Crash of a Boeing 727-232 in Dallas: 14 killed

Date & Time: Aug 31, 1988 at 0901 LT
Type of aircraft:
Operator:
Registration:
N473DA
Flight Phase:
Survivors:
Yes
Schedule:
Jackson - Dallas - Salt Lake City
MSN:
20750
YOM:
1973
Flight number:
DL1141
Crew on board:
7
Crew fatalities:
Pax on board:
101
Pax fatalities:
Other fatalities:
Total fatalities:
14
Captain / Total flying hours:
17000
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
4000
Aircraft flight hours:
43023
Circumstances:
Flight DL1141 (Jackson - Dallas - Salt Lake City) left Gate 15 at 08:30 and was instructed to taxi to runway 18L. When first in line for takeoff (at 08:59) the flight was cleared for takeoff. The takeoff was uneventful until the airplane reached the rotation phase (at 154 knots, 6017 feet down the runway). As the main gear wheels left the ground, the airplane began to roll violently, causing the right wingtip to contact the runway (1033 feet after lift-off), followed by compressor surges. The plane continued and struck the ILS localizer antenna array 1000 feet past the end of runway 18L. After impacting the antenna installation, the airplane remained airborne for an additional 400 feet, then struck the ground, traversed a ground depression and slid sideways until it came to rest near the airport perimeter fence, 3200 feet from the runway end. Parts of the aircraft had separated in the slide and a fire had erupted in the right wing area, quickly engulfing the rear, right side of the airplane after it came to rest. Twelve passengers and two crew members were killed. The aircraft was destroyed.
Probable cause:
The board determines that the accident was caused mainly by the captain and first officer's inadequate cockpit discipline which resulted in the flight crew's attempt to takeoff without the wing flaps and slats properly configured; and 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.
Findings:
Occurrence #1: loss of control - in flight
Phase of operation: takeoff - initial climb
Findings
1. (c) preflight planning/preparation - improper - pilot in command
2. (c) overconfidence in personal ability - pilot in command
3. (c) procedures/directives - not followed - copilot/second pilot
4. (c) procedures/directives - not followed - pilot in command
5. (f) procedure inadequate - company/operator management
6. (f) insufficient standards/requirements, operation/operator - FAA (organization)
7. (f) inadequate method of compliance determination record keeping - FAA (organization)
8. (c) lowering of flaps - not performed
9. (c) lowering of slats - not performed
10. (c) safety system (other) - inoperative
----------
Occurrence #2: in flight collision with terrain/water
Phase of operation: descent - uncontrolled
Final Report:

