Delta Air Lines Flight 191

For other flights numbered 191, see Flight 191.

Delta Air Lines Flight 191

The wreckage of Flight 191's tail section. A Boeing 727 can be seen in the background.
Accident summary
Date	August 2, 1985
Summary	Microburst, pilot error
Site	Dallas/Fort Worth International Airport
Passengers	152
Crew	11
Injuries (non-fatal)	28 (including 1 on ground)
Fatalities	137 (including 1 on ground)
Survivors	27
Aircraft type	Lockheed L-1011-385-1 TriStar
Operator	Delta Air Lines
Registration	N726DA
Flight origin	Fort Lauderdale–Hollywood International Airport
Stopover	Dallas/Fort Worth International Airport
Destination	Los Angeles International Airport

Delta Air Lines Flight 191 was a regularly scheduled Delta Air Lines domestic service from Fort Lauderdale, Florida, to Los Angeles, via Dallas that crashed on August 2, 1985, at 18:05 (UTC−05:00). The Lockheed L-1011 TriStar operating this flight encountered a microburst while on approach to land on runway 17L (now marked 17C) at Dallas/Fort Worth International Airport (DFW). The pilots were unable to successfully escape the weather event, and the aircraft impacted the ground over a mile short of the runway. The flight hit a car driving north of the airport and impacted two water tanks, disintegrating. The crash killed 136 on board, 128 of the 152 passengers and 8 of the 11 crew, as well as the driver of the car. The National Transportation Safety Board (NTSB) determined that the crash resulted from the flight crew's decision to fly through a thunderstorm, the lack of procedures and training to avoid or escape microbursts, and the lack of hazard information on wind shear.

Involved

Aircraft

File:Lockheed L-1011-385-1 TriStar 1 N726DA Delta Air Lines, Montreal (Dorval), July 1984..jpg

N726DA, the aircraft involved in the accident, at Montreal Airport in July 1984.

The aircraft was a Lockheed L-1011-385-1 TriStar (registration number N726DA). It was delivered to Delta on February 28, 1979, and had been operated continuously by the airline since that date. The aircraft was powered by three Rolls-Royce RB211-22B engines.

Crew members

Flight 191 was manned by three flight crewmen and eight cabin crew members.

The captain, Edward N. Connors, age 57, had been employed by Delta Air Lines since 1954. He qualified to captain the TriStar in 1979 and had passed his proficiency checks. The NTSB report mentioned that other flight crew that had flown with Connors prior to the accident described him as a meticulous pilot who strictly adhered to company policies. The report also reported that Connors "deviated around thunderstorms even if other flights took more direct routes" and "willingly accepted suggestions from his flightcrew." Since his qualification in 1979, Connors had passed all eight of the en route inspections he had undergone, and the NTSB report notes that he had received "favorable comments" regarding "cockpit discipline and standardization." Connors had logged over 29,300 hours of flight time, 3,000 of which had been in the TriStar.

Flight 191's first officer was Rudolph P. Price Jr, age 42. Delta captains who flew with Price described him as an "above average first officer" and possessing "excellent knowledge" of the TriStar. Price had logged 6,500 flight hours, including 1,200 in the TriStar. The flight engineer, Nick N. Nassick, age 43, had logged 6,500 hours of flight time, including 4,500 in the TriStar. Fellow Delta employees described him as "observant, alert, and professional."

Flight 191 had eight flight attendants aboard: Frances Alford, Jenny Amatulli, Freida Artz, Vicki Chavis, Diane Johnson, Alyson Lee, Joan Modzelewski, and Wendy Robinson. Of these, Amatulli, Chavis, and Robinson were the only surviving flight crew members.

Passengers

Of the deceased, 73 originated from the Miami metropolitan area. Of them, 45 were from Broward County, 19 were from Palm Beach County, and 9 were from Dade County. One of the passengers was Don Estridge, known to the world as the father of the IBM PC; he died aboard the flight along with his wife, Mary Ann, two IBM summer interns, and six additional family members of IBM employees. Another passenger was Jean Hancock aged 41, a computer analyst and lyricist and the sister of musician Herbie Hancock.

