PB89-9 10406

NTSBAAR-89/04

NATIONAL
TRANSPORTATION
SAFETY
BOARD

AIRCRAFTACCIDENTREPORT
DELTAAIRLINES,INC.
BOEING 727-232,N473DA
DALLAS-FORTWORTHINTERNATIONAL
AIRPORT,TEXAS
AUGUST31,1988
 The National Transportation Safet Board is
an independent Federal agency declicated to
promoting aviation, railroad, highway, marine,
pipeline, and hazardous materials safety.
Established in 1967, the agency is mandated by
the Independent Safety Board Act of 1974 to
investigate transportation accidents,
determine the probable cause of accidents,
issue safety recommendations, study
transportation safety issues, and evaluate the
safety effectiveness of government agencies
involved in trans-portation.
The Safety Board makes public its actions
and decisions through accident reports, safety
studies, special investigation reports, safety
recommendations, and statistical reviews.
Copies of these documents may be purchased
from the National Technical Information
Service, 5285 Port Royal Road, Springfield,
V i r g i n i a 2 2 1 6 1 . Details on available
publications may be obtained by contacting:

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Public Inquiries Section, AD-46
800 Independence Avenue, S.W.
Washington, D.C. 20594
(202)382-6735
 TECHNICAL REPORT DOCUMENTATION PAGE
I. Report No. I 2. Government Accession No. 3. Recipient’s Catalog No.
NT&MAR-89104 1 PB89-910406
1. Title and Subtitle Aircraft Accident Report- 5. Report Date
Belta Air Lines, Inc. Boeing 727-232, N473DA, September 26,1989
Dallas-Fort Worth International Airport, Texas
9ugust31,19BB 6. Performing Organization
Code
7. Author(s) a. Performing Organization
Report No.
3. Performing Organization Name and Address 10. Work Unit No.
4965A
National Transportation Safety Board
Bureau of Accident Investigation 11. Contract or Grant No.
Washington, D.C. 20594
13. Type of Report and
Period Covered
Highway Accident Report
12. Sponsoring Agency Name and Address August 17,19B8

NATIONAL TRANSPORTATION SAFETY BOARD

Washington, DC. 20594 14. Sponsoring Agency Code

IS. Supplementary Notes

16. Abstract
This report examines the crash of Delta flight 1141 while taking off at the Dallas-Forth Worth,
Texas on August 31, 1988. The safety issues discussed in the report include flightcrew
orocedures;wake vortices; engine performance; airplane flaps and slats; takeoff warning system;
:ockpit discipline; aircraft rescue and firefighting; emergency evacuation; and survival factors.
Recommendations addressing these issues were made to the Federal Aviation Administration, the
American Association of Airport Executives, the Airport Operations Council International, and the
National Fire Protection Association.

17. Key Words 18. Distribution Statement

This document is available to
the public through the
National Technical Information
Service, Springfield, Virginia
22161

19. Security Classification 20. Security Classification 21. No. of Pages 22. Price
(of this report) (of this page)
UNCLASSIFIED UNCLASSIFIED 135
llTSB Form 1765.2 (Rev. 5188)
 CONTENTS

EXECUTIVE SUMARY ............................................. V

1. FACTUAL INFORMATION
1.1 History of the Flight ........................................
1.2 Injuries to Persons ...........................................
1.3 Damage to the Airplane ........................................ 5
1.4 Other Damage .................................................. 5
1.5 Personnel Information ......................................... 5
1.6 Airplane Information ..........................................
1.6.1 Weight and Balance ............................................ s
1.6.2 Lift and Roll Systems ......................................... 7
1.6.3 Takeoff Warning System ........................................ 11
1.6.4 Stall Protection System ....................................... 11
1.6.5 Auto Pack Trip System .........................c ............... 11
1.7 Meteorological Information .................................... 12
1.8 Navigational Aids ............................................. 12
1.9 Communication ................................................. 12
1.10 Aerodrome Information ......................................... 12
1.11 Flight Recorders .............................................. 13
1.11.1 The Cockpit Voice Recorder .................................... 13
1.11.2 The Flight Data Recorder ...................................... 14
1.12 Wreckage and Impact Information ...............................
1.12.1 Impact Marks and Ground Damage ................................ :1
1.12.2 Airplane Damage ............................................... 16
1.13 Medical and Pathological Information .......................... 30
1.14 Fire .......................................................... 30
1.15 Survival Aspects .............................................. 30
1.15.1 Aircraft Rescue and Fire Fighting ............................. 32
1.15.2 Disaster Plans ..... ..2 ........................................ 33
1.16 Tests and Research ............................................ 33
1.16.1 Stall Warning System .......................................... 33
1.16.2 Takeoff Warning System ........................................
1.16.3 Flap Warning Switch ........................................... 3;
1.16.4 Trailing Edge Flap System ..................................... 37
1.16.5 Leading Edge Flap and Slat System ............................. 37
1.16.6 Auto Pack Trip System .........................................
1.16.7 Airplane Performance .......................................... 3":
1.16.8 Takeoff Warning System Inspections ............................
1.16.9 Flight Demonstration .......................................... 4403
1.17 Other Information ............................................. 43
1.17.1 Delta Flight Standards Organization ........................... 43
1.17.2 Checklist Procedures .......................................... 44
1.17.3 Sterile Cockpit ............................................... 46
1.17.4 Human Performance Research Projects . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.17.5 FAA Surveillance .............................................. 4":

1.18 Useful or Effective Investigative Techniques .................. 53

iii
 ANALYSIS
f:1
2..2
General .......................................................
The Accident ..................................................
54
54
2.3 Determination of Trailing Edge Flap and Leading
Edge Flap and Slat Position at Impact ....................... 58
2.4 Determination of Trailing Edge Flap and Leading
Edge Flap and Slat Position During Takeoff .................. 60
2.5 Airplane Performance Study .................................... 67
. 2.6 Flightcrew Actions After Takeoff ................., .............
2.7 Cockpit Management and Crew Discipline ........................ ::
Delta Air Lines Operations and Training ....................... 76
2’*: FAA Surveillance ..............................................
2:10 Survival Factors .............................................. ii;
2.10.1 Aircraft Rescue and Fire Fighting ............................ 81
2.10.2 Left Aft Galley Door ..........................................
2.10.3 Aft Airstair Exit ............................................. 8":
2.11 Fire Propagation ..............................................
2.12 Refueling Procedures .......................................... 8";
2.13 Airline Safety Programs ....................................... ‘87
2.14 Previous Safety Board Recommendations ......................... 89

CONCLUSIONS
::1 Findings ......................................................
3.2 Probable Cause ................................................ 9":

4. RECOmEHDATIOHS ............................................... 94

5. APPENDIXES
Appendix A--Investigation and Public Hearing .................. 101
Appendix B--Personnel Information ......................... ..- .. 102
Appendix C--CVR Transcript .................................... 104
Appendix D--Delta Air Lines B-727 Checklist ................... 132

iv
 EXECUTIVE SUI’MARY

About 0901 central daylight time on August 31, 1988, Delta Air Lines,
Inc., flight 1141, crashed shortly after lifting off from runway 18L at the
Dallas-Fort Worth International Airport, Texas. The airplane, a Boeing
727-232, U.S. Registry N473DA, was a regularly scheduled passenger flight and
was en route to Salt Lake City, Utah, with 101 passengers and 7 crewmembers.

The flightcrew reported that the takeoff roll appeared to be normal in

all respects, with no warning lights, audible warnings, or unusual engine
instrument conditions. The captain stated that the rotation was initially
normal, but as the main gear wheels left the ground he heard "two
explosions." He said it felt as though the airplane was experiencing
"reverse thrust." The captain stated that the airplane began to "roll
violently."

The airplane struck the instrument landing system (ILS) localizer

antenna array approximately 1,000 feet beyond the end of runway 18L, and came
to rest about 3,200 feet beyond the departure end of the runway. The flight
was airborne approximately 22 seconds from liftoff to the first ground impact
near the ILS localizer antenna. The airplane was destroyed by impact forces
and the postcrash fire.

Of the persons on board flight 1141 12 passengers and 2 crewmembers

were killed, 21 passengers and 5 crewmembers were seriously injured, and 68
passengers sustained minor or no injuries.

The National Transportation Safety Board determines that the probable

cause of this accident to be (1) the Captain and First Officer's inadequate
cockpit discipline which resulted in the flightcrew's attempt to takeoff
without the wing flaps and slats properly configured; and (2) the failure of
the takeoff configuration warning system to alert the crew that the airplane
was not properly configured for the takeoff.

Contributing to the accident was Delta's slow implementation of

necessary modifications to its operating procedures, manuals, checklists,
training, and crew checking programs which was necessitated by significant
changes in the airline following rapid growth and merger.

Also contributing to the accident was the lack of sufficiently

agressive action' by the FAA to have known deficiencies corrected by Delta and
the lack of sufficient accountability within the FAA's air carrier inspection
process.

V
 NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D.C. 20594
AIRCRAFT ACCIDENT REPORT
DELTA AIR LINES, INC.
BOEING 727-232, N473DA
DALLAS-FORT WORTH INTERNATIONAL AIRPORT, TEXAS
AUGUST 31, 1988

1. FACTUAL INFORMATION
1.1 History of the Flight

On August 31, 1988, Delta Air Lines, Inc., flight 1141, a Boeing
727-232, N473DA, was a regularly scheduled passenger flight from Jackson,
Mississippi to Salt Lake City, Utah, with an intermediate stop at the
Dallas-Fort Worth International Airport (DFW), Texas. The flight was
conducted subject to the provisions of Title 14 Code of Federal Regulations
(CFR), Part 121.

Flight 1141 departed Jackson, Mississippi for DFW at 0630 eastern

daylight time. The only logbook discrepancy was an inoperative No. ,l main
fuel tank quantity gauge. The first officer flew the leg to DFW and noted
nothing out of the ordinary en route. The landing and taxi-in to the gate at
DFW were uneventful. Flight 1141 arrived at gate 15 at DFW at 0738 central
daylight time.

The first officer and captain proceeded to company operations upon

arrival. The second officer remained with the airplane and performed his
walkaround inspection duties. The mechanic who handled flight 1141, while it
was parked at gate 15, stated that he checked the logbook and noted that the
No. 1 main fuel tank quantity gauge was inoperative. Operation of the
airplane with the fuel quantity gage inoperative was permitted by Delta's
minimum equipment list. He had no other involvement with the flight.

The Delta agent responsible for the proper loading of the airplane
determined, as a result of dripstick and pitch and roll readings taken, that
the airplane had 561 gallons of fuel remaining in the No. 1 main fuel tank.
He calculated that 1,036 gallons should be added so that a total of
1,597 gallons would be contained in the No. 1 main fuel tank. This figure
(1,597 gallons) was converted to 10,700 pounds of fuel. An equal amount was
ordered to be the final fuel quantity in the No. 3 main fuel tank. The No. 2
main fuel tank was ordered to be filled to 10,600 pounds final weight.

The airplane fueler pumped the requested fuel quantities into the
three tanks. Upon completion of fueling, he went aboard the airplane to
inform the second officer of how he had refueled the airplane. While talking
to the second officer, he noticed that the fuel gauge for the No. 2 main fuel
tank was reading 500 pounds higher than the fuel gauge at his wing refueling
station and he brought this to the attention of the second officer. The
airplane was not dripsticked again after the refuel i ng.
 L

The second officer received the fuel slip (prepared by the fuelin
agent), final weather briefing, automatic terminal information service (ATISs
information, and automatic weight and balance system (AWABS) data prior to
pushback. The pushback occurred at 0830, as schedulpd. At 0837:20, the DFW
east ground controller instructed Delta 1141 to "...join the inner for
standard taxi to runway 18L." All three engines were started initially, but
the captain subsequently decided to shut down the No. 3 engine to conserve
fuel when it became apparent that there would be a delay before departure.
Figure 1 provides a diagram of the DFW airport.

When the airplane became number four in line for departure at

0857:08, the second officer made an announcement to the flight attendants to
prepare the cabin for departure. The captain then ordered that the No. 3
engine be restarted. At 0858:38, the local controller instructed, "Delta
eleven forty-one taxi into position runway one eight left and hold...."
With this clearance, flight 1141 was, in effect, directed to pass the
airplanes ahead of it on the taxiway and take the No. 1 position. At
0859:17, the local controller instructed, "Delta eleven forty-one fly heading
one eight five runway one eight left cleared for takeoff." The first officer
of Delta flight 1141 acknowledged both transmissions.

After the accident, the second officer stated that when engine
power was advanced for takeoff, the green AUTO PACK TRIP arming light did not
illuminate. As operation of this system was not required for this flight, he
did not advise the captain of this situation. He stated that the takeoff
roll appeared to be normal in all respects, with no unusual lights, audible
warnings, or unusual engine instrument conditions. However, immediately
after liftoff, the right wing dropped and he heard the comment "engine
failure" made by either the captain or first officer.

The captain stated, after the accident, that "all was

normal . ..everything was routine" up to rotation. Rotation was initially
normal, but as the main gear wheels left the ground he heard "two
explosions." He said it felt as though the airplane was experiencing
"reverse thrust." The captain stated that the airplane began to "roll
violently . ..it was all I could do to control the airplane."

The airplane struck the ILS localizer antenna array about

1,000 feet beyond the end of runway 18L, came to rest approximately
3,200 feet beyond the departure end of the runway (see figure 2) and was
destroyed by impact forces and the postcrash fire. The flight lasted
approximately 22 seconds from liftoff to the first ground impact near the ILS
localizer antenna.

Witnesses in the control tower and on the ground generally agreed

that flight 1141's takeoff roll appeared to be normal until shortly after
rotation. They stated that the airplane rotated in the vicinity of taxiways
 3

89012
AIRPORT DIAGRAM AL-6039 (FAAj
DALLAS-FORT WOdTH INTL (I)FF
DAUAS-FORT WORTH, TEX,
a
RWY 13L31d. 13R.311 i 1 REGIONAL TOWER
5120, D200, DT6CQ. DDT850 ELEV 126.55 Earl
3
RWY 17R-351, 171~35R 2 508, d; 3 12_44!‘y+si
S 120, D200. DTt N
- RwY 18L36R, 18R-36L si
S120, D200, Dl600, DDT850 6 121.8 Wed
RWY ?8S-365 CLNC DEL
mrrn,rrcn -m Is.-.. . C.... 1 I,*
. -“ 04
.--
KCJII1CICY ,”l-w* ALI-, -I
12500 Ibs. OR LESS AND ATIS ARR 117.0
.? --- .-_ -
ST01 ACFT. VW Ixxl

JULY 1985
FIRE STATION ANNUAL RATE OF CHANGE
O.l”WEST

7 CENTRAL f;

’ U.S. CUSTOMS

-I- / 799
GENERAL E,LEV
AVIATION 5 I
Rwy 185-365: 4000 X 100

AFIRE STATION
NO. 2
CAT2 -
f “0’0

ELEV
577

-I
CENlERLlNE LIGHTING
ON ALL T,4xlWAYS

AIRPORT DIAGRAM DALLAS-FORT

DALLAS-FORT WORTH, TEXA
WORTH INTL (DFW
173

Figure 1 .--Airport Diagram.

4
 5

29 and 30 to a higher than normal pitch angle and that flames or sparks were
emanating from the rear of the- airplane. They said that as the airplane
continued down the runway, the wings rocked from side to side and the
airplane appeared to be out of control. The witnesses lost sight of the
airplane after it struck the ground and disappeared into a cloud of dust.
None of the ground witnesses could recall the position of the flaps during
the takeoff roll or prior to impact. One passenger aboard the airplane
stated that shortly after liftoff, he noticed that the trailing edge of the
left wing appeared not to be in a straight line. He interpreted this
observation to be that the flaps were down to some extent.

On'board flight 1141 were 101 passengers, 3 flightcrew members and

4 cabin crew. Two flight attendants and 12 passengers were fatally injured.
Twenty-six persons, including the flightcrew and cabin crew, sustained
serious injuries. Sixty-eight passengers received minor or no injuries.

Th'e accident occurred during' the hours of daylight at

latitude/longitude coordinates of 32o52'N 97oO3'W.

1.2 I n j u r i e s to Persons
Flight Cabin
Crew Crew Passengers Other Total

Fatal 0 2 :;* 0
Serious : 0' 49 00
Minor
None 0 0 18 0
Total 3 4 101 0
*One passenger successfully exited the aircraft, but was
severely burned when he attempted to reenter the cabin. He
died 11 days later. It is believed that he attempted to
reenter the cabin in an effort to provide assistance to his
wife and other passengers in escaping from the aircraft.

1.3 Damage to the Airplane

The Boeing 727-232 was destroyed by ground impact and post impact
fire. Its value was estimated at $6-6.5 million.

1.4 Other Damage

Ground damage was confined to two airport runwayltaxiway markers,
the ILS localizer antenna installation, and an airport boundary fence. There
also was ground fire damage to terrain vegetation,

1.5 Personnel Information

The flightcrew and cabin crew of flight 1141 were qualified in
accordance with applicable Federal Aviation Regulations (FAR) and Delta's
procedures. (See appendix B.) Exami nati on of the f 1 i ghtcrew ’ s personal
 6

background and actions during the 2 to 3 days before the accident flight
revealed nothing remarkable. The flightcrew's training records also were
unremarkable. FAA records did not contain any incident or violation history
on any of the crewmembers.

.--The 48-year-old captain was hired by Delta Air Lines

o n O c t o b e r - The captain had been employed continuously by Delta
since his date'of hire.

The captain upgraded to captain initially on the DC-9 on

May 22, 1975. However, due to Delta's reduction in flying time in the DC-g,
he returned to his previous position as an L-1011 first officer. On
August 30, 1978, he was upgraded again to captain on the DC-9 and remained in
this capacity until August 1979. He completed Boeing 727 transition
training in August 1979, and he remained as a 727 captain until the time of
the accident.

The captain had received recurrent training on July 27-28, 1988,

and a proficiency check was administered on July 29, 1988. His most recent
en route check was completed on August 9, 1988. The simulator instructor who
gave the captain's last proficiency check described the captain's performance
as "text book" with no problems encountered. The captain possessed a first
class medical certificate with a limitation that corrective lenses are to be
worn to correct for near vision.

T h e F i r s t O f f i c e r .--The 36-year-old first officer was hired by

Delta on January 26 19/9 He had been continuously employed by the airlines
since that time. ihe fi'rst officer completed second officer qualification
training in March 1979. He remained as a second officer until November 1987.

The first officer completed Delta's B-727 first officer

qualification training on December 9, 1987. He remained in this position
until the time of the accident.

The first officer's last recurrent training was November 4-5,

1987, and his last proficiency check was on November 20, 1987. His last en
route check was accomplished on December 6, 1987. These checks were
conducted during his initial first officer training. He possessed a second
class medical certificate with no limitations.

The Second Officer .--The 30-year-old second officer was hired by

Delta on November 20 1987 The second officer attended Delta's B-727 second
officer training irogra; and was qualified as a second officer on
January 20, 1988. No additional training was required from the time he
completed initial training until the date of the accident. The second
officer possessed a second class medical certificate with no limitations.

1.6 Airplane Information

The Boeing 727-232, U.S. registry N473DA, was delivered to Delta
Air Lines in November 1973. The airplane was serial No. 20750, line No. 992.
 7

The airplane was a Boeing Commercial Airplane Company model

727-232, equipped with three aft-mounted Pratt L Whitney JT8D-15 series
turbofan engines. It was delivered in a passenger configuration. The '1
airplane had a total of four floor level exits and four over wing emergency )
exits, and a ventral stairway exit.

The certificated maximum taxi weight of N473DA was 185,200 pounds.

The maximum takeoff weight was 184,200 po'unds, and its maximum landing weight
was 154,500 pounds. The maximum zero fuel weight was 138,000 pounds.

The certificated usable fuel quantities were 1,818 gallons in fuel

tanks Nos. 1 and 3, and 4,550 gallons in fuel tank No. 2. The total usable
fuel quantity was 8,186 gallons; or 54,845 pounds. There was one fuel tank
in each wing and one fuel tank in the wing center section. The aircraft was
configured with two cargo compartments beneath the passenger cabin: one
located forward of the wing, and one aft of the wing.

1.6.1 Weight and Balance

Delta utilizes an AWABS, in which the gate agent enters into a

computer the details of the loading of the aircraft. The pilots are provided
with a final AWABS record prior to pushback.

The maximum allowable takeoff weight for the flight was

175,440 pounds, dictated by the maximum allowable structural landing weight
at Salt Lake City. This weight was below the maximum takeoff weights
authorized for runway 18L.

Delta provides its flightcrews with performance data for each

runway, using the most limiting factor, i.e., runway allowable or climb
limit. With flight 1141's actual takeoff weight of about 157,683 pounds, the
crew was authorized to use alternate power, i.e. reduced thrust, and a flap
setting of 150 for runway 18L.

1.6.2 L i f t a n d R o l l Systems

Lift devices of the Boeing 727-232, consist of three leading edge

flaps (Krueger flaps) located on the inboard lower surface of each wing, four
leading edge slats on the outboard portion of the wing, and inboard and
outboard trailing edge flaps (see figure 3). The trailing edge flaps are
driven by two completely independent systems. Each drive system normally is
hydraulically powered; electrical power is available for alternate operation.
Each trailing edge flap is actuated by two flap transmission assemblies. The
transmission assemblies on the outboard flaps are connected through torque
tubes and gearboxes to a hydraulic motor which is the primary driving source.
Another separate set of torque tubes and gearboxes interconnect the
transmission assemblies on the two inboard flaps. This system is driven by a
single hydraulic motor. Power to the motors is controlled by two
differential control valves with feedback modulation from the power
transmitting torque tubes.
 8

DlnBDARDAlL0RoN voRrExQENmAmRs
(0OlH SIDES OF FIN)
0ALANc0TA0

PtlUTTUBES.ONE
ElcH SIDE OF FIN ANTI-ml.ANCETASS

Dw0oARDFLAF

INBoAR AILERON

GROUND SPOILERS
LEADINaEWEFLAPS
(SHOWN EXTENDED) lN0OARDFiAF

Figure 3. --Boeing 727 flight control surfaces.

 9

The leading edge flaps and slats are driven by linear hydraulic
actuators. The actuators are controlled through a three-position control
valve activated by the outboard flap follow-up system. At 2o of flap, only
the middle two slats on each wing are deployed. The remaining leading edge
flaps and slats deploy after the flap handle is selected past 2O. An amber
light on the center instrument panel illuminates when the slats are in
transit. A green light illuminates when the slats are extended. (See
figure 4.)

Flap settings are controlled from the cockpit by moving the flap
lever through a detented arc on the right side of the center control stand.
This lever has control cable linkage to the differential control valves. The
flap lever is spring-loaded to lock in each of the detents and must be
lifted about l/4 inch to allow movementhto another detent.

Alternate provisions for flap extension are incorporated in the

system in the event of normal system failure. During alternate operations,
the trailing edge flaps are extended and retracted by two electric motors
which are coupled to the torque tubes. The leading edge flaps and slats can
be extended by a standby hydraulic pump. Pump operation is controlled by the
alternate flap control system.

An electro-mechanical flap position transmitter assembly is

provided for each trailing edge flap. The units mechanically sense the
position of each flap and generate an electrical signal which is fed to two
dual needle indicators in the cockpit. The indicators, located on the center
of the instrument panel, show the position of the inboard and outboard flaps,
respectively.

Two identical electrically operated protection systems are

provided to prevent asymmetrical operation of the trailing edge flaps. One
system prevents inboard flap asymmetry while the other prevents outboard flap
asymmetry. The airplane is not equipped with a mechanical system to prevent
the inboard or outboard set of flaps from deploying without the other set.

The outboard flaps are mechanically connected to the outboard

ailerons in such a way as to lock the outboard ailerons in the faired
position when the outboard flaps are in the up position. This feature is
incorporated into the system because deflection of the inboard ailerons and
flight spoilers are sufficient for high speed flight control. When the flaps
are extended down, both the inboard and outboard ailerons are operated
together. The lockout mechanism consists of an angle gearbox, torque tube,
jackscrew, and bellcrank.

The Boeing 727-232 has seven spoilers on each wing. The five
outboard spoilers are flight spoilers and the inboard two are ground
spoilers. The flight spoilers augment the ailerons in roll control and at
the same time are available to act as an air drag device. The ground
spoilers can be extended only when the airplane is on the ground and they
serve together with the flight spoilers as speed brakes to shorten the
landing roll. Each spoiler is positioned by its own hydraulic actuator.
 FLAPS POSITION INDICATOR AND LEADING EDGE FLAPS LIGHTS

FLAPS SELECTOR LEVER

Figure 4.-- Boeing 727 flap position indicator and flap selector lever.
 11

1.6.3 Jakeof f Warning System

The Boeing 727-232 is equipped with a takeoff warning system to
warn the crew when the aircraft is improperly configured for takeoff. The
warning system is activated when thrust lever No. 3 is advanced beyond a
predetermined position. The takeoff warning horn will sound when one or more
of the following conditions exist: (1) the stabilizer trim is outside the
takeoff range; (2) outboard trailing edge flaps are less than 50; (3) the
No. 4 and No. 5 leading edge slats are not extended; or 14) speedbrake
handle is not in the down detent position.

1.6.4 Stall Protection System

The aircraft is equipped with a stall warning system. This system

is actuated by an angle-of-attack sensor and uses the inboard flap position
as part of its actuation logic. In the event of activation, a stickshaker
vibrates the pilot's control columns and creates a unique sound. The system
is active only when airborne.

Prior to the accident, Delta's maintenance program required that a

takeoff warning system check be accomplished at every major inspection
interval and at every fourth service check. On August 11, 1988, during an
inspection of the accident airplane (an A-2 check), a discrepancy was noted
during the takeoff warning horn test. This discrepancy was entered as:
"aural warning horn weak and intermittent when throttles pushed forward."
The aural warning unit was replaced and the airplane was returned to service.
The contact points on the removed unit were cleaned and the unit functioned
properly during a bench test at Delta's maintenance facilities.

1.6.5 Auto Pack Trip System

The Boeing 727-232 aircraft is equipped with a system that

automatically shuts down the air-conditioning packs in the event of loss of
engine thrust during takeoff or initial climb. Turning off the packs
conserves engine bleed air to provide maximum available engine thrust.
Three indicator lights are provided on the air-conditioning control panel,
which are labeled AUTO PACK TRIP ARMED, LEFT A/C PACK TRIP OFF, and RIGHT A/C
PACK TRIP OFF. Engine fail lights are provided on the captain's/first
officer's glare shield.

The Auto Pack Trip switch on the flight engineer's panel is

selected to NORMAL prior to flight. The system will then arm if the main
landing gear struts are compressed, the inboard flaps are extended out of the
UP position, and all engines are set above approximately 1.5 EPR. A green
light on the flight engineer's upper panel illuminates when the system is
armed. Thrust loss on any one engine will then trip off both packs, shut
down both pack cooling fans, and illuminate the ENG FAIL lights.
 12

1.7 Meteor01 ogical Information

The DFW ATIS prior to the accident indicated: "DFW airport
departure information Golf, one two five two zulu weather, sky clear;
visibility one zero; temperature, six six; dew point, five niner; wind, calm;
altimeter, two niner niner niner; runways one three, one seven, one eight
departures in progress, use caution for bird activity on and in the vicinity
of the airport, advise clearance delivery that you have Golf."

Observations recorded by the National Weather Service immediately

prior to and after the accident indicated the following weather conditions:

0851 - clear, visibility, ten miles; temperature, seven

three; dew point, five one; wind, one zero zero at eight;
altimeter, two nine nine nine.

0906 - clear, visibility, ten miles; temperature, seven four,

dew point, five seven, wind, zero nine zero at nine,
altimeter, two nine nine nine.

There was no activation of the low level windshear alert system

(LLWAS) prior to, or after the accident.

1.8 Navigational Aids

There were no known difficulties with navigational aids.

1.9 Comunications
There were no known difficulties with communication equipment or
facilities.

1.10 Aerodrome Infomation

The DFW airport is located approximately midway between the cities
of Dallas and Fort Worth, Texas. It is owned by these cities and governed by
an eleven-member board of directors. Airport elevation is 603 feet. The
central terminal area is located between north/south parallel runways located
on the east and west side of the terminal area. The airport has three sets
of parallel runways. Runway 18L on which flight 1141 departed is 11,387 feet
long and 200 feet wide; runway 18L has elevations of 596 feet mean sea level
(msl) at the north end and 576 feet msl at,the south end. It is equipped
with high intensity edge lights, centerline and touchdown zone lights. The
runway is an ILS CAT I equipped, instrument runway; runway 18L ILS localizer
antenna array is situated approximately 1,000 feet south of the departure
end, and its upper-most elevation is 579 feet msl.

Seventeen local notice to airmen (NOTAMS) were in effect at the

time of the departure of flight 1141. These NOTAMS concerned areas of
construction, closed taxiways and flocks of birds sighted on, and in the
vicinity of, the airport.
 13

The DFW air traffic control (ATC) facility is a Level V FAA

facility which operates 24-hours per day. The tower and terminal radar
approach control (TRACON) are split; i.e., the controllers are assigned
exclusively to either the tower or the TRACON. Administration of both the
tower and the TRACON is under the control of the facility manager and his
staff.
The DFW control tower operations exceed 670,000 annually and was
the third busiest airport in the country at the time of the accident. T h e
facility utilizes two airport surveillance radars (ASR-7 & ASR-8) which is
augmented with automated radar tracking system (ARTS) IIIA computer
tracking. The control tower has 10 positions of operation. These may be
combined or de-combined to meet daily and hourly traffic demand.

1.11 Flight Recorders

The airplane was equipped with a Fairchild model A-100A cockpit
voice recorder (CVR), serial No. 51362, and a Lockheed Model 109-D flight
data recorder (FDR), serial No. 654. The recorders were taken to the Safety
Board's flight and voice data recorder laboratories in Washington, D.C., for
examination and readout.

1.11.1 The Cockpit Voice Recorder

The CVR starts at 0828:38 central daylight time (see appendix C)

just prior to pushback from the gate at DFW, and continues until 0900:39.4.
Seven minutes and 42 seconds of nonpertinent conversations, beginning at
0839:42, were edited from the transcript. These conversations consisted of
casual, nonduty related topics among the flightcrew and included a
conversation with a flight attendant who was in the cockpit on two occasions
during the ground operation. The transcript starts again at 0847:28, just as
the flight changed from the DFW east ground controller to the west ground
controller. At 0848:14, 1 minute and 18 seconds and again at 0850:01,
1 minute and 22 seconds of the transcript were edited. These conversations
consisted of casual, nonduty related topics. At 0853:12, the transcript
starts again and continues unedited until the end of the recording.