Crash of a Lockheed L-1011-385 TriStar 1 in Dallas: 135 killed

Date & Time: Aug 2, 1985 at 1805 LT
Type of aircraft:
Operator:
Registration:
N726DA
Survivors:
Yes
Schedule:
Fort Lauderdale - Dallas - Los Angeles
MSN:
193C-1163
YOM:
1979
Flight number:
DL191
Crew on board:
11
Crew fatalities:
Pax on board:
152
Pax fatalities:
Other fatalities:
Total fatalities:
135
Captain / Total flying hours:
29300
Captain / Total hours on type:
3000.00
Copilot / Total flying hours:
6500
Copilot / Total hours on type:
1200
Aircraft flight hours:
20555
Aircraft flight cycles:
11186
Circumstances:
Delta Air Lines flight 191 was a regularly scheduled passenger flight between Fort Lauderdale, FL (FLL), and Los Angeles, CA (LAX), with an en route stop at the Dallas/Fort Worth International Airport, TX (DFW). Flight 191, a Lockheed L-1011 TriStar airplane, departed Fort Lauderdale on an IFR flight plan with 152 passengers and a crew of 11 on board at 15:10 EDT. The DFW Airport terminal weather forecast contained in the flightcrew's dispatch document package stated, in part, that there was a possibility of widely scattered rain showers and thunderstorms, becoming isolated after 20:00 CDT. The flight was uneventful until passing New Orleans, Louisiana. A line of weather along the Texas-Louisiana gulf coast had intensified. The flightcrew elected to change their route of flight to the more northerly Blue Ridge arrival route to avoid the developing weather to the south. This change necessitated a 10 to 15-minute hold at the Texarkana, Arkansas, VORTAC for arrival sequencing at the DFW Airport. At 17:35, the flightcrew received the following ATIS broadcast: "DFW arrival information romeo, two one four seven Greenwich, weather six thousand scattered, two one thousand scattered, visibility one zero, temperature one zero one, dew point six seven, wind calm, altimeter two niner niner two, runway one eight right one seven left, visual approaches in progress, advise approach control that you have romeo". Fort Worth Air Route Traffic Control Center (ARTCC) then cleared flight 191 to the Blue Ridge, Texas, VORTAC for the Blue Ridge Nine arrival, and to begin its descent. At 17:43:45, Fort Worth ARTCC cleared flight 191 to descend to 10,000 feet, gave it a 29.92 in Hg altimeter setting, and suggested that the flight turn to a heading-of 250 degrees "to join the Blue Ridge zero one zero radial inbound and we have a good area there to go through.!' The captain replied that he was looking at a "pretty good size" weather cell, "at a heading of two five five ... and I'd rather not go through it, I'd rather go around it one way or the other." Fort Worth ARTCC then gave the flight another heading and stated "when I can I'll turn you into Blue Ridge, it'll be about the zero one zero radial." At 17:46, the center cleared flight 191 direct to Blue Ridge and to descend to 9,000 feet, and flight 191 acknowledged receipt of the clearance. At 17:48, the captain told the first officer, "You're in good shape. I'm glad we didn't have to go through that mess. I thought sure he was going to send us through it." Three minutes later, the flight engineer said, "Looks like it's raining over Fort Worth." At 17:51, Forth Worth ARTCC instructed flight 191 to contact DFW Airport Approach Control. At 17:56:28, Regional Approach Control's Feeder East controller transmitted an all aircraft message which was received by flight 191. The message stated in part, "Attention, all aircraft listening... there's a little rainshower just north of the airport and they're starting to make ILS approaches ... tune up one oh nine one for one seven left." At 17:59, the first officer stated, "We're gonna get our airplane washed," and the captain switched to Regional Approach Control's Arrival Radar-1 (AR-1) frequency and told the controller that they were at 5,000 feet. At 18:00, the approach controller asked American Air Lines flight 351 if it was able to see the airport. (Flight 351 was two airplanes ahead of flight 191 in the landing sequence for runway 17L.) Flight 351 replied, "As soon as we break out of this rainshower we will." The controller then told flight 351 that it was 4 miles from the outer marker, and to join the localizer at 2,300 feet; the controller then cleared the flight for the ILS approach to runway 17L. At 18:00, the approach controller asked flight 191 to reduce its airspeed to 170 knots, and to turn left to 270 degrees; flight 191 then acknowledged receipt of the clearance. Flight 191 had been sequenced behind a Learjet 25 for landing on runway 17L. At 18:02, the approach controller told flight 191 that it was 6 miles from the outer marker, requested that it turn to 180 degrees to join the localizer at or above 2,300 feet, and stated, "Cleared for ILS one seven left approach." The flight acknowledged receipt of the transmission. At 18:03:03, the approach controller requested flight 191 "to reduce your speed to one six zero please," and the captain replied, "Be glad to." Thereafter, at 18:03:30, he broadcast, "And we're getting some variable winds out there due to a shower... out there north end of DFW." This transmission was received by flight 191. At 18:03:46, the approach controller requested flight 191 to slow to 150 KIAS, and to contact the DFW Airport tower. At 18:03:58, the captain, after switching to the tower's radio frequency, stated, "Tower, Delta one ninety one heavy, out here in the rain, feels good." The tower cleared the flight to land and informed it, "wind zero nine zero at five, gusts to one five." At 18:04:07, the first officer called for the before-landing check. The flightcrew confirmed that the landing gear was down and that the flaps were extended to 33 degrees, the landing flap setting. At 18:04:18, the first officer said, "Lightning coming out of that one." The captain asked, "What?" and the first officer repeated "Lightning coming out of that one." The captain asked, and at 18:04:23, the first officer replied, "Right ahead of us." Flight 191 continued descending along the final approach course. At 18:05:05 the captain called out "1,000 feet." At 18:05:19, the captain cautioned the first officer to watch his indicated airspeed and a sound identified as rain began. The captain then warned the first officer, "You're gonna lose it all of a sudden, there it is." The captain stated, "Push it up, push it way up." At 18:05:29, the sound of engines at high rpm was heard on the CVR, and the captain said "That's it." At 18:05:44, the Ground Proximity Warning System's (GPWS) "Whoop whoop pull up" alert sounded and the captain commanded "TOGA". The CVR recording ended at 18:05:58. Witnesses on or near State Highway 114 north of the airport saw flight 191 emerge from the rain about 1.25 miles from the end of runway 17L and then strike an automobile in the westbound lane of State Highway 114. Subsequent investigation showed that the airplane had touched down earlier and became airborne again before striking the automobile. After the plane struck the car and a light pole on the highway, other witnesses saw fire on the left side of the airplane in the vicinity of the wing root. The witnesses generally agreed that the airplane struck the ground in a left-wing-low attitude, and that the fuselage rotated counterclockwise after the left wing and cockpit area struck a water tank on the airport. A large explosion obscured the witnesses' view momentarily, and then the tail section emerged from the fireball, skidding backwards. The tail section finally came to rest on its left side with the empennage pointing south and was subsequently blown to an upright position by wind gusts. One hundred and thirty-four persons on board the airplane and the driver of the automobile which was struck by the airplane were killed in the accident; 27 persons on board the airplane and 1 rescue worker at the accident site were injured, 2 passengers on the airplane were uninjured.
Probable cause:
The flight crew's decision to initiate and continue the approach into a cumulonimbus cloud which they observed to contain visible lightning; the lack of specific guidelines, procedures and training for avoiding and escaping from low-level windshear; and the lack of definitive, real-time windshear hazard information. This resulted in the aircraft's encounter at low altitude with a microburst-induced, severe windshear from a rapidly developing thunderstorm located on the final approach course.
Final Report:

