Transcript for:
Legacy of American Airlines Flight 191 Crash

it's the worst single plane disaster in american commercial aviation history total loss of control the airplane crashed approximately 30 seconds after takeoff 273 people 271 on the plane and two on the ground were literally vaporized its effects are still felt by the families of the victims clear for takeoff there is no closure there is no such thing in the long run it served to fragment our family it's the crash of American Airlines flight 1 191 the crash of 191 just wasn't another story it was great Intrigue and unfortunately it was tragic Opera 25th of May 1979 2:45 p.m. a warm spring afternoon in Chicago Illinois the Friday before a holiday weekend and the roads were jammed with people people anxious to get away for a little rest and relaxation for most of these people it was a day more or less like any other but in just a few minutes for some things would suddenly change forever 153 2:55 p.m. ohare international airport it's a 3-day weekend and of course in Chicago O'Hare was crowded with people trying to head out to go to their vacation spots with that 3-day getaway aboard American Airlines flight 191 the pilot Walter H Lux co-pilot James R Dillard and flight engineer Alfred a udovich finished going through their pre-flight checklist they were preparing to fly their dc10 widebody aircraft on a routine trip from Chicago to Los Angeles between them they had over 46,000 hours of flight experience also aboard were 10 flight attendants and a full load of 258 holiday passengers among them was Richard forstrom age 36 a biomedical engineer he' been to a conference in Las Vegas and then he was in Toronto at a university um at a business meeting and he was on his way home another passenger was Terrence ktie a 53-year-old executive with the United States gypsum Corporation he was on a business trip to Chicago and as far as I remember he actually cancelled an earlier flight because he had relatives in Chicago he wanted to have dinner with or see so he came or was scheduled to come back home the next day also aboard flight 191 was Leonard stoel a 45-year-old rock music promoter from Los Angeles returning home to fulfill their family commitment he had a date with his son Gregory and he wanted to get back at a certain time for the holiday memor Day weekend there was one seat left and Lenny got on the plane9 take off 2:59 p.m. the weather in that sunny afternoon was perfect with a visibility of 15 Mi as the plane pushed away from the gate and taxi to Runway 32 right at 14 confirm heading 170 clear for takeoff 3:2 p.m. flight 191 was cleared for takeoff and began its takeoff rle 191 underway just as the plane lifted off the huge engine and its attaching pylon assembly which was slung under the left wing lurched and broke free it came over the top of the wing and landed onto the runway as it did that it took out part of the uh leaning edge of the wing about a 3T section the flight crew didn't know that they actually lost or the engine separated from the airplane they just knew that they had an engine failure in the cockpit the voice recorder picked up a single word d and then went dead in the control tower the air traffic controller saw it all look at this look at this equipment equipment BW American 91 heavy you want to come back in what Runway but the pilots didn't answer in fact the pilots never radiated an emergency they were too busy just trying to control the plane despite the terrible damage the pilots Were Somehow able to control the aircraft pulling it up to an altitude of 300 ft where flight 191 started rolling to the left and eventually rolled 112° to the left and then Dove 21° nose down 3:04 p.m. just 31 seconds after becoming Airborne flight 191 plunged to the ground 4,600 ft from the end of the runway an eyewitness to the event took these heart stopping photographs the crash destroyed a hanger and part of a caravan Park [Music] it was an inferno and in one instant 273 people 271 on the plane and two on the ground were literally vaporized it was the largest loss of life in a single plane accident in US [Music] history within minutes phones were ringing across America among the first to be notified were members of one of the national Transportation safety board's Elite go teams the go team which typically resides in Washington DC consists of a senior air safety investigator as the iic or investigator in charge and he's accompanied by team members which are specialist in specific areas such as operations structures systems power plants weather Air Traffic Control survival factors all of these team members comprised the go team officials at the Federal Aviation Administration were also a large part of the investigation Charles Foster was the faa's associate administrator for Aviation standards at the time attending a conference in Montreal it was about 4:30 in the afternoon and a secretary in the US office there came down and had me a slip of paper and on it it said call your office immediately I call my office in Washington DC fa headquarters and I was told that we had had an accident in Chicago of a dc10 it appeared all people were killed the administrator was on his way there and he wanted me to join him so about 6:30 that evening I was on a flight from Montreal to Chicago and it was quite an emotional flight to sit there and realize that my responsibilities in the fact I was now going to an accident where so many people have been killed within hours and PSB and FAA investigators were on the scene combing through the smoldering wreckage of flight 191 looking for Clues one of the big things with launching a team on a major investigation is to get them on scene and established as soon as possible to get the investigative process going as quickly as possible the concern of course is that you have multiples of people that you have to deal with you have hundreds of people that come together in a very short period of time that are going to basically coming together for the first time under the most adverse or tragic of circumstances you got to get them organized and focused and the process begun to get this investigation going in the meantime phones were also ringing at American Airlines when you lose an airplane everybody wants to know immediately because at that point it's how does the airline recover as fast as they possibly can from a public perception point of view also notified were Executives of McDonald Douglas the manufacturer of the dc10 and at us Aviation Underwriters the insurance Consortium that covered American Airlines for liability in case of an accident how are they then going to handle all the wrongful death cases that were then going to be filed at least 273 of them from the passengers the crew and the people on the ground well they swung into action the lawyers who might be filing