The flight started monitoring local control, i.e., the control

tower, frequency at 0857:22. The flight attendant left the cockpit and the
door was closed at 0857:35 after the second officer called for the flight
attendants to prepare the airplane for departure. The No. 3 engine was
restarted at 0857:42 and the last part of the taxi checklist was
accomplished. During this portion of the taxi checklist, in response to the
second officer's prompt of "FLAPS", the first officer stated "FIFTEEN,
FIFTEEN, GREEN LIGHT." The flight was cleared onto the runway at 0858:38 and
was cleared for takeoff at 0859:17.

The sound of increasing engine noise can be heard at 0859:35

followed by the first officer callouts of "Power set" and "Engine instruments
look good." A callout of VR was made at 0900:05.5 and V2 at 0900:10.7. The
takeoff appeared normal until 0900:15.1 when the airplane stall warning
stickshaker is heard. Startin at 0900:17.6, five sounds that were
identified as engine compressor sta3 l/surge sounds can be heard. A momentary
 14

(less than .2 seconds) electrical power interruption is experienced by the

CVR recorder at 0900:22.9 just after the callout of an "Engine failure" by
one of the crewmembers. A callout by the captain of "FULL POWER" was
recorded 0.6 seconds prior to the sound of the first impact. The sound of
the first impact was recorded at 0900:35.3, followed by three more distinct
impact sounds over the final 4 seconds of the recording.

A "snap" sound is heard on the CVR at 0900:12.5 which was believed

to have been produced by the landing gear down-lock solenoid moving to the
retracted position. A study was undertaken to compare the sound signature of
the " s nap " with several other recordings of the landing gear solenoid
retracting on similar model Boeing 727 airplanes. Two of the comparison
recordings were made on regularly scheduled revenue Delta flights. The third
comparison was a recording of the solenoid being manually actuated by ground
personnel. The results of the study indicated that there was an inconclusive
energy versus frequency match between the test recordings and the accident
airplane's "snap" sound to positively state that the source of the snap was
the retraction of the landing gear solenoid.

The study of the CVR did not disclose a sound which could be
associated with the movement of the flap control lever to either extend or
retract the flaps.

1.11.2 The Flight Data Recorder

The foil type recorder recorded the airplane's altitude, indicated

airspeed, magnetic heading, normal acceleration (i.e., perpendicular to the
airplane longitudinal axis), as well as microphone keying, and time. The
aluminum foil recording medium was removed with all parameter and ancillary
traces present. There was a slight jump in the altitude recording during
takeoff which was considered to be due to a sticking needle. There were no
indications of recorder malfunction or recording abnormalities during the
previous takeoff at Jackson, Mississippi.

1.12 Wreckage and Impact Information

1.12.1 Impact Marks and Ground Damage

The first impact mark was made by the tail skid contacting the
runway centerline and a runway centerline light between taxiways 27 and 29,
at a distance of approximately 4,990 feet prior to the departure end of
runway 18L (see figure 5). About 650 feet from this point, the right wing
tip struck the right side of the runway near taxiway 29, approximately
4,340 feet prior to the departure end of runway 18L. The taxiway markers for
taxiways 31 and 32 were found knocked over, but they did not exhibit any
impact damage. Additionally, the grass was found to be scorched between the
end of the runway and the ILS antenna. Approximately 5,300 feet from the
point of the right wing tip runway contact, and approximately 900 feet beyond
the departure end of runway 18L, the airplane impacted and destroyed the ILS
localizer antenna. From this point and beyond, airplane components such as
the right wing tip and portions of the right inboard and outboard ailerons
began separating from the airplane.
 15

TIME KIAS EVENT DISTANCE

- 01):59:33 0 START 3600
- 01:59:35 0 417 FT

- OI:59:48 38 “POWER SET” 1,213 FT

- 00:69:54 82 ‘80 KNOTS”

- 09:00:06 131 “VEE R” 4,041 Fl

- o9som 134 (NOSE STRUT EKTENSION) 4,263 IT

- 00:oozll 145 “VEE TWO” WWfl

- omo:13 1so (SNAP SOUND) 5,776 FT

- 09:00:13 154 ESTIMATED LIFTOFF 6,017 FT
- os:oo:15 156 TAIL SKID CONTACT
- 09:ooz15 156 (STICK SHAKER) $iE
- 09:ooz15 156 “80METHlN”S WRONDIOOH” aeoom
- os:oo:17 158 RIGHT WING TIP CONTACT 7.060 FT
- 09:00:18 158 (FIRST COMPRESSOR SURGE) 7,187 FT

- 09:ooz21 161 (LAST COMPRESSOR SURDE) Smo Fr

- 09:00:23 162 &a443 FT

- 09:ooz28 163 10,113 n

- OS:oo:29 163 “ELEVEN FORTV 0NE”S” 10,429 FT

- oe:ooz33 163 CROSS END OF RUNWAV 18L 11$367 FT

-?- 09:00:32 164 BEACON RADAR RETURN 11,444 FT

- 0@:00:35 164 “FULL POWER” 12.113 PT

- 09:00:3s 164 (1st IYpAcT--ILS ANTENNA) l2,2w FT

Q
Q - o9mw (BRDIYPYICT) 12ce7 FT

Q
Q - 09:00:39 WH IWPACT) 13$l7 PT
Q
Q - woo:39 ENDOFTAPE -
FINAL POSITION - 14.170 FT
0
0
1 INCH-1700 FEET

Figure 5.-- Flight 1141 takeoff events.

 16

After first impacting the antenna installation, the airplane

remained airborne for an additional 400 feet, then struck the ground with the
main landing gear wheels which produced a 350-foot linear ground depression.
The airplane then traversed a ground depression that was approximately
150 feet wide and 16 feet deep. As the airplane crossed the depression, it
impacted the ground on the far side. The airplane track then began to
gradually swerve to the right of the extended runway centerline. This portion
of the wreckage track was approximately 800 feet long.

The last 600 feet of the wreckage track indicated that the
remaining airplane structure slid sideways; most of the right wing structure
outboard of the center fuel tank had disintegrated, until it came to rest
near the airport boundary fence located approximately 3,200 feet from the
departure end of runway 18L. (See figure 1.)

1.12.2 Airplane Damage

The respective actuators for the nose and main landing gears were
in the extended positions. The tail skid shoe was intact and exhibited
evidence of ground contact with a runway light. Although the tail skid
cartridge sustained some damage at the end on one side, the cartridge was
intact and showed no evidence of being compressed, which would indicate light
contact between the skid and the runway. A runway centerline light had a
series of gouges and ridges that matched the ridges and gouges on the tail
skid shoe.

The Nos. 1 and 2 engines remained with the empennage. The No. 3
engine SepaFated from the empennage. Most of the external hardware and
accessories separated from the No. 3 engine during the CFaSh sequence and
were fragmented. On scene inspection of the Nos. 1 and 2 engines found that
the NI rotors rotated freely with no engine case penetrations. There was no
damage to the inlet guide vanes and no evidence of bird ingestion.

The No. 3 engine core was approximately 500 feet north of the main
wreckage. There was no evidence of bird ingestion. All 1st stage fan blades
had leading and trailing edge damage. The 2nd stage fan blades had severe
damage to the leading and trailing edges and were bent opposite to the
direction of rotation. No thermal damage or distress was observed in the
turbine area.

The thrust reversers for all three engines were in the stowed
position. The reversers for the Nos. 1 and 2 engines were found attached to
their respective engines. The No. 2 engine lower thrust reverser actuator
fairing was crushed inwards. It contained pieces of the ILS electrical
junction box and other evidence of ground contact.

Shortly after the accident, the three engines were disassembled at

the facility of the engine manufacturer. The No. 3 engine's 2nd through
6th, 8th, 9th and 11th compressor stages had blades which were bent opposite
to the direction of rotation. The inspection of the engines disclosed no
mechanical problems that would have precluded normal operation prior to
impact.
 17

Fuselage and Empennage.--The fuselage had separated into three

major sections: (1) the forward section consisted of the nose forward of
fuselage station (FS)-420 (see figure 6); (2) the center fuselage section
included the body structure between FS-420 and FS-95Oc; and (3) the aft
fuselage section extended from FS-95Oc aft to the end of the No. 2 engine
tailpipe.

The forward fuselage section had rotated to the left about 45O.
The entire lower fuselage structure sustained various degrees of tearing,
buckling and general overall distortion. Some sooting was noted in the area
between the first officer's side window and the separation.

The center fuselage section came to rest right side up and was
supported by the left wing and right wing center section. The left side
forward of FS720e showed no evidence of fire damage and all passenger windows
were intact. However, the left side between FS-720e and FS-95Oc had
sustained varying degrees of fire damage. In the general area of FS-95Oc,
some fuselage structure had been consumed by fire.

The right side of the center fuselage section between FS-420 and
FS-95Oc also contained fire damage with some fuselage areas totally consumed
by fire. All passenger windows on the right side were missing or melted.

The fuselage crown between FS-450 and FS-680 from the top of the
passenger window line on the right side to the top of the Delta logo on the
left side was consumed by fire. Another area of the top fuselage, between
FS-720~ and FS-840, was consumed by fire from the top of the right forward
overwing emergency exit door to the fuselage centerline.

The aft fuselage section had rolled to the left and rotated
counterclockwise about 450. The aft fuselage skin structure between FS-950c
and FS-950e on the left side was consumed by fire. The aft fuselage skin
structure on the right side between FS-950e and FS-1030 was found laying on
the ground alongside the fuselage. The entire aft fuselage section
generally sustained various degrees of breakup and fire damage.

V e r t i c a l / H o r i z o n t a l StabSlizer .--The vertical/horizontal

stabilizer assembly had folded downward to the left. It was nearly inverted
but still partially attached to the lower portion of the vertical stabilizer
by several stringers.

L e f t W i n g . --The left wing was complete and attached to the

fuselage with varying degrees of ground impact, heat, and fire damage
throughout. All flight control surfaces except for the outboard trailing
edge flap assembly remained attached-to the wing. The left wing lower
surface was intact but contained spanwise scratch and scuff marks.

Right Ying. --The entire right wing assembly was fragmented and the
pieces were FeCOVWed along the entire wreckage path. Most of the fragmented
wing pieces sustained fire damage. The wing tip leading edge lower surface
exhibited a deep lateral compression buckle. The outboard trailing edge tip,
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 19

and static wick were partially ground away. The position light boom, located
inboard of the tip outboard end, had also been partially ground away on its
lower surface, within 8 inches from its aft end. The distance between the
light boom and the trailing edge tip was equal to the distance between the
marks found on the runway.

w i n g - Center Section .--The left side of the wing center section

upper surface, above the main landing gear strut well, approximately 5 feet
outboard of the fuselage, exhibited a 15-inch burnthrough triangular hole.
The upper wing surface at the left wing root fillet panel exhibited a 4- by
3-foot burn-through hole that penetrated into the wheel well. The left main
landing gear assembly was attached to the left side of the wing center
section. There was no evl'dence of preimpact failure of the wing center
section.

S p o i l e r S y s t e a . --The area in the right wheel well where the

spoiler mixer is located had sustained severe fire damage, but the mixer
could be moved. The spring cartridge rod from the aileron power control-unit
and the mixer control rod from the spoiler ratio changer were severed by
fire. The spoiler control cables to the left wing were intact, and the
cables to the right wing were attached but slack. The speedbrake cable was
attached but was found slack.

The inboard spoiler shut-off valve lever in the right wheel well
was in the No. 1, or normal, position. The outboard spoiler shut-off valve
in the left wheel well was consumed by fire. The ground spoiler control
valve crank rig pin hole was aligned. The ground spoiler by-pass valve in
the left wheel well was damaged by the gear collapse but moved freely.

All the spoiler panels on the left wing, except ground spoiler
No. 6, were in the stowed position and locked. All spoiler installations
appeared normal except for being smoke covered.

The No. 6 spoiler could be raised manually. The actuator was

subsequently removed and tested at the airline's facility. The actuator was
found to be functional, but the adjustment of the overcenter mechanism
prevented downlocking.

On the right wing, the four outboard flight spoiler panels with
their respective actuators and rear wing spar attachments separated from the
wing. All were found to be in the stowed position and locked. The remaining
flight spoiler was located in the fuselage/right wing area of the wreckage
just outboard of the landing gear support beam. After the accident, the
assembly was found attached to the spoiler beam, and the actuator was found
in the extended position. The ground spoilers were mostly consumed by fire.

T r a i l i n g E d g e F l a p S y s t e m . --The flap control mechanism in the

cockpit area was found in the flap up position. (See figure 7.) The
mechanism was intact and functional. . The flap handle spring tension was
normal. T h e f l a p c o n t r o l c a b l e s w e r e a t t a c h e d , a n d c o n t i n u i t y was
established to the forward fuselage break. From the fuselage break, fu;$;,r
continuity of the cables was established to the outboard flap control
 20

INBOANOFLAP
TNANsMlssloN

’wEOAmFLAP
CONTROL VALVE

ouTmANDFLAP \
INBOARDFLAP
TNANsYInEN POWEN UNIT

OUTBDAND FLAP
lwmUE TUNE
OFFSET QEARBOX
mANsYIssloN
ASSEMBLY

Figure 7 .--Trailing edge flap system.

 21

located at the forward wall of the right wheel well. Movement of the cables
at the fuselage break produced a corresponding movement of the outboard flap
control valve input linkage.

Electrical continuity of wiring from the P6 circuit breaker panel,

which controls the flight control warning system to the alternate flaps
master switch, was verified.

The outboard flap power drive unit, located in the right wheel
well, sustained substantial fire damage. The follow-up cable from the drive
to the cable drum was intact, and the rig pin hole of the drum was
positioned at l/3 to l/2 hole-diameter from the full up position. The left
wing outboard flap torque tube was intact throughout the left wing. The
right wing outboard flap torque tube was severed by fire at the right side
of the right wheel well.

The outboard flap alternate drive mechanism in the left wheel well
sustained severe fire damage. All electrical wires were attached with their
insulation burned off. The gearbox could be turned by hand, and no external
damage other than fire damage was evident.

The left wing's outboard flap position transmitter was found

intact in the left wing. The right wing's outboard flap position transmitter
was attached to a portion of the spoiler beam that was found in the molted
area of the right wing at the fuselage.

The cables from the outboard flap control valve to the quadrant on
the aft wall of the right wheel well were intact. The cables were in their
respective pulley grooves. The quadrant had moved forward and the cables
were slack. The control rod from the quadrant to the inboard flap control
valve, located at the aft wall of the left wheel well, had separated from the
quadrant. The outboard flap by-pass valve was in the No. 1, or normal
position, the inboard flap by-pass valve was in the No. 2, by-pass, position.

The area of the left wheel well which contained the inboard flap
control valve was burned and the follow-up mechanism, from the inboard flap
power drive unit to the inboard flap control valve, had been consumed by
fire. The control rod attached to the inboard flap control valve was in a
flap up position. The follow-up chain/cable was found laying on the power
drive unit and was not broken.

The inboard flap power drive unit was jammed. The right wing's
inboard flap torque tube leading to the alternate drive gearbox located in
the right wheel well was intact. The right wing inboard flap torque tube,
from the gear box to the right wing, was burned off just outboard of the
gearbox.

The inboard flap alternate drive mechanism in the right wheel well
sustained severe fire damage. All electrical wires were attached with their
insulation burned off. The gearbox could not be turned by hand due to the
jammed inboard flap power drive unit. Slight movement of the torque tube
 22

connecting the gearbox to the power drive unit indicated that the gearbox
would turn.

The left wing's inboard flap position transmitter was intact but
slightly damaged by impact. The right wing's inboard flap position
transmitter was found separated into two pieces along the wreckage debris
path.

The left wing's outboard flap had separated from the wing with the
flap tracks and carriages attached. Both actuators were detached. The
outboard actuator assembly remained attached to the wing, and the inboard
actuator assembly had pierced the fuselage just aft of the No. 1 engine cowl.
The ballnuts on both jackscrews were within one turn of the upstop, and both
ballnuts could be rotated freely.

The left wing's inboard flap was attached to the wing and was in
the retracted position.

Portions of the right wing inboard flap were found throughout the
wreckage debris path. The major portion of the inboard flap was found with
the fore flap attached by its inboard track but otherwise separated from the
assembly. The mid-flap and aft flap were intact, except for a small area of
the inboard end of the mid flap and the area where the aft flap attached to
its inboard track. The outboard track carriage was also attached. The
inboard track carriage, the inboard and outboard tracks, and the inboard and
outboard actuator assemblies were not attached.

The right wing's inboard actuator assembly transmission gearbox

and jackscrew were found separately in the wreckage debris path. The
transmission gearbox was crushed and could not be turned by hand. The
ballnut on the jackscrew was against the upstop, was jammed, and could not
be turned by hand.

The right wing's outboard actuator assembly was also found in the
wreckage debris path. The ballnut was 1 l/2 turns from the upstop, and both
the ballnut and transmission were free to rotate.

Portions of the right wing outboard flap were found throughout the
wreckage debris path. The outboard jackscrew cover showed evidence of
contact with gravel. Gravel was present at the ILS antenna installation
mound. The outboard track was found attached to a piece of the lower skin.
The fore flap sequence carriage was found in place on its track, capable of
sliding along the track. The outboard end of the mid flap was found with the
carriage and actuator assembly attached. The ballnut on the jackscrew was
2-turns from the upstop, and both the ballnut and transmission could rotate
freely.

The inboard end of the right wing's outboard flap was found with
the fore flap, aft flap, carriage, and actuator assembly attached. The
ballnut on the jackscrew was less than l-turn from the upstop. The gearbox
~IIJJ;; was fractured in the plane of the drive torque tube. However, the
i! and transmission could be rotated freely. The inboard track had
 23

separated and had been stripped of all components except for the fore flap
sequence carriage which could be slid along the track.

Leading Edge Flap and Slat System.--At the forward wall of the
right wheel well the input rod from the flap system follow-up drum to the
leading edge flab and slat control valve was attached to both devices and
bent. The rig pin hole in the control valve crank was positioned at l/3 to
l/2 hole-diameter from the full up position. The control valve could not be
moved by hand.

The A hydraulic system leading edge bypass valve was in the No. 1,
or normal, position.

The left wing No. 1 slat was extended from the retracted position
and resting on the ground. The upper fairing was extended approximately
2 inches from the fully retracted position, and the actuator rod was out of
the uplock position. When the wing was raised, the slat could not be moved
by hand due to fire and impact damage.

The left wing's No. 2 slat was extended from the retracted
position and resting on the ground. The upper fairing was extended
approximately 4 3/4 to 5 inches from the fully retracted position, and the
actuator rod was out of the uplock position. When the wing was lifted, the
slat moved down slightly, but not to the fully extended position. It was
determined from smoke stains that the slat actuator rod had been extended
6 l/2 inches prior to the wing being raised.

The left wing's No. 3 slat was extended from the retracted
position and resting on the ground. The upper fairing was extended
approximately 4 3/4 to 5 inches from the fully retracted position, and the
actuator rod was out of the uplock position. When the wing was raised, the
slat moved down slightly, but not to the fully extended position. It was
determined from smoke stains that the slat actuator rod was extended
7 inches prior to the wing being lifted.

The left wing's No. 4 slat was in the retracted and uplock
position. When the wing was lifted, the slat could not be moved by hand due
to impact damage.

The left wing's No. 1 leading edge (Krueger) flap was extended
from the retracted position and resting on the ground. The upper fairing was
extended approximately 2 inches from the fully retracted position.

The left wing's No.2 leading edge flap was extended from the
retracted position and resting on the ground. The upper fairing was
extended approximately 3/4 inch of the fully retracted position. When the
wing was raised, the flap moved down slightly, but not to the fully extended
position. It was determined from the smoke stains that the slat actuator rod
had been extended 6 l/2 inches prior to the wing being raised. Full
extension on the flap actuator rod is 17.98 inches, and fully retracted the
rod measures 5.5 inches.
 24

The left wing's No. 3 leading edge flap was in the fully extended
and downlock position. It was determined from the smoke stains that the
acuator rod was near the fully extended and downlock position after the
accident.

The right wing's No. 4 leading edge flap, with its actuator
attached, was found in the melted area of the right wing adjacent to the
fuselage. It was determined from smoke stains that the actuator rod was in
the nearly retracted position during the postcrash fire. The right wing's
No. 5 and No. 6 leading edge flaps were found along the wreckage path.

The right wing's No. 5 slat was in one piece in the wreckage
debris path with its outboard track/roller rib assembly attached. The
outboard slat hook had been sheared off, and the inboard slat hook aft
fastener was sheared. The front of the slat, at the inboard track
attachment, had been ripped out. The slat was virtually undamaged inboard of
this attachment. There was a depression on the lower surface of the slat
which correlated with the roller induced deformation of the slat track
surface.

The outboard slat track for the No. 5 slat was also in the
wreckage debris path with a large portion of the wing spar and actuator
attached. The position of the actuator was not recorded at the wreckage
site. However, the actuator was subsequently removed from the wreckage, and
the condition of the actuator was documented. The rod end of the actuator
rod was missing, and the rod was bent. The exposed portion of the rod
measured 4 I/2 inches from the cylinder to the rod end separation, and the
actuator was in the fully retracted and uplock position.

The right wing's No. 6 slat was torn free of all attachments. The
inboard leading edge of the slat at the inboard track attachment was creased,
folded, and bent up approximately 90°. For some distance outboard of the
inboard track attachment, the leading edge of the slat was buckled, but there
was no evidence of impact damage: The actuator was found detached from the
slat. The end of the actuator rod had separated, and the rod was bent. The
exposed portion of the rod measured 4 l/2 inches from the cylinder to the rod
end separation, and the actuator was in the fully retracted and uplock
position.

The right wing's No. 7 slat was separated just outboard of the
inboard track attachment. The inboard slat track and roller rib assembly was
attached. The inboard leading edge of the slat exhibited extensive impact
damage. The outboard portion of the slat was found in the wreckage debris
path, and the leading edge also exhibited extensive impact damage. The
actuator was found separated from the slat with a portion of the slat
attachment structure attached to the rod end. The rod was extended
5 l/2 inches from the cylinder to the center of the rod end, and the actuator
was in a fully retracted and uplock position. That portion of the rod which
is normally external to the cylinder when the actuator is in the fully
retracted position was bent upward approximately 200 and outward slightly.
 25

The right wing's No. 8 slat was separated in two and both sections
were found in the wreckage debris path. The inboard 32-inch section had the
inboard slat track and roller rib assembly attached. There was no impact
damage along the leading edge of this section of the slat. The outboard
section of the slat had the actuator attached, and the actuator had pulled
free of its trunnion attachments. The actuator rod was extended 17.5 inches,
and there was no noticeable bending of the rod. The outboard slat hook was
missing, and the two fasteners on the inboard slat hook were sheared. This
section of the slat exhibited some impact damage along the leading edge, but
the slat to wing mating surface had only minimal damage.

Aileron System. --The aileron cables from the captain's yoke system
pulley were correctly attached and routed with no evidence of fraying. The
bus cables between the captain's yoke system and first officer's yoke system
pulleys were intact and in good condition.

The aileron trim assembly was in good condition, and the cables
were correctly routed with no evidence of fraying. The aileron trim knob
could be turned freely.

The aileron control mechanism in the left wheel well had sustained
substantial fire damage. The bus cables were attached to the drum. The
cables to the left wing were under tension, and the cables to the right wing
were slack. The aileron control quadrant including the centering spring and
trim mechanism was intact, and all linkages were attached. The control
mechanism was seized. The input linkage between the aileron quadrant and
the aileron power pack was intact, but the trim linkage and tierod had
burned and separated.

All hydraulic lines to the A-hydraulic system control modular unit

in the left wheel well were intact. The unit's shutoff valve lever was in
the No. 1, or normal, position. The shutoff valve lever of the B hydraulic
system control modular unit, located in the right wheel well, was also in the
No. 1, or normal, position.

The left wing's inboard aileron had sustained fire damage. The
access panel was removed, and the cables were under tension and in their
respective cable guides. There was no evidence of preimpact damage.

The left wing's outboard aileron had also sustained fire damage.
The aileron could not be moved. After the wing was subsequently raised, the
lockout actuator was found fully extended with the crank against the stop,
indicating that the ailerons were locked in the Oo position. The aileron
cables were intact and under tension. The shear rivets were not sheared.

The outboard end of the right wing's inboard aileron had

separated, and the remainder of the inboard aileron remained attached to the
top wing plank.
 26

The right wing's outboard aileron had separated into three

sections that were located along the wreckage path. The lockout mechanism
bellcrank had separated from the lockout actuator and into attaching
structure, and was free to rotate. The lockout actuator and its attaching
structure had separated from the wing as an assembly, and the actuator was
approximately l-turn from the fully extended position with the crank intact
and against the stop.

Cabin Fire Damage. -- The aft cabin floor was completely consumed by
fire from approximately station 950D to station 1130 with the exception of
the passageway that led to the left-rear door at the galley. Fire damage to
other components was also extensive in this area with most major interior
components destroyed.

The area forward of station 950D had less severe fire damage to
the floor and sidewall areas (continuing through station 740). As noted
previously, there was a large area of burnthrough on the cabin floor from
approximately station 740 to approximately station 720D on the right side.
From this point forward to approximately station 400, fire damage to the
right side of the interior was significantly more extensive than that of the
left side. From station 400 forward, the cabin was free of fire damage.

Damage to ceilings, sidewalls, overhead stowage compartments,

closets, etc., was closely correlated to areas of floor and fuselage
burnthrough. From station 400 aft, no ceiling panels were in place including
areas where the fuselage crown was present as well as the areas that were
burned through.

All floor exit level door liners were found. The aft right exit
had only the lower portion of the liner present from approximately the top of
the escape slide container downward. It was heavily sooted and showed some
signs of melting. The aft left door liner was essentially intact with heavy
charring and melting over the upper third of the surface. Both of the left
and right forward door liners were free of fire damage. The liner on the
ventral door was destroyed by fire.

Sidewclls were intact on the left side of the forward cabin from
station 381 to the area of the overwing exit. Many of these panels were
melted at the upper portion above the window, but were in place and otherwise
intact. Sidewall panels on the right side of the cabin in this zone were
completely destroyed. Small portions of other right side wall panels were
present near the floor toward the aft part of the cabin. Two sidewall panels
on the left side at approximately stations 950B and C (inunediately forward of
the separation in the aft fuselage) were relatively free of fire damage but
were heavily sooted.

From station 380 to station 760 on the left side, there were some
large remnants of overhead stowage units hanging from the structure. These
were extensively burned and melted, however, they were recognizable as
overhead stowage units. No other overhead stowage units were present.
 27

In most areas of the cabin wherever the sidewall and/or ceiling

panels were destroyed, the thermal insulation was also destroyed. The
following exceptions were noted:

In the aft right corner of the cabin in the sidewall area

just forward of and adjacent to the last row of seats.

Some small areas over the overhead stowage bin area along the
left side of the cabin between station 380 and 950.

A few sidewall areas on the right side of the cabin near

station 720.

.--The last row triple seats (right side) showed frame

burn througii====
and residual cushion fire blocking layer. Up to and including
row 28, all seats were missing, with the exception of the triple seat in row
30 left side, which had some cushion fire blocking layer remaining, along
with some seat frame structure burnthrough on the seat back cushions. Rows
23 through 26 (right side) were heavily fire damaged, but some cushion fire
blocking layer remained. The seat back c-ushions on 23E, 24E, and 26D were
burned through. Seats 27D, E, and F were severely damaged and its connnon
frame was twisted and displaced several feet rearward from the proper
position. Rows 26 and 27 (left side) had fire blocking layer present (frame
intact), with the exception of seat back 26C which was totally destroyed by
fire. Row 25 (left side) was missing (possibly falling down into the hole
of the floor area). Rows 23 and 24 (left side) had fire blocking layer
remaining, except for row 24A, B, and C, in which the seat back franm were
totally destroyed by fire. Seats 228 and C sustained severe damage to the
seat bottoms. The remaining seats in rows 20 through 22 (left side)
sustained fire damage to the seat backs, burning through the seat back
frame, but the seat bottom cushions in this area had some fire blocking
remaining. Rows 20 through 22 (right side) sustained fire damage to the seat
back frame with some fire blocking layer remaining, except for row 20, which
was pitched forward and bent up on the frame bottom.

Rows 15 through 19 (right side) sustained severe fire damage, with

no fire blocking layer remaining. Rows 10 through 14 (right side) were
destroyed by fire. Rows 10 through 19 (left side) had some fire blocking
layer remaining on the seat back and bottom cushions, with the exception of
rows 15 and 17, which sustained lesser amounts of fire damage.

In the first class section, seat row 1 (left and right sides) was
intact with little fire damage. Row 2 (left side) had some fire damage to
the seat back and bottom cushions with some fire blocking layer remaining.
Seats 3A and B were twisted with some fire damage. Seats 4A and B were fire
damaged with some cushion fire blocking layer re.maining on the seat bottom.
Row 3 (right side) was totally destroyed by fire. Row 4 (right side) was
missing.
 28

Cabin Doors and Over-wing Exits .--The main entry door separated
from its hinges and was recovered next to the forward fuselaqe. The forward
galley service door frame was extensively damaged and the door was lodged in
the wreckage.

The right floor level exit door side was found unopened. The
slide and slide cover were still in place and relatively undamaged, and the
girt and girt bar were missing. The steel cable intended to connect the girt
bar with the slide was separated just below the swaged fitting on the cable.
The floor girt bar fittings were in place and apparently in good condition
and were coated with soot. The girt bar and a portion ,of the attachment
cable were later found buried in the debris under the exit in the general
area of the rear cargo compartment. The steel cable was cleanly broken with
a slight flare of the broken strands; it was later reported that this cable
had been cut, and the girt bar had been removed by Delta personnel at the
request of CFR personnel.

The left side floor level exit door of the airplane was found
closed, although there was evidence of attempts to open the door. The
evacuation slide was in place, the air cylinder was pressurized, and the girt
bar was stowed on the slide cover. The girt bar fittings on the floor were
clean and in good condition.