Crash of a Douglas DC-9-32 in Chattanooga

Date & Time: Nov 27, 1973 at 1851 LT
Type of aircraft:
Operator:
Registration:
N3323L
Survivors:
Yes
Schedule:
Atlanta - Chattanooga
MSN:
47032/204
YOM:
1967
Flight number:
DL516
Crew on board:
5
Crew fatalities:
Pax on board:
74
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15949
Captain / Total hours on type:
3218.00
Copilot / Total flying hours:
6301
Copilot / Total hours on type:
4000
Aircraft flight hours:
18233
Circumstances:
Following an uneventful flight from Atlanta, the crew started the approach to Chattanooga Airport in poor weather conditions with limited visibility due to heavy rain falls. On short final, the crew failed to realize his altitude was insufficient when the airplane struck approach light located 1,600 feet short of runway 20 threshold. The airplane then struck the ground, lost its left wing and skidded for another 1,200 feet before coming to rest 250 feet to the left of the runway centerline. All 79 occupants evacuated safely and only seven passengers were slightly injured.
Probable cause:
The pilot did not recognize the need to correct an excessive rate of descent after the aircraft had passed decision height. This occurred despite two verbal reports of increasing sink rate by the first officer. The captain disregarded the reports by the first officer, possibly because of the influence of a visual illusion caused by the refraction of light through the heavy rain on the windshield. The excessive rate of descent was initiated by a wind shear condition which extended in the lower levels of the approach path and a glide slope that tended toward the lower signal limit.
Final Report:

