Delta Air Lines Flight 191

From Vero - Wikipedia
Jump to navigation Jump to search

Template:Short description Template:Use mdy dates Template:Use American English Template:For Template:Infobox aircraft occurrence Delta Air Lines Flight 191 was a regularly scheduled Delta Air Lines domestic flight from Fort Lauderdale, Florida, to Los Angeles, California, with an intermediate stop at Dallas/Fort Worth International Airport (DFW). On August 2, 1985, the Lockheed L-1011 TriStar operating Flight 191 encountered a microburst while on approach to land at DFW. The aircraft impacted ground just over Template:Convert short of the runway, struck a car near the airport, collided with two water tanks and disintegrated. Out of the 163 occupants on board, 136 people died and 25 others were injured in the accident, while the driver of the car struck by the aircraft also died.Template:Efn

The National Transportation Safety Board (NTSB) determined that the crash resulted from the flight crew's decision to fly through a thunderstorm, the lack of procedures or training to avoid or escape microbursts and the lack of hazard information on wind shear. Forecasts of microbursts improved in the following years, with the 1994 crash of USAir Flight 1016 being the only subsequent microburst-induced crash of a commercial, fixed-wing aircraft in the United States Template:As of.<ref>Template:Cite news</ref>

Involved

Aircraft

The accident aircraft was a Lockheed L-1011-385-1 TriStar (registration number N726DA).<ref name="AAR-86-05 Final Report">Template:Cite book</ref>Template:Reference page It was delivered to Delta Air Lines on February 28, 1979, and had operated continuously until the accident.<ref name="AAR-86-05 Final Report" />Template:Reference page Three Rolls-Royce RB211-22B engines powered the aircraft.Template:Cn

Crew members

The crew consisted of three flight crew members and eight cabin crew members. Of the 11 crew members, only 3 flight attendants survived.<ref name="AAR-86-05 Final Report" />Template:Reference page

In command of Flight 191 was Captain Edward Michael "Ted" Connors Jr., aged 57, who had been a Delta employee since 1954. He qualified to captain the TriStar in 1979 and had passed his proficiency checks.<ref name="AAR-86-05 Final Report" />Template:Reference page The National Transportation Safety Board (NTSB) mentioned in its final report that past flight crews who had flown with Connors described him as a meticulous pilot who strictly adhered to company policies.<ref name="AAR-86-05 Final Report" />Template:Reference page The report also stated that Connors "deviated around thunderstorms even if other flights took more direct routes" and "willingly accepted suggestions from his flight crew."<ref name="AAR-86-05 Final Report" />Template:Reference page Since his qualification in 1979, Connors had passed all eight en route inspections that he had undergone; the NTSB report also noted that he had received "favorable comments" regarding "cockpit discipline and standardization."<ref name="AAR-86-05 Final Report" />Template:Reference page Connors had logged over 29,300 hours of flight time, 3,000 of them in the TriStar.<ref name="AAR-86-05 Final Report" />Template:Reference page

First Officer Rudolph Przydzial "Rudy" Price Jr., age 42, had been a Delta employee since 1970.<ref name="AAR-86-05 Final Report" />Template:Reference page Delta captains who flew with Price described him as an "above average first officer" who possessed "excellent knowledge" of the TriStar.<ref name="AAR-86-05 Final Report" />Template:Reference page Price had logged 6,500 flight hours, including 1,200 in the TriStar.<ref name="AAR-86-05 Final Report" />Template:Reference page Flight Engineer Nicholas Nestor "Nick" Nassick, age 43, had been a Delta employee since 1976. He had logged 6,500 hours of flight time, including 4,500 in the TriStar. Fellow Delta employees described Nassick as "observant, alert, and professional."<ref name="AAR-86-05 Final Report" />Template:Reference page

Connors had served with the United States Navy from 1950 to 1954 and fought during two tours in the Korean War. Price had served with the United States Navy from 1964 to 1970 and fought in four tours in the Vietnam War. Nassick had served with the United States Air Force from 1963 to 1976 and had fought in four tours during the Vietnam War.<ref name="AAR-86-05 Final Report" />Template:Reference page<ref>Template:Cite news</ref><ref name="AOPA 2012">Template:Cite web</ref>