As part of the investigation, an attempt was made to open this

exit door from outside the airplane. The door would not open on the initial
attempt. Debris on the floor inside the cabin adjacent to the exit door
prevented the door from moving inward and forward as was required to position
the door so it could swing outward. The debris consisted primarily of
aluminum soft drink cans. The debris was cleared away, and a second attempt
was made to open the door from inside the airplane. It was difficult to move
the mass of the door inward and upward, due to the approximately 300
downslope of the floor. With additional assistance from persons who were
outside, the door was successfully opened. Subsequently, an attempt was made
to close and then re-open this door. The floor and door frame were examined
and cleaned for this attempt. The door would close, but it would not lock
into position, and the door handle remained about 150 from the fully locked
position causing the door to remain slightly ajar. One person, with maximum
effort, was then able to open the door from inside the airplane. The girt
bar was lowered from the slide cover, and fire debris was on the slide cover
under the girt. The door of the galley compartment door that contained a
drawer of soft drink cans was found open and the drawer was found among the
debris in the rear cabin. (During the investigation, the galley compartment
door was closed and was latched without difficulty.) The latch remained
secure against heavy force applied by the fingers to the edge trim of the
door.

Both left side overwing exit hatches were found removed. The
hatch from the forward exit was found between seat row 18A, B, C and row
19A, B, C. The hatch from the rear overwing exit was found outside the
airplane, in front of the left wing. The right side rear overwing exit hatch
 29

was found in place and was extensively damaged by fire; it was unlocked and
opened without undue effort. The hatch from the forward right side window
exit was found between seat rows 19D, E, F and 20D, E, F.

.--The No. 1 forward fuselage cargo door was intact and

=@?=k
in the closed and oc ed position. The No. 2 cargo door was separated from
the fuselage and recovered approximately 250 feet north of the fuselage
location. The door was buckled and fractured horizontally in the area
between the torque tube and the door handle. The outside skin on the
forward side of the lower half of the door was crushed inboard with the most
deformation occurring along the forward edge. Examination of the mating
fuselage door jam area disclosed a heavy inboard crush in the fuselage
forward and adjacent to the lower forward portion of the door jam. With the
lower portion of the No. 2 cargo door positioned in place with the mating
fuselage section, the inboard crushing was.continuous and consistent with the
cargo door being closed while the fuselage and door were crushed along the
fuselage and adjacent lower forward area of the door.

The No. 3 aft cargo door was separated from the fuselage and was
recovered inside the fuselage.

T h r o t t l e C o n t r o l s .--The throttle cables were intact and operable

from the cockpit to the forward fuselage break. There was no binding except
in the area of the fuselage break. Further continuity of the throttle cables
was established to the aft fuselage break.

The throttle cables in the aft fuselage were intact from the aft
fuselage break to the engine control quadrant for No. 1 and 2 engines.
There was no evidence of fraying or other damage. A section of one No. 3
engine cable, which was routed through the aft inboard pulley on the right
side of fuselage section 48 beside the ventral stairs, was missing. The
other sections of this cable, and the other No. 3 engine cable, had separated
at the aft fuselage break and at the pod separation. Short pieces of these
cables remained attached to the No. 3 engine pod which had separated from the
engine.

The engine control quadrants were intact and capable of normal

operation.

A i r - C o n d i t i o n i n g S y s t e m . --The right pack cooling fan 'and right

pack air cycle machine were found in the wreckage debris path. The fan had
sustained substantial impact damage, and three blades were missing from the
rotor. However, no rotational damage was evident. Both forward pack valves
were found in the open position. The flow multiplier bypass valve was in the
open position. The APU load control valve was in the closed position.

The left pack fan inlet door actuator was in the closed position.

C o c k p i t D o c u m e n t a t i o n .--The position of all cockpit controls,

instrumentation, and switches were normal for takeoff, except for the flap
handle which was in the "up" position. The outboard flap indicator was '
indicating beyond the full up position on the left side and beyond the full
 30

down position on the right side. The inboard flap indicator was on the 2o
range on the left side and between the 2O range and the full up position on
the right.

The landing gear handle was in the down position. The speed brake
handle was full forward and in the down detent. The stabilizer trim was set
to 5.7O noseup.

1.13 Medical and Pathological Infomati on

The cause of death of the 11 passengers and the two flight
attendants was determined to be smoke inhalation. Levels-of
carboxyhemoglobin (COHg) ranged from 15 to 81 percent. Tests for drugs and
ethanol were negative in all 13 persons. A 14th fatality was a passenger who
had successfully evacuated but later attempted to reenter the burning
airplane. This passenger died of severe burns, 11 days after the accident.

The captain suffered several skeletal system fractures. The first

officer sustained a concussion with possible intercranial hemorrhage and
lacerations contusions and abrasions. The second officer's injuries were
limited to intra-abdominal trauma.

Toxicological specimens of the three flightcrew members were taken

several hours after the accident. They were negative for alcohol and drugs,
except for those drugs that had been prescribed by the physicians who
treated the crew after the accident.

1.14 Fire

A fire ensued after the right wing contacted the ground and
quickly spread to engulf the rear, right side of the airplane after it came
to rest. The fire subsequently penetrated the fuselage.

1.15 Survival Aspects

The B-727-232 was configured for a three person flightcrew and

149 passengers (see figure 8). The passenger cabin was configured with 12
first-class passenger seats and 137 tourist class seats. A double occupancy
aft facing flight attendant seat was on the aft left side of the cockpit rear
bulkhead; a double-occupancy forward facing flight attendant seat was
located on the ventral airstairs door. A single flight attendant seat was in
row 32.

The investigation found that although the fuselage had separated

in several places, the occupiable volume of the cabin was not substantially
compromised. Passengers generally stated that impact forces were not severe.
Further, the cause of deaths of the passengers in the aft section of the
cabin were attributed to smoke inhalation and fire rather than impact
injuries. Exit from the aft cabin was hampered by the fire that impinged on
the right side of the airplane. Exit from the mid and forward cabin was
through breaks in the fuselage and through the left side exits, except for
the left aft service door which was not opened.
II\

31
 32

1.15.1 A i r c r a f t R e s c u e a n d Ffre F i g h t i n g

About 0901, the DFW control tower notified the airport's

Department of Public Safety (DPS) by means of the crash phone of an accident
at the south end of runway 18L. The DPS communications immediately notified
all DPS units and other airport personnel (via automated alert). Emergency
telephone notifications were initiated via an automated voice system.
Follow-up hospital notifications were made manually by DPS personnel via
telephone for redundancy. Notifications were completed in 21 minutes.

F i r e f i g h t i n g R e s p o n s e .--Immediately following the initial

notification, all units responded from four airport fire stations. The first
units arrived on scene about 4 minutes and 20 seconds after notification.
Additional DPS personnel responded from various locations around the airport
.' in police.patrol cars.

Three trucks arrived within 5 minutes of notification; three more

trucks within 6 minutes; and five more within 11 minutes. The airplane was
reported to be engulfed in flames when the first fire trucks arrived. The
on-scene incident commander estimated that the majority of the fire was
"knocked down" within 5 minutes of the time of the alarm. The fire was
extinguished (including small spot fires) in about 40 minutes. The total
amounts of extinguishing agents used to suppress, contain and extinguish the
fire were 15,800 gallons of water and 650 gallons of aqueous film forming
foam (AFFF). Approximately 60 firefighters responded to the accident.

Police Response .--The initial police response involved searching

the area for survivors and assisting firefighters. A security perimeter and
traffic control points were established at surrounding major roadways.
Approximately 80 DFW police personnel were involved in the response.

Uedical R e s p o n s e .--The DPS emerge,ncy medical service responded

immediately with two mobile intensive care units and one mobile rapid
response vehicle. The DFW paramedics operating the rapid response vehicle
called for dispatch of the medical triage support trailers while en route to
the site. Cellular telephones were utilized by DFW paramedics to coordinate
with local area hospitals.

A team of physicians from a nearby hospital arrived by helicopter

at 0947. Five area hospitals were notified of the accident by DFW DPS
personnel within 6 minutes of the alarm, one hospital sent personnel to the
scene. A total of 13 helicopters responded.

DFW DPS Training.--The State of Texas requires all DFW

police/fire/rescue personnel to complete certification requirements for
structural and aircraft firefighting as well as certification as police
officers. Although most officers are usually assigned functionally to one
discipline in either police or firefighting, personnel who are assigned to
the patrol-rescue division provide handline and firefighting support for CFR
vehicle operators, even though their normal daily activities are as police
officers.
 33

1.15.2 Disaster Plans

DFW had a current emergency plan in accordance with 14 CFR

139.325.

On August 2, 1985, a Delta Air Lines, Inc. L-1011 was involved in

an accident at DFW.' There was a full emergency response from DFW Airport
and the surrounding communities. This was considered to be equivalent to a
full scale emergency drill. At the time of the accident involving flight
1141, a full scale emergency drill was being planned.

1.16 Tests and Research

1.16.1 Stall Warning System

The B-727 stall warning system is designed to activate when the

airplane approaches a stall angle of attack (AOA) based upon the
configuration of the wing. The system is activated by an AOA sensor and
references the inboard flap position. The system is active only when the
left main gear is fully extended, and there is no measurable electrical or
mechanical delay before activation. The airplane body AOA required for
stickshaker activation are 110 for flap settings of O" thru 2O, and 14O for
flap settings of 5O thru 15O. The stickshaker would not normally activate
at any AOA below ll”.

Inspection of flight 1141's stall warning module (overhead panel)

and left wing flap position transmitter showed them to be functional. The
AOA sensor could not be checked due to damage.
1.16.2 Takeoff Warning System

The aural warning unit was removed from the cockpit and tested at
Delta's facilities in Dallas. The unit was powered by a B-727 battery
through a 3-amp circuit breaker to represent the actual airplane
installation, and the horn operated normally with the 3-amp circuit breaker
remaining closed.

Continuity of the wiring from the terminal block to the aural

warning unit (through the bus bar and the aural warning circuit breaker) was
verified. Continuity of wiring from the flight control warning test switch
panel to and through the takeoff throttle relay and leading edge warning
inhibit relay was also verified.

The speed brake warning switch was not recovered.

'Aircraft Accident Report--*Delta Air Lines Inc., Lockheed L-1011-385-1,

N7266A Dallas/Fart U&rth International Airport, texas, August 2, 1985"
(NTSB/AAR-86/05).
 34

The upper and lower stabilizer takeoff warning switches were in

their proper position, and both switches checked normal for continuity and
activation. The flight control warning test switch, landing gear accessory
module, and the associated relays tested satisfactorily.

The No. 3 autothrottle clutch pack assembly containing the takeoff

warning system throttle switch was removed in its installed condition from
under the cockpit. It had been torn loose and was sandwiched between the
flooring and the electrical equipment compartment. It exhibited some impact
damage. Continuity tests were conducted on the switch as installed in the
clutch pack 'assembly. Continuity between the common and normally closed
terminals could not be established. During the first two finger activations
of the switch assembly, there was no continuity between the common and
normally open terminals of the switch. During the subsequent activation,
however, continuity was established. The switch exhibited a blue-green
corrosion-type substance around the normally open terminals.

The switch was tested for continuity and resistance while

installed in the No. 3 autothrottle clutch pack assembly using a 6 volts
direct current (VDC) power supply set at 100 milliampere (ma). Upon
activation, the normally open switch moved to the closed position and
resistance in the switch was measured to be 1.47 ohms.

The part number of the actuator installed on the switch was ADH
3721R2, which is the correct part per Boeing drawing No. 65-42356. However,
the switch manufacturer recommends actuator part number ADD 3721R for this
application. The depth of the circular-cylinder-shaped button on the ADD
3721R actuator is 0.044 inches less than the button on the ADH 3721R2
actuator. (See figure 9.)

The adjustment tab on the actuator, which is provided for slight

adjustments to switch operation, was bent upward i5o to 200. The Boeing
maintenance manual recommends bending the tab not more than +1/4o. (See
figure 9.)

Switch activation movement, with the switch assembly still

installed in the,clutch pack assembly, was observed through a microscopic TV
camera and recorded. The outer bottom edge of the actuator button would
initially contact the top center of the switch plunger and would remain in
this position as the plunger was being depressed and the switch tripped. As
the switch tripped, the exposed portion of the switch plunger would slide
slightly inward toward the bottom of the actuator button and become
perpendicular to the switch casing. Approximately 10 switch activations were
observed, and each time the switch properly tripped.

The cables that were still attached to the clutch pack assembly
containing the switch assembly were then removed to free the jammed cam which
moves the switch actuator mounted on the clutch pack assembly structure.
Proper orientation of the cam to the switch, as it would relate to thrust
lever position, was then established. During this procedure, numerous switch
activation sounds were heard. Other switches are installed in the clutch
 35

Figure 9.-- Photo of throttle switch.

.
 36

pack assembly. It is not known if the takeoff warning switch activated each
time the outermost surface of the cam made contact with the switch actuator.

During one of the cam movements, the outer bottom edge of the
actuator button was observed sliding off the top of the switch plunger and
making contact with the switch housing without depressing the plunger.
During subsequent switch activations, the actuator button would sometimes
fully depress the switch plunger and trip the switch, and at other times
would slide off the top of the switch plunger and not depress the actuator.
In addition, the actuator button occasionally depressed the switch plunger
but there was not sufficient travel of the plunger to trip the switch. The
actuator button is mounted on the adjustment tang as a nonrigid assembly
containing a "free-floating" spring. It was found that by either applying
finger pressure to the button assembly or rotating the spring, the button
could be positioned to: (1) fully depress the switch plunger and trip the
switch, (2) partially depress the switch plunger and not trip the switch, or
(3) slide off the plunger without depressing it.

Switch activation movement was again observed through a

microscopic TV camera and recorded. Wear patterns were observed along the
cylinder side of the button. The button was rotated to create a new wear
pattern for a later comparative study.

The switch exhibited a blue-green corrosion-type substance around

the normally open terminals on the exterior of the housing. In addition, the
plunger hole had enlarged due to side loads having been exerted on the
plunger.

The switch was later installed on a test jig provided by the

manufacturer, and all plunger travel measurements met the manufacturer's
specifications.
The switch was dismantled, and the internal surface of the switch
housing also exhfbited the blue-green corrosion-type substance. However, the
switch contacts were free of this substance. There was no visible impact
damage to the internal components of the switch.

The cam installed on the No. 3 autothrottle clutch assembly which

operates the takeoff warning switch was designed to provide for switch
activation between 11.50 and 13.50 throttle lever angle. However, the cam
had been modified by machining the cam back approximately 0.55 inches to
provide for switch activation between 18.50 and 20.50 throttle lever angle.
The cam had been modified, per Boeing instructions, to prevent nuisance
activatfons of the takeoff warning system when applying power to taxi in
periods of high density altitudes.

The cam has two adjustment slots to allow the cam to be adjusted
to compensate for manufacturing tolerences. The modified cam was found to be
installed within limits, but 0.10 inches from the full travel adjustment.
 37

1.16.3 Flap Warning Switch

The flap warning switch, located at the outboard flap follow-up

drive in the right wheel well, had sustained substantial fire damage but was
intact. The switch was bench tested as installed in the outboard. flap
follow-up drive. Eight ohms resistance was measured from the common termi,nal~
to the normally closed (NC) terminal, and 7 ohms resistance was measured
from the common terminal. to the ,normally open (NO) terminal upon switch
activation, which are normal values.

1.16.4 T r a i l i n g E d g e F l a p S&em

The inboard and outboard flap position indicators were tested and
the results were within manufacturer's specifications. The inboard and
outboard flap asymmetry-shut-off relays resistance and continuity checks were
satisfactory.

The outboard flap bypass valve was found to have been in the
No. 1, or normal, position. The inboard flap bypass valve was in the No. 2,
or bypass, position. The inboard and outboard flap control valves were, flow
checked, and both valves showed flow to port-A.

1.16.5 Leading Edge Flap and Slat System

The eight leading edge slat actuators were functionally tested and
disassembled. With the exception of the No. 7 actuator, the actuators could
be hydraulically unlocked from both the uplock and downlock positions, and
they operated normally. An attempt to unlock the No. 7 actuator from the
uplock position was stopped at 2,100 psi due to safety concerns.

All leading edge slat actuators, except for the No. 7 actuator,
were disassembled following the manufacturer's procedures for normal
disassembly. There was no evidence of internal impact damage of actuators
No. 1 through No. 6, and their locking rings were intact. One land of the
No. 8 actuator's locking ring, which was intact, displayed a small smear on
one side under a microscope, and there were two very small indentations on
the piston flange. The actuator operated normally after reassembly.

The No. 7 actuator had to be sawed open. The internal shoulder of

the actuator cylinder, located approximately 2 l/2 inches from the end of the
cylinder, had completely broken off, the~cylinder body circumferentially. The
shoulder was displaced to the rear of the actuator which prevented the
locking slide movement mechanism from moving forward to the unlock position.
The lockring was intact with no visible damage.

The leading edge flap and slat control valve was placed in a test
fixture, and the rig pin hole in the control valve crank was 0.132 inches out
from the full up position. The crank could not be moved. The valve was
flushed with alcohol, and a spectrum analysis was made on the .residue.
During the flushing, it was noted that the valve was internally ported to an
all leading edge flaps and slats retracted position.
 38

1.16.6 Auto Pack Trip System

The test results of all the components of the auto pack trip
system that could be tested, except for the engine No. 3 pressure switch,
were satisfactory. During one of the three tests on the No. 3 switch, the
switch activated at 128.5 psi. The test specifications require a switch
activation at 120 plus or minus 5 psi. The external surface of the switch
exhibited minor heat damage. The results of the remaining two tests on the
No. 3 switch were satisfactory.

1.16.7 A i r p l a n e Perfarkce

The Safety Board's performance study was based upon data derived
from the airplane's FDR and CVR, radar, ground contact data, and time-
correlated FDR and CVR information.

Based upon the airplane's final weight tabulation and the

information contained in the company's dispatch papers, the airplane's
takeoff weight was determined to be 157,683 pounds, at brake release, and the
required flap setting for takeoff was to be 15 degrees. The takeoff speeds
on the Delta takeoff card for that weight and configuration were as follows:

Critical engine failure speed (V1) was 131 knots, rotation

speed (Vr) was 131 knots, and the safe climb speed with the
critical engine inoperative (V2) was 145 knots.

The performance study's computations were based on these following

data: takeoff weight--157,683 pounds; center of gravity--22.5 percent mean
aerodynamic chord (MAC); runway elevation --596 feet msl; runway gradient to
liftoff--nominal; altimeter setting-- 29.99 inHg; surface winds--090 degrees
at 9 knots; and the temperature--740 F.

The results of the computations were compared to the airplane's

actual takeoff performance. The airplane's acceleration up to and through V2
was in accordance with predicted rates. The first officer called both Vr and
V23 and the timing of the callouts were consistent with the computed values
cited above. The airplane began to rotate at Vr. With proper takeoff
configuration, the performance study determined that a normal liftoff pitch
attitude would have been 8.60 noseup pitch at an airspeed of 144 knots. The
liftoff point would have been 5,210 feet down the runway. The initial rate
of climb after takeoff would have been about 2,500 feet per minute, at a
climb angle of 9.60, with the flaps set at 150. Flight 1141's body pitch
attitude was calculated to be approximately loo at the estimated liftoff,
with an airspeed of 158 knots.

Based upon FDR data, liftoff occurred at 9:00:13.4 at a point

6,017 feet down the runway, 807 feet beyond the normal liftoff point. The
elapsed time from the start of takeoff to the estimated liftoff was
40.7 seconds. Based on the performance study, the normal elapsed time to
main gear liftoff is approximately 37 seconds. The tail skid contacted the
runway 1.4 seconds after the estimated liftoff, approximately 383 feet beyond
the estimated liftoff point. A tail strike on the Boeing 727-232 requires a
 39

body angle of approximately loo with the main landing gear on the runway. At
that point, the airplane's airspeed had increased to 160 knots.

Given the airplane's weight and balance, actual takeoff thrust,

and compensating for ground effect, the calibrated stall airspeeds of the
airplane were determined to be 154 knots with no flaps; 147 knots with 2o of
flap; 127 knots with 50 of flap; and 120 knots with 150 of flap. The stall
warning, i.e., stickshaker, occurred approximately 1.7 seconds after the
estimated liftoff point at 161 knots and continued for 20.2seconds until the
sound of the first impact. The right wing tip struck the ground
approximately 3.7 seconds after the estimated liftoff.

At normal takeoff speeds, at a body angle of 100 with 150 of flap,

the accident airplane would have 53,105 pounds of lift available in excess of
the weight of the airplane. With the flaps up (00 of flap), the airplane
would weigh 984 pounds more than the lift produced. However,, a 1 knot
increase in speed would have resulted in the lift being greater than the
weight even with no flaps. At 2o of flaps, the lift would have exceeded the
weight by 10,125 pounds.

The airplane accelerated to Vr in 32.8 seconds after the start of

takeoff. For a normal takeoff, the time to accelerate to Vr is about
34 seconds. Boeing has determined that different flap/slat positions have
negligible effects on takeoff ground roll acceleration.

At the public hearing, a Boeing B-727 test pilot noted that the
wing's leading edge devices were very powerful in improving lateral
stability. He noted that with the flaps up the airplane is less tolerant of
side slip and will tend to drop a wing as the AOA approaches stall. He
stated that although.the aircraft is still controllable, lateral control is
degraded an additional amount with the flaps up since the outboard ailerons
are locked in a trailing position. Further, the stick force gradient
required to enter a flaps up stall is relatively flat, thus, there is very
little discernible increase in stick force as the AOA increases. However,
once the flaps are set at 5o and above, he testified that there is a
noticeable increase in stick force gradient as the airplane is rotated from
initial stall warning all the way to a full stall.

The UP or 2o flap positions would normally activate stickshaker

if the airplane is at or above 110 AOA. For flaps at 5o or 150, stickshaker
would normally activate if the airplane is at or above 140 AOA. Airplane
drag increases with increasing AOA which will reduce the acceleration
possible for a given thrust setting. FDR indicated airspeed data increases
from approximately 156 KIAS at the start of stickshaker to 164 KIAS when the
first impact occurred. For flaps up or 20, the stall AOA is about 140. For
flaps 5 or 15 o, the stall AOA is 17 to 180. Typically, there is a 5o margin
between stall warning and stall.

Boeing‘s calculations and wind tunnel testing of the lift

available with the outboard flaps at 150 and the inboard flaps up, i.e.
“split flaps,” indicated that the stall warning is at 110 and stall AOA is
18.5“. For "split flaps," the available lift would be slightly less than
 40

with a normal flap setting of 5O. The stall AOA for "split flaps" is about
go higher than the stall AOA for flaps at 15O or 5O. (See figures 10 and
11,) The "split flaps" scenario will be discussed later in this report.
1.16.8 Takeoff Harning System Inspections
As a result of the Northwest Airlines DC-g-82 takeoff accident at
Detroit, Michigan,2 the FAA issued Air Carrier Operations Bulletin
No. 8-88-4. This bulletin specified action that was to be taken by principal
inspectors to review overall takeoff warning system performance; i.e., test
the systems, ensure that each carriers' procedures are consistent with
airplane manufacturers' current recommendations, and ensure that the
checklists appropriately support required crew actions for each of their
assigned carriers. The bulletin was approved by FAA headquarters in June
1988. The flight standards district office (FSDO) responsible for Delta
received the bulletin on August 30, 1988. FAA officials testified that the
delay from the approval. of the bulletin to its arrival at the district office
was attributed to normal processing and publication time. The principal
operations inspector (POI) for Delta testified that the bulletin reached his
desk on September 5, 1988, and was put in the mail to Delta on
September 14, 1988.
On September 16, 1988, the FAA issued Action Notice A8000.30,
which addressed the need to check the takeoff warning system of Boeing Model
727 series airplanes. The result of that inspection found that all current
takeoff warning systems were acceptable from a reliability standpoint,
including those systems with single point sensors. The FAA's inspection of
the Boeing 727 takeoff warning systems found 35 anomalies in the 1,190
airplanes that were surveyed. Anomalies included component failures as well
as system adjustment problems. Twelve of the functional problems found were
attributed to the throttle lever switch. It was the FAA team's opinion that
this condition, if not corrected, could result in an attempted takeoff when
the airplane was not in the proper takeoff configuration. The FAA team
recommended that the Boeing 727 takeoff warning system be changed from a
throttle activated system to an engine pressure ratio (EPR) activated system
which had been the subject of a Boeing service bulletin in 1979. The Delta
B-727 fleet contained airplanes that had the takeoff warning system activated
by the throttle switch and others that were-activated by EPR. This mixed
fleet resulted from the acquisition of 8-727s through Delta's merger with
Western Airlines. Western Airlines had previously modified its B-727s to EPR
activated systems. Delta had evaluated the service bulletin and determined
that the modification was not needed for its operation, therefore, the Delta
B-727s retained the throttle activated systems. As a result of this
investigation, the FAA issued airworthiness directive (AD) 88-22-09, which
required repetitive and functional check of the takeoff warning system at

‘Aircraft Accident Report --‘Northwest Airlines, Inc., McDonne\-Dougles

Dc-9-82, N312RC, Detroit Metropolitan Uayne County Airport, Romulus,
Michigan, August 16, 1987” (NTSg/AAR-88/05). i
 Gear Height = OS Oleos Extended
EPR t 1,95/t.96/1.95
OH = 157.700 lb.
CO = .225MAC
= 156Oft*

0 CL @ MInImum LIftoff Speed

1.6 0 0) “SPLIT FLAP”

0
0
0
0
1A
nW
qs ‘Gear Height = 2.5 ft.

cL 12
.

UNCOMPRESSED TAILSKIDCONTACT

0.6

6 6 12 14 16 16 20
0.6

6 6 10 12 14 16 16 20 22 24

BB

Figure 10 .--Boeing 727 city curves, in ground effect zero altitude.

2.2
GearHebht t 2 0R.
EPR = 1p5n.96n.95
GH % 157mOlb.
CG t .225MAC
2.0 S % 156Oti
REF

1.8
LI suckshaker
0 InitlmlBuffet

1.6 L!isfr’

1.2

6 6 16 12 14 16 16 20 22
0.6

6 6 10 12 - is 16 16 20 22 24

aB

Figure 11--Boeing 727 city curves, in ground effect, altitude equal 20 feet.
 43
200-flight-hour intervals, and repair or replacement of any inoperative
component, if necessary, prior to further flight. The AD became effective on
November 10, 1988.

1.16.9 Flight Demonstration

On March 21, 1989, a flight demonstration was conducted utilizing

a Delta Boeing 727-200. The purpose of the flight demonstration was to
validate the wind tunnel data on the Boeing 727 coefficient of lift and
coefficient of drag versus AOA to actual flight data. The flight
demonstration found very good correlation of the actual coefficients of lift
and drag to the wind tunnel derived data.

During the investigation of the accident, parties had suggested

that flight 1141 had departed in a split flap condition, and that the crew
had raised the flaps prior to impact in a attempt to prevent the accident.
The split flap condition was defined as the inboard flaps retracted and the
outboard flaps at 150. Flight demonstration data disclosed that the lift
curve for the split flap condition was slightly below the curve for a flap
setting of 5O, which closely agreed with the calculated data.

1.17 Other Information

l

1.17.1 Delta's Flight Standards Organization

As a result of a FAA National Inspection Team Report on the safety

audit of Delta conducted in July of 1987, Delta created the position of
System Manager, Flight Standards. The person in this position reports
directly to the Vice President, Operations. This position oversees the line
check airman program, and places the line check airman under centralized
control. Fleet managers and standards managers for each aircraft type in the
Delta fleet report directly to the system manager.

Fleet managers are responsible for the technical support to the

pilots for the operation of their particular airplane type; they have, in
part, responsibility for airplane manuals, checklists and document revisions.
They also publish and distribute quarterly information packages related to
their airplanes and the operation of the airplanes. Further, they are
charged with standardization matters.

The line check airmen program is under the standards manager

function. Line check airman at each base report to a lead check airman, who,
in turn, reports directly to the standard's manager for his particular
airplane type. The function of the standards manager's office is, in part,
to ensure that the check airman program is executed in a standardized
manner, to standardize fleet operations, and to monitor and analyze all
operational aspects of fleet operations.

Delta's training department also was reorganized in 1987 and is

headed by a system manager of training, who reports directly to ~the Vice
P r e s i d e n t , Operations. The training department is responsible for the
initial and recurrent training of all pilot and instructor personnel.
 44

The investigation revealed that Delta did not insist on a

standardized approach towards cockpit management. Testimony from management
and training personnel indicated that captains were allowed wide latitude in
their conduct of cockpit operations. Over the last few years, Delta has been
developing a program to incorporate cockpit resource management (CRM)
training in Delta's pilot training programs. A CRM steering committee; with
assistance from consultants, has developed a CRM program and a method of
intergrating this program into the existing training system. Additionally,
Delta has developed an associated line oriented flight training (LOFT)
syllabus which incorporates the present 6-month training cycle.
Implementation of the CRM program is scheduled to begin in late 1989 and each
crewmember shall have received CRM training by mid-1990.

1.17.2 Checklist Procedures

Delta's expanded checklists are contained in the Normal Procedures

section of the Boeing 727 Pilot Operating Manual. The checklist contains
captain, first officer, and second officer actions in which a “challenge and
response" format is used. The captain is required to verbally initiate the
checklist procedure. The second officer reads aloud the challenge, and the
appropriate crewmember makes the proper response. Not all items on the
checklist are required to be read aloud such as tasks performed by the
second officer or pilot actions which the second officer verifies. *

Delta procedures require that when the airplane is on the ground

the captain should call for all checklists. The captain will respond to the
"Before Start checklist" or delegate the first officer to respond. The first
officer normally responds to all other checklists during ground operations.

In flight, the pilot who is flying the airplane calls for the
appropriate checklist and the pilot not flying makes the response. The pilot
flying the aircraft calls for any landing gear or flaps change and the pilot
not flying accomplishes the change. When each checklist is complete, the
second officer makes the appropriate announcement.

T a x i C h e c k l i s t .--The Taxi checklist section of the Pilot Operating

Manual contains the item “Flaps", as follows:

FLAPS . . . . . . . . . . . . . . . . . . . . , , GREEN LIGHT

Ensure INBD and OUTBD FLAP position

indicators display takeoff setting
Ensure green LE FLAPS light
illuminated
Flaps may be extended anytime after departing
ramp area
 45

T h "Operating
e Techniques" page associated with the taxi
checklist states:

The flaps should not be extended until well clear of

congested areas. Normally flaps should not be extended until
all engines have been started. The FLAP lever may be moved
directly-to the takeoff position. Once flaps are extended,
operate -all flight controls through their full range of
travel. Hold nose wheel steering firmly during the rudder
check.

