ASN Aircraft accident McDonnell Douglas DC-10-10 N110AA Chicago-O'Hare International Airport, IL (ORD)
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Status:Accident investigation report completed and information captured
Date:Friday 25 May 1979
Time:15:04
Type:Silhouette image of generic DC10 model; specific model in this crash may look slightly different
McDonnell Douglas DC-10-10
Operator:American Airlines
Registration: N110AA
MSN: 46510/22
First flight: 1972
Total airframe hrs:19871
Engines: 3 General Electric CF6-6D
Crew:Fatalities: 13 / Occupants: 13
Passengers:Fatalities: 258 / Occupants: 258
Total:Fatalities: 271 / Occupants: 271
Ground casualties:Fatalities: 2
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location:Chicago-O'Hare International Airport, IL (ORD) (   United States of America)
Crash site elevation: 204 m (669 feet) amsl
Phase: Takeoff (TOF)
Nature:Domestic Scheduled Passenger
Departure airport:Chicago-O'Hare International Airport, IL (ORD/KORD), United States of America
Destination airport:Los Angeles International Airport, CA (LAX/KLAX), United States of America
Flightnumber:AA191
Narrative:
American Airlines Flight 191, a McDonnell-Douglas DC-10-10, crashed on takeoff from Chicago-O'Hare International Airport, Illinois, USA. The aircrtaft was destroyed and all 271 occupants were killed. Additionally, two persons on the ground sustained fatal injuries.
At 14:59 hours local time Flight 191 taxied from the gate at O'Hare Airport. The flight was bound for Los Angeles, California, with 258 passengers and 13 crewmembers on board. Maintenance personnel who monitored the flight's engine start, push-back, and start of taxi did not observe anything out of the ordinary.
The weather at the time of departure was clear, and the reported surface wind was 020° at 22 kts. Flight 191 was cleared to taxi to runway 32R for takeoff. The company's Takeoff Data Card showed that the stabilizer trim setting was 5° aircraft noseup, the takeoff flap setting was 10°, and the takeoff gross weight was 379,000 lbs. The target lowpressure compressor (N1) rpm setting was 99.4 percent, critical engine failure speed (V1) was 139 kts indicated airspeed (KIAS), rotation speed (VR) was 145 KIAS, and takeoff safety speed (V2) was 153 KIAS.
Flight 191 was cleared to taxi into position on runway 32R and hold. At 15:02:38, the flight was cleared for takeoff, and at 15:02:46 the captain acknowledged, "American one ninety-one under way." The takeoff roll was normal until just before rotation at which time sections of the No.1 (left) engine pylon structure came off the aircraft. Witnesses saw white smoke or vapor coming from the vicinity of the No. 1 engine pylon. During rotation the entire No. 1 engine and pylon separated from the aircraft, went over the top of the wing, and fell to the runway.
Flight 191 lifted off about 6,000 ft down runway 32R, climbed out in a wings-level attitude.
About nine seconds after liftoff, the airplane had accelerated to 172 knots and reached 140 feet of altitude. As the climb continued, the airplane began to decelerate at a rate of about one knot per second, and at 20 seconds after liftoff, and an altitude of 325 feet, airspeed had been reduced to 159 knots. At this point, the airplane began to roll to the left, countered by rudder and aileron inputs. The airplane continued to roll until impact, 31 seconds after liftoff, and in a 112-degree left roll, and 21-degree nose down pitch attitude.
At 15:04 Flight 191 crashed in an open field and trailer park about 4,600 ft northwest of the departure end of runway 32R. The aircraft was demolished during the impact, explosion, and ground fire.

The No.1 engine pylon failure during takeoff was determined to have been caused by unintended structural damage which occurred during engine/pylon reinstallation using a forklift. The engine/pylon removal and reinstallation were being conducted to implement two DC-10 Service Bulletins. Both required that the pylons be removed, and recommended that this be accomplished with the engines removed. The Service Bulletin instructions assumed that engines and pylons would be removed separately, and did not provide instructions to remove the engine and pylon as a unit. Additionally, removal of the engines and pylons as a unit was not an approved Maintenance Manual procedure.
The lack of precision associated with the use of the forklift, essentially an inability to perform the fine manipulations necessary to accomplish reinstallation of the engine/strut assembly, in combination with the tight clearances between the pylon flange and the wing clevis resulted in damage to the same part that had just been inspected.
Inspections of other DC-10 pylon mounts following the accident resulted in nine additional cracked mounts being identified.

Probable Cause:

PROBABLE CAUSE: "The asymmetrical stall and the ensuing roll of the aircraft because of the uncommanded retraction of the left wing outboard leading edge slats and the loss of stall warning and slat disagreement indication systems resulting from maintenance-induced damage leading to the separation of the no.1 engine and pylon assembly procedures which led to failure of the pylon structure.
Contributing to the cause of the accident were the vulnerability of the design of the pylon attach points to maintenance damage; the vulnerability of the design of the leading edge slat system to the damage which produced asymmetry; deficiencies in FAA surveillance and reporting systems which failed to detect and prevent the use of improper maintenance procedures; deficiencies in the practices and communications among the operators, the manufacturer, and the FAA which failed to determine and disseminate the particulars regarding previous maintenance damage incidents; and the intolerance of prescribed operational procedures to this unique emergency."

Accident investigation:

cover
Investigating agency: NTSB
Status: Investigation completed
Duration: 210 days (7 months)
Accident number: NTSB/AAR-79-17
Download report: Final report

Classification:

Engine separation
Loss of control

Sources:
» NTSB Safety Recommendations A-79-98/105
» NTSB-AAR-79-17


Follow-up / safety actions
On June 6, 1979, after a series of postaccident inspections disclosed damaged aft bulkheads in the wing to engine pylons, the Administrator of the FAA issued an Emergency Order of Suspension. The Order suspended the DC-10 series aircraft type certificate "until such time as it can be ascertained that the DC-10 aircraft meets the certification criteria of Part 25 of the FAR and is eligible for a Type Certificate."
On June 26, 1979, the FAA issued Special Federal Aviation Regulation 40 which prohibited the "operation of any Model DC-10 aircraft within the airspace of the United States."
On July 13, 1979, after a series of formal investigations, the Administrator found that the DC-10 met the requirements for issuance of a type certificate. Accordingly, the Emergency Order of Suspension was terminated.

In November 1979 the FAA fined American Airlines $500,000 for using a faulty maintenance procedure on its DC-10 aircraft by using forklift trucks to mate the complete engine/pylon assembly with wing attachment points. Continental Airlines was fined $100,000 on a similar charge.

FAA issued 1
NTSB issued 12 Safety Recommendations

Show all...

Photos

photo of DC-10-10-N110AA
accident date: 25-05-1979
type: McDonnell Douglas DC-10-10
registration: N110AA
photo of DC-10-10-N110AA
accident date: 25-05-1979
type: McDonnell Douglas DC-10-10
registration: N110AA
photo of DC-10-10-N110AA
accident date: 25-05-1979
type: McDonnell Douglas DC-10-10
registration: N110AA
 

Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Chicago-O'Hare International Airport, IL to Los Angeles International Airport, CA as the crow flies is 2783 km (1739 miles).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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