Passengers

Of the 152 passengers, 128 were killed in the crash. Twelve of the twenty-four survivors were seated in a cluster near the aircraft's tail.<ref name="The New York Times">Template:Cite news</ref> The NTSB report lists 126 passenger fatalities rather than 128, but notes that two of the passengers listed as survivors died more than thirty days after the crash, on September 13<ref>Template:Cite news</ref> and October 4, 1985.Template:Efn Of the dead, seventy-three originated from the Miami metropolitan area; forty-five were from Broward County, nineteen were from Palm Beach County and nine were from Dade County.<ref>Template:Cite news</ref><ref>Template:Cite news</ref>

Among the deaths was Don Estridge, known to the world as the father of the IBM PC; he died aboard the flight along with his wife.<ref name="Invisible Killer 2008">Template:Cite episode</ref> Two IBM summer interns, four IBM employees from the IBM branch office in Burbank, California, and six additional family members of IBM employees also perished.<ref name="Sanger 1985">Template:Cite news</ref>

Accident

History

File:Delta 191 wreckage.jpg
Another view of the remains of N726DA, as a Boeing 727 approaches to land.

Flight 191 was a regularly scheduled passenger flight from Fort Lauderdale–Hollywood International Airport to Los Angeles International Airport, with a scheduled stop at Dallas–Fort Worth International Airport (DFW). The flight departed Fort Lauderdale on an instrument flight rules flight plan at 14:10 Central Daylight Time (UTC−05:00).<ref name="AAR-86-05 Final Report" />Template:Reference page<ref name="Bedell 1985">Template:Cite news</ref>Template:Efn The flight's dispatch weather forecast for DFW stated a "possibility of widely scattered rain showers and thunderstorms."<ref name="AAR-86-05 Final Report" />Template:Reference page Another dispatch weather alert warned of "an area of isolated thunderstorms ... over Oklahoma and northern and northeastern Texas."<ref name="AAR-86-05 Final Report" />Template:Reference page The flight crew reviewed these notices before takeoff.<ref name="AAR-86-05 Final Report" />Template:Reference page

As the aircraft flew past New Orleans, Louisiana, a weather formation near the Gulf Coast strengthened. The flight crew decided to deviate from the intended route to make the more northerly Blue Ridge arrival to DFW.<ref name="AAR-86-05 Final Report" />Template:Reference page The flight held for ten to fifteen minutes over the Texarkana, Arkansas, VORTAC. At 17:35, the crew received an Automatic Terminal Information Service (ATIS) broadcast for weather on approach to DFW, and the Fort Worth Air Route Traffic Control Center (ARTCC) air traffic controller cleared the flight to the Blue Ridge, Texas, VORTAC and instructed the flight to descend to Template:Convert.<ref name="AAR-86-05 Final Report" />Template:Reference page

At 17:43:45, the Fort Worth ARTCC controller cleared the flight down to Template:Convert.<ref name="AAR-86-05 Final Report" />Template:Reference page The controller suggested they fly a heading of 250° toward the Blue Ridge approach, but Connors replied that the route would take them through a storm cell, stating, "I'd rather not go through it, I'd rather go around it one way or the other."<ref name="AAR-86-05 Final Report" />Template:Reference page After a brief exchange, the controller gave the flight a new heading.<ref name="AAR-86-05 Final Report" />Template:Reference page At 17:46:50, the controller cleared the flight direct to Blue Ridge and instructed the crew to descend to Template:Convert. Connors expressed his relief that the controller did not send them on the original trajectory.<ref name="AAR-86-05 Final Report" />Template:Reference page At 17:51:19, Nassick commented, "Looks like it's raining over Fort Worth."<ref name="AAR-86-05 Final Report" />Template:Reference page At 17:51:42, the Fort Worth ARTCC controller transferred the flight to DFW Airport Approach Control, which cleared the flight to descend to Template:Convert.<ref name="AAR-86-05 Final Report" />Template:Reference page Two minutes later, the controller asked Flight 191 to deviate by 10° and to slow their airspeed to Template:Convert. The crew acknowledged the request.<ref name="AAR-86-05 Final Report" />Template:Reference page As the flight descended, the crew prepared the aircraft for landing. At 17:56:19, the feeder controller cleared the flight down to Template:Convert. Nine seconds later, the controller announced that rain was north of the airport, and that the airport would be using instrument landing system (ILS) approaches.<ref name="AAR-86-05 Final Report" />Template:Reference page