According to Delta training personnel and other Delta flightcrews,

Delta's procedure prior to March 1988 had been to extend flaps only after all
three engines had been started. This procedure was changed in March 1988 to
allow flap extension anytime after departing the ramp area. One c,aptai n
stated that, while there was no specific procedure, simulator instructors
taught captains "by inference" to check the flap position when checking the
rudders as part of the flight controls check on the taxi checklist. One
pilot instructor stated that the captain, ultimately, is responsible for the
completion of all checklist items; however, actual pilot responsibility is
not specified in the Pilot Operating Manual. Another pilot stated that the
assurance that a checklist had been completed was the second officer's report
of checklist completion as well as the captain's mental involvement in all
cockpit activities.

Before Takeoff, Checklist .--The Pilot Operating Manual notes that

orior to takeoff, a briefinq is to be made in minimum but adequate detail
outlining the plan of action-for takeoff. However, it also states that this
briefing may be given as part of the BEFORE START CHECK. The captain is
required to brief his crew on their responsibilitfes during the takeoff. The
briefing presumes the use of standard procedures but includes additional
emphasis on items necessary for that particular takeoff, i.e., special noise
abatement procedures, possible windshear, 250 flap takeoff procedures,
possible additional requirements. The before takeoff briefing was not heard
on the CVR of flight 1141. The captain stated during the Safety Board public
hearing that he accomplished the briefing prior to pushback from the gate,
which was before power was applied to the CVR.

T a k e o f f ' P r o c e d u r e s .--Delta requires the captain to make the

decision to reject or continue the takeoff. Therefore, after the initial
power application, the captain must keep liis hand on the throttles until VI,
to enable him to respond rapidly to a rejected takeoff situation. At Vr, the
pilot flying is trained to rotate the aircraft smoothly and continuously
until a stabilized climb speed of V2 + 10 knots is achieved. Rotation rate
should be approximately 2o to 3o per second. Initial pitch attitude will
vary from approximately 13 o to 180 depending on gross weight and flap
setting. For a 150 flap takeoff, the pilot flying is to maintain V2 +
10 knots and flaps 150 until clean-up altitude.
 46

The operating mdnual states that on every takeoff, the captain

must be prepared to reject the takeoff. If a serious malfunction is
recognized prior to Vi, the takeoff should be aborted. If prior to Vi, a
malfunction occurs which does not affect the safety of flight, the captain
should evaluate all factors and either abort or continue the takeoff. When
the captain decides either to reject or continue, he is required to announce
his intentions clearly to the other crewmembers. If an engine malfunction is
recognized at or after Vi, the takeoff should be continued and the pilot is
expected to continue the normal rotation to the initial climb attitude.

After takeoff, the initial climb attitude is immediately adjusted

to maintain a minimum of V2. If climb airspeed exceeds V2, the pilot is to
increase pitch attitude to stop acceleration but not to reduce climb speed
back to V2. If an engine failure occurs above V2 speed, the pilot will
attempt to maintain the speed at which the engine failure occurred.

If alternate (derated) power was used for takeoff, the pilot will
increase thrust to normal power on the operating engines as the situation and
aircraft control permit. The flight director may be used to assist in
heading control with an engine inoperative.

1.17.3 Sterile Cockpit

Delta's sterile cockpit procedure corresponds to FAR Part 121.542,

which prohibits cockpit activities not related to the safe operation of the
airplane during critical phases of flight. Critical phases of fli,ght are
identified in the FAR as: all ground operations involving taxi, takeoff,
landing, and all other flight operations below 10,000 feet except cruise
flight. Taxi is defined as movement of the aircraft under its own power on
the surface of the airport. When the airplane has been stopped during the
taxi phase, Delta procedures state that PA announcements promoting Delta,
describing the route of flight, giving weather, etc., are permissible.
Examples of activities not permitted by Delta procedures during critical
phases of flight are completing paysheets, eating meals, and engaging in
nonessential communications between the cockpit crew or anyone else in the
cockpit. The Delta flight attendant manual provides guidance on the sterile
cockpit procedure and nonessential communications with the flightcrew.

1.17.4 Human Performance Research Projects

During the Safety Board's public hearing on the Northwest

Airlines, Flight 255 accident at Romulus, Michigan, on August 16, 1987 (op.
cit.), the Board sought and received testimony from psychologists concerning *
projects which either have evaluated or are evaluating man/machine
interactions and how interpersonal relationships among flightcrew personnel
affect their performance of cockpit duties.

A professor of management sciences and computer information

testified that, if forced to describe the term "complacency" he would state
that it was a "relaxing of one's guard." He testified, "that the notion in
automation is that if the equipment is reliable, and most of it is extremely
reliable, this will generate complacency, a relaxing of one's guard."
 47

The management sciences professor described what he thought of as

six lines of defense against an untoward consequence resulting from human
error. The first line of defense was human vigilance; the second, another
crewmember detecting error; the third, secondary indications, such as
cockpit displays and instrumentation; the fourth, warning and alerting
devices; the fifth, persons other than crewmembers detecting the error, i.e.,
ATC personnel or ground personnel; and the sixth, machines that take action
on their own to rectify the error, i.e., the DC-g-82's autoslat and stick
pusher systems. With regard to the first line of defense, the professor
testified that it was, "of course, normal procedures, and that is the crew
doing the right thing,, supported by checklist, training, experience, manuals,
discipline, check airmen, and what not."

With regard to checklist presentations, the management sciences

professor testifed that he did not know of any human factors research on how
a checklist should be designed and that he could not find anything in his
library on the subject. "There are a couple of human engineering handbooks
and under 'checklist' about all they said was the type ought to be visible
and it ought to be easy to handle..."

A National Aeronautics and Space Administration (NASA) research

psychologist testified to the role structure in the cockpit environment. He
testified that the term "role structure" refers basically to the degree and
specificity of the structure of a group's activities. "With cockpit crews
you would have a very well defined role structure, each position being well
defined and having specific responsibilities in the cockpit." He testified
that role structure performs a very valuable function and that, "the safety
of the system, I think, in many ways is a testament to how well defined and
how functional the roles are in the cockpit. But one of the other
characteristics of a well defined role structure is it significantly reduces
ambiguity about who is going to do what and at what particular time."

The NASA pyschologist further testified that various studies using

airplane simulators have disclosed crews whose performances could be
classified as "effective" or "less effective," that a number of differences
which they have seen "between the so-called effective crews and the so-called
less effective crews are very reliable and appear time and time again." He
testified that with regard to the highly effective crews, "there is much more
communication in general . ..but there are also differences in the type of
communication. ..you see much more task oriented communication." He
testified that one of the patterns visible, “is what we call the information
acknowledgment sequence... We find that (with) crews that are highly
effective . ..we tend to see many more acknowledgments to anything that is
said."

The psychologist testified that the manner in which the subject

flightcrews used their checklists also was evaluated. He testified that it
was rare to see a checklist ignored completely or not done, but this had
occurred from time to time during various phases of flight in the simulator.
There was a lot of variation with regard to checklist usage, from the conduct
described above to a ‘very cl early read chal 1 enge/response method01 ogy .‘I
 Additionally, he testified that evidence suggested that the way
the checklists were used directly related to the number of errors made by the
flightcrews. The flightcrews that performed their checklist duties "by the
book", challenge (and) response methodology...tend to- perform more
effectively." He testified that he was not familiar with any body of
research relating to the construction and presentation of checklists, but it
was his opinion that, "there are probably. many ways to do a checklist
correctly. What's important is that everyone agrees on how it should be
done, and then it's done the same way every time by all the people that are
concerned."
3
An article in the Boeing Airliner Magazine concerning
flightcrew-caused accidents and citing the Boeing fleet over a IO-year period
as an example stated that:
16 percent of the operators have crew-caused accident rates
higher than the fleet average, and these operators account
for over 80 percent of the total accidents.

Conversely, 80 percent of the operators had no crew-caused

accidents over the same period...

The authors of the article contacted a small group of operators,

"most of which had a better than average crew-caused accident history," with
a view to obtaining information on the policies and techniques that
contributed to their safe operations. They found that:
Management recognizes the need for aircrews performing in a
standardized way and the importance of cockpit discipline in
providing the environment for proper crew coordination.

The article noted that a strong check airman program acts as a

continuous quality control check on the training depaltment and that methods
exist for assuring the uniformity of check pilot techniques and instruction.

Some of the cockpit discipline procedures used by these operators

were:

There is a firm requirement for in-depth takeoff and approach

briefings for each flight segment...One operator requires an
RTO (rejected takeoff) touch drill in which each control
used during the RTO is sequentially touched by the pilot
making the takeoff.
Cockpit procedural language is tightly controlled to maintain
consistency and to avoid confusion from non-standard
callouts, which can result from crewmembers using differing
phraseology. Callouts and responses are done verbatim. The

5L.G. Lautman and P.L. Gallimore, “Control of the Crew-Caused Accidenti’

Airliner Magazine, Boeing Commercial Airplane Company, April-June 1987.
 :

49

recurrent training program and check pilot system rigidly

enforce this requirement.

1.17.5 FM Surveillance

Delta Air Lines .holds air carrier certificate No. 26 and is

authorized to conduct domestic and flag passenger and cargo operations under
14 CFR Part 121. The certificate-holding office is FAA Flight Standards
District Office No. 67.

In addition to the principal operations inspector (POI), one

assistant principal operations inspector and five aircrew program managers
(APM) provide FAA operations certificate supervision. Mid-South FSDO-67
currently has an office manager plus five operations inspectors type-rated in
the B-727. The office currently has a total.of 14 operations inspectors who
are qualified to conduct air carrier surveillance and inspections of Part 121
operators.

Inspection and surveillance activities conducted by Flight

Standards District Office No. -67 on Delta's, B-727 operations and training
since October 1, 1987 until the day of the accident consist of: 69
organizational or technical inspections, 123 airmen certification
inspections, and 149 general surveillance inspections.

FAA records indicate that for the period of August 1, 1986, to

September 2, 1988, Delta Air Lines, Inc. had experienced: 3 accidents and
108 incidents; 284 enforcement actions had been initiated. Also the FAA had
conducted three major inspections of Delta since 1985. The inspections
included:

(1) a 1985 inspection of Delta by the FAA's Southern

Region as a result of the Delta 191 accident.

(2) a 1986 regularly-scheduled NASIP inspection of Delta.

‘(3) a 1987 safety audit of Delta as a result of six

highly-publicized incidents.

Additionally, after the accident involving flight 1141, the FAA

conducted a follow-up survey of its 1987 Safety Audit in the fall of 1988.

In November 1985, the FAA's Southern Region conducted a special

review of Delta Air Lines' operational procedures, largely as a result of the
Delta 191 accident at DFW on August 2, 1985. The review culminated with the
debriefing of the regional director and the division manager, the POI, and
Delta management on November 26, 1985. Among the findings of the review team
were:
 50

(1) Delta Air Lines' method of recording maneuvers on

roficiency checks and in-lieu-of training does not
specify unsatisfactory performance. If an airman's
performance is not satisfactory, he is not given credit
for the maneuver until he demonstrates the task
satisfactorily. This results in extension of the
training period for the training or evaluation or
rescheduling to another day. This occurred on numerous
occasions during this review period. A review of prior
records should reveal similar occurrences when not under
the eyes of the FAA. If this is not the finding, it is
very likely that a substandard performance is being
accepted by some check airmen.

(2) Flightcrews are not being trained as a crew. Instead,

check airmen often act as second officer and the check
airman. When captains are scheduled together, they act
as first officer for each other. The result in all
cases is a decrease in the productivity of the training
or checking process.

(3) Check airmen or instructors accepted a marginal or

unsatisfactory performance by airmen as an acceptable
level of performance.

During the spring of 1986, the FAA dispatched a NASIP team to

Delta Air Lines, Inc. The NASIP team concept was formed as a result of the
FAA's desire to periodically review all the major air carriers' compliance
with regulations. Airworthiness and Operations teams were formed to review
the carriers' operational and maintenance procedures.

Whereas the 1985, 1987, and 1988 inspections conducted at Delta

reviewed the carrier in a "qualitative" manner, the NASIP teams strictly
_assess compliance with regulations. As such, the findings of the NASIP team
tend to be very specific, and only regard noncompliance of regulations.
While the NASIP team did cite a few problems in Delta's training and
proficiency check programs, the findings in general do not reflect a concern
as to Delta's training and check airmen procedures.

In mid-1987, Delta experienced a series of highly publicized,

pilot-related incidents. These incidents included: an inadvertent shutdown
of both engines on a B-767 after takeoff; a navigational error that resulted
in a near midair collision over the Atlantic Ocean; landing on the wrong
runway; landing at the wrong airport; and twice departing without an ATC
clearance. As a result, the PO1 assigned to Delta and the division manager
of Flight Standards, Southern Region, concluded that an inspection should be
conducted at Delta in order to determine the relationship, if any, between
the incidents and Delta's operational procedures. The request for the
inspection was coordinated with the Manager, Evaluation Staff, Office of
Flight Standards, FAA headquarters. The special inspection team met at
Delta's headquarters on July 24, 1987. The areas examined included:
 (1) Enroute inspection and line check program
(2) Flight manuals and procedures
(3) Flight training program
(4) Delta's long range navigation procedures

In its final report; this inspection team noted "...instances of a

breakdown of communications, a lack of crew coordination, and lapses of
discipline in Delta's cockpits." The report associated this behavior to
II
. ..a lack of clear-cut, definitive guidance from those ,responsible for
developing and standardizing cockpit procedures. Delta's management has
maintained a policy of delegating the maximum degree of responsibility and
discretion to its crewmembers. The behaviors discussed...are a direct
reflection of Delta's training programs and manuals. Guidance, training, and
practice in crew coordination and cockpit management are minimal."

The report also contained other areas of concern. These included

cockpit discipline and coordination observed during en route inspections,
manuals andLchecklists that contained minimal guidance, excessive training
and failure to report unsatisfactory performances on checkrides, and minimum
training standards. At the Safety Board's public hearing in Dallas, Texas,
the team leader of the 1987 inspection testified that all the key FAA
personnel from the Southern Region and Washington headquarters were debriefed
as to the results of the inspection.

Interviews by Safety Board personnel of Delta flightcrews and

management subsequent to the accident indicated a lack of knowledge related
to specific crewmember duties, for example the crewmember responsible for
verifying flap position. The investigation found that Delta management
permitted maximum flightcrew discretion in cockpit operations. In Delta's
critique on the 1987 Safety Audit, the Vice President, Operations stated:
"While each (FAA) team member may have come with a preconceived scenario for
flight deck operation, it should be recognized that deviation from that
scenario does not, per se, indicate an absence of standardization or
discipline. In fact, many of the elements of our procedures are left to the
discretion of the captain." Testimony at the public hearing from the PO1 for
Delta indicated that he believed that the FAA was well aware of this
philosophy at Delta, and the possible negative effect it had on flightcrew
performance.

In an August 31, 1988, memorandum, the FAA's PO1 for Delta

summarized the changes instituted by Delta Airlines as a result of the 1987
FAA inspection. These changes included, in part, the following:

1. The Line Check Airman Program has been reorganized.

2. The Flight Training Department has been reorganized.

3. Before-takeoff briefings and before-landing briefings

are now being conducted with greater emphasis on
details.
 52

4. Numerous checklist changes have been made reflecting the

changed procedures and additional briefing items.

5. All proficiency check airmen and line check airmen were

briefed on the results of the FAA inspection. Emphasis
was placed on the need for maintaining high standards at
all times.

6. A new policy on the documentation of training/checking

of crewmembers was developed. Unsatisfactory
proficiency checks and any additional training conducted
are now fully documented on the crewmember's training
record.

7. Additional checklists, were developed for line check

airmen to aid in standardizing training and to
reemphasize the initial operating experience training.

8. Line checks conducted by line check airmen have improved

with an emphasis on higher standards, standardization
and cockpit resource management.

9. Proficiency checks have become more challenging by

emphasizing higher standards. These higher standards
have been reflected in the larger number of
unsatisfactory proficiency checks being recorded.
Additionally, all failures are reported to the mid-south
Flight.Standards Office and all rechecks are conducted
by the FAA when possible.

At the public hearing, the FAA's Manager of the Flight Standards

Division, Southern Region, testified that the 1987 special inspection
"confirmed some of our suspicions, based on our surveillance and the trends
we had noted, and pointed out some areas that we felt we needed to discuss
with Delta and see what they would offer as resolutions to these problems."
The PO1 stated that the problem areas were generally non-regulatory in nature
and that he had to rely on his own salesmanship to convince Delta on the
need to act on the special inspection teams recommendations.

A follow-up survey of Delta was accomplished by the FAA in the

fall 1988. The purpose of this survey was to reexamine Delta's operations in
those areas defined in the 1987 audit, determine the corrective actions taken
by Delta with regard to the findings and recommendations contained in the
Safety Audit Report, define any issues which have yet to be resolved, and to
estimate the future effectiveness of Delta's actions. The team found that:

Delta's management has instituted programs to improve both

line operations and the training program. Organizational
changes have been made which created a Flight Standards
Department, centralized management of the Line Check Airman
program, and realigned responsibility for development of
operational procedures and manuals. Both line operations and
 53
training were found to be improved over last year's audit.
However, deficiencies identified in the previous audit were
observed. Ineffective crew coordination and failure to
follow established procedures were observed in line
operations. A minimum degree of challenge to -the flight
crewmembers and the acceptance of minimum standards were
observed on proficiency checks. Manuals and procedures have
been improved where specific findings and recommendations
were previously made. However, fundamental changes to
checklists and procedures are 'still pending. The team
observes that some of the major actions taken by management
have not yet become fully operational or have not yet become
effective. For instance, the effect of the changes in the
line check airman program is only now beginning to be'
apparent. On the average, each captain would have only been
administered on line check since revision of the program. A
Cockpit Resource Management (CRM) training program has been
in development for some time but is not scheduled for
implementation until January 1, 1989."

Some of the major actions taken by Delta management that had not
become fully operational or effective at the time of the team's survey were
CRM training and LOFT training.

1.18 Useful or Effective Investigative Techniques

During the initial portion of the takeoff, a sound could be heard

on the area microphone of the CVR recording. This sound. increased in
frequency as the airplane accelerated down the runway for takeoff. The
unknown sound was associated with the airplane moving down runway 18L at DFW
but the exact source could not be innnediately identified. The list of
possible sources of the sound could have been the runway grooving, the nose
gear tires or wheel bearings, or the main gear tires or wheel bearings. The
approximate aircraft ground speed was calculated using indicated airspeed
information from the FDR and the reported temperature and winds at the time
of the accident. With this information, the airplane's tires and the wheel
bearings were mathematically eliminated as possible sources of the sounds.
The runway grooving was identified as the source of the sounds. Measurements
were taken of the grooving and a test recording was made in a like Boeing 727
airplane taking off on the same runway which verified the, results of the
CVR-derived groundspeed calculations for the accident airplane.
 54
2. ANALYSIS
2-l General
The investigation determined that the flightcrew was qualified in
accordance with applicable Federal Aviation regulations and company
regulations.

The airplane had been maintained and operated in accordance with

applicable Federal Aviation regulations and company operations,
specifications. There was no evidence of any preexisting discrepancies or of
any preimpact structural, flight control, or engine failures which would have
been causal to the accident.

Although the No. 1 fuel gauge was inoperative and the fuel tanks
were not drip sticked following refueling, the evidence indicates that the
airplane was refueled properly. There was no evidence that there was a fuel
imbalance that would have caused flight control problems.

There were no abnormal airplane movements prior to takeoff, changes

in ground control frequencies, or weather-related factors which could have
distracted the flightcrew from its duties.

The analysis of this accident addressed the performance of the

airplane's trailing edge flap and leading edge flap and slat control systems,
as well as the performance of the airplane's takeoff warning system and the
performance of the engines. Also addressed in this analysis was the FAA's
surveillance of Delta and Delta's efforts to correct or improve problem
areas identified during FAA inspections.

2.2 The Accident

The following were determined from evidence obtained from the

airplane's CVR and FDR, and marks on the surface of runway 18L: (1) the
airplane accelerated normally to Vl/Vr; (2) the captain began rotating the
airplane to the takeoff attitude at about 131 knots indicated airspeed
(KIAS),-- which was the proper rotation airspeed for takeoff conditions and
gross weight with the airplant! configured with 150 trailing edge flaps and
'extended leading edge flaps and slats; (3) the calculated aerodynamic data
indicate that a oositive load factor, i.e.. liftoff. should have occurred at
144 knots calibrated airspeed (KCAS) with a- noseup attitude of about 8.60 and
150 of flaps. However, actual liftoff occurred when it reached a noseup
atti tude of about loo and an airspeed of about 158 KCAS.

The investigation found that the airplane's rotation attitude is

limi ted to about loo by the airplane's geometry while it is on the runway and
the marks found on the runway surface confirmed that the tail skid struck the
runway at or immediately after the main landing gear lifted off.

Data correlation showed that the stall warning stickshaker

activated within 2 seconds after liftoff at a pitch attitude of about 11.40
and an airspeed of about 161 KCAS; 2 seconds later the airplane rolled
 55

sharply to the right and the right wing tip struck the runway surface.
Compressor surges from one or more engines were heard immediately
thereafter. The airplane reached a height above the liftoff point of about
20 feet and then it began to descend. The first impact with the localizer
antenna installation occurred only 22 seconds after liftoff. (See figure
12.) After initial activation, the stall warning stickshaker sounded
ccntinually until impact.

The point during takeoff at which an airplane leaves the ground

and the climb gradient is established depends upon the force of lift which is
acting on the airplane. Although the vertical component of engine thrust
contributes to the total lift force when the airplane rotates to a noseup
pitch attitude, the primary component of the total lift force is the
aerodynamic lift produced by the airplane's wing. This aerodynamic wing lift
force, for any specific trailing edge flap and leading edge flap and slat
configuration, is a function of the airspeed and wing AOA. The evidence in
this accident is conclusive that the aerodynamic wing lift force to establish
a safe takeoff (which should have been developed with the flaps set at 150
from the time that the airplane was rotated beyond an 8.60 noseup attitude
at an airspeed in excess of 144 KCAS) was never attained.

Although the possibility of degraded engine performance was

suggested by the evidence of compressor surges, a reduction of thrust does
not explain the lift deficiency evident by the airplane's failure to climb.
Based upon this rationale; engine performance has been ruled out as an
initiating cause of this accident. However, the occurrence of the
compressor surges after the stickshaker activation and the possible effect on
the flightcrew actions and airplane performance during the 22-second flight
are discussed further in this analysis.

In analyzing the causes of this accident, consideration was given

to all conceivable factors that could explain why the magnitude of the lift
force developed by the wing was less than that which would be expected.
Contamination of the wing's airfoil which could have affected the aerodynamic
characteristics was disregarded since the magnitude of the lift deficiency
was too great to be attributed to leading edge roughness, particularly in the
absence of freezing precipitation temperatures. The possibility of windshear
as a cause was also ruled out for two reasons: (1) the effect of a
horizontal wind shear is a sudden decrease in airspeed which correspondingly
decreases wing lift, an occurrence which is not consistent with the airspeeds
recorded during flight 1141's takeoff; and (2) the existing weather was not
conducive to the strong convective activity associated with significant
downdrafts or windshears that would affect the airplane's climb performance.

Consideration was also given to the possibility that the airplane

encountered the wingtip vortex generated by a departing airplane immediately
preceding the flight. Recorded radar data disclosed that at the time that
Delta flight 1141 was receiving its takeoff clearance, the preceding flight,
Delta Flight 1486, a B-727, was in excess of 7,000 feet down the runway and
about 100 feet in the air. This separation exceeded the FAA's requirements,
which state that a departing aircraft cannot begin its takeoff roll until
the other aircraft is airborne and that, for Category III aircraft, a minimum
 PERSPECTIVE FRONT VJEW

14 DEGREES PITCH
11 DEGREES ROLL

Figure 12.--PerSpeCtive
front view of
impacting ILS antenne array. flight 1141
 57

distance of 6,000 feet is established. Additionally, as the required

separation distance was established between the two airplanes and as the
preceding airplane was not categorized as a "heavy" airplane, there was no
requirement for the controller to issue a wake turbulence cautionary
advisory.

Analysis of the surface winds at departure times of flight 1486 and

flight 1141 and the possible rate of sink for wingtip vortices indicated that
the vortices created by flight 1486 were not near the runway when flight 1141
rotated for takeoff. Even those analyses which assumed that all of the
factors which would be most conducive to a vortex encounter, i.e., no loss of
vortex strength or interaction with the ground and worst case movement of the
vortex, showed that the vortex from flight 1486 would still be at least
700 feet to the southwest of flight 1141's takeoff flight path. Therefore,
the Safety Board determined that an encounter with a wake vortex was not a
factor in this accident.

The only remaining plausible explanation for the deficiency in

aerodynamic lift is that the airplane's wings were not properly configured
for takeoff. That is, either the ground or flight spoilers were deployed or
the wing leading and trailing edge devices were not extended during the
takeoff roll.

Therefore the possibility was considered that the wing flaps and
slats were properly extended, but for some unknown reason spoilers might have
deployed during the attempted takeoff. Spoilers decrease lift while
simultaneously increasing the drag force. Ground spoilers reduce the lift
force and increase drag during the ground run, allowing landing distances to
be shortened. Flight spoilers are used to assist in roll control or to
increase the descent rate while airborne. Physical evidence indicated that
all but one of the flight spoilers were in the stowed and locked position.
The remaining flight spoiler was found in the wreckage path with its actuator
extended. One ground spoiler 04 the left wing was in the stowed and locked
position. The other spoiler was stowed but could not lock due to
misadjustment of the overcenter mechanism. The ground spoilers on the right
wing were consumed by fire. Analysis of the change in aerodynamic forces
that would be expected due to deployment of either one or both types of
spoilers showed that neither one matched the accident circumstances. The
acceleration of Flight 1141 is higher ttian predicted for the case in which
ground spoilers are deployed.

Therefore, the deficiency in aerodynamic lift must have been

because all or some of the trailing edge flaps and the leading edge flaps and
slats were not extended. In this case the.aerodynamic lift produced by the
wing at the normal takeoff and climb airspeeds would be significantly less
than that required for normal performance. There is considerable physical
evidence that all of the trailing edge flaps and some of the leading edge
flaps and slats were fully retracted when the airplane came to rest after
impact. The physical evidence regarding the position of the trailing edge
flaps and leading edge flaps and slats at the initiation of and during the
takeoff is less conclusive. Accordingly, the Safety Board sought to
determine the position of these lift devices.
 58

2.3 Determination of Trai 1 ing Edge Flap and Leading Edge Flap
and Slat Position at Impact

The evidence considered in the determination of the positions of

the trailing edge' flaps and leading edge flaps and slats at the time of
impact included the wreckage documentation of the cockpit flap control
mechanism, the trailing edge flap drive mechanisms, the outboard aileron
lockout mechanisms, and the leading edge flap and slat actuators.

C o c k p i t F l a p C o n t r o l L e v e r . --The cockpit flap control lever was

found in the 00 (flaps up) detent. l'he flap control mechanism was intact and
functional after the accident. The control lever is spring-loaded to lock in
each of the seven/flap position detents. To move the lever from a detent, it
must be raised about l/4 inch before it can be moved to a new position.
Further, the mechanism quadrant contains a gate at the 2O position which is
designed to prevent the lever from being inadvertently moved to the O"
position. Thus, a movement of the lever from the 150 position to the Oo
position requires that the lever be raised out of the 150 detent,.moved over
the 100 and 5O positions to the Z" detent, depressed and passed under a
'gate", and reraised before movement to the Oo detent position. It is
unlikely that this sequence of lever movements occurred during the impact.
Although the flap control lever could have been moved by a crewmember or
rescue personnel following the accident, such a movement would have had to be
intentional and, most likely, accomplished by someone familiar with the
mechanism. There is no evidence that such an action occurred.

Trailing .Edge Flap Drive Mechanisms.--The movement of the flap

control lever is mechanically transmitted to the inboard and outboard
trailing edge flap hydraulic control valves. These hydraulic valves are
thereby repositioned so that hydraulic fluid flow under pressure is applied
to the inboard and outboard flap drive motors. These motors, in turn, rotate
torque tubes which transmit rotary motion to jackscrews which move the
trailing edge flap panels. All of the tray ing edge flap drive mechanisms,
the jackscrews on the left-wing outboard Ylaps, the torque tube on the
left-wing inboard flaps, and the jackscrews on both the inboard and outboard
right-wing flaps", were found in positions which corresponded to near fully
retracted trailing edge flaps. It was noted that the jackscrew ballnuts were
not on the upstops and the rigpin holes were slightly out of the flaps up
position. However, it is believed that these positions were either the
current rig of the airplane or that a hydraulic transient surge during the
impact sequence caused actuators to move slightly. The flap drive
.mechanisms are irreversible by design; i.e., an externally applied load to
the flap surfaces will not cause the jackscrews to rotate. Therefore, the
positions of the flap drive mechanisms can not be attributed to impact
damage.

Outboard Aileron Control Lockout Device.--Roll control of the B-727

airplane IS achieved by a set of inboard ailerons, a set of outboard
ail'erons, and spoilers. When the wing flaps are- retracted to the Oo
position, the outboard ailerons are “locked out" so that they remain in the
neutral position irrespective of inputs from the aileron control system. The
outboard aileron control lockout mechanism consists of a jackscrew which
 59

changes the geometry of the linkage to the control surface. The jackscrews
are driven by the outboard trailing edge flap torque tubes via gearboxes.
In the cases of the accident airplane, the left and right outboard aileron
lockout jackscrews were both found fully extended, corresponding to
locked-out ailerons. The jackscrew positions were consistent with the other
physical evidence that the trailing edge flaps were retracted. These
mechanisms are also of a design which is not susceptible to movement as a
result of impact loading.

Leading Edge Flaps and-slats. --The leading edge flaps and slats are
positioned in conjunction with the trailing edge flaps. When the trailing
edge flaps are extended, mechanical motion is transmitted through cables and
linkages from the outboard trailing edge flaps to the leading edge flap and
slat hydraulic control valve. When the outboard trailing edge flaps are
extended to 2O, the control valve is positioned to port hydraulic fluid
under pressure to extend two of the four leading edge slats on each wing.
When the outboard trailing edge flaps are extended to 5O, the hydraulic
pressure is applied to all of the leading edge flaps and slats. The leading
edge flap actuators are linear hydraulic cylinders which have an internal
mechanism to lock them in the fully extended position only. Thus, when
hydraulic pressure is removed, unless the pistons are fully extended, they
are free to move within the cylinders with externally applied loads.
Therefore, the postimpact position of the leading edge flaps in the extended
position is not necessarily indicative of the preimpact position.

