — after all that has happened — that would reveal that the thing is basically faulty.

    • Ben says:

      I already see “Can an aircraft design be dangerous enough, that it would be different this time?,”and it is another Boeing product in the pipeline in the 777X.
      The 777X literally has folding wingtips built into the design of the plane from product launch at day one, and even well before these revelations on Boeing and the 737 MAX erupted, I found the plane having a fatal accident for certain very early in its service life from those folding wingtips failing.

      • Rod says:

        Do you really think a failed folding wingtip is enough to cause loss of control? Not sure what all the implications of such a failure are, but certainly quite a few aircraft have returned safely from far worse damage than that.

  18. James Priyam says:

    Sir
    This write up is one of your best.
    We are expecting more such.
    Thanks and best wishes.
    James Priyam

  19. Tom says:

    I remember this well, I was just out of college. A few days after the grounding I had to travel from Buffalo to NYC for a flight attendant interview with Pan Am. Because PAA didn’t serve Buffalo I had to fly American — which, amazingly, had been using DC-10s on two of their daily trips from BUF to LGA and also to ORD. It was kind of spooky showing up at the Buffalo airport and seeing an AA DC-10 parked there forlornly. What’s more, the 727-200 I ended up with looked like it had seen much better days…

  20. Chilling. I remember this one well. I was about 14.
    Patrick…the first image is not displaying.

  21. Rod says:

    Gimlet Winglet: “I don’t want to be on any Boeing planes developed after 2011. What else is wrong with them?”

    This sort of echoes a remark on the Aviation Safety Reporting System by a MAX pilot in the US after Jakarta and the ensuing revelation (surprise!) of MCAS’s very existence: “What ELSE don’t I know about this aircraft?”

  22. Rod says:

    Regardless of the relative burdens borne by the companies flying the two aircraft types and regardless of people’s ignorance about the matter, I’ve been reading some reports on the FAA’s meeting this week with regulators from other countries concerning the MAX. One predicted relaunch of the blasted thing after another has slid by, and operators are continually announcing further delays.

    Some are now daring to say the grounding could last up to a year. The FAA is bending wayyyy over backwards to wash itself clean of past sins and to sound like a real-life regulator. If you’re an airline, what do you do about even a couple of dozen less important aircraft that you might not be able to use for a Very Long Time? There has to come a point where you get the feeling you’re throwing good money after bad, say “To hell with this, Jack”, order up some neos and, in the meantime, rescue a bunch of airplanes from Mojave oblivion.

  23. Blair Kooistra says:

    Two chilling details:

    United 191 shared the same flight number as another big tri-jet disaster: The Delta 191 wind shear crash at Dallas-Fort Worth airport in August 1985.

    Second, it always morbidly fascinated me that the American DC-10’s at the time featured a look-ahead camera in the cockpit transmitting back to the passenger cabin. . . I can only hope the electrical outage that helped bring the plane down also shut off the transmission of the plane’s final moments to the doomed passengers in the cabin.

    • Ben says:

      I find “191” a “cursed” flight number with how many catastrophic and deadly aviation disasters have happened with that flight number.

  24. B says:

    Wow, you learn something new every day – one other remarkable similarity between the DC-10 and the 737 MAX is that both planes apparently had a useful safety feature that was optional. The DC-10 that crashed only had a stick shaker on the captain’s side, not the FO’s side. The second stick shaker was an option, and American chose not to purchase it.

    As a direct result of the AA 191 crash all DC-10s were required to have two stick shakers installed:

    https://bit.ly/30DT7J8

    One would expect to see this exact same directive for the 737 MAX and the “AOA DISAGREE” software display option.

    • Gimlet Winglet says:

      Boeing has already stated that the missing AOA DISAGREE display was an error and they will rectify it for free. They’ve also said they will make the optional AOA numerical display a standard feature. But it does not add to one’s confidence level to hear that they unintentionally disabled the AOA DISAGREE display, which was a known feature of the 737NG. How the hell does that get through their development process? It is also another change from the 737NG that they failed to inform the pilots about.

      • Jim says:

        Mr. Gimlet
        Forgive me in advance for a long post.
        For context here, go back to NASA hero types Chris Kraft & Gene Kranz plus Kelly Johnson of legendary Skunk Works. These hero types (to all aviation and/or space fans), all have publicly stated the danger/peril/risk of having chart boys (not their words) in the authority chain.
        Not only did Boeing mess up the design by using a 50-year-old template, but their disclosures have been unacceptably miserable, one of which took nearly a year to actually transmit to the carriers. (One of the carriers’ pilot union members was truly furious at this one.)

        Zero of this disclosure failure has been proprietary and is widely available in many media sources.

        This industry, with many others, has been infested by bean counters, MBAs, heavy breathers, umbrella holders, flashlight holders, special assignment specialists (usually absent–away on special assignment), team leaders, team facilitators, facilitating teamers, aka CHART BOYS.

        Said chart boys, even with their advanced degrees in something other than engineering, probably CANNOT make wise decisions even if they were ethically leaning to do so. But you can bet your last ruble that they know the stock price as of the last 5 minutes.