the wrongful death suits on behalf of victims and their family members also not not the crash one was Gerald Sterns among the best in the small fraternity of lawyers who specialized in aviation cases we finished up with the Paris dc10 and a couple of others so uh I I thought right away there's got to be something you know to hear that would be of interest in fact flight 191 was the fourth fatal accident involving a dc10 since its introduction in 1971 and the plane was a major carrier of passengers around the world the reaction of the public and news media to the accident was extraordinary the public reaction was as you might suspect huge and negative so the dc10 was already much in the news by the time of the May 25th 1979 crash in Chicago everybody thought this time it was a defect with the plane devastating news to McDonald Douglas in engaged in an intense competition with Rivals Lockheed and Boeing for the line share of the World Market in widebody Jets but all this pales in comparison to the devastation felt by the families of the victims Marlene forstrom received a visit from one of her husband's co-workers and so it was kind of like oh gosh what are you doing here Mike and then I knew what he was doing there I you you know I knew my husband was flying and I you know I just turned to him and said did the plane crash I was ironing and had the television on and they interrupted the program and they told about the crash out of Chicago I called his office to find out you know what if they knew what flight he was going to be on and the secretary said they didn't she didn't know but she would check and call me back and she didn't call back for a long time and when she did she confirmed it Daniel ktie the youngest of Dorothy and Terren Katie's four boys was 15 at the time it was my dad's birthday and I walked into the house and it was a very odd scene because on one side of the house there were presents for my dad's birthday and on the the other side of the house was a set of grieving people and of course it's just surreal look at they wrote they wrote on every page for Stanley stole the call he received from Leonard's girlfriend to tell him of his brother's death was tragically familiar 17 years before he had received a similar call my parents were coming out to visit us from New York on March 1st 1962 and they were on American Airlines flight one and that plane took off turned over and crashed into Jamaica Bay killing all 94 people on board that plane while the families of those on flight 191 tried to absorb their shock and grief the pressure on the key players in the investigation began to mount you had an airline that was trying to win the battle on the transcon routs in the United States you had a manufacture were involved in a heated battle to win the widebody construction race against lock and Bowen all of these combined and it didn't go away with questions about the safety of the dc10 looming investigators with the FAA and NTSB also felt the heat which was building an intensity there's the B there's a nut still attached to part of the B this is the ca 26th of May 1979 less than 24 hours since the crash of American Airlines flight 1 191 at Chicago's oare International Airport in which 273 people were killed as the investigation pressed forward the media Spotlight intensified on the [Music] crash due to the magnitude of the disaster the investigation team eventually included well over 100 people from the NTSB the FAA and Private Industry including American Airlines and McDonald Douglas these groups were also represented on the NTSB go team Des ATT to the scene at the airline of course they're part of that go team the engine manufacturer they're part of the go team the actual airplane manufacturer they're part of the Go Team every subcontractor they're part of the go team they allow these people to be on go teams for an understandable reason because they're the people who understand the mechanics the physics the chemistry uh of the individual items that they manufactured they can actually be helpful in an investigation they can also be a real hindrance if the investigation turns in their Direction many in the NTSB and FAA however saw this practice in a different light some people may think well yeah because they manufactured something then they're going to make sure that they defend their position well I tell you that the other side there the guys that operated airplane are going to defend their position too so there is an adequate interplay there to get to the truth so it was a natural system of checks and balances you got a lot of information you had everybody look at everybody else they would provide information that you may not normally get if you were trying to do that investigation by yourself but it wasn't the only potential division within the investigative team there was also a difference in the roles of the FAA and the NTSB the national Transportation safety board basically is the investigative portion of the of the accident and then the um the Federal Aviation administ ation in this case uh if it's an aviation accident would be the regulatory agency the NTSB had only one mandate to investigate an accident and determine its probable causes then recommend the necessary changes to prevent a similar disaster from occurring again these guys have the hardest job they do the hardest work under usually very terrible conditions to what it's CSI time they have to find the cause no matter what without without allegiance to politics or lobbying or or or financial pressure but at the time of the crash of Flight 191 the FAA had a dual function historically the FAA has had an impossible job in fact a schizophrenic mandate it was given that mandate by an act of Congress to do two things to make and enforce policy safety and regulate the Airlines and then at the same time to promote the business of Aviation a lot of people have fell there's a big conflict there however personally I never see any conflict to me the way you promote Aviation is make it as as safe efficient and effective as it can be ultimately it was at the faa's sole discretion whether or not to implement the recommendations made by the NTSB in their investigations many critics of the FAA have claimed over the years that the agency has a tombstone mentality that there know they know there's a problem they know the causes are there and yet they don't react they don't actually proactively make policy they wait till after people die but by the same token the faia has to be very very careful and cautious because a lot of times people can propose things that you may find out that there's some other factors related to that proposal that are not in the safest thing to do and I think this is what's happened in the past when the ntsp would make some recommendations the fa would not immediately adopt no