Flight

History of the flight

Flight 191 was a regularly scheduled passenger flight from Fort Lauderdale–Hollywood International Airport in Fort Lauderdale, Florida to Los Angeles International Airport in Los Angeles, California, with a scheduled stop at Dallas/Fort Worth International Airport. The flight departed Fort Lauderdale on an instrument flight rules (IFR) flight plan at 15:10 Eastern Daylight Time (UTC−04:00). The flight's dispatch weather forecast for DFW stated a "possibility of widely scattered rain showers and thunderstorms." Another dispatch weather alert warned of "an area of isolated thunderstorms ... over Oklahoma and northern and northeastern Texas." The flight crew reviewed these notices before takeoff.

As the aircraft flew past New Orleans, Louisiana, a weather formation near the Gulf Coast strengthened. The flight crew decided to deviate from the intended route to make the more northerly Blue Ridge arrival to DFW. The flight held for 10–15 minutes over the Texarkana, Arkansas VORTAC. At 17:35:26 Central Daylight Time (UTC−05:00), the crew received an Automatic Terminal Information Service (ATIS) broadcast for weather on approach to DFW. At 17:35:33, the Fort Worth Air Route Traffic Control Center (ARTCC) air traffic controller cleared the flight to the Blue Ridge, Texas VORTAC and instructed the flight to descend to 25,000 feet (7,600 m).

At 17:43:45, the Fort Worth ARTCC controller cleared the flight down to 10,000 feet (3,000 m). The controller suggested they fly a heading of 250° toward the Blue Ridge approach, but Captain Connors replied that the route would take them through a storm cell, stating, "I'd rather not go through it, I'd rather go around it one way or the other." After a brief exchange, controller gave the flight a new heading. At 17:46:50, the controller cleared the flight direct to Blue Ridge and instructed the flight crew to descend to 9,000 feet (2,700 m). The captain expressed his relief that the controller didn't send them on the original trajectory. At 17:51:19, the second officer commented, "Looks like it's raining over Fort Worth." At 17:51:42, the Fort Worth ARTCC controller transferred the flight to DFW Airport Approach Control, which cleared the flight to descend to 7,000 feet (2,100 m). Two minutes later, the controller asked the Delta flight to deviate by ten degrees and to slow their airspeed to 180 knots (210 mph). The flight acknowledged the request. As the flight descended, the crew prepared the aircraft for landing. At 17:56:19, the feeder controller cleared the flight down to 5,000 feet (1,500 m). Nine seconds later, the controller announced that there was rain north of the airport, and that the airport would be using instrument landing system (ILS) approaches.

At 17:59:47, Price said, "We're gonna get our airplane washed." At around the same time, the captain switched to the arrival radio frequency and informed the approach controller that they were flying at 5,000 feet (1,500 m). The controller replied that the flight should expect to approach Runway 17L (now Runway 17C). At 18:00:36, the approach controller asked an American Airlines flight that was two aircraft ahead of Flight 191, and on the same approach, if they could see the airport. The flight responded, "As soon as we break out of this rain shower we will." At 18:00:51, Flight 191 was instructed to slow to 170 knots (200 mph) and to turn to heading 270°. Flight 191 was instructed to descend to 3,000 feet (910 m) at 18:01:34. One minute later, the approach controller turned the flight toward Runway 17L and cleared them for an ILS approach at or above 2,300 feet (700 m). Half a minute afterward, the controller asked the flight to reduce their speed to 160 knots (180 mph), which the flight crew acknowledged. At 18:03:30 the controller advised, "And we're getting some variable winds out there due to a shower ... out there north end of DFW." Several seconds later, an unidentified flight crew member commented, "Stuff is moving in."

Just three miles ahead of Flight 191 was a Learjet 25 on the same approach to Runway 17L. While on final approach, the Learjet flew through the storm north of the airport and encountered what was later described as "light to moderate turbulence". The Learjet encountered heavy rain and lost all forward visibility, but was able to continue its ILS approach and land safely. When later asked why he did not report weather conditions to the tower, the Learjet's captain testified that he had nothing to report because "the only thing that we encountered was the heavy rain." The tower controller handling landings on Runway 17L saw lightning from the storm cell after the Learjet landed, but before he saw Flight 191 emerge from the storm.

Crash

File:Delta191-PathToImpact.png

The flight path in the final moments. William Mayberry is killed in his car at "4".