The leading edge slat actuators are also linear hydraulic

cylinders, but, unlike the leading edge flaps the slat actuators have
hydromechanical locking mechanisms in both the fully-extended and
fully-retracted positions. If the actuator piston rods are in a midstroke
position when hydraulic pressure is removed, they can be driven by external
loads to the extended or retracted position. However, if the actuators are
fully extended or fully retracted when hydraulic pressure is removed, the
actuator piston rods will remain mechanically locked unless external loads of
sufficient magnitude and in the proper direction are applied to damage the
internal locking mechanism. In the accident airplane, four of the eight
leading edge slat actuators were found in -the fully retracted (uplock)
position. The other four were in a midstroke position without evidence of
damage to the internal locking mechanisms.

This finding led to the consideration of the possibility that the

leading edge slats were in the process of retracting when impact occurred.
However, as the trailing edge flaps are retracted from 50 to 00, the Nos. 1,
4, 5, and 8 leading edge slats and the leading edge flaps will retract to the
full up position before the Nos. 2, 3, 6, and 7 slats begin to retract. The
slat actuators that were found in the midstroke position (Nos. 1, 2, 3, and
8) are not consistent with the sequence of operation during flap retraction
or extension.

Three of the right wing's four leading edge slats were in the
locked position, and three of the left wing's four leading edge slats were in
the unlocked position.
 60

Since there is inconsistency between the four hydraulically

unlocked leading edge slats and the flaps up position of the trailing edge
flaps, the slats must have been hydraulically unlocked during the wing
separation. The leading edge flap and slat control valve is located in the
right wheel well. This control valve is connected to the outboard flap
follow-up drum by a control rod, and the valve and drum are mounted on
different structural portions of the fuselage. The airplane struck the
ground with sufficient force to separate both the forward fuselage and the
tail section aft of the wing. The control rod would only have had to move
momentarily 1.0 to 1.5 inches to port hydraulic fluid to all of the leading
edge devices. The fact that three of the right wing's four slats remained in
the locked position is logical since that wing'disintegrated at the same time
the control valve moved, and hydraulic continuity was lost, and there was no
pressure or flow to unlock the slats. The left wing remained attached to the
fuselage throughout the impact sequence,-and three of those slats were in the
unlocked position. The postimpact position of the leading edge slats
actuators is probably the result of the sequence of events during the impact;
i.e., a deflection of the mechanical linkage at the leading edge flap and
slat control valve while there still existed residual hydraulic pressure
sufficient to unlock some of the leading edge slat actuators.

Based on the physical evidence and its analysis of the position of

the trailing edge flap drive mechanism, the outboard aileron lockout
mechanism and the leading edge flap and slat actuators, the Safety Board
concludes that the cockpit flap control lever was in the Oo detent and that
the trailing edge flaps and leading edge flaps and slats were fully retracted
before impact. This conclusion suggests that, either the takeoff was
initiated with the flaps retracted, or that a flightcrew member repositioned
the cockpit flap control lever subsequent to the beginning of the takeoff
and at a sufficient time interval before impact to permit full hydraulic
retraction of the trailing edge flaps and leading edge slats. It takes
about 20 seconds, on the average, to retract the flaps and slats from an
initial setting of 15O. Thus, there was insufficient time, assuming the flap
control lever was moved by a crewmember between stickshaker and impact, for
the flaps to have retracted.

2.4 Detemi nation of Trai 1 i ng Edge Flap and Leading Edge Flap and Slat
Position Duri ng Takeoff
While the physical evidence from wreckage documentation was
conclusive that the wing was in a clean, i.e., flaps and slats retracted,
configuration at the time of impact, other evidence is used to analyze the
possibilities that the flaps were not set by the flightcrew during
pre-takeoff activities, or that the flaps were set and subsequently retracted
before impact. The evidence consisted of knowledge of the pre-takeoff
activities from the conversations and sounds recorded on the CVR, information
obtained from the flightcrew and witness interviews and testimony taken at
the Safety Board's public hearing, findings from the examination of the
airplane's takeoff warning system, air-conditioning system components, and
trailing edge flap bypass valves, and the study of the airplane's aerodynamic
performance based on the airspeeds, altitudes and normal accelerations which
were recorded on the FDR.
 61

Accomplishment o f C h e c k l i s t s .--According to Delta's procedure at

the time of the accident, the first officer was to set the wing flaps to the
takeoff position after departing the ramp area. The procedure did not
require that the first officer announce his actions of setting the flaps.
However, the CVR was examined for noises that might have been made during a
movement of the cockpit flap control lever from the Oo detent to the
150 detent. Three different sound sequences were identified as possible
movement of the flap control lever. However, in a spectrum analysis, only
one of these sound sequences bore some similarity to the sound sequences of
flap control lever movement which was recorded on another B-727 for
comparison purposes. That sound sequence occurred as the No. 3 engine was
being restarted after it was shut down because of 'an air traffic control
takeoff delay. Since that sound sequence did not positively correlate to
flap lever movement, and because the first officer stated that he did not set
the flaps as the No. 3 engine was restarted, the sound was attributed to
other routine cockpit activity. 'Thus, it is concluded that the action of
setting the wing flaps to the 15O detent could not be verified from the CVR
examination.

As a result of the takeoff delay and in accordance with Delta's

procedures; the flightcrew shut down the No. 3 engine and withheld the
accomplishment of part of the TAXI and the BEFORE TAKEOFF checklist items
until after the No. 3 engine was restarted. The flightcrew began to restart
the engine when they believed that they were No. 4 for takeoff. Within
15 seconds they received clearance from the tower controller to taxi onto
runway 18L and hold for takeoff. At this point, the CVR shows a distinct
difference in the crew's conduct in the accomplishment of the checklists.
Apparently, the second and first officer recognized the need for expeditious
completion of the remaining checklist to prevent delay on the runway. Thus,.
where the checklists previously had been accomplished in a orderly/measured
manner, the tone and behavior of the crewmembers clearly became rushed. The
second officer and first officer hurried to complete the challenge and
response checklist items as the airplane was being taxied from taxiway F to
the runway. Upon the second officer's prompt of "FLAPS", the first officer
responded "FIFTEEN, FIFTEEN, GREEN LIGHT." Presumably, the first officer's
response would be based on a visual check of the needle positions on the
inboard and outboard flap position indicators and illumination of the green
leading edge flaps and slats indicating light located on the center
instrument panel. There were no background sounds recorded on the CVR as the
first offjcer responded to suggest tha,t controls or switches were being
manipulated in response to the "FLAP" or 'FLIGHT CONTROLS' challenges.
Further, the time between the checklist challenges and responses was less
than one second, with little time to accomplish actions required to satisfy
the proper response.

At the Safety Board's public hearing, all three members of the

flightcrew testifed that, by habit, they would have verified the trailing
edge flap indicators and leading edge flap and slat light indicators during
the checklist completion; however, none specifically recalled having done so
on the accident flight. It is likely that the captain's attention was
diverted to the visual task of taxiing the airplane onto the runway and that
the second officer was attempting to complete the checklist hurriedly to
 62

prepare for the takeoff, and, consequently, neither the captain or second
officer looked specifically at the instrument panel to verify the first
officer's response. It is not possible to know whether the first officer
actually looked at the flap position indicators and light as he answered the
"FLAPS" challenge. Because of the repetitive nature of checklist
accomplishments, it is not uncommon for crewmembers to fall into a habit of
answering to challenges by rote with the normal response without actually
observing the appropriate indicator, light or switch. During the public
hearing the second officer mentioned an incident where a first officer
provided the correct response of Flaps 250 when, in fact, the flaps were set
at 150. This can be particularly true if the respondent has a mindset that
the action necessary to satisfy the indicator checklist has been completed.
Furthermore, on the B-727 flap position indicators, the Oo position is at
9 o'clock while the 150 position is directly opposite at 3 o'clock. Thus, in
both cases, the needles would be oriented horizontally. It is conceivable
that a person observing the indicators quickly could perceive that the left
and right needles on both the inboard flap and outboard flap indicators were
matched and horizontal without noting that this actual orientation was
opposite to normal. It is less conceivable that a person would miss an
indication of a significant split between the left and right needles on
either the inboard or outboard indicator, or that they would miss a
difference in the directional orientation of the needles on the two
collocated indicators. Finally, it is even more difficult to explain how a
person would respond "green" to a light that is colocated with the flap/slat
gages when that light is not illuminated. Therefore, the Safety Board
concludes that first officer responded to the flap challenge in the taxi
checklist without looking at the status of the light and indicators.

In any event, the first officer‘s proper response to the taxi

checklist regarding flap position cannot be considered as assurance that the
flaps were properly set before takeoff, and such a presumption is
contradicted by other substantial evidence.

Additionally, the passenger's statement that he noticed that the

trailing edge of the wing was not straight cannot be taken as assurance that
the flaps were extended. It is possible that what he noticed was the
deployment of the flight spoilers or inboard aileron as the captain tried to
regain control of the airplane. Glancing at the wing while the spoiler was
up, would have given the appearance of an "unstraight" trailing edge. In the
excitement of the moment he may have interpreted this appearance as the flaps
being extended.

T a k e o f f Warrrin'g S y s t e m .--The B-727 takeoff warning system is

.designed to provide an. aural alarm in the cockpit when the No. 3 engine
thrust lever is advanced past a predetermined position while the airplane is
on the ground, and the outboard trailing edge flaps are not extended. The
input ,for the ,trailing edge flap position is taken from a switch on the
outboard flap follow up mechanism. When the outboard flaps are retracted or
extended to a position less than 50, the ground circuit to the takeoff
warning system is completed and will cause the alarm horn to sound. The
input for the leading edge slats is taken from the .No. 4 slat on the left
wing and the No. 5 slat on the right wing. If either of these slats are not
 63

extended, the ground circuit will be completed and the. alarm horn will sound
when the No. 3 engine thrust lever is advanced.

If the takeoff warning horn had sounded as the captain of flight

1141 advanced the thrust levers for takeoff, the sounds would have been
clearly evident on the CVR. The lack of the alarm leads to two possible
conclusions: (1) that only the outboard trailing edge flaps and the leading
edge flaps and slats were properly set for the takeoff and subsequently were
retracted at or before liftoff; or (2) ~ the takeoff warning system
malfunctioned.

The device that arms the takeoff warning system consists of a

'switch and switch actuator mounted on the No. 3 engine autothrottle clutch
assembly. Advancement of the No. 3 engine thrust lever causes a cam in the
clutch assembly to engage the switch actuator which translates the rotary
cam motion into linear motion to operate the switch. The button on the
actuator depresses the plunger on the switch, closing a circuit and arming
the aural takeoff warning system. Until the system is armed by the thrust
lever switch, the electrical circuit between the takeoff warning system horn
and the flight control position switches remains open.

During the first two activations of the switch assembly by finger

manipulation during the on-scene phase of the investigation, there was no
electrical continuity indicated between the common and normally open
terminals of the switch. A third activation did indicate electrical
continuity. Based upon this inconsistency and the observation of a
blue-green corrosion-type substance surrounding the normally open terminals,
a follow-on teardown inspection of the switch assembly was conducted.

The first misactuation of the switch, i.e., the actuator button

slipping off the switch plunger, was observed during the early stages of
this teardown investigation. Because of this and subsequent switch
misactuations observed by the group, Boeing proceeded to conduct extensive
examinations of the switch assembly. Their reports concluded that it was
unlikely that any misactuation occurred prior to the group's examination of
the switch assembly due to a lack of multiple scoring marks on the switch
plunger. However, the reports also concluded that preexisting corrosion type
contamination could have adversely affected the electrical performance of the
switch.

The investigation noted that the Boeing service manual and Boeing
Service Bulletin 727-31-30 are not consistent regarding adjustment of the
switch. Revision 4 of the service bulletin, which was applicable at the time
of the accident, stated that the tab adjustment of the switch may be bent to
adjust for the correct switch operating point. There is no limit given for
the amount of bending adjustment possible. The maintenance manual, dated
January 20, 1985, states not to bend the actuator tab more than + 1/4o from
the plane of the actuator arm and that adjustments are to be madeby moving
the switch body in the slotted switch support mount.
 64

The investigation noted that it is possible to bend the adjustment

tab without visually checking that the actuator button and the switch
plunger are making contact over the majority of their surfaces. Thus it is
possible for maintenance personnel, who are not aware of the limitations
stated in the maintenance manual, to bend the tab to the point that the
button and plunger no longer make firm contact while attempting to adjust the
activation of the warning system. This would explain why the tab of the
switch from the accident airplane was found bent well past the limits given
in the maintenance manual.

Irrespective of Boeing Company conclusions, the findings that

(1) the switch did not electrically close during the first two attempts at
the accident site; (2) successful activations of the switch during the
teardown investigation was "hit-or-miss" due to the positioning of the
actuator button to the switch plunger; and (3) the internal contacts of the
switch showed contamination, will support a conclusion that the takeoff
warning system did not arm when the No. 3 engine thrust lever was advanced
for takeoff.

Such a conclusion is supported further by the Safety Board's

findings that 3 weeks prior to the accident, the aural warning horn had been
written up in the airplane's maintenance records in the "AZ" inspection as
being weak and intermittent. The corrective action taken by maintenance
personnel was to replace the aural warning horn and test the system. The
removed unit was taken to the repair shop where its contacts were cleaned and
functionally tested. The unit was found to function properly and was sent to
the spare parts inventory.

The Safety Board's investigation could not determine if, at the

time that the aural warning horn was replaced, all components of the takeoff
warning system were inspected to verify that indeed the warning horn was the
cause of the intermittent operation. Discussions with maintenance personnel
disclosed that the warning horn is readily accessible and easily replaced.
Therefore, it normally is the first component of the system to be removed and
replaced by a serviceable unit from the spare parts inventory. If the system
then functions properly, it is most likely that no further work or
troubleshooting would be accomplished. While such a procedure is expedient
it does not assure that an intermittent condition has, in fact, been
corrected because the other components of the system have not been checked.
Therefore, the possib lity exists that the aural warning horn was not the
cause of the problem and because other components in the system were not
tested after the unit was replaced, the real cause of the problem may well
have gone undetected.

Therefore, he evidence suggests that there was an intermittent

problem in the takeoff warning system that was not detected and corrected
during the last maintenance action. This problem could have manifested
itself during the takeoff of flight 1141; and thus the flightcrew was not
provided with the aural warning of misconfigured airplane which is the
function of the takeoff warning system.
 65

Air Conditioning Auto Pack Trip Systers.--The B-727 auto pack trip
system is designed to automatically shut down the air-conditioning system in
the event of an engine thrust loss during takeoff so that the thrust produced
from the remaining operating engines is not reduced by the extraction of
bleed air that is needed for air conditioning. The system is normally armed
when the bleed air pressure from each engine reaches 120 psi, the airplane is
on the ground, the auto pack trip arm switch is in the NORMAL position, and
the inboard trailing edge flaps are out of the Oo position.

The first indication of an abnormality during flight 1141 was the

second officer's observation that the green auto pack trip arming light
failed to illuminate when engine thrust was advanced for takeoff. The
second officer is required to verify that the auto pack trip arm switch is in
the NORMAL position during his completion of the BEFORE TAKEOFF checklists
and the switch was found to be in NORMAL when the cockpit was examined after
the accident. There was no history of any discrepancies of the auto pack
trip system or other evidence that would explain the failure of the system to
arm, provided the arming criteria were satisfied. The failure of the system
to arm can,be attributed to discontinuity in the arming circuit because the
inboard trailing edge flap up limit switch was found open.

The failure of the auto pack trip system to arm is corroborating

evidence that the inboard flaps were retracted when the takeoff roll was
initiated. It is controversial as to whether or not the second officer
should have notified the captain that the auto pack trip light failed to
illuminate during the takeoff ground roll. As the system was not required
for this takeoff, the second officer believed that he was not required to
inform the captain of the failure. However, Delta procedures require that.
the captain should be informed of all malfunctions. Since the accident,
Delta's procedures have been modified to eliminate this dichotomy.

F l a p B y p a s s V a l v e P o s i t i o n s . --The inboard and outboard trailing

edge flaps on the B-/Z/ are independent, both mechanically and hydraulically;
i.e., the inboard flaps and outboard flaps are driven by separate hydraulic
motors that are connected to independent hydraulic circuits. Although the
inboard and outboard flaps are independent, the left and right inboard flaps
are mechanically connected and the left and right outboard flaps are
mechanically connected by their respective torque tube drives so that,
precluding. a mechanical failure, the,left and right flaps will move
symmetrically. Further protection is provided against left to right flap
extension asymmetry which could occur because of a failure of the torque tube
drive mechanism for either the inboard or outboard flaps by an electrical
comparator which senses an angular difference between ,the left and right
pointers on the inboard or outboard flap position indicators. A separation
between the left and right pointers of 8 to 20 degrees will energize an
electrical circuit to drive a bypass valve in the appropriate hydraulic
subsystem (inboard or outboard) to a BYPASS position. This action will
remove hydraulic pressure from the flap drive motor, stopping further
movement of the affected flaps.
 66

Following the accident, the inboard flap bypass valve in the

airplane's left wheelwell was found in the BYPASS position, while the
outboard flap bypass valve in the right wheelwell was found in the NORMAL
position. If these valves had been in the "as found" positions before
takeoff, the outboard flaps would have extended to a position corresponding
to the cockpit flap control lever placement, but the inboard flaps would have
remained at the position in which they were when the bypass valve moved to
BYPASS. This finding led to speculation that the first officer may have set
the flaps to 150, but only the outboard flaps extended while the inboard
flaps remained retracted.

The known sequence of events during the accident provides a

rational understanding of these postimpact findings. The airplane's right
wing was severely damaged and separated from the airplane while the left wing
remained relatively undamaged and intact. The damage to the right wing
undoubtedly resulted in damage to the right inboard and outboard flap
follow-up mechanisms or a separation in electrical continuity during the
crash sequence which would have been sensed by the flap position indicator
comparator as left to right asymmetry. It is reasonable to conclude that the
electrical continuity to the left wheelwell remained for the 1 second
necessary to drive the motor-operated inboard flap bypass valve to the BYPASS
position, and that electrical circuits to the outboard bypass valve were
destroyed before that valve could be driven from the NORMAL position.
Therefore, the "as found" position of the flap bypass valves provide no
positive evidence upon which to assess the pre-takeoff flap setting.

W i t n e s s O b s e r v a t i o n .--The passenger who had been seated in 28C

stated at the public heanng that his attention was directed to the left wing
of the airplane just after rotation when he felt a sudden roll to the right.
From his seated position, he could observe the outboard trailing edge of the
left wing and he stated that the flaps appeared to be extended. Al though the
witness had some piloting experience in light airplanes and had general
knowledge regarding the location and function of the flaps, his testimony can
be given only limited credibility. For example, he was not able to correctly
identify the location of the flight spoilers. This may be significant since
the flight spoilers are immediately forward of the outboard flaps. Thus, the
break in the upper wing surface produced by spoiler deflection, as would be
expected as the pilot attempted to stabilize lateral oscillations, could
have been perceived as flap extension.

Perhaps of more significance, the witness stated that he did not

perceive up or down deflection of the outboard aileron. Since the airplane
was rolling due to lateral instability at the time that the witness was
observing the outboard wing trailing edge, it is reasonable to believe that
he would have observed aileron movement. That he didn't observe such
movement could support the conclusion that ailerons were locked out, a
condition which would have existed only if the outboard flaps were retracted.
 67

2.5 Ajrplane Performance Study

The failure of the takeoff warning system to provide an alarm, the

failure of the auto pack trip system to arm, and the perception of the
outboard flap position by the witness could be explained by an abnormal
takeoff wing flap configuration; the inboard trailing edge flaps retracted
and the outboard trailing edge flaps extended, i.e., "split flaps". Further,
the possibility that the first officer set the flaps to 150 and failed to
note the disparity between the inboard and outboard flap position
indications could not be ruled out based on evidence presented so far because
of the position of the inboard flap bypass valve as found after impact.
Therefore, the possibility that the takeoff was initiated with the airplane
in this "split flap" configuration and the flaps were retracted before
impact was examined thoroughly in the context of other evidence. The
comparison of the events and airspeed-altitude profile of flight 1141 witli
the known aerodynamic performance, stall characteristics, and handling
qualities of the B-727 airplane was the most compelling evidence to discount
the "split flap" takeoff theory.

As previously stated, the generation of a lift force by a wing

airfoil depends upon a smooth flow of air passing over the wing and the
amount of the lift force depends upon the speed of the air passing over the
wing and the angle at which the air impinges the wing's leading edge (AOA).
As the AOA is increased, the lift generated by the wing is increased until
the AOA reaches a point at which the airflow can no longer adhere to the
upper surface of the wing. The wing is said to be stalled when a further
increase in AOA and consequent airflow separation results in a sometimes
drastic reduction in the amount of lift produced. In this condition the air
behind the wing is turbulent and the airplane may experience severe
buffeting. Since the airflow separation can occur non-uniformly across the
wing's span and between the left and right wings, the airplane may roll
suddenly as it approaches the stall ADA. Furthermore, the turbulent air
behind the wing entering the inlets of rear fuselage mounted engines may
cause engine compressor surges.

The leading edge flaps and slats have an aerodynamic effect that
permits an airplane to fly at higher AOA before the smooth flow of air
begins to separate from the wing's upper surface. Thus, with the leading
edge devices extended, a wing can generate greater amounts of lift at AOA
beyond that at which stall would occur without the leading edge devices
extended, irrespective of the position of the trailing edge flaps. Trailing
edge flaps add to the amount of lift generated by a wing at a given airspeed
and AOA by increasing the camber of the wing. However, for the same leading
edge configuration, the increase in wing camber from the extension of the
trailing edge flaps will cause airflow separation and stall to occur at a
slightly lesser AOA than with the flaps retracted (less than lo).

Since the 8-727's leading edge flaps and slats are hydraulically
extended as a result of a mechanical interconnection with the outboard
trailing edge flaps, a failure of the inboard flaps to extend for any reason
would not have precluded the extension of the airplane's leading edge
devices. Therefore, the performance of a B-727 with the inboard trailing
 68

edge flaps retracted, the outboard trailing edge flaps extended to l5O, and
the leading edge flaps and slats extended was analyzed and compared with the
performance achieved by flight 1141. (See figure 13.) It is readily
apparent from the calculated aerodynamic effects of trailing edge flaps and
leading edge devices that the wing in the "split flap" configuration would
have generated less lift at a given airspeed and AOA than it would have with
all of the trailing edge flaps extended to 15o; but it is also apparent that
the AOA at which airflow separation would have occurred with "split flaps"
would have been about the same (or even slightly higher on the inboard wing
section) than it would have been in the normal 150 trailing edge flap
configuration. The theoretical aerodynamic data provided for the split flap
configuration by the Boeing Company indicate that the stall AOA is about 180;
the data obtained from the March 23, 1989, demonstration flight indicate that
an airplane under the conditions of flight 1141 maintains good flight
characteristics without airflow separation (as indicated by buffet or roll
instability) up to AOA greater than 150. However, unlike the takeoff warning
system, the stall warning stickshaker circuitry is predicated upon the
inboard flap position and an assumption that the leading edge devices are
also retracted when the inboard flaps are retracted. Thus, the stickshaker
stall warning will alarm at an AOA of ll” appropriate to stall for the clean
wing configuration. In the split flap configuration, the 110 AOA stickshaker
warning would have provided about 16 percent airspeed and 7o AOA margin to
stall. If the stickshaker warning was set at 140 AOA, the more typical
7 percent airspeed and 4o AOA margin to stall would have been available.

The performance analysis, based upon the lift versus AOA data for
the split flap configuration, indicates that had flight 1141 been so
configured during the takeoff roll, the airplane's tail may have contacted
the runway surface as the captain rotated to the takeoff attitude. However,
the airplane, with its geometry-limited loo pitch attitude would have lifted
off at about 150 KCAS instead of the actual liftoff speed of 158 KCAS. A
continued rotation at a rate greater than 1.5O per second would have resulted
in stickshaker activation; but there would have been considerable margin to
stall when the warning occurred and the airplane would have transitioned to a
climbing flightpath with a vertical acceleration in excess of 1.26. If the
captain had ignored the stickshaker warning and continued to exert sufficient
back force on the control column to raise the airplane's nose at a rate of
30 per second, the airplane would have achieved a 3o climbing flightpath at
an AOA of about 15O within 2 seconds after liftoff. There would have been
no airflow separation to explain the sudden roll of the airplane, and there
would have been no engine inlet air turbulence to explain the compressor
surges which were evident on the CVR. A more likely and proper flight crew
reaction to the stickshaker activation would have been to relax the back
force on the control column to silence the stickshaker, provided that that
response would not result in a loss of critical altitude. Under such
circumstances, the airplane would have continued to accelerate while
developing sufficient lift force to transition to a climbing flightpath.
These performance data indicate that about 10 seconds after liftoff, the
airplane would have been about 100 feet above the ground and climbing at
about 1,200 feet per minute. The stickshaker would have activated only
momentarily.
900.0
1 I 1 1 F I ape U p , R o d u c o d Powor

( 2 1 Flapa U p , Yaxlmum Powor appllod 3 moea aftor atfck l hakor

( 3 ) Flap@ U p ; Uaxlmum Powor, 1 0 dag AOA

750.0 + ( 4 1 Split Flapa, R o d u c o d Powor, 1 8 dog Pitch

I
( 5 1 Split F l a p s , R o d u c o d Powor, 1 0 d o g AOA

( 6 1 Flape 1 5 - R-due-d Powm. 1 8 don Pitch

600.0

12000.00 13000.00

Figure 13. --Takeoff profiles.

 70

The Safety Board concludes that the actual performance of flight

1141 is not explainable by the "split flap" theory. A possibility that one
flightcrew member reacted to the delayed liftoff and stickshaker onset by
intentionally or inadvertently retracting the flaps to Oo is also
implausible, since the 20 seconds required for the trailing edge flaps and
leading edge devices to retract with consequent effect on flight performance
would place the airplane far beyond the point at which the roll instability
and .engine compressor surges actually occurred. If the flaps retraction
sequence had started at rotation, the airplane would have had sufficient lift
to climb several hundred feet prior to the flaps reaching 00. Furthermore,
each of the flightcrew members positively stated that they did not reset the
flap control lever after the takeoff was initiated, and that they knew of no
situation in which they would have done so.

The airplane performance study indicated that all of the events as

they occurred on flight 1141 only can be explained by assuming that the
takeoff was initiated with the trailing edge flaps and leading edge devices
fully retracted. An analysis of the calculated lift versus AOA
characteristics for a B-727 with a clean wing showed that the airplane would
fail to lift off the runway when rotated to the loo geometry-limited
attitude until it reached a CAS between 158 and 159'knots, which correlates
precisely with the actual lift-off airspeed of flight 1141 as indicated on
the FDR. The airplane continued to accelerate thus achieving a slight
lift-versus-weight margin to climb. However, the data indicated that the
captain continued to exert back force on the control column as he attempted
to raise the airplane's nose to the normal climb attitude. The airplane's
vertical acceleration when the stickshaker activated at ll" AOA and 161 KCAS
is consistent with the theoretical performance of the airplane in the clean
wing configuration, with consideration for ground effect. The continued
increase in pitch attitude resulted in little change in climb performance,
typical of an airplane very near stall. The sudden roll to the right and the
cyclic vertical accelerations evident on the FDR are indications of airflow
separation on the outboard wing. Such roll instability is a known
characteristic of the B-727 with leading edge devices retracted and the
outboard ailerons locked out. According to statements by a Boeing test
pilot, the B-727 tends to retain roll stability and control during approach
to stall with the leading edge devices extended and the outboard ailerons
active. The roll, itself, and the control action (spoiler deflections) used
to correct the roll resulted in a further loss in lift and climb performance.
The engine compressor surges also are consistent with airflow separation on
the inboard wing section which produces turbulence at the side
fuselage-mounted engine inlets. It is probable, based on data from the
engine manufacturer, that the compressor surges did not significantly
degrade the thrust produced by the engines. The airplane performance
analysis shows that the minimal acceleration of the airplane from liftoff to
impact was the result of the high drag force produced at high AOA, rather
than a loss of thrust.

The airplane's performance during and subsequent to the takeoff

rotation, including the delayed liftoff, the roll instability, the engine
compressor surge and the flight profile ending at impact, strongly support a
conclusion that the trailing edge flaps and leading edge devices were fully
 71

retracted when flight 1141 began its takeoff roll. This conclusion is
further supported by the evidence that the inboard and outboard flaps were
retracted at the instant of impact, combined with statements by the
flightcrew that no one moved the flap lever during the flight. It. is
considered extremely unlikely that a flightcrew member would move the flap
lever during takeoff without verbalizing such intended action. No such
comments were recorded on the CVR nor were there any noises which could be
construed as recorded flap lever movement. Thus, it is concluded that.the
flap lever was not set to the 15 o detent during pre-takeoff activities, the
first officer, as well as the other crewmembers, did not note the actual
flap position when he responded to the checklist challenge, and the
airplane's takeoff warning systems did not provide a warning of improper
takeoff configuration.

2.6 Flightcrew Actions After Takeoff

Even though the analysis determined that the flightcrew did not
configure the airplane properly for takeoff, the accident may not have been
inevitable. Thus, the flightcrew's actions after takeoff were analyzed to
determine whether the accident could have been prevented or otherwise
minimized.

The sound of stickshaker was heard on the CVR tape at 0900:15.1 and
continued until impact. At 0900:34.7, the CVR tape indicated that the
captain states "full power.' This call was made 0.6 seconds prior to the
sound of the first impact. In his testimony at the public hearing, the
captain stated that he made the call "full power" after he had already
applied full power. Unfortunately, due to aerodynamic noise masking the
engine noises, it is not possible to determine if the engines were
accelerating prior to impact. However, it does not seem likely that a person
would make such a callout after accomplishing the action. It is more likely
that such a call would be made coincident with the application of power, or
would be a request for the first officer to advance the throttles. Given the
roll oscillations that were noted by witnesses, it would be expected that the
captain would have had both hands on the control yoke in trying to regain
control of the aircraft. During the public hearing, the second officer
testified that, after the aircraft rolled to the right, he observed that both
of the captain's hands were on the control yoke. Therefore, it is concluded
that the captain's call of "full power" was a command for the first officer
to advance the throttles, and that power had not been increased prior to
0900:34.7. Despite the captain's statement at the public hearing that he
applied maximum power before impact, there is no evidence that power was ever
actually increased above the reduced takeoff rating.