At 17:59:47, Price said, "We're gonna get our airplane washed."<ref name="AAR-86-05 Final Report" />Template:Reference page<ref>Template:Cite news</ref> Around the same time, Connors switched to the arrival radio frequency and informed the approach controller that they were flying at Template:Convert. The controller replied that the flight should expect to approach Runway 17L. At 18:00:36, the approach controller asked an American Airlines flight that was two aircraft ahead of Flight 191, and on the same approach, if they could see the airport.<ref name="AAR-86-05 Final Report" />Template:Reference page The American Airlines flight responded, "As soon as we break out of this rain shower, we will."<ref name="AAR-86-05 Final Report" />Template:Reference page At 18:00:51, Flight 191 was instructed to slow to Template:Convert and to turn to heading 270°. Flight 191 was instructed to descend to Template:Convert at 18:01:34.<ref name="AAR-86-05 Final Report" />Template:Reference page One minute later, the approach controller turned the flight toward Runway 17L and cleared them for an ILS approach at or above Template:Convert.<ref name="AAR-86-05 Final Report" />Template:Reference page Half a minute afterward, the controller asked the flight to reduce their speed to Template:Convert, which the crew acknowledged. At 18:03:30 the controller advised, "And we're getting some variable winds out there due to a shower ... out there north end of DFW."<ref name="AAR-86-05 Final Report" />Template:Reference page Several seconds later, an unidentified flight crew member commented, "Stuff is moving in."<ref name="AAR-86-05 Final Report" />Template:Reference page

Just Template:Convert ahead of Flight 191, a Learjet 25 was on the same approach to Runway 17L.<ref name="AAR-86-05 Final Report" />Template:Reference page While on final approach, the Learjet flew through the storm north of the airport and encountered what was later described as "light to moderate turbulence". The Learjet encountered heavy rain and lost all forward visibility, but was able to continue its ILS approach and land safely.<ref name="AAR-86-05 Final Report" />Template:Reference page When later asked why he did not report weather conditions to the tower, the Learjet's captain testified that he had nothing to report because "the only thing that we encountered was the heavy rain."<ref name="AAR-86-05 Final Report" />Template:Reference page The tower controller handling landings on Runway 17L saw lightning from the storm cell after the Learjet landed, but before he saw Flight 191 emerge from the storm.<ref name="AAR-86-05 Final Report" />Template:Reference page

Crash

File:Delta191-PathToImpact.png
The flight path in the final moments. William Mayberry is killed in his car at "4".

At 18:03:46, the approach controller once again asked Flight 191 to reduce its speed, this time to Template:Convert, and then handed the flight over to the tower controller. Twelve seconds later, Connors radioed the tower and said, "Tower[:] Delta one ninety one heavy, out here in the rain, feels good."<ref name="AAR-86-05 Final Report" />Template:Reference page The tower controller advised Flight 191 that the wind was blowing at Template:Convert with gusts up to Template:Convert, which the captain acknowledged.<ref name="AAR-86-05 Final Report" />Template:Reference page The flight crew lowered the landing gear and extended their flaps for landing. At 18:04:18, Price commented, "Lightning coming out of that one. ... Right ahead of us."<ref name="AAR-86-05 Final Report" />Template:Reference page<ref>Template:Cite web</ref> Connors called out that they were at Template:Convert at 18:05:05. Fourteen seconds later, he cautioned Price to watch his airspeed.<ref name="AAR-86-05 Final Report" />Template:Reference page<ref>Template:Cite news</ref> At the same time, the cockpit voice recorder (CVR) captured the beginning of a sound identified as rain hitting the cockpit.<ref name="AAR-86-05 Final Report" />Template:Reference page Connors warned Price, "You're gonna lose it all of a sudden, there it is."<ref name="AAR-86-05 Final Report" />Template:Reference page At 18:05:26, Connors told Price, "Push it up, push it way up."<ref name="AAR-86-05 Final Report" />Template:Reference page Several seconds later, the CVR recorded the sound of the engines spooling up. Connors then said, "That's it."<ref name="AAR-86-05 Final Report" />Template:Reference page At 18:05:36, Connors exclaimed, "Hang on to the son of a bitch!"<ref name="CVR Audio">Template:Cite AV mediaTemplate:Cbignore</ref><ref name="Cox book">Template:Cite book</ref> From this point, the aircraft began a descent from which it never recovered. The angle of attack (AOA) was over 30° and began to vary wildly over the next few seconds.<ref name="AAR-86-05 Final Report" />Template:Reference page The pitch angle began to sink and the aircraft started descending below the glideslope.<ref>Template:Cite AV media</ref>