matter what their affiliation however all the people involved in the investigation felt a tremendous sense of urgency to find the reason for the crash quickly through the process of elimination they were soon able to rule out several factors there was nothing about the pilots that indicated pilot era there was nothing about weather there was nothing about any other planes in the area there was nothing any about fuel there was nothing about any kind of terrorist activity they could rule all that out now the question really was what could they rule in how many Sunday 27th of May 1979 Elwood Woody driver the head of the ntsb's investigative team held a press conference on display was a broken bolt found along the runway near the wreckage of flight 191 he announced that they had identified the probable cause of the engine loss any other [Music] questions it appeared that the major cause at that time was due to a bolt that was one of the critical elements of attaching the pylon to the wing itself and Woody indicated that this was what had actually caused the accident well thank you very much we'll try to then just as the press conference was winding down an ntsp metallist named Michael Marx arrived he was not part of the original go team and was only asked to help with the investigation the evening after the crash and I went into the auditorium and just went over to to the table and sat down and that's when Bob Gordon who happened to be the structures man gave me this bolt underneath the table and whispered in my ear said what do you think Mike and I took a look at the bolt and I I don't remember my response to him but it was something like so what Marx could tell almost at once that the bolt was not the cause of the accident that it had broken as a result of the crash but there had been no other metallist on the go team to determine this is a a classic example of what not to do in an accident investigation to jump to conclusions in the beginning without substantiation you can't really speak second day into an investigation when you haven't had an opportunity to get all the information what he was I think very interested in finding out what the cause the accient was and I think that he latched on to the fact that it was that boat in his defense he gets his information from the people that are surrounding him so if there was an implication to him that this bolt was a cause then that's how we got to that point mark convinced dri to cancel a planned appearance the following morning on the Today Show but the damage had been done you can imagine what it was like I mean ABC NBC CBS everybody was there all the locals people from foreign they were just going bananas with with this information in the mind of the public the worst fears about the safety of the dc10 had been confirmed everybody immediately said aha we know what happened it was a design flaw it was a construction flaw these bolts were the cause some of the victim's families already had doubts about the dc10 I wasn't surprised that somebody would come out and say that I didn't know if that was the real cause of the accident that could have been one reason it could have been another reason but I did hear about that and I wasn't surprised others were hardly aware of the investigation for understandable reasons in my 15-year-old world how it unfolded was something that it's not that it didn't concern me but I really didn't understand it all I knew is that something horrible had happened and we were simply waiting to see what the result would be it didn't matter you know he he was dead so you know why it crashed and and what caused it is is interesting but it wasn't going to bring him back meanwhile on the 28th of May 1979 the FAA ordered a fleetwide inspection on all dc10 Pyon attachment bolts we're concerned about was the bolt properly installed was it not properly put on the boat was it properly secured and so forth as the inspections of the pylon attachment bolts continued Engineers of McDonald Douglas poured over the blueprints of the dc10 desperately trying to prove that it wasn't the bolt or any other floor in the design of the plane that led to the accident despite the focus on McDonald Douglas another internal inves ation was also being conducted at American Airlines Donald Lloyd Jones American Senior Vice President of Operations audited a report on the airlines maintenance practices including those used on the crash dc10 the search took Americans investigators to the company's main maintenance facility in Tulsa Oklahoma in this case the report that was asked for by Donald Lloyd Jones and American Airlines was done by a man named Mac eastburn what happened to the eastburn report became one of the most explosive ly controversial aspects of the entire investigation May 28th 1979 3 days after the crash of Flight 191 in Chicago Illinois as the investigation into the causes of the disaster continued American Airlines Financial Officer John salvio was in a warehouse outside New York doing some digging of his own into the immediate cost of the crash to the airline well the books for that particular plane weren't in New York City they were out in Queens and some Warehouse so John svaj is pulling the numbers on the books they're looking at all the financial variables here as to how much they lost in the actual loss of this airplane and they came up with a couple of totals and they said wait a minute there's something wrong here with these numbers let's run them again they ran them again they ran them a third time they could not believe what they were reading but you know what the numbers didn't lie and the chairman of the board said well how bad is it salvagio told his boss that incredibly American Airlines had actually made a $25 million profit as a direct result of the crash it happened because they had the plane insured for full replacement value within 72 hours of the crash of Flight 191 Executives at American Airlines received a check from their insurance company for nearly $50 million to cover the loss of the dc10 due to the effects of inflation this was nearly twice what they had paid for the plane in 1972 at almost the same time us Aviation Underwriters were taking action of another kind they got the passenger manifest immediately from their client the airline and within 24 hours letters were written to the victim's families and each letter basically said the same thing we want to share our sympathy we lost people too we're going to take care of everything for you don't hire an attorney of course we felt they were extremely misleading for a whole lot of reasons basically what that letter is doing it's giving legal advice to a potential adversary and it's also practicing law without a license and we thought it was improper and we actually uh took them on in the Federal Court in Boston I tried to get a restraining