Crash of a Douglas DC-9-31 in Boston: 88 killed

Date & Time: Jul 31, 1973 at 1108 LT
Type of aircraft:
Operator:
Registration:
N975NE
Survivors:
No
Schedule:
Burlington - Manchester - Boston
MSN:
47075/166
YOM:
1967
Flight number:
DL723
Crew on board:
6
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
88
Captain / Total flying hours:
14840
Captain / Total hours on type:
1457.00
Copilot / Total flying hours:
6994
Copilot / Total hours on type:
217
Aircraft flight hours:
14639
Circumstances:
As Delta Flight 723 was descending, the approach clearance was given by the controller after a delay, because the controller was preoccupied with a potential conflict between two other aircraft. This caused the flight to be poorly positioned for approach. The aircraft passed the Outer Marker at a speed of 385 km/h (80 km/h too fast) and was 60 m above the glide slope. The flight director was inadvertently used in the 'go-around-mode', which led to abnormal instrument indications. This caused some confusion. The first officer, who was flying the approach became preoccupied with the problem. The DC-9 continued to descend and struck a seawall 3000 feet short of and 150 feet to the right of runway 04R, crashed and caught fire. RVR at the time was 500 m with 60 m overcast. Two passengers survived, one died a day later while the second passed away on December 11, 1973.
Probable cause:
The failure of the flight crew to monitor altitude and to recognize passage of the aircraft through the approach decision height during an unstabilized precision approach conducted in rapidly changing meteorological conditions. The unstabilized nature of the approach was due initially to the aircraft's passing the outer marker above the glide slope at an excessive airspeed and thereafter compounded by the flight crew's preoccupation with the questionable information presented by the flight director system. The poor positioning of the flight for the approach was in part the result of nonstandard air traffic control services.
Final Report:

Crash of a Convair CV-880-22-2 in Chicago

Date & Time: Dec 20, 1972 at 1800 LT
Type of aircraft:
Operator:
Registration:
N8807E
Flight Phase:
Survivors:
Yes
Schedule:
Tampa - Chicago
MSN:
22-00-29
YOM:
1960
Flight number:
DL954
Crew on board:
7
Crew fatalities:
Pax on board:
86
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5500
Captain / Total hours on type:
2400.00
Copilot / Total flying hours:
3600
Copilot / Total hours on type:
500
Aircraft flight hours:
37640
Circumstances:
Flight DL954 from Tampa landed uneventfully at Chicago-O'Hare Airport. The crew was cleared to taxi to the gate and to cross runway 27L when the airplane was struck by a North Central Airlines Douglas DC-9-31 registered N954N. En route to Duluth via Madison, the DC-9 was carrying 41 passengers and a crew of four and his pilot just received the clearance to take off from runway 27L. One of the DC-9's wing struck the tail of the Convair that stopped immediately. out of control, the DC-9 veered off runway and came to rest in flames. The Convair was damaged beyond repair and the DC-9 was destroyed by a post crash fire. Among the 93 occupants on board the Convair, 10 were injured. Among the 45 occupants on board the DC-9, 10 were killed and 35 were injured, some of them seriously.
Probable cause:
Failure of the air traffic control system to ensure separation of aircraft during a period of restricted visibility. This failure included the following:
- The controller omitted a critical word which made his transmission to the flight crew of the Delta CV-880 ambiguous,
- The controller did not use all the available information to determine the location of the CV-880,
- The CV-880 flight crew did not request clarification of the controller's communications.
Final Report:

Crash of a Douglas DC-9-14 in Fort Worth: 4 killed

Date & Time: May 30, 1972 at 0724 LT
Type of aircraft:
Operator:
Registration:
N3305L
Flight Type:
Survivors:
No
Schedule:
Fort Worth - Fort Worth
MSN:
45700/11
YOM:
1965
Flight number:
DL9570
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
6220
Captain / Total hours on type:
845.00
Copilot / Total flying hours:
7800
Copilot / Total hours on type:
450
Aircraft flight hours:
18998
Circumstances:
The crew (three company pilots and a FAA pilot) were completing a local training flight at Fort Worth-Greater Southwest (Amon Carter Field) Airport. Following a normal approach to runway 13, the airplane passed over the threshold when it rolled left and right, causing the right wing struck the runway surface. Out of control, the airplane rolled to the right and crashed in flames. All four crew members were killed.
Probable cause:
An encounter with a trailing vortex generated by a preceding "heavy" jet which resulted in an involuntary loss of control of the airplane during final approach. Although cautioned to expect turbulence the crew did not have sufficient information to evaluate accurately the hazard or the possible location of the vortex. Existing FAA procedures for controlling VFR flight did not provide the same protection from a vortex encounter as was provided to flights being given radar vectors in either IFR or VFR conditions.
Final Report:

