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Transcript of SF320
Physics What Exactly Happened ? Number one engine and pylon sheared off, flipping over the top of the left wing cutting off power to the captain’s flight director instruments, stall warning system, and slat disagreement warning light American Airlines flight 191 disintegrated into an open field and trailer park about 4,600 feet northwest of the departure end of runway 32 right and erupted into an explosion and massive ground fire killing all 271 passengers and crew members on board, 2 people on the ground, and injuring 2 people on the ground giving them second and third degree burns The separation resulted from damage by improper maintenance procedures which led to failure of the pylon’s structure American Airlines was fined 500,000 dollars and Continental Airlines 100,000 dollars by the FAA for using forklift trucks to remove and install engines and pylon assemblies. The Maintenance Alert Bulletin is also to be issued to states with regulatory responsibilities to foreign air carriers to have them conduct the same inspections and adapt the new maintenance practices of their DC – 10 fleet. FAA implemented design change that called for crossover between the two stall warning systems so that the stick shaker could be actuated by either the left or right computer. OUTCOME ? FAA & NTSB Lay Down The LAW NTSB recommended the FAA issue an emergency Airworthiness Directive inspecting all pylon attach points on all DC – 10 FAA to issue Airworthiness Directive to require inspections of all DC – 10 aircraft that had engines and pylons removed and reinstalled for damage to the wing The FAA was also recommended to issue a Maintenance Alert Bulletin to contact their assigned air carriers to advise them to cease maintenance practices of removing the engine and pylon together FAA issued an emergency order of suspension on June 6, 1979, grounding the entire DC – 10 fleet nationwide NTSB required additional stick shaker motors to be built into the stall warning systems of all McDonnell – Douglas DC – 10 aircraft PROCEED WITH CAUTION! MISTAKES The last time the aircraft was serviced was eight weeks prior, March 29th and 30th Improper maintenance procedures performed by the airlines. When interviewed, the personnel actually performing the maintenance to the aircraft admit they were using a “shortcut” in order to save time The crew began to disassemble the bolts holding the assembly to the aircraft but then changed shifts with the next crew scheduled that day leaving the engine and pylon supported only by the forklift “The damage was sustained and cracks were found on the upper flange were limited to [unsatisfactory] operations wherein the engine and pylon assembly was supported by a forklift” PROPER PROCEDURES “first removal of the engine and then removal of the pylon…the sequence shown for the removal of the attach fittings was: the forward upper attach assembly, the forward lower attach assembly, the thrust link, and the aft bolt and bushing " “McDonnell-Douglas nor the Federal Aviation Administration has the authority to either approve or disapprove the maintenance procedures of its customers STRUCTURE FAILURE To save time and money American Airlines decided to remove the engine and pylon as a single unit instead of first removing the engine and then removing the pylon as the service bulletin directed them to (SB54-48 and SB54-59). After a maintenance shift change it was noticed that the upper part of the rear bulkhead (the flange) was actually in contact with the wing (the clevis). The aft bulkhead, along with its upper flange, were damaged The stress from the weight created a crack on the lower part of the flange, in line with the clevis. The post-crash investigation revealed that a 10 inch crack was on the flange. Liveware Crew Resource Management Pilot Error Preflight Lux will handled communication and Dillard operated the aircraft on takeoff. This is uncommon, usually the captain is responsible for the safe lift-off and touchdown. When the engine fails, they experience a slight roll to the left after takeoff but are able to correct the issue momentarily. At this point, communication recording stop. Reducing engine power caused an even further decrease in lift over the left wing and eventually caused it to stall, bringing the aircraft into a roll towards the ground. Possible Preventative CRM Tactics ask flight attendants to keep an eye out of the windows during takeoff and to report anything unusual NTSB Deficiencies In Detection Changed procedure that allowed the pylon and the engine to be removed as one piece FAA was not notified about the new maintenance procedure This crash truly opened the eyes of the public to the lack of regulation by the FAA and certainly the airlines as to what safety regulations they sacrifice to get the job done Proactive Detection The FAA should have been more involved with maintenance procedures The maintenance teams themselves should be more careful The management at each airline should be fully informed of maintenance procedures The double check system The McDonnel manufacturing company is also partially at fault References -Chicago Air Crash [Television series episode]. (2006). In Metcalfe, N. (Executive Producer), Seconds From Disaster. United States: National Geographic. Retrieved from
-Chicago Plane Crash / Flight Engine Down". Seconds From Disaster. National Geographic Channel. Mara E. Vatz. “Knowing when to stop: the investigation of flight 191” Massachusetts Institute of TechnologySeptember 2004.
-Friewald, D. (2013). Crm lesson 15. Class Presentation, Safety Factors Department, Embry-Riddle Aeronautical University, Daytona Beach, , Available from Blackboard. Retrieved from https://erau.blackboard.com/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=/webapps/blackboard/execute/launcher?type=Course&id=_987678_1- Mara E. Vatz. “Knowing when to stop: the investigation of flight 191” Massachusetts Institute of TechnologySeptember 2004.
-National Transportation Safety Board, Bureau of Accident Investigation. (1979). Aircraft accident report-American airlines, inc. dc-10-10, nlloaa. (mSB-AAR-79-17). Washington D.C.: National Transportation Safety Captain Lux
First Officer Dillard The Event Systemic Maintenance Errors The Patterns of Behavior The engineers disregarded the manufactures recommendations in order to save money by reducing labor cost American Airlines was not the only airline to disregard manufacturer recommendations Flight 191 Accident Conclusion Is Watching You