order from the multi-district judges to stop this letter from going out but they turned me down among those who received this letter was the family of Leonard stokel Lauren and Gregory did receive a letter stating that American Airlines would take care of you you don't have to go to an attorney but for the stuggle the promising words in USA's letter rang Hollow because of another letter they'd received 17 years earlier in the wake of the 1962 crash that killed Stanley and Leonard's parents it was almost the exact same letter I didn't believe a thing they said the reason being is when I went to the airport to go to New York as soon as we found out about the crash I went up to the counter and I said my name is Stanley stole my parents are on flight one and they said I would have to pay for my ticket and I said what I also paid for my flight when I had to go home after that I knew that I I couldn't trust them so I had to turn it over to the attorneys and let them handle it Tuesday 29th of May the first business day after the crash the stule lawyers filed the first of what ultimately became scores of lawsuits against American Airlines and McDonald Douglas of course obviously the families need time to react but I would say within a month or so we started getting inquiries uh my brother uh who lived in San Francisco area was in business and he called me and said he knew an attorney who specialized in this field and uh he recommended him to me and so I called him and he came down talked to us and um that's how we get started while the legal system was guar up metallist Michael Marx of the NTSB was moving forward with his part of the investigation ironically the continuing media tension on the broken pylon attachment bolt actually helped marks in his search for the true cause of the accident there was a blessing in disguise to me because uh the focus was no longer directly on me or on that on any other part of the investigation so the news media would leave me alone in this case I was able then to look at other components sifting through the wreckage marks turned his Focus to the pylon of the left engine I could see a suspicious fracture that was in the back of the pylon it was puzzling it had an area in there that had what appeared to be very high stress type of fatique cracking and it had an overstress fracture and it it didn't make a lot of sense the crack itself was in the rear bulkhead of the pylon the same place where the broken bolt that Woody driver displayed during his press conference came from soarks took the bulkhead and heads to the NTSB metalogy lab in Washington DC at American Airlines almost 36 hours had passed since senior Vice President of Operations Donald Lloyd Jones ordered the internal investigation into the maintenance History of Flight 191 he read the written report of the investigation called the eastburn report and was shocked by its contents the report was so potentially devastating to American Airlines that on advice of the attorneys American Airlines shredded the report Chicago Illinois early June 1979 less than a week after the crash of Flight 191 at O'Hare International Airport lawyers for American Airlines and McDonald Douglas started gearing up for a major Showdown they were preparing to do battle over who should pay the greater part of the settlements in the flight 191 lawsuits the Airlines and the manufacturers realize that the worst thing that that could happen to them would be to get into a courtroom battle with a bere family and a competent lawyer where the the airline and the manufacturers are fighting with each other that's that's very bad from their point view they're just going to get an inflated aggravated award so they started working on what are called sharing agreements but initially American Airlines refused to participate in a sharing agreement with McDonald Douglas demanding instead that McDonald bear the entire cost of the settlements however as the dispute ground on someone leaked word to McDonald Douglas of the existence of the eastburn report so McDonald Douglas goes to federal court in Chicago because that's where the crash happened and subpoenas the eastborne report American Airlines attorneys go up in court and their first response is we don't know what you're talking about McDonald Douglas says what are you talking about we know there's a report American goes well we'd like to amend our position you see there was a report but now there is no report and the judges said excuse us what happened to the report well it was destroyed the judge order Donal Lord Jones The American Airlines executive who commissioned the East Ben report to testify under oath as to its contents but lawyers for McDonald Douglas also pursued another Avenue knowing the report had something to do with maintenance done on flight 191 just prior to its fatal flight they hired private detectives in Tulsa Oklahoma the site of American's main maintenance facility and they basically map out all over Tulsa and find out okay who did the engine change what are their names we want to talk to them and they found him eventually over 150 American Airlines employees were subpoenaed by McDonald Douglas to give depositions in the case one of them was a supervisor at Tulsa named Earl Russell Marshall in the meantime the families of those killed on flight 191 were facing their own legal ordeal as their lawsuits moved forward in the coming months they confronted issues they never could have imagined well it wasn't a happy time that's for sure I felt U I felt like we were on trial instead of the Airlines and I thought the airlines should have been on trial this set of lawyers decided that their best way of pursuing the case was to show that my father was a bad father that he was worthless for example they asked me questions about how involved my dad was in my life I played Little League Baseball how often did he come to the games was he enthusiastic about my baseball playing they asked my mom questions about their sexual life and whether they were happy that way what they were trying to prove as far as his worth as a financial provider I don't know but I think that they were also trying to show that he was not only a bad father but he was a bad husband so from the very beginning as far as the lawsuit went my part of it was trying to figure out what the value of his life was I had to sit down and figure out how much we spent on dry cleaning how much he spent on lunch how much he spent on gas going to work and back just how much of our family income was spent on him and that's what the loss it was about while the legal side of the case began to unfold NTSB Metalist Michael Marx was in his lab in Washington DC carefully Examining The Cracked pylon Bulkhead from flight 191 basically you you examine the fractures with the with microscopes they have various types