Crash of a Convair CV-340-38 in Evansville

Date & Time: Mar 20, 1968 at 2007 LT
Type of aircraft:
Operator:
Registration:
N4820C
Survivors:
Yes
MSN:
152
YOM:
1954
Crew on board:
3
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7000
Captain / Total hours on type:
2000.00
Circumstances:
En route, the crew informed ATC about the failure of the left engine and was cleared to divert to Evansville-Dress Airport for an emergency landing. On short final, the captain decided to make a go-around when the airplane stalled and crashed short of runway threshold. All 42 occupants were evacuated among them 10 were injured. The aircraft was considered as damaged beyond repair.
Probable cause:
Failure of the left engine in flight following the rupture of an exhaust valve in number 15 cylinder. The pilot lost control of the airplane when he started a single engine go-around and aborted.
Final Report:

Crash of a Douglas DC-8-51 in New Orleans: 19 killed

Date & Time: Mar 30, 1967 at 0050 LT
Type of aircraft:
Operator:
Registration:
N802E
Flight Type:
Survivors:
No
Site:
Schedule:
New Orleans - New Orleans
MSN:
45409/19
YOM:
1959
Flight number:
DL9877
Crew on board:
6
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
19008
Captain / Total hours on type:
475.00
Copilot / Total flying hours:
16929
Copilot / Total hours on type:
15
Aircraft flight hours:
23391
Circumstances:
Delta Air Lines DC-8-51 N802E was scheduled as Flight 9877, to provide crew training for a captain-trainee and a flight engineer-trainee. In addition the flight engineer-instructor was being given a routine proficiency check. At 23:14 a weather briefing was given to the instructor pilot, indicating, "... the only significant weather was a restriction in visibility which was expected to reduce to about two miles in fog and smoke near 0600...". The flight departed the ramp at 00:40 with the captain-trainee in the left seat and the check captain in the right seat. At 00:43 the crew advised the tower they were ready for takeoff and would "...like to circle and land on one (runway 1)." The tower controller then cleared them as requested. The aircraft was observed to make what appeared to be a normal takeoff and departure. At 00:47 the crew reported on base leg for runway 01, and the controller cleared the flight to land. A subsequent discussion revealed that they would execute a simulated two-engine out approach, execute a full stop landing and then takeoff on runway 19. The tower controller observed Flight 9877 in a shallow left turn on what appeared to be a normal final approach. The degree of bank increased to approximately 60° or greater when the aircraft hit the power lines approximately 2,300 feet short and 1,100 feet west of the runway threshold. The DC-8 crashed into a residential area, destroying several homes and the Hilton complex. All six crew members were killed as well as 13 people on the ground, clients and employees at Hilton Hotel. 18 other people were injured, some of them seriously. The aircraft was totally destroyed by impact forces and a post crash fire.
Probable cause:
Improper supervision by the instructor, and the improper use of flight and power controls by both instructor and the Captain-trainee during a simulated two-engine out landing approach, which resulted in a loss of control.
Final Report:

Crash of a Curtiss C-46 in Baton Rouge

Date & Time: Nov 24, 1964 at 1045 LT
Type of aircraft:
Operator:
Registration:
N9885F
Flight Type:
Survivors:
Yes
Schedule:
Atlanta-New Orleans
MSN:
32878
YOM:
1944
Flight number:
DL029
Crew on board:
2
Crew fatalities:
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7209
Captain / Total hours on type:
478.00
Aircraft flight hours:
19842
Circumstances:
Weather at New Orleans was below landing minima, so the flight was diverted to Baton Rouge. Weather at Baton Rouge was a ceiling 300 feet overcast, visibility 1,5 miles in light rain and fog, wind 360deg/5 knots. Runway 13 ILS minima were 300 feet ceiling and 3/4 mile visibility, weather was below circling minima. However, the approach was continued and the plane touched down fast 2,500 feet past the runway threshold. Approaching the end of the runway, the pilot attempted to ground loop, but the plane just turned 20° and slid off the runway. Both pilots were evacuates while the aircraft was damaged beyond repair.
Probable cause:
"Failure of the captain to execute a go around during a landing overshoot under existing unfavourable wind and adverse runway conditions. Ineffective braking caused by hydroplaning. The copilot completed the approach and the captain took over control after touchdown.
Final Report:

Crash of a Douglas DC-7 in Chicago

Date & Time: Dec 16, 1961
Type of aircraft:
Operator:
Registration:
N4871C
Survivors:
Yes
MSN:
44261
YOM:
1954
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed on landing for unknown reason. There were no injuries among the occupants while the aircraft was damaged beyond repair.