At 18:05:44, with the aircraft descending at more than Template:Convert<ref name="AAR-86-05 Final Report" />Template:Reference page the ground proximity warning system (GPWS) sounded.<ref name="AAR-86-05 Final Report" />Template:Reference page<ref name="Cox book" /> The captain responded by declaring "TOGA", aviation shorthand for the order to apply maximum thrust and abort a landing by going around.<ref name="AAR-86-05 Final Report" />Template:Reference page<ref name="Cox book" /> The first officer responded by pulling up and raising the nose of the aircraft, which slowed but did not stop the plane's descent. At 18:05:52, still descending at a rate around Template:Convert,<ref name="AAR-86-05 Final Report" />Template:Reference page the aircraft's landing gear made contact with a plowed field Template:Convert north of the runway and Template:Convert east of the runway centerline.<ref name="AAR-86-05 Final Report" />Template:Reference page Remaining structurally intact, Flight 191 remained on the ground while rolling at high speed across the farmland.<ref name="AAR-86-05 Final Report" />Template:Reference page The main landing gear left shallow depressions in the field that extended for Template:Convert before disappearing and reappearing a few times as the aircraft approached Texas State Highway 114.<ref name="AAR-86-05 Final Report" />Template:Reference page

The aircraft struck a highway street light, and its nose gear touched down on the westbound lane of Highway 114, skidding across the road at at least Template:Convert.<ref name="mypalmbeachpost">Template:Cite news</ref> The aircraft's left engine hit a 1971 Toyota Celica driven by 28-year-old William Mayberry, killing him instantly.<ref>Template:Cite news</ref><ref name="AAR-86-05 Final Report" />Template:Reference page<ref name="Bedell 1985" /> As the aircraft continued south, it hit two more street lights on the eastbound side of the highway and began fragmenting. The left horizontal stabilizer, some engine pieces, portions of the wing control surfaces and parts of the nose gear came off the aircraft as it continued along the ground. Some witnesses later testified that fire was emerging from the left wing root.<ref name="AAR-86-05 Final Report" />Template:Reference page Surviving passengers reported that fire began entering the cabin through the left wall while the plane was still moving.<ref name="AAR-86-05 Final Report" />Template:Reference page One survivor stated that he watched passengers attempt to escape the fire by unbuckling their seatbelts and trying to flee, but they were sucked out of the plane, while others who stayed caught on fire due to leaking jet fuel. He only survived due to being doused by rain from openings in the plane.<ref name="mypalmbeachpost" /> The aircraft's motion across open land ended when it crashed into two water tanks on the edge of the airport property; the aircraft grazed one water tank about Template:Convert south of Highway 114, and then struck the second one. As the left-wing and nose struck the water tank, the fuselage rotated counterclockwise and was engulfed in a fireball.<ref name="AAR-86-05 Final Report" />Template:Reference page The fuselage from the nose rearward to row 34 was destroyed.<ref name="AAR-86-05 Final Report" />Template:Reference page The tail section emerged from the fireball, skidding backward and came to rest on its left side before wind gusts rotated it upright.<ref name="AAR-86-05 Final Report" />Template:Reference page

Post-crash response

File:Delta191-CabinSeatDiagram.svg
Diagram of the injuries suffered in the cabin

All airport fire and emergency units were alerted within one minute of the crash. Forty-five seconds after first being alerted, three fire trucks from the airport's fire station No. 3 arrived at the crash and began fighting the fire. Additional units from fire stations No. 1 and No. 2 arrived within five minutes, and despite high wind gusts and heavy rain, the fire was mostly under control within 10 minutes after the alert was sounded.<ref name="AAR-86-05 Final Report" />Template:Reference page