The captain testified that Delta's procedures when encountering

stickshaker after liftoff were to apply maximum available thrust, rotate
toward 15O of pitch, and to respect all stall warnings, i.e., stickshaker or
buffeting. Additionally, the captain testified that he followed Delta's
procedures after encountering stickshaker. The performance study found that
the airplane was rotated over 130 when it passed the ILS antenna and may have
exceeded 15O at various portions of the flight. In any event, the nose of
the airplane was not lowered to silence the stickshaker.
 72

The investigation found that Delta's procedures for encountering a

stickshaker or buffeting close to the ground are, in part, to apply maximum
power and to rotate toward 150 of noseup pitch attitude. Additionally, the
Delta procedure states that the pilot is to stop rotation if stickshaker or
buffeting is encountered. It is concluded that not applying maximum thrust
after the onset of stickshaker and not respecting stickshaker warnings were
the significant reasons for the captain's inability to gain control of the
airplane after liftoff.

The investigation found that the most appropriate reaction after

activation of the stickshaker was to apply maximum available thrust and to
lower the nose below stickshaker AOA. Although a clean wing is not an
authorized takeoff configuration for the B-727, the airplane performance
analysis showed that a marginal climb capability was available if stickshaker
AOA had not been exceeded and/or if maximum power had been applied within
3 seconds of initial stickshaker activation. Maximum throttle position
increases thrust approximately 25 percent from about 34,500 to 43,000 pounds
total thrust. Therefore, had maximum power been applied 3 seconds after
stickshaker, performance calculations predict that the airplane would have
gained 20 knots of airspeed and over 200 feet of altitude before reaching the
ILS antenna. If stickshaker AOA had not been exceeded, further altitude gain
could have been expected. Moreover, a check of configuration--the flap
control lever and flap indications-- immediately upon activation of the
stickshaker would have disclosed the reason for the airplane's performance
deficiency.. Had the first officer or second officer moved the flap control
immediately, the extension of the leading edge devices would have provided
sufficient stall margin to regain control.

2.7 Cockpit Management and Crew Di scipl i ne

The Safety Board sought to determine the relationship between crew

performance and the events in this accident. The investigation revealed that
Delta did not insist on a standardized approach towards cockpit management.
Testimony from management and training personnel indicated that captains were
allowed wide latitude in their conduct of cockpit operations. The CVR
indicated that the captain's approach towards cockpit management was passive
and that he allowed events to materialize rather than firmly control the
sequence of events.

The CVR transcript shows that the captain only occasionally entered
the conversation in the cockpit which was carried almost exclusively by the
first officer. The first officer acted as the social element in the cockpit,
initiating and sustaining informal discussions, commenting on political
events and past flying experiences and generally acting as the social focus
in the cockpit. The second officer, while occasionally drawn into the
conversation, appeared to be business-like and more professional. For
instance, in the absence of any requests for specific checklist, he seemed to
keep track of events and the airplane's progress and he initiated the
appropriate checklists on his own. He subtly prompted the flight attendant
to leave the cockpit when the airplane became number 4 for departure by
initiating the pre-departure cabin announcement on the PA system in which the
flight attendants are told to prepare the cabin for departure. This action
 73

by the second officer also may have been a not so subtle reminder for the
captain that the number 3 engine had yet to be restarted.

It can be argued that the second officer had as much a

responsibility as the captain and the first officer to verify the flap
position when the first officer responded to the flap challenge on the BEFORE
TAKEOFF checklist. However, when the runway lineup and takeoff clearances
were received in short order and earlier than expected, the second officer
became quite rushed in accomplishing the remainder of the TAXI checklist as
well as the entire BEFORE TAKEOFF checklist. He then had the responsibility
to accomplish a number of additional items before he could turn and slide his
seat forward in order to monitor the takeoff. Thus, it is readily evident
that the nonspecific and unspecified task of monitoring the captain's and
first officer's responsibilities could become a task to be carried out "as
time permits' for the second officer. The record is clear in this case that
insufficient time was available to the second officer to carry out this task.
Thus, the Safety Board believes that the second officer's actions were
appropriate and not causally related to the flap position, anomaly which
resulted in this accident.

The captain is responsible for the logical and timely completion of

cockpit duties by the crewmembers. Guidelines for the timing and logic of
cockpit duties are provided by procedures recomnended by the airplane
manufacturer and instituted by the carrier through the publication of these
procedures in its training manuals and its Pilot's Handbook or Operating
Manual. It is the captain's responsibility to maintain the necessary
discipline in the cockpit so that company procedures are carried out
properly. In other words, the captain sets the tone and working atmosphere
in the cockpit. If he does not do so, crew discipline in the cockpit can,
deteriorate rapidly. The evidence indicates that this was the case in this
accident.

The captain did not stop the first officer's interruptions of

cockpit duties when he initiated nonrelevant conversation or made comments
about his observations outside the cockpit while the airplane was being
pushed back, while the engine start checklist was run, when the airplane was
taxied from the push-back position and during the subsequent 25 minutes taxi
time before takeoff clearance was received. At the point where the first
officer would have lowered the flaps to the takeoff position, ramp control
gave flight 1141 instructions to give way to another airplane, and he became
engaged in a conversation. with the captain about the. position of that
airplane. When flight 1141 started moving again, the first officer had
another opportunity to continue his normal routine and lower the flaps;
however, the second officer initiated the taxi checklist at that point and
the first officer became involved in the required responses to the checklist
items. Immediately after the taxi checklist was completed, the first officer
began lengthy conversations with a flight attendant. Thus, his routine was
interrupted at key points and an entire segment of the first officer's habit
pattern was overtaken by subsequent routines. The Safety Board believes
that, had the captain exercised his responsibility and asked the flight
attendant to leave the cockpit or, as a minimum, stopped the nonpertinent
 74

conversations, the 25-minute taxi time could have been utilized more
constructively and the flap position discrepancy might have been discovered.

In any event, because the captain apparently relied on the other

crewmembers to accomplish cockpit activities, rather than monitoring and
setting the pace of these activities himself, the Safety Board believes that
the captain never perceived a need to visually or tactually check whether the
first officer lowered the flaps after he taxied the airplane from the ramp or
when the flaps were called just prior to takeoff. Instead, he relied on the
professionalism of the first officer for the proper execution of his duties
when the taxi checklist was being completed just before takeoff, and the
first officer responded positively to the flap challenge on the checklist.

The Safety Board believes that, had the captain taken a more
active role in running the cockpit, the accident may have ,been prevented.
The investigation found that the cockpit discipline problems noted on flight
1141 were not isolated to this cockpit. These problems were previously
observed and reported at Delta in FAA inspection reports. However, neither
FAA nor company management initiated sufficient corrective action. In its
Northwest Airlines DC-g-82 accident report, the Safety Board observed almost
identical cockpit management shortcomings. As a result of that accident, the
Safety Board observed that the FAA should require its operations inspectors
and designated check airmen to emphasize the importance of disciplined
application of operating procedures and rigorous adherence to prescribed
checklist procedures. (Safety Recommendations A-88-69 and A-88-71, which -
will be discussed later in this report). The Safety Board reiterates its
conviction of the need for rigorous FAA surveillance of training programs
that emphasize cockpit management procedures.

With respect to the issue of checklist discipline, there is no

evidence that the intent, presentation, and execution of checklists at Delta
were significantly different than at any other company in the industry.
Procedures were in place that provided for an orderly execution of all
required items; i.e., the captain was required to ask for the appropriate
checklist to be completed and the first and second officers were expected to
accomplish the items on the checklist or verify that they had been
accomplished. Because of the repetitive nature of checklist accomplishment
and the fact that the required response to checklist items is most often the
same, (i.e., flaps are usually set at 150 for takeoff; there always is a
green light associated with the slat setting), it is very easy for
crewmembers to fall into a habit of reciting checklist challenge and response
items by rote and providing a response to a challenge on the basis of what
should be the proper response rather than the actual condition of the system
that was queried. Examples of such mistakes were brought out at the public
hearing, when both the first and the second officers recounted instances of
responses to flap position challenges being given on the basis of
expectations rather than reality. The Safety Board believes that this
accident once again points out the paramount importance of cockpit discipline
in the accomplishment of checklists. Because there is no ideal way for
management to monitor individual performances of crewmembers in a cockpit,
standard operating procedures and checklists are developed as a means for
crewmembers to self-monitor their performance. This requires self-discipline
 75

on the part of all crewmembers and positiveeleadership on the part of the

captain. These concepts can be instilled in crewmembers through the
training process.

However, a greater involvement is necessary to make the safety

performance of an air carrier successful. That involvement must emanate from
an awareness by management that the effectiveness-of an air carrier's safety
posture begins at the top of an organization. This safety concept was
illustrated well in the previously referenced Boeing study on "Control of
Crew-Caused Accidents," in which it was shown that the difference in the
safety performance between air carriers appears to be the strong emphasis by
top management on safety issues and management's acknowledgement of its
accountability in that regard.

The connection between crew behavior, 'as evidenced in this

accident, and the management attitude at Delta Air Lines, as observed by FAA
as well as Safety Board personnel, was characterized well by Bruggink in his
paper on air carrier management accountability:4
An attitude of disrespect for the disciplined application of
checklist procedures does not develop overnight; it develops
after prolonged exposure to an attitude of indifference.

The same paper summarized:

Unless management first acknowledges its own role in the

development of operational settings that provide errors,
human error avoidance programs can not serve their intended
purpose in a practical and cost-effective manner.

There is evidence to show that Delta Air Lines' management had

initiated training and other policy changes after the series of mishaps that
were experienced in 1987. Some of these changes included the initiation of a
cockpit resource management (CRM) program. The Safety Board realizes that it
takes time to bring about fundamental and far reaching changes in an
organization as large as Delta Air Lines. Furthermore, Delta was in a period
of rapid growth and had recently merged with another airline with its
attendant problems of cultural differences, management integration and a host
of personnel problems, to name only a few. While the Safety Board views
these problems sympathetically, it believes that Delta Air Lines management
could have been more attentive to the obvious shortcomings in its safety
posture and more agressive in implementing changes in its training and crew
checking programs and the guidance provided its crewmembers. In light of
this discussion, the Safety Board finds that the slow implementation of
procedural modifications by Delta Air Lines were a contributing factor in
this accident.

4Bruggink, G.M. "Reflections on Air Carrier Safety" FSF Flight Safety

Digest, June 1988.
 lb

2.8 Delta Air Lines Operations and Training

In mid-1987, Delta flightcrews were involved in six incidents

resulting from pilot operational errors. The FAA's 1987 special inspection
of Delta, conducted as a result of these incidents, confirmed that Delta's
policy of delegating the maximum degree of responsibility and discretion to
its crewmembers was, in large part, responsible for--"observed instances of a
breakdown of communications, a lack of crew coordination, and lapses of
discipline in Delta's cockpits." In response to a finding by the FAA's 1987
special inspection team of a "...lack of organization, coordination,
standardization and discipline in the cockpit that can be attributed to
minimal guidance in the flight manuals and a lack of direction from those who
develop, supervise and manage flight training and standardization programs
. . . ", Delta's vice president of Flight Operations and chief pilot responded
that "many elements of our procedures are left to the discretion of the
captain." A similar response was noted by Safety Board investigators when
Delta management and training officials were interviewed subsequent to the
flight 1141 accident.

The lack of the cockpit coordination and discipline noted by FAA

inspectors in the inspection was evident in the cockpit of flight 1141. The
CVR transcript indicated that the captain did not initiate even one
checklist; the second officer called only one checklist complete; required
callouts were not made by the captain and second officer during the engine
start procedure; the captain did not give a takeoff briefing; the first
officer did not call out "VI"; the sterile cockpit policy was violated; and
all three crewmembers did not notice that the flaps were in the up position
prior to takeoff.

Another deficiency noted by the FAA special inspection teams were

inadequate manuals and procedures. In its 1987 special inspection final
report, the FAA team reconnnended that "Delta Air Lines study, develop, and
publish specific crew duties for each crewmember. These functions should be
placed in applicable manuals, and receive wide emphasis during the training
and checking phases." Examples of the absence of such guidance to
crewmembers in the cockpit of flight 1141 were: (1) the captain and second
officer not knowing each other's responsibility with respect to verifying the
flap indicator; and (2) the second officer's not announcing that the APT
system had not armed because he believed it was not required, yet the captain
and first officer expected that he would call it out. Subsequent to the
accident, when Safety Board investigators asked Delta pilots, instructors,
and management personnel "who would be responsible for verifying the flap
position?", a variety of answers were given. With this ambiguity among
management and training instructors, it is understandable that the flightcrew
did not know each other's responsibility with respect to flap position
verification. Consequently, the Safety Board believes that Delta did not
provide its flightcrews sufficient guidance regarding its operating
procedures.

The Safety Board noted also that Delta had been criticized by FAA
inspectors in 1985 and 1987 for providing "excessive training" to its
crewmembers in lieu of noting performance deficiencies during proficiency
 77

checks. In fact, the 1987 special inspection team report noted that "team
members observed numerous occasions on which check airman conducted excessive
training during check rides...." As a result, the FAA team admonished Delta
for documented cases of proficiency check airman failing to record
unsatisfactory performances by Delta pilots. The report stated, "In the
opinion of General Counsel this practice constitutes a lack of compliance
with FAR 121.401(c)...." The team recommended that Delta management and each
check airmen should be informed of the General Counsel's opinion and that all
unsatisfactory performance should be recorded.

Additionally, the 1987 special inspection team report noted that

Delta's check airmen were not upholding a high level of standards on
proficiency checks. The final report stated .that "the team observed that
orals are in general very brief, questions shallow, and the standard of
knowledge low." The inspection team reconended that "Delta's management
needs to give serious consideration to the implications of tolerating minimum
standards in training and on proficiency checks."

Concern over the continuing breakdown in cockpit discipline at

Delta Air Lines as exhibited by the crewmembers of flight 1141 caused the FAA
to follow up on its 1987 special investigation. A national inspection team
headed by the team leader of the 1987 inspection surveyed the airline in
October 1988. The stated purpose of the survey was "...to re-examine Delta's
operations in those areas defined in the 1987 audit. determine the corrective
actions 1 iken by Delta with regard to the findings and recommendations
contained in the Safety Audit Report, define any issues which tiave yet to be
resolved, and to estimate the future effectiveness of Delta's actions."

The inspection team in its November 10, 1988, report found that,
while def ciencies identified in the previous audit were observed, Delta Air
Lines management had instituted programs to improve both line operations and
the training program. Also, organizational changes were made which-created a
Flight Standards Department, centralized the management of the Line Check
Airman Program and realigned responsibility for the development of
operational procedures and manuals.

The Safety Board notes that in February 1989, Delta Air Lines
received FAA approval for its revised, operating and training procedures.
Included in these procedures are revised checklists which incorporate
"critical" items requiring status verification of systems critical to flight
by all crewmembers. The Safety Board acknowledges these improvements,
including the establishment of a Cockpit Resource Management (CRM) training
program.

The lack of CRM training and Line Oriented Flight Training (LOFT)
was evident in the circumstances surrounding this accident. It was obvious
that these crewmembers did not exercise the management, communications, and
interactive skills necessary for effective cockpit management. These
attributes are of increasing importance in the present day cockpit
environment with its sophisticated and often complex electronic flight
management systems. It has been shown that CRM training, combined with
realistic LOFT scenarios can be effective in alleviating the human
 78

performance problems that have continued to dominate the causal elements of a

majority of past accidents.

The Safety Board since 1968 has shade numerous safety

recommendations aimed at improving the manne? in which pilots are trained.
These recommendations were directed towards maximizing the utilization of
resources available to the pilots and the effective coordination of these
resources involving the entire cockpit crew. Thus, the Safety Board in these
recommendations focused on skills in communications, interpersonal relations,
and information processing as elements of CRM training. Delta at the time of
this accident was in the process of implementing a CRM training program; the
Safety Board is aware that this training program presently is a functional
entity within Delta's training department. However, the Safety Board is
disappointed that the FAA has not seen fit to mandate such training for the
entire air carrier industry, despite its demonstrated safety value.
As a result of the Safety Board's Safety Recommendation A-88-69,
regarding the need for CRM training, the FAA on February 22, 1989, published
Notice of Proposed Rulemaking (NPRM) 89-4.5 This NPRM proposes to "establish
a voluntary alternative method for meeting the training, evaluation,
certification and qualification requirements for flight crewmembers, flight
attendants, aircraft dispatchers, instructors, evaluators and other
operations personnel subject to the training requirements of 14 CFR 121 and
135". The Notice was published to coincide with a draft Advisory Circular
(AC-120-xx), which provides a means acceptable to the Administrator for
approval of an Advanced Qualification program (AQP), based on the above
mentioned NPRM. The AC proposes guidelines for operators who have advanced
flight simulators on how to set up a CRM program for its crewmembers.

In response to FAA's request for comments on this NPRM, the Safety

Board, in a letter dated June 27, 1989, expressed cautious optimism about the
apparent progress being made by the FAA towards the fulfillment of several
long-standing safety recommendations. However, it also believes that the
voluntary progress of air carrier operators towards CRM must be buttressed
by a standardized regulatory program. The Safety Board believes that various
aspects of the proposed AQP will require close attention by the FAA. One of
these is the need for a means to assure standard implementation of the AQP.
Also, the FAA must establish rigid criteria for approving extensions of the
time periods during which recurring training sessions must be held under the
AQP because the frequency of proficiency evaluations for flight crewmembers
is a direct function of the frequency of the recurring training sessions,
Since the proposed Special Federal Aviation Regulations (SFAR) contains no
guidelines or other criteria on which to base the granting of extensions, the
Safety Board believes that the FAA should eliminate the extension provisions
from the SFAR, pending the establishment of such guidelines and criteria.

‘Federal Register 54FR7670, February 22, 1989; Federal Aviation

Administration; Docket No. 25804, Notice No. 89-4; 14 CFR 61, 63, 65, 121,
135; Special Aviation Regulation No. XX; Advance Qualification Program.
 79

2.9 FM Surveillance

The investigation of this accident found that the FAA had

conducted four inspections of Delta since 1985. With the exception of the
1986 NASIP inspection, there were consistent observations of deficiencies in
Delta's training, checking, and line operations that were evident from 1985
to as recently as October 1988. These deficiencies included poor flightcrew
discipline and coordination, including improper use of checklists, and abuses
in Delta's training and checking programs.

The Safety Board gathered considerable testimony at the public

hearing concerning the oversight of Delta by the FAA. The relationship
between an air carrier and the FAA is unique and complex. Deregulation of
the industry in 1978, combined with the growth in air travel, has made the
FAA's job of overseeing the airlines more difficult than -it use to be.
Nevertheless, the FAA was aware of certain deficiencies in Delta's check
airman program as far back as 1985. Additionally, in 1987, the incidents
involving Delta flightcrews and the findings of the 1987 inspection team
should have indicated to Delta and the FAA that immediate corrective action
was necessary.

The results of the 1987 and 1988 special inspections of Delta

indicated that a potential for a mishap existed if remedial action was not
taken. Many of the observations made by the inspection teams were evident in
the cockpit of flight 1141--that is, poor discipline, poor crew
coordination, and a lack of knowledge concerning individual responsibility.
While the air carrier has the primary responsibility to operate in a safe
manner, the deficiencies noted by the FAA special inspection teams warranted
corrective action by Delta and agressive followup by the FAA. The FAA
personnel questioned on this point at the public hearing responded by
stating that the deficiencies noted by the special inspection teams at Delta
were "nonregulatory" in nature, and therefore beyond the principal
inspector's direct control. While this may be true from a technical
viewpoint, the purpose of the special inspection teams sent to Delta was to
look beyond minimum compliance and to identify operational areas that needed
improvement.

The Safety Board recognizes the difficulty that occurs when the FAA
is faced with a nonregulatory, or "gray area," such as the quality of crew
coordination and discipline, unless such behavior is observed to be unsafe.
In such a case, the air carrier must assume the responsibility for changing
its corporate philosophy if that philosophy is found to be counter-productive
to sound flightcrew behavior. However, it should be expected that the FAA
would have applied more leverage in implementing changes concerning
procedures or checklist usage. It is in this area that the Safety Board
believes that the FAA should have taken more agressive action. For instance,
the 1987 special inspection team recommended that "Delta Air Lines . . .
publish specific crew duties for each crewmember." At the public hearing,
the PO1 testified that implementing this type of nonregulatory procedural
change often depends on his "salesmanship" ability. However, the Safety
Board notes that the rationale for conducting the 1987 inspection was to
establish if the incidents that occurred in 1987 due to pilot performance
 80

were related to Delta's operational procedures. The results of the FAA

inspection did, in fact, establish that such a relationship existed.
However, neither the FAA nor Delta instituted the changes recommended by the
team prior to the accident involving flight 1141 or prior to the 1988 special
inspection. Therefore, the Safety Board concludes that the lack of
sufficiently aggressive action by the FAA to correct the known deficiencies
at Delta Air Lines is a contributory factor in the cause of this accident.

It is evident that the PO1 may not be the best individual to ensure
that recommendations are carried out after an inspection of an air carrier
that he is responsible for overseeing. In that regard, an inspection of an
air carrier is, in fact, an inspection of the ability of the PO1 to
accomplish his duties. Therefore, a "quality assurance" program must be
exercised by FAA headquarters to ensure that recommendations from inspection
teams are expeditiously carried out. The Safety Board believes that the FAA
should develop a formalized plan to address and rectify deficiencies in the
implementation of corrective action recommended by inspection teams.

The investigation sought to identify existing boundaries of

responsibility of the PO1 regarding the level of regulatory compliance and
the quality of operations demonstrated by the assigned air carrier. During
this investigation, evidence of accountability of the PO1 and the district
office for the performance of the assigned carrier(s) was not apparent.
Evidence suggests that FAA surveillance and inspection programs and the in-
house evaluation of PO1 performance have no relationship to each other. The
POI's performance seems to be related only to the quantity of work and the
ability to handle approvals smoothly and directly. The Safety Board is
concerned that the PO1 has the authority to approve critical areas of air
carrier operational programs without being held responsible for those
approvals. There does not appear to be a recurring qualitative assessment of
PO1 approvals by FAA management.

The FAA's followup of the 1986 NASIP inspection is also indicative

of a lack of PO1 accountability. The negative findings of an airline
operational inspection become the responsibility of the PO1 to promote and
monitor corrective action. Thus, the POI, in effect becomes the arbiter of
his own shortcomings, with no assessment being made by outside interests of
the quality of the corrective action. Therefore, the accountability for the
on-going quality of the POI’s work performance does not appear to exist.

It appears that the current surveillance system can lead to rubber

stamp approvals of an air carrier's operations and maintenance programs.
Improvements are needed to encourage and support the POI's efforts to secure
compliance and to promote upgraded levels of performance by the assigned air
carrier in both pilot training and crew coordination areas. Without such
improvements, the system of program approval can be driven by the momentum
and interests of the air carrier. It appears the present system is sustained
by the personal motivation and dedication of the concerned FAA inspector
personnel rather than by an FAA system that includes internal oversight of
itself and its inspection workforce. It is apparent that the need exists for
a program of FAA management emphasis on the accountability of its POIs. In
addition, there is a need for a program which standardizes the approvals of
 81

air carrier operations programs in order to promote a uniform and acceptable

level of safety performance in the current competitive air carrier industry.
Therefore, the Safety Board concludes that the absence of effective FAA
management control of its inspector workforce, the lack of accountability of
principal inspections, and the shortcomings in the NASIP program are
contributory factors in the cause of this accident.

2.10 Survival Factors

2.10.1 Aircraft Rescue and Fire Fighting r

Notification/Comnunicationq.--Theinitial notification of the DFW
emergency units was timely and efficient. It took DPS communications
personnel 21 minutes to complete notifications. This was. a considerable
improvement over the 45 minutes it took to complete the majority of
notifications during the response to the Delta flight 191 accident at DFW in
1985.6 This significant reduction in notification time is attributable, at
least in part, to improvements in distributing the communications workload
between the DPS communications center and the emergency operations center
(EOC). In addition, the installation and operational use of the Automated
Voice Notification System in the EOC significantly reduced the notification
times. These changes were instituted following the Delta flight 191 accident
in response to Safety Recommendation A-86-87.
Other communications improvements were most notable in the area of
field communications and coordination with area hospitals. The use of
cellular telephones in ambulances, in supervisory vehicles and in the new
command post vehicles, afforded significant benefits to DFW DPS supervisors
and hospitals in coordinating patient tracking and disposition.

The Safety Board believes that because of its benefits, operators

of other large airports should evaluate the potential benefits of using
Automated Voice Notification Systems for emergency/mutual aid notifications.
Medical Resnonse. --Forty-seven injured persons received triage at
the primary and secondary areas. The medical stabilization techniques used
on these persons by DFW and mutual-aid paramedics enabled ambulances to
deliver all surviving persons to area hospitals in stable condition less than
one hour after the accident. The experience and training of the responding
emergency medical services (EMS) personnel was of significant importance in
the success of the on-site triage and transportation of the injured.
Police ResDonse. --Due to the cross-training of'DFW DPS personnel,
police actions per se cannot be readily separated from fire and medical
actions since all DFW DPS personnel also participated in firefighting and
EMS roles, as required, throughout the rescue effort.. Once established,
security and traffic .control were excellent, although this was facilitated
somewhat by the fact that the aircraft came to rest just within the airport
operations area fenceline.

6NTSB/AAR-86/05, op.cit.
 82

One difficulty arose when some mutual aid personnel attempted to

gain entry through a nearby gate and found that it had been chained and
locked with a lock to which the DPS did not have a key. It was later
determined that the lock had been placed on the gate by someone other than
airport personnel. Some delay was experienced by mutual aid units while they
obtained a cutting tool in an attempt to gain access through this gate.
This delay had no negative effect on the success of the rescue activities,
since the majority of emergency vehicles and personnel were already in place
on the aircraft side of the fence. It should be noted, however, that under
different circumstances, such delays could have an adverse impact on rescue
efforts. DFW DPS has since provided bolt cutters for all emergency vehicles
in order to preclude any such recurrence. The Safety Board believes that
bolt cutters should be part of the standard equipment list for emergency
vehicles. Overall, the performance of the ARFF Teams indicated a well
trained and coordinated approach that enhanced significantly the potential
for saving lives.

2.10.2 L e f t A f t Galley D o o r

The left aft galley door was not opened during the emergency
evacuation of the airplane and 10 bodies were found in the area of that
galley. The physical evidence and passenger testimony during the Safety
Board's public hearing showed that attempts were made to open the door, but
none were successful. Several possibilities were examined to explain why it
would not open.

During the investigation, when the first attempt to open the door
was made, soft drink cans from the left aft galley were found at the bottom
of the door. It was considered that the cans might have been dislodged
during impact, but before the airplane came to rest, they rolled down the now
inclined galley floor, and lodged against and jammed the bottom of the door.

However, there is some question as to whether the cans were on the

floor prior to the airplane coming to rest, or were knocked out of the rack
during firefighting operations. Considering the extent of the burn injuries
sustained by the fatalities, it is reasonable to suspect that at least some
of the cans would have bulged or burst since they were in the same area--
however, none were so effected. Most notable, the aluminum drawer in which
the cans were stowed was found intact in the area of the airplane which had
sustained the most severe fire damage, but the drawer had sustained no
thermal damage. Therefore, it must have been deposited there after the fire
had been extinguished.

Also, since the girt bar was found in the stowed position, it is
believed that upon discovering that the door would not open, the flight
attendant who attempted to open the door was the one who stowed the girt bar.
(It is assumed that at least the initial attempt to open the door was made by
a flight attendant, however, the bodies of the flight attendants were not
found nearest the door.) This would be in accordance with Delta's flight
attendant training procedures which address difficulty opening a,door
following a gear-up (belly) landing. Stowing of the girt bar would not have
 83

been possible if the soft drink cans had been laying on the girt. It is
concluded therefore, that the soft drink cans were properly stowed at the
time of impact and did not prevent the door from opening.

During the examination of the wreckage, it was most difficult for

two male investigators outside the airplane to move the mass of the door
simultaneously inward, and upward, due to the 300 left roll attitude of the
fuselage. With the assistance of an additional male investigator on the
inside, several more attempts were made to open the door. Not until the
fourth or fifth attempt did they finally succeed in opening the door. Even
then, the door could not be opened until the investigator inside the airplane
'was able to lift the ZOO-pound door assembly (160 pound door plus 48 pound
slide) and move it over a restriction. These attempts spanned a time of
between 5 and 10 minutes of intermittent effort with discussions of the
problem taking place between attempts. It should be noted that these
attempts were being made under nonstress conditions apd by investigators
familiar with the operation of the door.

When the door was opened, shiny, therefore fresh, burrs were seen
on the door's lower aft stop fitting. This burring would not occur if the
door were properly aligned in its frame. It was also noted that the door
fitting had rubbed the stop fitting at the point of the burr when the door
was opened and closed. Also, the door's upper hinge was sprung and the sheet
metal just under the hinge was torn to just forward of the hinge. According
to the record of the layover check performed on August 30, 1988, the day
before the accident, no difficulties were noted with the operation of the
door.

When the airplane slid along the ground during the accident
sequence, it did not experience very high G loading, except for localized
loading. This is borne out by the FDR information, passenger interviews,
and a general, but not complete, lack of injuries indicative of high G
forces. The airplane did, however, sustain impact damage as it slid along
the hard uneven ground. While sliding, the underside of the airplane
deformed as a result of repeated impacts. While there was no single
significant G spike, the repeated impacts compounded the damage, increasing
the deformation as the airplane slid. This deformation absorbed energy and
would account, to some degree, for the general lack of vertical G forces felt
in the cabin. The deformation in the area of the left aft galley door
finally progressed to the point that the frame distorted, to an unknown
degree, and caused the misalignment between the door and its frame.

After the door was opened, an attempt was made to close it. The
operating hardware of both the door and frame was cleaned for the attempt.
It could be closed but would not lock; the operating handle would only come
to within about 150 of the fully locked position, and the door remained
slightly ajar. One person, with maximum effort, was then able to open the
door from inside the airplane.
 84

In view of the aforementioned tests and examinations, it is

therefore concluded that the left aft service door could not be opened due to
deformation of the door frame which resulted from the airplane's repeated
impacts with the ground.

The position of the bodies in the rear cabin and in the galley area
indicated that there was a queue of persons waiting to use the exit, and more
likely they also crowded at the exit. During this time smoke was entering
the galley. This, of course, reduced visibility and induced respiratory
distress, and when combined with the steep angle of the floor, probably
caused those persons at the galley to fall against the door. Given the sense
of urgency, if not outright panic, which surely existed as conditions
worsened, combined with the angle of the floor and the worsening smoke and
toxic fumes, it is likely that passengers were pushing against the flight
attendant who would have been trying to open the door, totally negating
attempts to open the already jammed door.

