Air Crash Investigation: Flight 191
24/7/2012
“FLIGHT ENGINE DOWN”
Air Travel
Most effective and safest forms of transport
< 1 for every 2 x 109 personmiles flown
Air crash – One of worst situation
Team Members: Seran Karikalan 1002764 Sivaguru S/O Sivagnanam 1003260 Ng Aiting 1067138 DARE 3B 24
Number of lives it takes with it
Human Error
Manufacturers to Engineers
No one wishes for air crashes
Synopsis
On 25th May 1979, 15:00Hrs
A McDonnell Douglas (MD) DC-10 American Airlines Took-off from Chicago O’Hare Int. airport
Yet, 70% is caused by Human errors “That wouldn’t happen to me”
Is main cause for such errors
Just before lift off
Lost power from No.1 engine
Synopsis
Suddenly rolled heavily to left
Smoke gushing out
Introduction
Air crash do not occur independently Led by ‘chain of errors’
Any one broken link would prevent it
Within 30 seconds
Smashed into nearby trailer park
Analysing
Series of events Maintenance factors Other contributing factors Error preventing strategies
All on-board 271 + 2 other dead
1
24/7/2012
Events
Crash Involved…
On 25th May 1979, American Airlines Flight 191 was en route from Chicago, O’Hare airport to Los Angles, California Had carried 258 passengers and 13 crew members on board
Events
•
Events
•
8 weeks before the crash Flight 191
– Major Maintenance – Spherical Bearings had to
On Crash Day…
– During Take off the left engine
be replaced
– Engine and pylon had to
be removed to gain access
– Came up with own
procedure
– Crack formed in hidden
and pylon ripped off from the left wing – Damaged a meter of leading edge, hydraulic system – Electrical power was disabled as left engine generated electricity
area
Events
•
On Crash Day…
– The loss of hydraulic power
caused Slats to retract due to ram air effect – Stick shaker had failed due to electrical power loss – Plane had loss of lift on the left wing – Plane stalled, rolled left and crashed
2
24/7/2012
“FLIGHT ENGINE DOWN”
Air Travel
Most effective and safest forms of transport
< 1 for every 2 x 109 personmiles flown
Air crash – One of worst situation
Team Members: Seran Karikalan 1002764 Sivaguru S/O Sivagnanam 1003260 Ng Aiting 1067138 DARE 3B 24
Number of lives it takes with it
Human Error
Manufacturers to Engineers
No one wishes for air crashes
Synopsis
On 25th May 1979, 15:00Hrs
A McDonnell Douglas (MD) DC-10 American Airlines Took-off from Chicago O’Hare Int. airport
Yet, 70% is caused by Human errors “That wouldn’t happen to me”
Is main cause for such errors
Just before lift off
Lost power from No.1 engine
Synopsis
Suddenly rolled heavily to left
Smoke gushing out
Introduction
Air crash do not occur independently Led by ‘chain of errors’
Any one broken link would prevent it
Within 30 seconds
Smashed into nearby trailer park
Analysing
Series of events Maintenance factors Other contributing factors Error preventing strategies
All on-board 271 + 2 other dead
1
24/7/2012
Events
Crash Involved…
On 25th May 1979, American Airlines Flight 191 was en route from Chicago, O’Hare airport to Los Angles, California Had carried 258 passengers and 13 crew members on board
Events
•
Events
•
8 weeks before the crash Flight 191
– Major Maintenance – Spherical Bearings had to
On Crash Day…
– During Take off the left engine
be replaced
– Engine and pylon had to
be removed to gain access
– Came up with own
procedure
– Crack formed in hidden
and pylon ripped off from the left wing – Damaged a meter of leading edge, hydraulic system – Electrical power was disabled as left engine generated electricity
area
Events
•
On Crash Day…
– The loss of hydraulic power
caused Slats to retract due to ram air effect – Stick shaker had failed due to electrical power loss – Plane had loss of lift on the left wing – Plane stalled, rolled left and crashed
2
24/7/2012
References: Earl L. Wiener and David C. Nagel, 1988. Human Factors in Aviation. United States of America: Academic Press. David O’Hare, 1999. Human Performance in General Aviation. Great Britain: Ashgate. Mara E. Vatz, 2004. Knowing When to Stop[online]. Massachusetts Institude of Technology. Available from: http://dspace.mit.edu/bitstream/handle/1721.1/39430/59008054.pdf?sequence=1 [Accessed 20 July 2012]. United States Government, 1979. Aircraft Accident Report[online]. Washington: National Transportation Safety Board. Available from: http://www.airdisaster.com/reports/ntsb/AAR79-17.pdf [Accessed 20 July 2012]. MrCriticOfAll, 2011. Seconds From Disaster-S03E15-Chicago Air Crash(Flight Engine Down) (Chicago Flight 191)[online]. National Geographic. Available from: http://www.youtube.com/watch?v=cPx4aYenWPk [Accessed 15 July 2012] Glam Family, 2012. Air Safety[online]. Seattle: Creative Commons Attribution/Share Alike License. Available from: http://www.enotes.com/topic/Air_safety [Accessed 19 July 2012] Time Magazine U.S., 1979. Nation: The Worst U.S. Air Crash[online]. United States: CNN and CNN Money. Available from: http://www.time.com/time/magazine/article/0,9171,946244-3,00.html [Accessed 21 July 2012] Christopher Kilroy, 1996. Investigation: American Flight 191[online]. AirDisaster.Com. Available from: http://www.airdisaster.com/investigations/aacrash.shtml [Accessed 21July 2012] Aviation Safety Network, 2012. Flight 191 Accident Description[online]. Flight Safety Foundation. Available from: http://aviationsafety.net/database/record.php?id=19790525-2 [Accessed 21 July 2012] Peter B. Ladkin, 1999. Report on the 1979 Chicago Crash[online]. German: National Transportation Safety Board. Available from: http://www.rvs.uni-bielefeld.de/publications/Incidents/DOCS/ComAndRep/OHare/NTSB/COPY/ohare-full.html [Accessed 21 July 2012] 6