of microscopes you have a what we call a bench binocular microscope eeral microscope and you look at these components underneath it you can do other tests at this particular time that's mainly what was happening the fractures were in a part of the bulkhead called the flange this flange was fractured and it showed evidence of a large 10in size fracture and then very small areas relatively speaking of what appeared to be a higher stress fatigue Zone and that means it's repetitive stresses that are producing the fracture those zones were only about 1 and 1/2 in on each side so we had a total fracture in that area that that was about 13 in what's more marks could tell that something had produced the original fracture prior to the crash because of the stresses on the pylon during takeoff the crack suddenly expanded ripping open causing the engine pylon assembly to tear away from the plane the real puzzling part was why do we have this this fatigue and why do we have this overstress we got something here that basically is not explained by normal fracture mechanism so it's got to be some kind of a fracture that occurs for some other reason well my supervisors had some information that they suspected it might be maintenance related so they went to Tulsa Oklahoma both the NTSB investigation and the legal inquiry surrounding the crash of Flight 191 eventually converged on tala what was finally revealed there shocked the world of commercial [Music] Aviation 6th of June 1979 12 days after the crash of Flight 191 the FAA took the unprecedented step of grounding the entire fleet of dc1s in America a total of 138 planes the order affected hundreds of thousands of the traveling public and cost the airlines involved millions in Revenue than [Music] you it had never happened before to an American Fleet every dc10 in this country or any dc10 trying to fly to the United States could not do so the economic impact was huge and at McDonald Douglas it was devastating within days they started losing order after order after order for new dc10 every day the dc1s were not flying the cost and the pressure grew it was a very dramatic action we had a lot of questions a lot of concerns about the grounding the airplanes why we did it we had criticism from many sources the process that led the FAA to take this Monumental step was intense a major factor was what was discovered in the days prior to the grounding at American Airlines maintenance fa facility in Tulsa Oklahoma during the first week of June NTSB investigators searched through the maintenance records of the dc10 that became flight 191 and began to form a theory about what caused the crack in the pylon bulkhead I remember getting a call that was on Saturday morning do you think that this could be the result of a maintenance operation such as if you remove the engine or put the engine back on and it all dawned on me just as clear as could be that yes I said not only could it be but I can prove it because there was a deformation that was occurring right at the very top of this where the mating clevest where the engine and the pylon come together as if the cevis had impacted that area and had produced the downward motion onto the flange that caused the crack in order for the CL us to go down and make an impact it had to have been disassembled at the time when that impact occurred that cevus would not normally be at that position so it just became crystal clear right at that very moment the damage occurred almost 2 months before the crash when during a required repair flight 91's left engine pylon assembly needed to be removed maintenance procedures prescribed by McDonald Doug call for mechanics to First remove the engine from the pylon then remove the pylon from the wing but in an effort to save time and reduce the possibility of errors in reconnecting the various components mechanics at Tulsa plan to remove the engine and pylon as a single unit using a forklift to support the assembly as it was being disconnected from the wing McDonald Douglas was aware of the procedure but did not approve of its use because if the forklift truck isn't perfectly aligned with the engine if it's not perfectly pressurized by the hydraulic system of the forklift truck the engine won't be properly fastened and you could do damage to the engine or the wing however since maintenance of an aircraft is the exclusive responsibility of an airline McDonald Douglas had no authority to stop the practice American Airlines as with any airline has the authority to based on their experience in service experience modify a manufacturer's maintenance procedure and it can be done without FAA approval what's more American was using this one-step procedure on all of its dc1s and on this particular aircraft it was back at the Tulsa maintenance base for its when required maintenance procedures 30th of March 1979 after a forklift was positioned under the engine maintenance Personnel disconnected the rear attachment point of the engine pylon assembly but before they could remove the front attachment bolts the workshift changed and while they were gone the hydraulic pressure in the fork clip had a leak in it or changed and it tilted the pylon which they didn't see this caused the rear attachment point of the engine pylon assembly to jam back up into its fitting on the wing cracking the rear bulkhead of the pylon the new workshift didn't notice the damage which occurred inside the pylon and finish what they thought was a routine repair during subsequent flight the crack in the bulk had expanded until that fateful day in Chicago when it completely ripped open causing the engine pylon assembly to tear off the plane but this wasn't the end of the story for during the ensuing inquiry investigators discovered that two other airlines continental and United were also using a one-step engine pylon removal procedure although United's methods employed an overhead crane instead of a forklift the FAA ordered emergency inspections of those Airlines dc1s at first the inspections found nothing out of the ordinary but by now there was another factor in the case we had had a suit file against the FIA by the airline passenger Association recommending that we ground all the dct1 I was prepared to sign an affidavit the next day to send back to the judge stating that we had adequate precautions in place that we were making inspection and there nothing wrong is for a safety of the aircraft Foster also testified before a congressional committee saying that as far as the FAA was concerned the dc10 was safe in fact on the way back to the FAA I mentioned my colleagues that I felt comfortable for the first time that we really had a handle on what was going on about 9:00 that night I get a call from the one of the people in the fa headquarters and told me we had a report from San Francisco Cisco that a dc10 