2.10.3 A f t Airstair E x i t

Although the flight attendants were trained to use the aft airstair
as a secondary emergency exit if the normal exits were unusable, they were
also trained that the airstairs may not be usable following a gear-up
landing.

In this accident, the aft airstair exit was not usable because the
airplane was resting on its fuselage and the airstairs could not be lowered.
Also, the pressure bulkhead door to the tailcone was jammed closed due to
impact damage (for the same reasons as stated for the left aft galley door).
When Delta personnel attempted to recover the FDR and CVR from the tail
section of the airplane, the operating handle of the bulkhead door would not
move, consequently the door would not move. They requested assistance from
DPS personnel who ultimately had to use pry bars to open the door.

Since any attempt to open the solidly jamned door would have left
no evidence, it could not be determined if an attempt was made to use the aft
airstair exit. I

2.11 Fire Propagation

Examination of the physical evidence indicated that the external
fire was initiated when the right wing and tail struck the localizer antenna
array. The fire intensified when the airplane struck the lip of the
depression in the terrain. The right wing was destroyed and the fuel tanks
lost all structural integrity. Flames not only impinged on the right side of
the fuselage, but extended around the fuselage, heating the inboard wing area
on the left side. As the fuselage slid, the aft cargo door opened and was
pushed in. The forward door of the aft cargo compartment opened outward, and
was torn off at its hinges. The hinges ripped the fuselage open causing a
large opening in that area.
 Evidence showed that the fire entered the aft cargo compartment
before the airplane came to rest. After the airplane stopped, the fire
burned through the cargo compartment liners and cabin floor. The fire also
entered the cabin through the aft break in the fuselage, the opened
right-hand overwing exit, and later through a burn through in the center wing
box area. The fire entering the fuselage through the aft break trapped
passengers in the aft end of the cabin. The fire burning through the floor
probably caused the fatalities in that area. The autopsy reports showed the
cause of death to all fatalities as smoke inhalation.
The forward cabin remained survivable for about 4 minutes and
20 seconds, despite the large fuel fire at the ruptured area. Some of this
survival time can be attributed to the use of fire blocking materials on the
seat cushions. There was evidence of the fire blocking slowing the spread
of fire into the cabin. Many seat cushions -remained-intact or showed signs
that the blocker inhibited burning. With a large fuel fire entering the
cabin, fire blocking will not stop the spread of fire, but will slow it down
giving added time for escape. The Safety Board's investigation found that
the airport's aircraft rescue and fire fighting equipment was in place and
applying extinguishing agents to the airplane about 4 minutes and 20 seconds
after the accident and the last passengers to leave the airplane reported
being hit by foam as they exited. The predicted survival time, based upon
FAA tests without the fire blocking layers in place, would have been about
Z-minutes and 50 seconds. While there is some margin for error in both
times, it should be noted that the divergence of the graphs representing fire
test points, hence the benefit in survival time, is greater with the passage
of time.' (See figure 14.) It is therefore concluded that a number of
lives were saved because the seat cushions were covered with fire blocking
material.
Due to a number of variables such as size of the openings in the
fuselage, wind, and intensity of the fire, an exact number of persons who
were saved because of the fire blocking material cannot be determined. Any
attempt to determine an exact number is very sensitive to assumptions. Of
primary importance is an assumption of a linear evacuation rate. In this
case, the evacuation rate varied greatly. At the aft break in the fuselage,
nearest the fire, the evacuation progressed rapidly and it was not used by a
large number of persons (three persons through the side of the break, eight
through the overhead section of the break). Therefore, the evacuation there
was completed while it was still in progress at the other exits. The last
exit that was used during the evacuation was the forward break in the
fuselage. This exit was furthest from the fire, was used by the largest
number of persons, and, due to obstructions, had the slowest evacuation rate.
Another assumption which must be made in order to calculate a
number of additional survivors, using available test data, is that the
fuselage maintained its integrity, trapping smoke and superheated gases. In
this accident, both ends of the fuselage were open at the top and around most

‘DOT/FAA/CT-83/43, Aircraft Seat Fire Blocking Layers: Effectiveness

and Benefits Under Various Scenarios.
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 87

of the circumference, allowing smoke and gases to vent. The opened fuselage
may have acted as a chimney, drawing cool clean air into the cabin, to some
degree, replacing the venting air. Therefore, a determination of how many
lives were saved by the fire blocking layer was not attempted.

2.12 Refueling Procedures

Though not causal to the accident, the Safety. Board is concerned

about the procedures used in refueling flight 1141. The investigation found
that the No. 1 main fuel tank quantity indicator was inoperative and that the
airplane was dripsticked and level checked in order to determine the amount
of fuel to add to each tank. The airplane was not dripsticked after
refueling. After the airplane was fueled, it would have been prudent to have
had the fuel tanks dripsticked once again and the level of the airplane
verified. The Safety Board is concerned that with an inoperative fuel gauge
it is possible that the airplane could have been incorrectly fueled, i.e.,
too much or too little fuel in the No. 1 fuel tank. Such a situation could
cause the airplane to be laterally unbalanced or not have sufficient fuel for
the flight. Therefore, it is recommended that the FAA require that whenever
an airplane operating under 14 CFR Parts 121 or scheduled 135 is allowed to
fly with an inoperative fuel quantity gauge, that dipstick, dripstick, or
other appropriate measurements of fuel quantity are taken, and that the
level of the airplane is taken into consideration.

2.13 Airline Safety Programs

As part of the Safety Board's investigation of this accident, it

examined the issue of airline flight safety programs. This issue was
explored primarily during testimany at the Safety Board's public hearing.
The purpose of this effort was to elicit industry views about the purpose of,
the need for, and the conceptual framework for an airline flight safety
program. No attempt was made to compare Delta Airlines' program with other
airlines or with any other standard. Further, no correlation was drawn
between the events that led up to the accident involving flight 1141 and the
viability of Delta's safety program. In general, the Safety Board's
objective was to raise an awareness about the issue of,airline flight safety
program as a starting point for possible improvements in the future.

In general, airline safety programs are broken down into three

distinct areas: flight safety, ground (industrial) safety, and maintenance
quality assurance. Ground safety essentially is governed by Occupational
Safety and Health Administration (OSHA) regulations. There are no Federal
Aviation Regulations (FAR) governing ground safety. Similarly, there are no
FAR's governing airline flight safety programs. However, there are specific
regulations that deal wi,th airplane maintenance programs, specifically the
inspection and quality assurance function of maintenance. '

Part 121 of the Federal Aviation Regulations (FAR) contain

requirements for airline management personnel. Included in the required
management personnel is a qualified Chief Inspector. The FAR's also specify
the basic qualifications of the required management personnel, including the
Chief Inspector. Part 121 of the FAR's also contain requirements related to
 88

the inspection and quality assurance functions as compared to the maintenance

functions at an airplane. Specifically, airlines must establish that the
person(s) performing maintenance are not the same person(s) performing
inspection of completed work, and these persons cannot be reporting to the
same supervisor. In fact, the regulations require that each airline
establish a continuing analysis and surveillance system to evaluate the
performance of its inspection and maintenance programs. These regulatory
requirements provide a redundancy or "second set of eyes" within the airline
maintenance departments. Further, these requirements establish specific
criteria against which the FAA can assess the quality of an airline's
maintenance department.

The Safety Board believes that a similar redundancy should be

required for airline flight operations departments by means of an independent
flight safety department. Of course, the flight operations personnel are
charged with the safety of flight operations by meeting the regulations and
establishing a training, checking, and operations program. However, without
an independent flight safety department the redundancy is not provided.

At the Safety Board's public hearing, testimony on the subject of

airline flight safety departments was obtained from the Director of Flight
Safety for United Airlines, the Director of Operational Safety for Canadian
Airlines International, and the Director of Aviation Safety Programs for
Transport Canada within the Ministry of Transport of Canada. All three
individuals emphasized the need for an independent flight safety department.
The term "safety net" was used to stress the need for redundancy in
preventing flightcrew errors that lead to accidents. They also emphasized
the need for the flight safety officer to report directly to the Chief
Operating Officer, or equivalent level, to provide the audit for oversight
functions.

The testimony revealed that the Safety Advisory Comnittee (SAFAC)

of the International Air Transport Association (IATA) had recommended to the
Technical Committee of IATA that it adopt a resolution regarding airline
flight safety departments. The SAFAC Committee is made up of professional
safety officers of the world's airlines. The Technical Committee is made of
Senior Vice President of Operations personnel from the world's airlines. The
IATA Technical Committee is the senior body in IATA that addresses
operational safety concerns on behalf of the membership of over 160 airlines.
In 1988, the Technical Committee adopted a resolution recommending that all
member airlines should establish a safety department managed by a
professional safety manager. The resolution also recommended that the
safety department should accomplish certain key flight safety functions.

The 21 key flight safety functions recommended by the IATA

resolutions are grouped into four major categories. They are: accident
prevention programs; collection, analysis, and dissemination of safety
information; technical (maintenance) and training department liaison; and
emergency response procedures. It is important to note that three of the
major categories, which account for 17 of the 21 key functions are
"proactive" accident prevention functions, as compared to the "reactive"
accident and incident investigation emergency response functions. All three
 89

of the aviation flight safety professionals who testified at the Safety

Board's public hearing emphasized the need for an independent proactive
flight safety program at airlines.

The Director of Aviation Safety Programs for Transport Canada

testified that his agency strongly urges airlines in Canada to adopt the
independent safety officer program. In fact, Transport Canada sponsors a
program which includes training for airline CEO's to demonstrate to them the
need and cost benefit for such programs. Further, Transport Canada provides
training seminars for airline safet.y officers. No such programs exist within
the FAA.

An accident or other unsafe incident is really a symptom of a

failure somewhere in the system. It is traditionally reported from airline
accident statistics that about 80% of airline accidents result from
flightcrew errors. For this season alone, it seems appropriate that the
flight operations department needs an audit or redundant organizational
function responsible for flight safety. It is easily recognized that the
person(s) responsible for flight safety within the flight operations
department, such as the Chief, Pilot, the Director of Training, and the
Director of Flight Operations, may not be able to recognize or admit personal
or organizational shortcomings for his/her own programs. There is a real
possibility that objectivity may suffer. However, an independent safety
officer, who reports to the top manager of the airline would be in an
excellent position to provide objective views of possible safety problems
within the flight operation departments.

The Safety Board believes that the FAA should initiate a joint
airline industry program to develop guidelines and regulatory provisions for
airline flight safety programs. It seems logical that the same rationale
that requires the separation of maintenance and inspection departments, and
the quality assurance ("second set of eyes') function in airline maintenance
should be applied to flight operations. Similarly, the provisions for
,specific management positions and qualifications of those managers contained
in the extant regulations should be developed for flight safety. That is,
the regulations should specify the need for a qualified safety officer and
flight safety program at airlines, and separation of management oversight of
these two important functions. Further guidance by means of an FAA advisory
Circular, which outlines the structure, ,functions, and responsibilities of
such a program should be developed. The guidance and regulatory provisions
would then provide a means by which the FAA could evaluate an airline's
safety performance other than by accidents and incidents.

2.14 Previous Safety Board Recomnendations

As a result of the Safety Board's investigation of an accident
involving Aloha Air Lines flight 243 near Maui, Hawaii on April 28, 1988, the
following safety recommendations were issued to the FAA on July 21, 1989:

Evaluate the quality of FAA surveillance provided by the

Principal Inspectors as part of the National Aviation Safety
Inspection Program (NASIP).(A-89-64)
 90

Integrate the National Aviation Safety Program (NASIP) team

leader in the closeout of the team findings. (A-89-65)

The Safety Board is awaiting a reply from the FAA regarding these
recommendations.

As a result of the Safety Board's investigation of the Northwest

Airlines, Inc,. flight 255 which crashed shortly after takeoff from Detroit
Metropolitan Wayne County Airport on August 6, 1987, the Safety Board sent
the following recommendations to the FAA:

Require that all 121 and 135 operators and principal

~ operations inspectors emphasize the importance of disciplined
application of standard operating procedures and, in
particular, emphasize rigorous adherence to prescribed
checklist procedures. (A-88-67)

Convene a human performance research group of personnel from

the National Aeronautics and Space Administration, industry,
and pilot groups to determine if there is any type of method
of presenting a checklist which produces better performance on
part of user personnel. (~-88-68)

Expedite the issuance of guidance material for use by Part 121

and 135 operators in the implementation of team-oriented
flightcrew training techniques, such as cockpit resources
management, line oriented flight training, or other
techniques which emphasize crew coordination and management
principles. (A-88-69)

The FAA stated in its letter of September 22, 1988, that it was
planning to take positive action regarding these recommendations. The Safety
- Board found the actions proposed by the FAA to be responsive to the intent of
the recommendations, and, therefore, classified these three recommendations
as "Open-Acceptable Action" pending review of the final action taken by the
FAA. c

Additionally, as a result of the Northwest flight 255 accident, the

Safety Board sent the following recommendation to all Part 121 air carriers:

Review initial and recurrent flightcrew training programs to

ensure that they include simulator or aircraft training
exercises which involve cockpit resource management and active
coordination of all crewmember trainees and which will permit
evaluation of crew performance and adherence to those crew
coordination procedures. (A-88-71)

The Safety Board has received responses from a majority of Part 121
air carriers. These responses have indicated that most air carriers either
currently have, or are developing, cockpit resource management programs.
Delta provided the Safety Board with a copy of its crew resource management
program. This program complied with the intent of the recommendation.
 91

Therefore, the recommendation, in terms of Delta, was classified'as "Closed--

Acceptable Action."

During the investigation of the Delta flight 191 accident at DFW

airport on August 2, 1985, the Safety Board noted problems in communications
and coordination with off-airport medical units during the implementation of
the Dallas/Fort Worth Airport emergency plan. The Safety Board issued the
following recommendations to the DFW Airport Board:

Revise its disaster response notification procedures' to

provide for timely and effective notification of mutual-aid
agencies whose assistance is needed. (A-86-87)

Revise its procedures for coordinating with area hospitals

during mass casualty disasters to provide the hospitals with
timely information regarding estimated numbers of victims,
injury categories, destinations, and arrival times. (A-86-88) '

Conduct full-scale demonstrations of the Dallas/Fort Worth

Airport Emergency Plan and Procedures every,2 years. (A-86-89)

In reply to Safety Recommendations A-86-87 and -88, the DFW Airport

Board informed the Safety Board that a Watson Automated Voice notification
system was installed at the airport and that cellular telephones have been
installed in ambulances and,the command post vehicles. Safety
Recommendations A-86-87 and -88 have been classified as "Closed--Acceptable
Action."

DFW Airport was in the process of planning a disaster drill when

the accident involving flight 1141 occurred. The Safety Board has
classified recommendation A-86-89 as "Closed--Acceptable Alternate Action."

As a result of the Safety Board's 1984 special study of airport

certification and operations, the following recommendation was issued to the
Federal Aviation Administration:

Amend CFR 139.55 to require a full-scale demonstration of

certificated airport emergency plans and procedures at least
once every 2 years, and to require annual validation of
notification arrangements and coordination agreements with
participating parties. (~-84-34)

On January 1, 1988, 14 CFR 139, as revised, became effective and

139.325(g) (5) requires that the certificate holder: "Hold a full-scale
airport emergency plan exercise at least once every 3 years." The Safety
Board finds that this modification to CFR 139 complies with the intent of the
recommendation. Therefore, Safety Recommendation A-84-34 is now classified
as "Closed--Acceptable Action."

As a result of the Safety Board's investigation of an accident *

involving Pan American flight 759 at Kenner, Louisiana, on July 9, 1982, the
following safety recommendation was issued to the FAA on July 13, 1982:
 92
At an early date and pending the effective date of the
recommended amendment of 14 CFR 121.343 to require
installation of Digital Flight Data Recorder systems capable
of recording more extensive parameters, require that operators
of all aircraft equipped with foil flight data recorders be
required to replace the foil recorder with a compatible
digital recorder. (A-82-65)

As of April 1989, the FAA has required that all Part 121 aircraft
be equipped with Digital Flight Data Recorders. This recommendation has
been classified as "Closed--Acceptable Action."

3. CONCLUSIONS
3.1 Findhgs
1. The flightcrew was properly certificated and qualified for
the flight.

2. The airplane was certificated, equipped, and maintained in

accordance with Federal regulations and approved procedures.

3. The flightcrew deviated from Delta's policies and procedures

with respect to checklist execution, cockpit discipline, and
required callouts.

4. Extensive non-duty related conversations and the lengthy

presence of the flight attendant in the cockpit reduced the
flightcrew's vigilance in ensuring that the aircraft was
properly prepared for flight.

5. Weather was not a factor in the accident.

6. Wake vortices from the previously departing Boeing 727 were

not causal to the accident.

7. There was no preimpact failure of any engine; the compressor

surges encountered after the onset of stickshaker did not
substantially reduce the amount of available thrust.

8. The flightcrew did not extend the airplane's flaps or 'slats

for takeoff.

9. The takeoff warning system had an intermittent failure problem

which was not corrected during the last maintenance activity
and which manifested itself during the takeoff of flight 1141.

10. Failure of the takeoff warning system to activate was most

likely due to contamination or misalignment of the takeoff
warning system throttle switch.
 93

11. Failure of the auto pack trip light to illuminate as the

throttles were advanced should have been reported as a
malfunction to the captain by the second officer.

12. The captain's action of continuing to increase AOA after the

onset of stickshaker and his failure to apply maximum power in
accordance with Delta's procedures reduced the climb and
acceleration performance of the airplane.

13. Delta Air Lines' corporate philosophy of permitting maximum

captain discretion contributed to the poor discipline and
performance of flight 1141's flightcrew.

14. The FAA was aware of the flightcrew performance deficiencies

in Delta's operations, as well as irregularities in Delta's
training and checking programs.

15. Neither Delta nor the FAA took sufficient corrective actions
to eliminate known flightcrew performance deficiencies.

16. The initial notification of the Dallas-Fort Worth

International Airport (DFW) emergency units was timely and
efficient. The response by Department of Public Safety (DPS)
aircraft rescue and fire fighting personal was well
coordinated and enhanced significantly the potential for
saving lives.

17. The left aft service door could not be opened due to
deformation of the door frame which resulted from the
airplane's repeated impacts with the ground.

18. A flight attendant, while attempting to open the left aft

service door, stowed the girt bar on the door as per Delta's
flight attendant training procedures which address the
difficulty in opening a door following a gear-up landing.

19. It would have been unlikely for any one person of average
strength to open the left aft service door under the
circumstances existing. at the time of the attempted
evacuation.

20. A number of lives were saved by the use of the fire blocking
layer on the passenger seats. An exact number of additional
survivors could not be determined.

21. The corrective actions taken by the Dallas-Fort Worth Airport

Board in response to Safety Recommendations A-86-87 and -88
following the Delta flight 191 accident in 1985 greatly
improved the communications and coordination of the aircraft
rescue and fire fighting personnel and medical teams in this
accident.
 94

3.2 Probable Cause

The National Transportation Safety Board determines that the
probable cause of this accident to be (1) the Captain and First Officer's
inadequate cockpit discipline which resulted in the flightcrew's attempt to
takeoff without the wing flaps and slats properly configured; and (2) the
failure of the takeoff configuration warning system to alert the crew that
the airplane was not properly configured for the takeoff.

Contributing to the accident was Delta's slow implementation of

necessary modifications to its operating procedures, manuals, checklists,
training, and crew checking programs which were necessitated by significant
changes in the airline following rapid growth and merger.

Also contributing to the accident was the lack of sufficiently

aggressive action by the FAA to have known deficiencies corrected by Delta
and the lack of sufficient accountability within the FAA's air carrier
inspection process.

4 . RECOmENDATIONS

As a result of its investigation of this accident, the'Nationa1

Transportation Safety Board made the following safety recommendations:

--to the Federal Aviation Administration:

Require that principal operations inspectors review the

operations manuals of their assigned carriers and ensure that
the manuals clearly state the roles of each flight crewmember
in visually confirming the accomplishment of all operating
checklist items, especially those checklist items considered
"critical" to flight. (Class II, Priority Action) (A-89-121)

Direct all principal operations inspectors to review the

training and operations manuals of their assigned, air
carriers and ensure that the verification of flap position
during stall recognition and recovery procedures is a part of
those procedures. (Class II, Priority Action) (A-89-122)
/
/ Modify National Aviation Safety Inspection Program inspection
I procedures to ensure that following safety inspections of Part
i 121 air carriers, deficiencies are corrected expeditiously and
i that the leader of the inspection team is made part of the
evaluation of the proposed actions. (Class II, Priority
Action) (A-89-123)

Require 14 CFR Part 121 operators to develop and use Cockpit

Resource Management programs in their training methodology by
a specified date. (Class II, Priority Action) (A-89-124)
 95

Perform a directed engineering study of the takeoff warning

system(s) in the Boeing 727 model airplanes, with special
emphasis on the takeoff warning system throttle switch
installation. The study should evaluate the reliability,
maintainability, and methods to improve the design of the
system. (Class II, Priority Action) (A-89-125)

Issue an Airworthiness Directive :to require modification of

the takeoff warning system in the Boeing 727 model airplanes
based upon the results of the directed engineering study.
(Class II, Priority Action) (A-89-126)
Modify the Boeing 727 checklists to require flightcrews to
check the operation of the takeoff warning system prior to
each flight. (Class II, Priority Action) (A-89-127)

Modify Air Carrier Operations Bulletin (ACOB) distribution

procedures to expedite the approval and transmission of ACOB's.
to the principal inspectors and airline officials. (Class II,
Priority Action) (A-89-128)

Direct principal operations inspectors to inspect their air

carriers operating under 14 CFR Parts 121 or scheduled 135 as
to procedures for refueling with an inoperative fuel quantity
gauge and require, as necessary, that these air carriers
modify their refueling procedures to require dipsticking,
dripsticking, or have other appropriate measurements of fuel
quantity taken, with consideration given to the level of the
airplane. (Class II, Priority Action) (A-89-129)
Initiate a joint airline industry force to develop a directed
approach to the structure, functions, and responsibilities of
airline flight safety programs with the view toward advisory
and regulatory provisions for such programs at all Part 121
airlines. (Class II, Priority Action) (A-89-130)

--to the American Association of Airport Executives and the Airport

Operations Council International:
Inform your membership of the aircraft rescue and fire
fighting efforts in this accident and of the benefits of using
automated voice notification systems for emergency
response/mutual aid notifications. (Class II, Priority
Action) (A-89-131)
Recommend that member airports equip all of'their emergency
vehicles with bolt cutters. (Class II, Priority Action)
(A-89- 132)
 96

--to the National Fire Protection Association:

Inform the members of the Technical Committee on Aircraft

Rescue and Fire Fighting (ARFF) of the ARFF efforts in this
accident and of the benefits of using automated voice
notification systems for emergency response/mutual aid
notifications. (Class II, Priority Action) (A-89-133)

Recommend to the Technical Committee on Aircraft Rescue and

Fire Fighting (ARFF) that the appropriate manual be modified
to include bolt cutters as recommended equipment for ARFF
vehicles. (Class II, Priority Action) (A-89-134)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

IS/ Jams L . K o l s t a d
kting Chairman

/S/ Jim B u r n e t t
mber

/S/ John K. Lauber

member

/S/ Joseph T. Nall

He*er

IS/ Lemofne V. Dickinson, Jr.

Hen&v

Jim Burnett, Member, filed the following concurring/dissenting

statement:

I concur with the facts and findings of this accident report;

however, I dissent from the probable cause statement. I believe that the
Federal Aviation Administration (FAA) and Delta Air Lines, Inc. (Delta) were
direct causes of the accident.

The accident report documents factually that the FAA and Delta
were aware, a year before the accident, of serious deficiencies in Delta‘s
flight operations and training programs. Despite this knowledge, both failed
to correct the deficiencies until after the. accident occurred. For example,
one of the report's findings, which was adopted by all five Board Members,
concludes that "neither the FAA nor Delta took sufficient corrective action
to eliminate known flightcrew performance deficiencies.” Many of these same
deficiencies were evident in the behavior and performance of the accident
flightcrew. As the memorandum to the Board from the Chief of the Aviation
Accident Division pointed out, "this particular crew was operating
essentially in accordance with the same procedures and cockpit discipline
concepts that the FAA had chastised earlier and that Delta was defending as
adequate." I believe that had the FAA and Delta addressed and corrected
these known deficiencies in an aggressive, effective and timely manner, the
 97

accident would have been prevented. Their failure to do so, in my view,

links them directly to the probable cause of the accident.

Following an unprecedented number of flightcrew-related operational

incidents during June 1987, the FAA's Acting Administrator announced a
national special emphasis surveillance of Delta. The Acting Administrator
stated in a press release dated July 15, 1987, that "each incident apparently
involved human error and this is a matter of great concern to us"...; and
that the FAA will initiate immediate, action to correct any deficiencies
uncovered during the course of the inspection. The ten-member national
inspection team assembled in Atlanta, Georgia on July 24, 1987, and spent six
weeks conducting an indepth inspection of Delta's flight operations and
training programs.

The report of the national inspection team dated September 4, 1987,

contained over 40 findings of serious deficiencies in Delta's flight
operations and traitiing programs.. In my view, several of the findings
constitute noncompliance with specific Federal Aviation Regulations; however,
no enforcement actions were taken as a result of the violations. The report
listed some 55 recommendations for corrective actions. FAA and Delta senior
management staff were briefed on the results of the inspection.

In a written response to the national inspection team's report

dated November 12, 1987, Delta stated that "many of the conclusions drawn
were incorrect." In many instances Delta defended the observed crew
behavior as company approved procedure. On several findings that Delta
agreed with, Delta's response letter did not include a description ,of how
they intended to deal with the problem. As a result of Deltars disagreement
and FAA's apparent indifference, many of the recommendations remained in
abeyance and no corrective action was implemented.

A year after the national inspection was completed, Delta was

involved in the fatal accident at Dallas. It was apparent that meaningful
changes had not been made following the national inspection, because many of
the deficiencies that had been observed a year previously were evident in the
accident crew's performance. These deficiencies included a lack of cockpit
discipline and flightcrew coordination, improper checklist use, and an
absence of overall flightcrew professionalism. These deficiencies were
causal to the accident and, as a result, the aircraft was not configured
properly for takeoff.

Subsequent to the accident, FAA conducted a follow-up survey of

Delta's flight operations and training programs to determine the adequacy of
corrective actions taken as a result of the national inspection team‘s
recommendations. The team‘s report dated November 10, 1988, stated that
while many improvements had been made, numerous deficiencies identified
during the national inspection a year previously had not been corrected. The
survey found that "fundamental changes to checklists and procedures are still
pending."
 98

The Acting Manager of the Georgia Flight Standards District Office

informed the NTSB in a memorandum dated August 8, 1988, that "a major
revision of Delta Air Lines aircraft crew checklists for all Delta aircraft
began after the flight 1141 accident." The FAA suggested additional changes
to this revision in a memorandum to Delta dated December 13, 1988. Delta's
new B-727 pilot's checklist and revised pilot's operating manual received
final FAA approval and became effective on February 20, 1989. The new
checklist included changes to designate critical items that require dual
crewmember response, to identify items that require challenge and response,
and to establish specific crewmember responsibilities for each checklist
item. Flaps are required to be checked and verified twice: first, on the
taxi checklist by the first officer; and second, on the before takeoff'
checklist by the captain and first officer. The revised pilot's operating
manual contains new sections emphasizing cockpit checklist philosophy and
crew duties. Many of these changes incorporate actions recommended by the
national inspection team. Following introduction of these changes, every
Delta crewmember received a line check to assure his familiarization with and
use of the new checklists and operating procedures.

In summary, I believe that Delta senior management and FAA were

causal to the accident because they failed to assure that the known serious
deficiencies in Delta's flight operations and training programs were
addressed and corrected in an effective and prompt manner. Both were
sufficiently knowledgeable concerning the problems, had the opportunity and
responsibility to correct them, but failed to do so. And yet, in hindsight
after the accident occurred, comprehensive changes were made in six months.
I believe that had this same level of commitment and change been made after
the national inspection of Delta, the accident would have been prevented.

At the time of announcing its 1987 special emphasis surveillance of

Delta, the FAA, in an apparent move to reassure the flying public, promised
immediate action to correct any deficiencies uncovered. One year and one
accident later is not immediate. The public deserves protection, not mere
reassurance.

I support our staff's proposal to include the corporate actions and

policy of Delta.Air Lines as being directly causal, and join with the
proposals by the Chief of Aviation Accident Division and the Chief of the
Operational Factors Division to include the FAA's failure to take immediate
corrective action as being directly causal. I cannot support the language in
the Board-adopted probable cause which suggests that Delta, one of the major
players in the airline industry and the aviation economy, was somehow
victimized by the circumstances of its economic environment. I see no
support in the record for such a position.

Therefore, I would favor a probable cause statement which would

read as follows:

The National Transportation Safety Board determines that the

probable cause of this accident to be (1) the Captain and
first officer's inadequate cockpit discipline which resulted
in the flightcrew's attempt to takeoff without the wing flaps
 99

and slats properly configured; and (2) the failure of the

takeoff configuration warning system to alert the crew that
the airplane was not properly configured for the takeoff.
Also causal to the accident was the failure of Delta Air
Lines' management to provide leadership and guidance to its
flightcrews through its training and check airmen programs to
promote and foster optimum cockpit management procedures, and
the failure of the Federal Aviation Administration to correct
known deficiencies in the training and check airmen programs
of Delta Air Lines.

/s/ J i m B u r n e t t
Ukder

September 26, 1989

 103

Second Officer Steven Mark Judd

Second Officer Steven M. Judd, 30, was hired by Delta Air Lines on
November 20, 1987. He holds ATP certificate 520723890, with airplane
multiengine land rating and commerical pilot privileges in airplane single
engine land. He additionally holds flight engineer certificate 520723890
with a turbojet powered rating. He was issued an FAA first class medical
certificate with no restrictions on October 27, 1987. Since more than
6 months had elapsed since the issuance of his medical certificate, the
certificate had been downgraded to a second class medical certificate.

The second officer qualified as a Boeing 727 second officer on

January 20, 1988. At the time of the accident, he had flown 3,000 hours, 600
of which were in the Boeing 727. During the last 90 days, 60 days, and
30 days before the accident, he had flown 128 hours, 22 minutes; 61 hours,
56 minutes; and 1 hour, 7 minutes, respectively.