The first paramedics arrived within five minutes of the crash and immediately established triage stations. In later testimony to NTSB officials, on-site EMTs estimated that without the on-scene triage procedures, at least half of the surviving passengers would have died.<ref name="AAR-86-05 Final Report" />Template:Reference page Most of the survivors of Flight 191 were located in the aircraft's rear smoking section, which broke free from the main fuselage when the aircraft hit the water tanks.<ref name="AAR-86-05 Final Report" />Template:Reference page Authorities transported most of the survivors to Parkland Memorial Hospital.<ref name="Magnuson 2005">Template:Cite magazine</ref>

The cockpit and passenger section forward of seat row 34 had been completely fragmented by impact with the water tanks and post-crash fires; all but eight of the occupants in this section were killed. The remainder of the surviving passengers and crew were in the rear cabin and tail section, which separated relatively intact and landed on its side in an open field, and most of these were in the center and right portions of the fuselage from seat row 40 rearwards.<ref name="AAR-86-05 Final Report" />Template:Reference pageTemplate:Efn Overall, the disintegration of the Tristar was so extensive that the NTSB investigation was quite difficult. Survivors reported that fire broke out in the cabin prior to hitting the tanks and began spreading through the aircraft's interior, which is consistent with the right wing's collision with the light pole and fuel tank ignition. Some of the people in the tail section were unable to free themselves due to injuries, so rescue crews had to extricate them. Most survivors were also soaked with jet fuel, further adding to the difficulty of exiting the wreckage.<ref name="AAR-86-05 Final Report" />Template:Reference page

Two of the passengers who initially survived the crash died more than 30 days later. On the ground, an airline employee who assisted in rescuing survivors was hospitalized overnight for chest and arm pain.<ref name="AAR-86-05 Final Report" />Template:Reference page The crash ultimately killed 137 people, including 128 of the 152 passengers and eight of the 11 crew (including all three flight crew members<ref name="AAR-86-05 Final Report" />Template:Reference page), and the driver of the car.<ref name="The New York Times"/>

Delta Air Lines Flight 191 has the second-highest death toll of any aviation accident involving a Lockheed L-1011 anywhere in the world, after Saudia Flight 163, which killed 301.<ref name="ASN">Template:Cite web</ref>

Investigation

Numerous public safety agencies responded to the crash, including the Dallas/Fort Worth Airport Department of Public Safety, the Texas Department of Public Safety, the Irving Fire Department, the Irving Police Department, and all available third-watch personnel from the Dallas Police Department's Northwest Patrol Division and the Northeastern Sector of the Fort Worth Police Department's Patrol Division.Template:Citation needed

After a long investigation, the NTSB deemed the cause of the crash to be attributable to pilot error (for their decision to fly through a thunderstorm), combined with extreme weather phenomena associated with microburst-induced wind shear.<ref name="AAR-86-05 Final Report" />Template:Reference page<ref name="crew blamed">Template:Cite news</ref> The NTSB also determined that a lack of specific training, policies, and procedures for avoiding and escaping low-altitude wind shear was a contributing factor.<ref name="AAR-86-05 Final Report" />Template:Reference page

The NTSB attributed the accident to lack of the ability to detect microbursts aboard aircraft; the radar equipment aboard aircraft at the time was unable to detect wind changes, only thunderstorms. After the investigation, NASA researchers at Langley Research Center modified a Boeing 737-100 as a testbed for an onboard Doppler weather radar. The resultant airborne wind shear detection and alert system was installed on many commercial airliners in the United States after the Federal Aviation Administration mandated that all commercial aircraft must have on-board wind shear-detection systems.<ref name="AAR-86-05 Final Report" /><ref>Template:Cite web</ref><ref name="auto">Template:Cite web</ref>

The NTSB was also critical of the airport for failing to notify emergency services in surrounding municipalities in a timely manner. While the airport's on-site emergency services were notified almost immediately, the DFW Department of Public Safety (DPS) Communications Center did not begin notifying off-site emergency services until nearly 10 minutes after the crash and did not finish its notifications until 45 minutes after the crash. During notifications, DPS also failed to request ambulances from the adjacent communities of Irving, Grapevine, and Hurst; however, Hurst responded with ambulances after personnel at its ambulance company overheard the airport crash report on a radio-frequency scanner. The NTSB concluded that the overall emergency response was effective due to the rapid response of on-airport personnel, but found "several problem areas" which under different circumstances "could affect adversely the medical treatment and survival of accident victims at the airport".<ref name="AAR-86-05 Final Report" />Template:Reference page