pylon had a crack in it and it was a aircraft that had been previously inspected I come into the office and say I want to talk to the person who actually saw the crack the United Airlines maintenance worker confirmed the existence of the crack and that it was Major but it was in a place that couldn't be checked easily then we got together in a headquarters there trying to decide what do we do now here we were we had a United Airlines problem we had not solved yet we had a lawsuit from a judge we we could not go the next day I certainly was not going to sign anything saying we knew what was going on on dc1s I'd been up on the hill and told the Congress that we had a good handle on it and then we decided at that time several of us that we were going to have to ground the airplanes after clearing the decision with the head of the FAA Langhorn Bond and Brock Adams the Secretary of Transportation who are both overseas at the the time Foster picked up the phone and began the process of grounding the dc10 I called president of the dougas aircraft company as I set my office I looked up at the clock it was 4:04 a.m. I'll never forget the minutes actually when I called and told him that we're going to take some action it took probably the most guts by a person in the FAA in the dark of the night to determine and decide that they were going to ground that airplane there were so many influences there was so much pressure both ways by the NTSB to ground it by the industry to keep it flying it was a very weighty decision and in the long run I think it was the right decision that he made Marlene forstrom was aboard a dct1 with her two small children traveling to a memorial service for her husband Richard on the very day the planes were grounded Angela forstrom was 7 years old at the time I remember being scared to fly obviously because my father had just been killed in an airplane crash and then being on this plane and it taking a really long time you know that we were having to sit on this plane and not knowing what was going on and then eventually getting the news that we were having to be taken off the plane because of the fact that it was a dc10 and it was being grounded for safety reasons and my mom got very emotional and of course whenever I saw my mom cry it immediately made me cry so I remember just being really up upset about having to get off the plane and having to kind of relive again this trauma and having to talk about it and experience it I had people ask me about you know what in the world was I doing Flying the dc10 um in the first place and it was sort of like it was the convenient time to fly my husband was already dead if that one crashed too you know what we'd be with him for many of the other families of those killed aboard flight 191 the revelations about the faulty maintenance practices on the dc10 were devastating when we found that out we were absolutely taken back about the entire story it hurt us it it really it was shocking to [Music] us it was shoty maintenance on a on American's part I think it goes to the idea of accountability and cutting Corners you have a company and a culture perhaps that simply cut corners and it had tragic tragic results eventually six other dc1s four with American Airlines and two with Continental were found to have pylon cracks caused by the faulty maintenance procedures they were repaired in the weeks ahead before they too could cause catastrophic accidents nonetheless the pressure to put the dc1s back in the air quickly was intense the lobbying efforts of McDonald Douglas at this point to the FAA were saying you are ending this company as a as a financially viable institution if you don't let us fly these planes with the dc1s on the ground Airlines were starting to hurt so the airlines started lobbying for it just to be able to get their planes back in the air they had nothing to replace the dc10 with but the FAA was determined to make a thorough inspection of the entire dc10 fleet before allowing the planes to fly again we had a outside independent organization actually do a risk analysis of of all the things that were related to different kinds of systems on the airplane far and above what we would normally have done in a normal certification of an aircraft because we wanted to make sure if there's anything wrong with this airplane that we we would find it for some of the victim's family members however even these safeguards were not enough my reaction was that I would never set foot on one I mean I hope they were safe but my feeling was that I I wouldn't want to be on it or any of my family to be on it I thought that the DC 10 should be taken out of service completely 13th of July 1979 36 days after the dc10 was grounded all the cracks and the damaged aircraft were repaired and the faulty maintenance procedures halted the FAA lifted its ban and the dc10 took to the air once again but this did not solve all the problems with the dc10 for incredibly the engine falling off was only part of the reason flight 1 191 [Applause] crashed the investigation into the crash of Flight 191 on the 25th of May 1979 was one of the most difficult and heavily scrutinized ever undertaken by the FAA and NTS be part of the reason was the horrible toll in human life another was the nearly complete disintegration of the airplane on impact making the Gathering and interpretation of evidence extremely difficult so it should be pretty pretty accurate data even so investigators were able to piece together a detailed timeline of exactly what happened to the dc10 after its engine and pylon tore off during takeoff this initiated a complex sequence of events which ultimately doomed the aircraft see what happens that engine fell off and that's what engines are supposed to do if they're in trouble they're supposed to detach themselves from the airplane because they are more dangerous attached to the wing and vibrating big time than if they just drop off but in the case of flight 191 the engine did not come off the plane cleanly it also ripped off a 3-ft section of the left Wing's Leading Edge as the engine came off and tore out the front part of the wing it took out the hydraulic systems that were all in there and the hydraulic systems are used to maintain the slats the slats are used for extending the wing in other words you as it goes out in front of the Wing makes a bigger air foil and therefore produces more lift on the wing at a slower speed this wouldn't have caused a problem as all commercial airliners are designed with backup systems in case a primary system is lost but McDonald Douglas Engineers had rooted both their primary and secondary hydraulic lines through the same place as a result both were lost when the engine tore off the plane this design of the cables for and hydraulic system had come up from the dc9 it was a continuation of