The second officer's off-duty time before reporting for duty on the
day of the accident and his on-duty and flight hours on the -day of the
accident were the same as those listed for the captain and the first officer.
 104

APPENDIX C

COCKPIT VOICE RECORDER TRANSCRIPT

TRANSCRIPT OF A FAIRCHILD A-100A COCEPIT'VOICE RECORDER,

S/N 51362, REMOVED FROM DELTA AIR LINES B727 WHICH WAS INVOLVED
IN AN ACCIDENT AT DALLAS-FT. WORTH INTERNATIONAL AIRPORT ON
AUGUST 31, 1988

LEGEND
CAM Cockpit area microphone or sound source
RDO Radio transmission from accident aircraft
PA Public address system
-1 Voice identified as Captain
-2 Voice identified as First Officer
-3 Voice identified as Flight Engineer
-4 Voice of flight attendant in cockpit
-? Voice unidentified
xxx Miscellaneous aircraft
APP Approach Control
CTR Center
GPWS Ground Proximity Warning System
UNK Unknown
* Unintelligible word
# Nonpertinent word
% Break in continuity
( 1 Questionable text
(( 1) Editorial insertion
w-w Pause
Note: All times are expressed in certral daylight time.
 101

5. APPENDIXES

APPENDIX A

INVESTIGATION AND PUBLIC HEARING

1. Investigation
The Safety Board was notified of the accident about lo:30 a.m.
eastern daylight time, August 31, 1988. A team of investigators was
dispatched from Washington, D.C., and arrived on the scene that afternoon.
Investigative groups were formed of operations, air traffic control,
witnesses, meteorology, survival factors, structures, powerplants, systems,
flight data recorder, maintenance records, cockpit voice recorder, airplane
performance, and human performance.

The parties to the investigation were the Federal Aviation

Administration, Delta Air Lines, the Boeing Commercial Airplane Company, the
Air Line Pilots Association, Pratt & Whitney Division of United Technologies
Corporation, the Dallas/Fort Worth International Airport, and the Midland,,
Texas Fire Department.

2. Public Hearing

A 4-day public hearing was held in Irving, Texas, beginning

November 29, 1988. Parties represented at the hearing were the Federal
Aviation Administration, Delta Air Lines, the Boeing Commercial Airplane
Company, the Air Line Pilots Association, Pratt & Whitney Division of United
Technologies Corporation, and the Dallas/Fort Worth International Airport.

.
 102

APPENDIX B
PERSONNEL INFORHATION

Captain Larry Lon Davis

Captain Larry L. Davis, 48, was hired by Delta Air Lines on

October 18, 1965. The captain holds airline transport pilot (ATP)
certificate No. 1518525 with B-.727, DC-g, and airplane multiengine land
ratings and commerical privileges in airplane single engine land and sea. He
was issued a first class medical certificate on June 7, 1988, with a
limitation to have corrective lenses in his possession for near vision when
exercising the privilege of his certificate.

On July 27-28, 1988, the captain completed recurrent training on

the Boeing 727. On July 29, 1988 and August 9, 1988, he received a
proficiency check and an en route check, respectively. He had flown
approximately 17,000 hours, 7,000 of which were in the Boeing 727. During
the qast 90 days; 60 days, and 30 days before the accident, he had flown
119 hours, 27 minutes; 99 hours, 56 minutes; and 61 hours, 56 minutes,
respectively.

The captain had been off duty 27 hours 27 minutes before reporting
for duty on the day of the accident. At the time of the accident, he had
been on duty 2 hours 35 minutes, of which 1 hour and 13 minutes was flight
time.

First Officer Carey Wilson Kirkland

First Officer Cary W. Kirkland, 37, was hired by Delta Air Lines
on January 26, 1979. He holds ATP certificate 1904535, with airplane
multiengine land rating and commerical privileges in airplane single engine
land. He was issued an FAA first class medical certificate with no'
restrictions on January 18, 1988. Since more than 6 months had elapsed since
the issuance of his medical certificate, the certificate had been downgraded
to a second class medical certificate. Pursuant to applicable regulations,
he was qualified to exercise his commerical privileges and was qualified to
serve as first officer on the flight.

He qualified as a Boeing 727 first officer on December 9, 1987.

His last proficiency check was completed on November 20, 1987, and his last
en route check was on December 6, 1987. At the time of the accident, he had
flown 6,500 hours, 4,000 of which were in the Boeing 727. During the last
90 days, 60 days and 30 days before the accident, the first officer had
flown 160 hours, 23 minutes; 123 hours, 57 minutes; and 60 hours, 43 minutes,
respectively.

The first officer's off-duty time before reporting for duty on the
day of the accident and his on-duty and flight hours on the day of the
accident were the same as those listed for Captain Davis.
 -l-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME b

SOURCE CONTENT SOURCE CONTENT

0828: 38
((start of recording))

0828: 43
CAM-3 I sure hate goin' with one inop
I'd appreciate gettin' it fixed

0828:47
CAM-1 it's kinda' of a weak point on the
seven twenty seven fuel gages *
0828:51
CAM-2 yeah
0829 : 00
CAM-6 thank you
0829: 01
CAM-3 thanks very much

0829:02
CAM-6 did we get the sign off

CM-3 *

0829:05
CAN- 1 yeah yeah signed and delivered
0829: 12
PA-6 ((cabin departure anouncement by
gate agent))
0829:22
CAM-6 see you later
 -2-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

0829:30
RDO-2 ramp Delta eleven forty one ready to
push fifteen

0829:32
RAMP eleven forty one off of fifteen let's
go tail straight back and call se
your taxi instructions

0829: 37
RDD-2 okay
0829: 45
CAM-2 did you get anything *-

0829: 46
INT -7 oh you can release brakes and give
them a call

0829: 49
INT -1 brakes off tail straight back

0829:50
INT -7 roger

0829: 55
CAM-2 did you get anything

0829: 58
CAM-2 for tomorrow

083O:OO
CAM-2 put in a white slip
 -3-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME &
EC: CONTENT SOURCE CONTENT

083O:Ol
CAM-1 I got a thing I got to look it up
and see if I want I
want to look at the rotation and
see what it is

CAM-1 I may put in one when I get back

0830:09
CAM-? if you can

0830: 13
CAM-1 - I forgot to get my pay check did
you get yours

CAM-P yeah I got mine

0830: 17
CAMA- there been so much happen ***

0830: 26
CAM ((sound of trim in motion horn))

0830: 29
CAM-2 we generally require a fresh Infusion
along about the end of the month and
in the middle
0830: 33
CAM-2 in,order to keep everybody happy
0830: 37
INT -7 alright engines are cleared to start
0830:41
INT -1 okay
 -4-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME ?i

SOURCE CONTENT SOURCE CONTENT

0830:43
CAM-3 beacon

0830:44
CAM-2 it's on

0830:46
CAM-3 parking brake

CAM-2 it's off

0830:47
CAM-3 forty psi

0830:49
CAM-2 guys like 8 you know can put twenty
six thousand down on a house you know
and not even bat an eye
0830:55
CAM-3 ((sound of laugh)) lifes savings
0831:Ol
CAM- 1 well he has been dillgent in his savings
0831:04
W-2 that's right

0831:06
W-2 he diligently dumped it there
0831:07
CAN ((sound of engine igniter starts))

CAM-3 I was a homebody in the Navy

 -5-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME 41 TIME I
SOURCE CONTENT SOURCE CONTENT

0831: 13
CAM-2 batchin' it batchin' it makes it
did you live in the "4"

0831:17
CAM-3 I lived in the "Qa rat as a ensign
but I lived in a - start valve
closed - forty psi
0831: 19
CAN ((sound of engine igniter stopped))
0831:20
CAM-3 start valve open
0831:24
CAM-1 It’s interesting you know they're pushin'
this guy back and that tug driver
can't begin to see em - *

CAM-2 *

CAM-1 - gettin' out

0831:37
CAM ((sound of engine igniter starts))
0831:39
CAM-3 oil pressure's up 5

0831:48 8
Y
CAM ((sound of ingition stopped)) x
c)
0831:49
CAM-3 start valve's closed forty psi
 -6-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

0831:SO
CAM-2 you want all of 'em

CAM-1 yeah
0831:Sl
INT -7 alright brakes set you guys have
a great trip

0831:54
CAM-3 start valve open “P

0831:57
INT -1 brakes are set you have a good day thank you

0832:OO
CAM-3 oil pressure rising
0832:08
CAN ((sound of engine Igniter starts))
0832:17
((sound of engine igniter stopped))
0832:19

CAM-3 start valve closed forty psi

0832:,24
CAN ((sound of three generators coming
on the line))
0832:29
CAM-3 engine instruments

CAM-2 checked normal

 -7-

INTRA-COCKPIT AIR-GROUNDCOMNUNICATIONS

THE & TIME &

SOURCE CONTENT SOURCE CONTENT

0832:32
CAM-3 engine anti-ice

0832:33
CAM-2 closed

0832:46
CAM-2 yeah it look's like they're homin'
in on that thing over there - puttin'
the jetways in today

0832:SO
CAM-3 alright
0832:54
PA ((sound of flight attendents cabin briefing starting))

CAM-3 look's like they'll be ready

'before long
0832:58
RDO-2 ramp Delta eleven forty one's ready to taxi

0833:03
RAMP eleven forty one give me a'right turn bring
it between south ramp and thirty hold short
of inner
0833:lO
RDO-2 eleven forty one roger
0833:17
CAM (( sound of two clicks))
0833:24
CAM (( sound of click))
0833:33
CAM ((sound of trim in motion))
 -8-

INTRA-COCKPIT AIR-GROUNDCOMMUNICATIONS

TIME & TIME &'

SOURCE CONTENT SOURCE CONTENT

0834:Sl
PA ((cabin briefing stops))

0835:OO
(( Recording interruption sound))

0835:31
CAM- 1 how about lookin' down here at
Delta's now and then
CAM ((sound of laugh))

CAM-? yeah *
0835:43
CAM-3 while we're still young

0835:48
CAM-3 how about lookin' down here
while we still have teeth in
our mouths

0835:35
CAM-1 what's that

0835:52
CAM-3 hw about lookin' down our way
while we still have teeth in
our mouths
0835~55
CAM ((sound of laugh))
0835:57
CAM-2 yz;ui;agray at the south ramp

CAM-? *
 -9-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME 81 TIME &

SOURCE CONTENT SOURCE CONTENT

0836:09
CAM- 1 I guess we oughta shut down number
three save a few thousand dollars

0836:13
CAM-P I'll 1'11 call and ask ground if we
can if we just like to shut down over
here

0836:24
CAM-2 ask him if he can give us give us ,a
two minute warning to start our engines

0836:36
CAM-3 okay

0836:SO
((sound of scraping noise on tape))

0837:20
GND Delta at thirty make a left turn say
your number

0837:24
RDO-2 that's ah eleven forty one

0837:26
GND Delta eleven forty one okay give way to
company to your left the seven two join
the inner for standard taxi one eight left
%
RDO-2 ah seven thirty one roger H
u
0837:38 E
CAM-l we're gunna wait for him
e,
o&37:40
CAM-2 yeah
 -lO-
INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT
0837:53
CAM-l where is he

0837:57
CAY-2 he's right there

CAM-1 *

0838:21
CAM-2 just now comin' out

0838:22
CAM- 1 we certainly taxiied out before he did
0838:26
CAM-1 did he say standard to one eight

0838:53
CAM-3 take off data has been computed
for one eight left

CAM-2 okay
0838:57
CAM-3 auto pack trip light is not required
- pitot heat

0838: 59
CAM-2 it's on
0839 : 00
CAM-3 airspeed and epr bugs
0839:Ol
CAM-2 thirty one and forty five on both sides
and alternate epr set
0839:OS
CAM-3 airspeed warning switches
 INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME &
SOURCE CONTENT

0839: 06
CAM-2 three A's

0839 : 08
CAM-3 altimeter and flight Instruments
0839 : 09
CAM-2 set cross checked

0839: 11
CAM-3 stab trim
083g:12
CAM-2 ah five point six

0839:36
CAM-4 a lotta people goin' out this morning
0839: 40
CAM-3 yeah big push

((7 minutes and 42 seconds of nonpertinent conversation between the flight crew and a flight attendent))
0847 : 28
CAM- 1 don't we have to change to ground here
0847 : 30
CAM-2 yeah I'm sorry I'm sittin' here talking to
the flight attendent
 -12-
-
INTRA-COCKPIT AIR-GROUND COMMUNICATIONS E
c)
TIME & TIME &
SOURCE CONTENT SOURCE CONTENT

0847:41
RDD-2 ground Delta eleven forty one's with ya on top of
the thirtyone bridge

0847:45
GND eleven forty one come south on the inner until
taxiway twenty one then move to the outer hold
short of nineteen

0847:53
CAM-2 I said thirtyone I meant eighteen
0847:56
GND say this again for a second so I can hear his
answer Delta eleven forty one come south on the
inner till taxiway twenty one then move to the
outer
0847:59
CAM-l I think he knows

0848:02
RDO-2 eleven forty one roger
0848: 09
CAM-2 transition at twentyone hold short
of nineteen
0848:12
CAM- 1 okay
 -13-

INTRA-COCKPIT AIR-GROUNDCOMMUNICATIONS

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

((1 minute and 18 seconds of non-pertinent conversation between the flight crew and a flight attendent))

085O:Ol
CAM-4 are we gunna get takeoff or are we just
gunna roll around the airport
0850:04
CAM-2 well we we thought we were gunna have to
retire sittin' there waitin' for taxi
clearance
0850:21
CAM-4 my gosh we've got a long taxi to do
0850:24
CAM-1 yeah we are gettin' down here where we let
all the Americans get off first
0850:34
CAM-1 once they're all gone we can go
((1 minute ati 22 seconds of non-pertinent conversation between the flight crew and a flight attendent))

0853:12
CAM-P what kinda birds are those
0853:16
CAM-1 Egrets or what ever they call 'em
0853:18
CAM-4 yeah Egrets -
 -I4-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME Ih TIME &

SOURCE CONTENT SOURCE CONTENT

CAM-2 are they

CAM-4 I think so
0853:21
CAM-4 Are they a cousin to the ones by the sea

0853:25
CAN- 1 I don't know they whenever I mow grass
out in my pasture they come in and it
stirs up the grasshoppers and everything -

0853:34
CAM-3 boy they just flock here

0853:36
CAM-2 I've seen them all over the place out around
here

CAN- 1 grasshoppers *

CAM-4 real *

0853:41
CAM-1 they ah in fact they sit on the back of our
horse now and then you see one out there
just sittin' on the back of the horse
 -15-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

0853:45
CAM-4 oh is that right

0853:46
CAM-2 I've seen them sittin' on the back of a lot
of cows

CAM-1 yeah

0853:50
CAM-4 are they the ones that pick the bugs off
of them and stuff

0853:53
CAM-1 I guess and they hang around them because
while they're grazing you know they stir up
the insects and they can get 'em easier

0853:58
CAM-4 uh huh

0854:00x
CAM-4 they're pretty birds

0854:07
CAN-2 they got one more American and I think we'll
be able to go here - start clearin' some of
this -
 -16-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME 81

SOURCE CONTENT SOURCE CONTENT

0854:18
CAM-I It’s interesting how they sit around the
airport like this without being afraid

%25 didn't we taxi

0854:26
CAM-2 I’m surprised they're not complainin'
about the noise

0854:28
CAM-4 all the way around

0854:30
CAM-4 we go to the other side

6854:33
CAM-I all the way around down here over back up
here

0855:lO
CAM-3 boy this Is somethin'-

CAM-3 if this is how it is on a severe clear

vfr day --

*
E5i'5 can you imagine-(laugh)
 -17-

INTRA-COCKPIT AIR-GROUNDCOMMJNICATIONS

TIME Ih TIME &

SOURCE CONTENT SOURCE CONTENT

CAM-4 imagine --

0855:16
CAM-2 imagine what it would be like if we had I

weather today
0855:20
CAM-2 I tell you what Dallas Fort Worth Center
is ah hundred percent better than it was
three years ago -

0855:25
CAM-4 is it really
0855:26
CAM-2 with its with regard to weather gettin' in
and gettin' out and all
0855:33
CAM-2 if it clouded up and even looked like there
was going to be weather it I useta think
it backed up you'd be holdin' slowin'
down doin' all kinds of stuff
0855:41
CAM-? wh
0855:59
CAM-1 did you see that bird
 -lS-

INTRA-COCKPIT AIR-GROUNDCOmUNICATIONS

TIME & TIME b

SOURCE CONTENT SOURCE CONTENT

CAM-4 Yes
0856:02
CAM-I he got the jet blast
0856: 03
CAM-4 yeah he did he got it
0856: 04
CAM-2 ah what a crash
0856 : 08
CAM-4 he said what in the world was that
0856: 09
CAM-2 ever go out to Midway and see the
gooney birds they're somethin' to watch
0856: 15
CAM-3 they crash and look around to see if
any-body saw 'em you know
0856: 17
CAM-2 yeah

0856: 19
CAM-2 they would they you know if you'd do
a runup the flight would come up and
do a runup and the gooney birds would
be back there in the prop wash just
hangin' in the air you know and then
they shut pull pull the power back and
then they'd just *
 -19-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

T I M E 81 TIME &
SOURCE CONTENT SOURCE CONTENT

CAM ((sound of laugh))

0856:35
CAM-2 hit the ground you know -- they were
hilarious

0856:38
CAM-2 they'd send a truck out you'd get ready
to take off they'd send a pickup truck
out and they'd go move the-birds off
the runway so you could takeoff
0856:44
CAM-4 oh really oh how funny where are they
where was that
0856:47
CAM-2 Midway Midway Island

0856:48
CAM-4 Midway Island

0856:49
CAM-2 they come back and they nest in exactly
the same spot that they were born

0856:52
CAM-4 on.the runway
 -2o-

INTRA-COCKPIt AIR-GROUND COMMUNICATIONS

TIME & TIME b
SOURCE CONTENT SOURCE CONTENT
0856:53
CAM-2 yeah whether it was a runway or what it
was they come back to the exact same spot
and ah so there's some kind of a law or
somethin' that you can't build anything on
the island anymore because --

0857:04
CAM-4 uh huh
0857:07
CAM-2 it's a sanctuary for the birds or somethin'

0857:08
PA-3 good morning ladies and gentleman we‘re
number four for departure, flight attendents
prepare the cabin please
0857:22
CAM ((flight switched to tower frequency))
0857:32
CAM-4 we're ready
0857:33
CAM-3 thank you

0857:35
CAM ((sound similar to cockpit door being
closed))
 -21-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME 41 TIME I
SOURCE CONTENT SOURCE CONTENT

0857:42
CAM-1 might as well start

0857:49
CAM-3 forty psi

0857351
CAM-2 number three

0857:54
CAM-3 start valve open

0858:Of
CAM ((sound of engine igniter starts))

0858:09
CAM-3 oil pressure

0858:16
CAM ((engine igniter stops))

0858:17
CAM-3 start valve cl.osed fbrty psf

0858:23
CAM ((sound of generator coming on line))

0858:24
CAM-3 engjneinstruments
 -22-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

0858:26
CAM-2 checked normal

0858:30
CAM-3 engine anti-ice

0858:31
CAM-2 it's closed
0858:38
TWR eleven for-ty one taxi position runway one eight
left and hold the Bandit will cross ahead

0858:44
RDO-2 okay eleven forty one's position and hold

0858:46
CAM-3 shoulder harness
0858:47
CAM-2 they're on

CAM-3 flaps

0858:48
CAM-2 fifteen fifteen green light

0858:49
CAM-3 flight controls
 -23-

INTRA-COCKPIT AIR-GROUNDCOMMUNICATIOI'JS

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

0858:SO
CAM-2 tops and bottoms are checked
0858:53
CAM-3 nav instruments

0858:54
CAN-2 they're set
0858:57
CAM-3 takeoff briefing
0858:58
CAM-2 is complete
0858:59
CAM-3 flight attendents have been notified
- and acknowledged
0859: 00
CAM-3 anti-skid
0859:Ol
CAM-2 on

0859:02
CAM-3 continuous ignition

0859:04
CAM-2 on
 -24-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME I

SOURCE CONTENT SOURCE CONTENT

0859:OS
CAM-3 nav lights
0859:06
CAM-2 on

0859:07
CAM-3 transponder

CAM-2 on

0859:08
CAM-3 before takeoff checklists complete
CAM-2 thank you
0859: 17
TUR Delta eleven forty one fly heading one eight five
runway one eight left cleared for takeoff

0859:20.4
RDO-2 eleven forty one one eight five cleared to go

0859:35
CAM ((sound of increasing engine noise))

0859:48.4
CAM-2 power's set
 -25-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

0859:49.8
CAM-2 engine instruments look good

0859t51.4
CAM- 2 airspeed's comin' up both sides

0859:53.5
CAM-2 eighty knots

0900:05.5
CAM-2 vee “R”
0900:06.5
CAM ((sound similar to nose strut extension))

0900:10.7
CAM-2 vee two

0900:12.5
CAM ((sound of snap))

0900: 15.1
CAM sound of stick shaker starts and
$ntinues until end of tape))

d900:15.5
CAM-I (somethin’s wrong/ooh)

0900: 17.6
CAM ((sound of compressor stall))
 -26-

INTRA-COCKPIT AIR-GROUNDCOMMUNICATIONS

TINE & TIME &

SOURCE CONTENT C
SOURCE
O N T E N T

0900:18.3
CAN ((sound of compressor stall))

. 0900:19.1
CAM-P engine failure
0900:19.5
RDO ((sound of microphone key for 6.6 seconds))

0900:19.9
CAM ((sound of compressor stall))

0900:20.4
CAM ((sound of compressor stall))
0900:21.1
CAM ((sound of compressor stall))

0900:21.7
CAM-2 we got an engine failure
0900:22.9
CAM ((sound of momeotary power interruption
to the cvr))

0900:26.9
CAM-I we're not gunna make it
0900:28.9
RDO-2 eleven forty one's-
 -27-

INTRA-COCKPIT AIR-GROUND COMMUNICATIONS

TIME & TIME I

SOURCE CONTENT SOURCE CONTENT

0900:33.4
RDO ((sound of-microphone keying for 0.3 seconds))
0900:34.7
CAM-I full power
0900:34.9
CAM-2 **

0900:35.3
CAN ((sound of first impact))
G
0900:36.6 F
RDO ((sound of microphone keying for 0.3 seconds))
0900:37.1
CAM ((sound of second {mpact))

0900:37.3
RDO-? send the - call the equipment
0900:37.4
CAN ((sound of third impact))
0900:37.4
CAN ((sound of scream))

0900:38.5
CAM ((sound of fourth impact))
0900:39.4
((end of tape))
 132

APPENDIX D

DELTA AIR LINES’ 8727 PILOT’S CHECKLIST

l lNTEa wIDlc TE STOP ITEM S

A M :S F UNCTION B-727 PILOT’S CHECKLIST A F* A-0
NOCWUENGOE (- 232 & -247 M o dified) a & ..)r DATE %lf4E

c *.* *‘
*.*.*.*‘
*.*.*‘
*.*.*.*.*.*.*.*.*.*.*.*.*.*.*.*.*.~
Am% START
, s1*NDBv RIDDM R#HI#Iw~ i A aEcsvsnu ...................... aam
i ANTI-SKID STABTRIM’ A --am .............. #YOVE
!A)lnTscE AlJToPlL01 i Aahum@owM ........................... ON
p!TOl* * MEAT
*.* *.*.* * * *.*.*.*.*.*.*.*.*.*.*.*.*.*.*.*.*.~ ~PlJsL~ ............................
BEFORE START A svBAaBNvDruvr ................ a ,z
~BNQ2aPuBuEDB .................. m#OD
l ucswusa- ................... at 'frAoK8 ............................
l FuELMoD ........... ABOARD - ~COCI(PmDooa ........ LoaED,&o~
OxvMAaKmE~ ................ a mbNElNslnuMEuTs .....................
sTANDBvRlmDEn ....................... -EN '*ILAmua ................... umg
FLlmTcoNTRoLBwlTwEs ................ ON
ANTMKID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TAXI
STALL wAnwIN . . . . . . . . . . . . . . . . . . . . . . . . . .
TrO DATA m BWY- BWV-
INSTRUMENT COMPARATOR . . . . . . . . . . . . . . . . z
AUTO PACK TRIP LT . . . . . . . . #~~~~TREoD
EMERQENcvExITuonrs.. . . . . . . . . . . . . . ARMED
OFF
M O T -T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
#2ENDACCESSDOORaaor,uowr ..............
AlRBPDrEPRBuQs . . . . . . . . . . . . . Bmxlss~
ENBINE STABT SWITWES . . . . . . . . . . . . . . . . . OFF
AIRSPDWARNSWS.. . . . . . . . . rrr.S-+AMB)
BEATBELTSMO~ . . . . . . . . . . . . . . . . .
ALT&RTlNsrs . . . . . . . . . . . . . . . . wII#oucK
WINDOWHEAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . z
CLOSED STAB TBIM . . . . . . . . . . . . . . . . . . . . . . . . . -ITS
ANTI-ICE . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PITOT HEAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WenBekyod&fthh8bed
lNTEmDRbExTEnloRLlans . . . . . . . . . . . . . . aET ‘
~*~‘
~*~‘
~‘~‘
~~~~~~~‘ ~~.~~~~.* *.*.* *.:
NAVIGATION LIGHTS fl47l . . . . . . . . . . . . . . . . . . err
ENGINE FIRE WARNINQ SVSTEYS . . . . . . . . . . . . CK i A PAas . . . . . . . . . . . . . . . . . . . . . . . . . . . BOTHOFF I
ALT & FLT lNSTS . . . . . . . . . . . . . . . . W-SSCU i~oALLEvPowER . . . . . . . . . . . . . . . . . . . . . . . . . . OFF .
COMPASS SELECTORS . . . . . . . . . . . . . . . . UVED ; A FUEL SVSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . SET :
GPWS ................................... a i PNEUMATIC PMaBlmE . . . . . . . . . . . . . . . . -PSI !
STATIC SDURCE SELECTOKS . . . . . . . . . . . NOBMAL i
MACH AIRSPEED WAI)NlND . . . . . . . . . . . . . . . . . CK
i DELAYED AFI’ER START :
i
INDICATOR LlGblTS & APO . . . . . . . . . . . . . . . . . . CK i A ELEC SYSTEM . . . . . . . . . . . . . . . . . . . . . . abarr :
ENGINE INSTRUMENTS . . . . . . . . . . . . . . . . . . . . . CR ! A WV POWER . . . . . . . . . . . . . . . . . . . . . . . . . . . ON .
LANDING DEAR . . . . . . . . . . . . ODWN. IN, 3 GREEN 1 A m BVSTEM . . . . . . . . . . . . . . . m KM TAKEOFF ’
8 RADAR b TRANS . . . . . . . . . . . . . . . . . . . . aism ;a SVSANVDPUMPS . . . . . . . . . . . . . . . . . . . CK AON ’*
- ---
PLMWT DIRECTORS . . . . . . . . . . . . . . . . . . . . . . STBv ;A ENG2’
AWUEEOS . . . . . . . . . . . . . . . . . . . . -&OSE ,
SPEED BRAKE . . . . . . . . . . . . . . . . . . . . . . . DETENT i A P A C K S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ON 1
REV. TNROTTLES & STAKT LEVERS . . . . . . . . . . . . . i
ENOINE NSTBUMENTS . . . . . . . . . . . . . . . . . . . . . C K ’
. . . . . . . DDWN.CLOSEDICUTOFF i
i.,.*e!F*.*.*.*.* . . . . . . . . *. .*.*.*.*.*.*.*.*
ANTblcE *.*.*.*.*.* . . . . . . . . . AS* REOD * * * J’
FLAPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UP
STAB TRIM . . . . . . . . . . . . . . . . . . . . . . . . . . NORMAL TAXI (CONTINUED)
AUTOCtLDT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 RADIOS I NAV MSTS . . . . . . . . . . . . . . . . cI( & SET A FUELNEAT . . . . . . . . . . . . . . . . . . . . . . . . . ASREOD
l RUDDER 4 AILERON TRlM . . . . . . . . . . . . . . . . . ZERO AFLTnwID SWITCH . . . . . . . . . . . . . . . . . . . . . . . . . FLT
STANDBY POWER . . . . . . . . . . . . . . . . . . . . . . . . . CK A FiOALTmTOBCt8t . . . . . . . . . . . . . . . . IN
l CABIN & SO PKEFLbDM . . . . . . . . . . . . . COMPLETE BNolKaRNARNEsa . . . . . . . . . . . . . . . . . . . . . . ON
l r AUT-OT TEST BW . . . . . . . . . . . . . . . . . mRMM ................. OREEN IJGHT
l A CIBCUIT BBEAKERS . . . . . . . . . . . . . . . . . . . . . . . . Fkizkmm . . . . . . . . . . . . . . . . . . . . . . . . a
l DEPAKTUBE BBIEFIND . . . . . . . . . . . . . . . . . . 2 NAVlNSTRUMMT8 . . . . . . . . . . . . . . . . . . . . . . . BET

BEFORE DISPATCH BEFORE TAKEOFF

A rlSVSBWVDPLMP . . . . . . . . . . . . . . . . . . . . . . . ON TAKEOR- . . . . . . . . . . . . . . . . . . . . . COMP
A APU&BAnm . . . . . . . . . . . . . STARlaa FuWAltoloAwn . . . . . . . . . . . N~WIEDIACK~
* PACK(S) . . . . . . . . . . . . . . . . . . . . . . . . . . . ASREOD ............................... ON
ENGINE START i!iEzL mNlmNm2l ................ ON
STARTSWtTCHES~TJ .. ..I.. . . . . . . . . RTSTABT
A DDOA WARWIND LlDNTS . . . . . . . . . . . . . . . . . . . . #[ NAV LIGNTB ..............
A PACUS ............................ BOTHOFF
@22p8-24?j

TRANSPONDER . . . . . . . . . . . . . . . . . . . . . . . . . . . z
A GALLEVVR . . . . . . . . . . . . . . . . . . . . . . . . . . OFF A wf
APUMASTMBWITCH . . . . . . . . . . . . . . . . . . . . .
A FUEL SVSTEY . . . . . . . . . . . . . . . . . . . . . . . . . . . . A FUEL NEAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BEACON . . . . . . . . . . . . . . . . . . . . . . . . . . .; . . ON A m
APULIDMT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PARKING BitiKE .................... ASREOD A AllTOPAcI(TRPBwITc)( . . . . . . . . . . . . . -AL
PNEUMATIC PRESSURE . . . . . . . . . . . . . . . 4 A CBDoIL~Bp47J . . . . . . . . . . . . GBOUND OFF

*U.S. GOVERNKNT f’RINfINt off lCE:q99oiz6?-9g~ rooo3S