Legacy

Reforms

Following the crash and the ensuing NTSB report, DFW's DPS made improvements to its postcrash notification system, including the introduction of an automated voice notification system to reduce notification times. In 1988, following the crash of Delta Air Lines Flight 1141 while taking off from DFW, DPS completed its notification of nearby emergency services in 21 minutes; the NTSB described this as a "significant improvement" over response times after the Delta Flight 191 crash.<ref name="AAR-89-04 Final Report">Template:Cite journal</ref>Template:Reference page Based on the improved response times, the NTSB issued a Safety Recommendation on January 9, 1990, calling for airport executives nationwide to consider the benefits of using automated voice notification systems for their emergency aid notifications.<ref>Template:Cite book</ref> Pilots were also required to train to react to microbursts and to quickly take evasive action in order to safely land the plane.<ref>Template:Cite news</ref><ref name="DMN Safety Overhaul">Template:Cite news</ref><ref>Template:Cite news</ref>

Trial

The Delta Flight 191 crash resulted in the longest aviation trial in American history, lasting 14 months from 1988 to 1989 and presided over by Federal Judge David Owen Belew Jr. of the Northern District of Texas.<ref name="NDTex 1989">Template:Cite court</ref><ref name="5th Cir. 1991">Template:Cite court</ref> The trial featured the first use of computer graphic animation as substantive evidence in federal court. While the use of such animation later became routine, its use in the Flight 191 litigation was sufficiently novel that it became the cover story of the December 1989 ABA Journal, the magazine of the American Bar Association.<ref name="ABA1989">Template:Cite news</ref>Template:Rp Preparing the animated video for trial cost the Department of Justice around $100,000 to $150,000 (inflation adjusted $Template:Inflation to $Template:Inflation), and required nearly two years of work.<ref name="ABA1989" /> The court found that both government personnel and the Delta flight crew were negligent, but that Delta was ultimately responsible because its pilots' negligence was the proximate cause of the accident, and the ruling was upheld on appeal to the Fifth Circuit Court of Appeals.<ref name="NDTex 1989" /><ref name="5th Cir. 1991" />

Dramatization and media

The crash was the subject of the television movie Fire and Rain.<ref>Template:Cite AV media</ref>

The Discovery Channel Canada/National Geographic television series Mayday dramatized the crash of Flight 191 in a season-five episode titled "Invisible Killer".<ref name="Invisible Killer 2008"/> The crash had previously been discussed in the Mayday season-one episode "Racing the Storm", which covered the weather-related crash landing of American Airlines Flight 1420.<ref name="Racing the Storm">Template:Cite episode</ref>

The crash was featured on an episode of When Weather Changed History and Why Planes Crash on The Weather Channel,<ref>Template:Cite episode</ref> and the episode "Deadly Weather" of Survival in the Sky on The Learning Channel.<ref>Template:Cite episode</ref>

The crash was mentioned in the feature film Rain Man.<ref>Template:Cite book</ref>

Working as a reporter for the Fort Lauderdale News and Sun-Sentinel in 1986, future crime fiction author Michael Connelly and two other reporters conducted extensive interviews of survivors of Delta Flight 191 and wrote an article detailing their experiences during and after the crash.<ref name="SS1">Template:Cite news</ref> The article explored the topic of survivor guilt and earned Connelly and his co-writers a finalist position for the Pulitzer Prize.<ref>Template:Cite web</ref>

Memorial

Ten years after the crash, survivors and family members of victims gathered in Florida to recognize the tenth anniversary of the accident.<ref>Template:Cite news</ref> In 2010, 25 years after the accident, a memorial was installed at Dallas-Fort Worth International Airport's Founders Plaza in Grapevine.<ref>Template:Cite news</ref>

See also

Template:Portal

Notes

Template:Notes

References

Template:NTSB Template:Reflist

Template:Commons category

Template:Aviation incidents and accidents in 1985 Template:Aviation accidents and incidents in the United States in the 1980s Template:Delta Air Lines Template:Irving, Texas