        You can also bet your last ruble that this particular 737 MAX mess is NOT limited to just this one component issue. The corporate decision-making authority chain is truly and epically polluted by chart boys.

        • Gimlet Winglet says:

          No apology needed for a long post. The long ones are usually the good ones.

          We’re mostly in agreement about the perils of letting non-pilots/engineers have agency in the development process.

          The other systemic problem that needs addressing is that Boeing (and other US aircraft manufacturers) have achieved regulatory capture over the FAA. They pay the FAA representatives’ salaries, and determine their assignments and promotions.

          This seattle times article frightens me, and I’m one of those boring dudes who tells people with fear of flying that it’s 1000 times more likely that you’ll get into a car accident on the way to the airport than you will die on the plane. I don’t want to be on any Boeing planes developed after 2011. What else is wrong with them?

          https://www.seattletimes.com/business/boeing-aerospace/engineers-say-boeing-pushed-to-limit-safety-testing-in-race-to-certify-planes-including-737-max

          • Jennifer Moore says:

            This investigative report is similarly upsetting: https://www.youtube.com/watch?v=rvkEpstd9os

          • Ben says:

            If you think the 737 MAX has fatal design flaws which it does, than you should even be more worried about the upcoming 777X.
            That plane even before all of these revelations happened had such a deadly design flaw right from product launch in 2013, that I found it an air disaster waiting to happen and certain. The 777X has folding wing-tips to fit into gates that the current rigid wing 777-200LR and 300ER models do, and I feel 100% certain that those folding wing tips are going to fail early in its life and cause a fatal accident.
            The Max’s fatal flaws are mainly software at the moment, and those are relatively easy to fix compared to a hardware flaw in the 777X’s case. I guarantee that the 777X will be far more like the DC-10 than the 737 MAX will be.

          • Ben says:

            How in the world can anyone not see this Boeing 777X folding wing tip screaming certain air disaster after all these revelations? https://en.wikipedia.org/wiki/Boeing_777X#/media/File:777X_Roll-Out_(40407369583).jpg I promise that the 777X is going to be the 737 MAX on steroids in the end due to this folding wing tip. I have firm confidence in this falling out of the sky like the Comet with its square windows.

        • Mark Maslowski says:

          I’m not sure if Chris Kraft & Gene Kranz are good examples, considering their contribution to the Apollo 1 disaster. Kelly Johnson might not be either considering that the Skunk Works designed a plane so dangerous – the F-104 – that it because known as “The Widowmaker.”

          • Rod says:

            Welllll, the Starfighter was Not an airliner. It had the wing-loading of an anvil and one single engine (1950s vintage).
            A beautiful thing to see fly, but more a projectile than an airplane.

            (Kelly Johnson’s youtube doc is excellent.)

          • Jim says:

            Mr. Maslowski
            The F-104 record wasn’t that much different from other airplane introductions. A jaw-dropping aspect of this one is the fact that the first airplane was available 11 months after Johnson interviewed actual pilots. We knew essentially next to zip about supersonic flight characteristics then, so the new airframe, new engine, new protocol, and all other new systems strapped together made for risk.
            And the oxygen atmosphere during earlier Apollo was the same as Mercury and Gemini.
            Granted, disasters are never acceptable but “honest” engineering errors are wildly, widely, hugely, and massively different from “chart boy” decisions made by bean counters who don’t know a rivet from an engine except one is loud AS it is installed while the other AFTER.
            So I’ll politely and respectfully stick with Johnson, Kranz, Kraft, et al over any collection of chart boys, MBAs, team leaders, and project managers, ever assembled.

    • Jim says:

      Mr. B:
      “they could have avoided catastrophe. . . .”
      Only on their very best day with a ton o’ luck and maybe a good dose of providential oversight. The drastically asymmetric lift situation would have been hard to counteract PLUS that thrust imbalance.

      It was discovered that the carriers cut corners during maintenance PLUS there was a row of discrepant fasteners from the manufacturer.

      My job (for decades) sometimes included reading IN DETAIL various NTSB reports and this one nearly caused nightmares for many 3rd-party observers. If the carriers had removed the engine, THEN the pylon (strut), they MIGHT have noticed the discrepant fasteners, but removing both at the same time eliminated this possibility.

      So I politely and respectfully offer that said stick shaker probably wouldn’t have mattered.

      Last point: in addition to changing the decal on the airplane exterior to eliminate the DC-10, the final iteration of the DC-10 got renamed MD-11. Yes, there are a ton of other changes, but . . . .

      • B says:

        Jim:

        FWIW – I don’t think based on my 30 seconds of reading the NTSB report that the stick shaker mattered for AA191. It seems like a hail Mary at best – one extra data poin and maybe in the future it’d help. I just thought it was fascinating that the FAA decided an “optional aka costs money” feature was actually so important they had to provide it for everyone free. And honestly with the MAX I’m simply astounded that they monetized a software switch. It is one thing if you are Tesla and you charge more for a switch to let the battery charge more – ridiculous but whatever. It’s another thing to charge money to show an alert on the display – that’s truly insane.