Case Study American Air Flight 191
Case Study Analysis
Activity Title:
Name:
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Cause(s) of Accident
The probable cause to the crash of American Airlines Flight 191 is the asymmetrical stall and the ensuing roll of the aircraft due to the un-commanded 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 number one engine and pylon assembly at a critical point during take-off.
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."
Through numerous simulations of the accident, the NTSB determined that it would have been possible for a flight crew to recover the airplane in a situation like that encountered by the crew of Flight 191, IF the crew had been fully aware of the situation and IF the crew had followed a very specific course of corrective action. In the case of Flight 191, no one had ever anticipated such a complex series of failures and procedures to handle the situation had never been developed. Also, because of the failure of the stall warning and slat disagreement indicators, it is likely that the crew was never fully aware of the situation, at least until it was too late to save the airplane. The NTSB strongly disagreed with McDonnell Douglas ' assessment that the probability of engine detachment and subsequent system failure was
Activity Title:
Name:
Date:
Cause(s) of Accident
The probable cause to the crash of American Airlines Flight 191 is the asymmetrical stall and the ensuing roll of the aircraft due to the un-commanded 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 number one engine and pylon assembly at a critical point during take-off.
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."
Through numerous simulations of the accident, the NTSB determined that it would have been possible for a flight crew to recover the airplane in a situation like that encountered by the crew of Flight 191, IF the crew had been fully aware of the situation and IF the crew had followed a very specific course of corrective action. In the case of Flight 191, no one had ever anticipated such a complex series of failures and procedures to handle the situation had never been developed. Also, because of the failure of the stall warning and slat disagreement indicators, it is likely that the crew was never fully aware of the situation, at least until it was too late to save the airplane. The NTSB strongly disagreed with McDonnell Douglas ' assessment that the probability of engine detachment and subsequent system failure was
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