design that they had had and had been very successful and the fa had to prove that there was nothing unusual or or unsafe at all about having that type of a design and having it operate in the same location from their position in the cockpit the pilots couldn't see that an engine had fallen off the plane all they knew was that they had suddenly lost power in their left engine so they initiated the prescribed emergency procedures for a power loss on takeoff another problem was that the engine loss had cut a crucial portion of the plane's electricity which came from a generator driven by the engine did it knocked out the Pilot's flight instruments and so the and it so happened the first officer was flying the airplane of critical importance was a device called a stick Shaker this actually makes the Pilot's control stick shake when the plane is nearing a stall which is a condition where the wings lack the lift to keep the plane in the air although the co-pilot's instruments were functional he lacked a stick Shaker at that time when the airplane was manufactured it was a customer option to have it mounted on the first officer side American Airlines didn't exercise that option so the stick Shaker only resided on the captain's control column despite the severity of the problem the co-pilot James Dillard performed perfectly flying the plane exactly as the emergency engine out procedures dictated one of these required him to fly the plane at takeoff speed called V2 and that's the speed that you fly at if you lose an engine to give you the best climb rate so to miss any obstacles near the airport and the procedures always up to that time was that once you lose an engine on take off you go to V2 speed so as the crew took off and they knew they had a problem uh their immediate reaction must go to V2 speed and it so happened that they were above V2 speed at that time Dillard pulled the nose up causing the speed of the plane to reduce slightly to V2 but what he didn't though was that as the plane climbed the hydraulic fluid in the left wing was slowly bleeding off and a result of that the pressure to keep the slats out was lost this caused the slats on the left wing to retract so you lost essentially some part of your wing and as as such what happens is that you lose lifting power so you have to go faster to maintain the lift as the left wing lost lift it began to dip nearing the threshold of a stall so now the stall speed of that Wing had changed compared to the stall speed on the right wing so as they went from the speed they had down to V2 speed they went through that through that stall speed of a wing with slat in and so the left wing stalled normally the pilot would be warned of this through his stick Shaker but in this case the co-pilot Dillard was flying the plane and didn't have one when it stalled the airplane just rolled over and went straight down in had they not reduced the speed had they maintained the air speed they had they could have flown the airplane out but with the power to many of their instruments cut off by the engine loss first Officer James R Dillard and Captain Walter H Lux had no way of knowing their plane was entering a stall until it was too late had the pilot been able to get the stick Shaker and install warning he would have probably pushed the nose over and before it ever slowed up to the point that he was going to lose the lift on the left wing ultimately the NTSB listed several factors as a probable cause for the crash of Flight 191 it also made several recommendations to correct those problems just how those recommendations were addressed would affect the potential safety of millions of people around the world were extraordin 21st of December 1979 nearly 7 months after the worst single plane disaster in US aviation history the crash of flight 1 191 at Chicago's O'Hare International Airport the national Transportation safety board released its final report on the accident among the causes it cited were improper maintenance procedures which led to the failure of the pl's pylon structure the vulnerability of the dct1 10's Leading Edge slat system to catastrophic damage and the inadequacy of the engine out takeoff procedures used during the emergency one of the contributing factors was the faa's lack of oversight and ability to identify and Report deficiencies from maintenance actions that could cause or contribute to the failure of a component part and lead to an accident the NTSB proposed numerous changes to correct these problems virtually all of them were adopted by the FAA which had final authority over whether or not to implement the ntsb's recommendations but one thing that neither the NTSB nor the FAA proposed were any design changes to the hydraulic system or the wing slats on the dc10 citing the extraordinar small chance of a similar accident never occurring again and the controllability of the aircraft even without wings slat Hydraulics as long as it was kept above stalling speed the FAA instead mandated other modifications we changed immediately the requirement that you go to V2 speed stating that if you're above V2 speed you stay there up to 10 knots over V2 speed another change was in the store warning system of the dc10 after this accident it was required to have a stick Shaker installed on both control columns and that that stick Shaker had to be independent of each other that is a total different electrical system would operate them independently so in the event of a loss of one electrical system the electrical system on the number two side or the good side would still be able to fire the stall warning system however since the faa's authority only extended to America all it could do was advise foreign carriers of these recommendations nevertheless officials believe that all foreign operated dc1s have been fitted with the new equipment as far as the compliance with air Wellness directors that the fa put out dealing with things that came out of the accident of the dct1 uh obviously we're all complied with with any aircraft that's on the US registry and I feel confident that same applied that dc10 operated in M Foreign Registries 25th of March 1981 almost 2 years after the crash of Flight 191 Earl Russell Marshall one of the American Airlines maintenance Personnel subpoenaed by McDonald dougas in their dispute with American over who would pay the bulk of the wrongful death settlements was scheduled to give his deposition in the case the following day his wife finds this guy slumped in his car in their garage dead at the wheel the coroner ruled it as carbon monoxide poisoning suicide ironically it was that point that motivated American Airlines to then call the McDonald Douglas lawyers and say okay let's now share liability in these cases McDonald Douglas then ceased its pressure to see what was in the East Ben report and the whole issue was quietly dropped its specific contents are still [Music] secret yet while the agreement between McDonald Douglas and American Airlines was completed within 2 years the lawsuits of the relatives of those killed on flight 191 ground on the law cases that related to the crash of all the victim's families went on for over 9 years and the reason for that in this particular crash and every other crash is there is no provision in any state law for the awarding of prejudgment interest in wrongful death cases it's a horrible horrible process it's demeaning um there is no thought of the people involved it is about the attorneys and the court system um it's it's I wouldn't wish that experience on anyone I've gone through this twice each time it was agonizing I am no attorney I can only tell you I was very disappointed with the settlements and I didn't have any respect for the legal system how took place estimates as to the amount of all the settlements made in the crash of Flight 191 run as high as $ 100 million but the exact cost remains unknown that is a very close kept secret with the insurance industry you have to understand how the insurance works with paying these cases off the last thing they want is for it to get out in the general public what they have paid to settle certain cases while American Airlines were shielded from direct liability by its insurance carrier the consequences for McDonald Douglas were devastating orders for the dc10 dried up almost immediately after the crash and never returned to pre- crash levels as the orders dropped down the assembly line slowed down McDonald Douglas had nothing left to do except to make another version of the dc10 called the md11 which was not successful they tried to extend the fuselage of the dc9 with the MD80 81 82 83 86 by that time they just couldn't compete anymore and they were ended up basically being bought out being absorbed by Bowen the effect on American Airlines was far less severe the FAA fined the airline $500,000 for improper maintenance a huge amount in 1979 and business was understandably slow in the months immediately following the crash but it came back strong and today American is still one of the most successful airlines in the world the dc10 is still flying today carrying Freight in America and passengers overseas after the problems that plagued the aircraft during the early years of its service since the crash of Flight 191 in 1979 it has a generally excellent safety record the best way to characterize any aircraft that has an inservice use is that it's like wine they get better with age why because we get a better understanding of the airplane we identify the deficiencies we correct them so over that period of time the airplane becomes better 25th of May 2004 marked the 25th anniversary of the crash of Flight 191 but for the families of the victims even the passage of a quarter of a century has done little to dim their memories there is no closure there is no such thing you know it's it's probably the worst used phrase in the world today you know it never hurts less it just hurts less often for a short period of time it brought our larger extended family together but I think in the long run it served to fragment our family my brothers literally moved all over the world whether to escape or to find something I don't know we loved Lenny we miss up he had a great career going and it ended abruptly I feel terrible for his children Gregory was 13 years old and look what he had to look forward to no father who he loved dearly I have the same thoughts I have every 25th of May in fact that it was his birthday always reinforces the date for me of course was life-changing was devastating I lost so much because [Music] I my children lost their father and they lost their mother for a [Music] while but I got through it and we all did we've come a long way and from 25 years to when this happened to us because we had basically no support um there was never a memorial service for the people that died there was never any Gathering of us together so that we could support each other and now I see that happening I see that they get therapists they get support that there is an attempt to help the families who are going through this despite the crash of Flight 191 air travel in 1979 was the most reliable form of transportation available it still is today commercial Aviation remains incredibly safe we had one period in this country where we went for 13 million takeoffs and landings without a single fatality I challenge any other industry to match that standard it's amazing there is three holes Out Among the reasons for this extraordinary safety record are the improvements made because of flight 191 one of the things about accident investigation is one you you have the tragedy we have a typically a large loss of life that is the tragic side of of accident investigation and airplane accidents what we don't want them to do is to have died in vain it is our responsibility as investigators and as an industry to identify what caused that accident so that we could prevent it from happening tomorrow and I think that this accident May 25th 1979 and what came out of that investigation Open the Eyes of the industry that maintenance is a key player in the cause or contributing factor to an accident we never looked at it before like that we are looking at it now I think that dis SKU are safer because of this accident and same are practically of every accident one of the things that we do is we go to an accident to determine what is wrong why did that accident happen and what can we do to prevent it aircraft accidents are horrible but we learn from them and I think cause that we do learn from them we having fewer and fewer of them many lessons were learned from the crash of Flight 191 all of them difficult it is for this very reason that they must not only be remembered but be put into practice so that history does not repeat itself part of the problem here is the media itself the crash itself Front Page News what really happened nobody seemed to care about it and in terms of the mainstream press uh and yet that was the story and that continues to be the story it's not that a plane crashes these things do happen thankfully not that often but why did it happen and what do we learn from it and how do we apply those lessons that's a much much bigger story and if we don't report that the bad patterns just continue as commercial Aviation advances the lessons of flight 191 will hopefully Ensure that the human cost of the tragedy are neither forgotten nor paid in vain and that they will help make the skies even safer in the [Music] future the series of disasters that struck the British Comet airliners in the 1950s causing the passenger Jets to break up in mid-flight are Revisited in a few minutes here on the History Channel