At 18:03:46, the approach controller once again asked Flight 191 to reduce its speed, this time to 150 knots (170 mph), and then handed the flight over to the tower controller. Twelve seconds later, the captain radioed the tower and said, "Tower[:] Delta one ninety one heavy, out here in the rain, feels good." The tower controller advised Flight 191 that there was wind blowing at 5 knots (5.8 mph) with gusts up to 15 knots (17 mph), which the captain acknowledged. The flight crew lowered the landing gear and extended their flaps for landing. At 18:04:18, Price commented, "Lightning coming out of that one. ... Right ahead of us." The captain called out that they were at 1,000 feet (300 m) at 18:05:05. Fourteen seconds later, he cautioned Price to watch his airspeed. At the same time, the cockpit voice recorder (CVR) captured the beginning of a sound identified as rain hitting the cockpit. The captain warned Price, "You're gonna lose it all of a sudden, there it is." At 18:05:26, the captain told Price, "Push it up, push it way up." Several second later, the CVR recorded the sound of the engines spooling up. Connors then said, "That's it." At 18:05:36, Connors exclaimed, "Hang on to the son of a bitch!" From this point, the aircraft began a descent from which it never recovered. The angle of attack (AOA) was over 30° and began to vary wildly over the next few seconds. The pitch angle began to sink and the aircraft started descending below the glideslope.

At 18:05:44, with the aircraft descending at more than 50 feet (15 m) per second the ground proximity warning system (GPWS) began a series of "whoop whoop pull up" audible warnings. The captain responded by declaring "TOGA", aviation shorthand for the order to apply maximum thrust and abort a landing by taking off and going around. The first officer responded by pulling up and raising the nose of the aircraft, which slowed but did not stop the plane's descent. At 18:05:52, still descending at a rate of approximately 10 feet (3.0 m) per second, the aircraft's landing gear made contact with a plowed field 6,336 feet (1,931 m) north of the runway and 360 feet (110 m) east of the runway centerline. Remaining structurally intact, Flight 191 remained on the ground while rolling at high speed across the farmland. The main landing gear left shallow depressions in the field that extended for 240 feet (73 m) before disappearing and reappearing a couple times as the aircraft approached Texas State Highway 114.

The aircraft struck a highway street light, and its nose gear touched down on the westbound lane of Highway 114. The aircraft's left engine hit a Toyota Celica driven by 28-year-old William Mayberry, killing him instantly. As the aircraft continued south, it hit two more street lights on the eastbound side of the highway and began fragmenting. The left horizontal stabilizer, some engine pieces, portions of the wing control surfaces, and parts of the nose gear came off of the aircraft as it continued traveling along the ground. Some witnesses later testified that there was fire emerging from the left wing root. Surviving passengers reported that fire began entering the cabin through the left wall while the plane was still in motion. The aircraft's roll across open land ended when it crashed into a pair of water tanks on the edge of the airport property; the aircraft grazed one water tank about 1,700 feet (520 m) south of Highway 114, and then impacted the second water tank. As the left wing and nose struck the water tank, the fuselage rotated counterclockwise and was engulfed in a fireball. The fuselage of the aircraft from the nose rearward to row 34 was destroyed. The tail section of the aircraft emerged from the fireball, skidding backwards, and came to rest on its left side before being rotated upright by wind gusts.

Post-crash response

File:Delta191-CabinSeatDiagram.svg

Diagram of the injuries suffered in the cabin

All airport fire and emergency units were alerted within one minute of the crash. 45 seconds after first being alerted, three airport fire trucks from the airport's fire station No. 3 arrived at the scene of the crash and began fighting the post-accident fire. Additional units from fire stations No. 1 and No. 3 arrived within 5 minutes, and despite high wind gusts and heavy rain, the fire was mostly under control within 10 minutes after the alert was sounded.

The first paramedics arrived at the scene within 5 minutes of the crash, and triage stations were immediately established. In later testimony to NTSB officials, on-site EMTs estimated that without the on-scene triage procedures, at least half of the passengers who survived the crash would have died. Most of the survivors of Flight 191 were located in the rear smoking section of the aircraft, which broke free from the main fuselage before the aircraft hit the water tanks. Authorities transported most of the survivors to Parkland Memorial Hospital.

Two of the passengers who initially survived the impact died more than thirty days after the accident. On the ground, an employee of an airline who assisted in rescuing survivors was hospitalized overnight for chest and arm pains.

The cockpit and passenger section forward of seat row 34 had been completely fragmented by impact with the water tanks and post-crash fires; all but eight of the occupants in this section were killed. The remainder of the surviving passengers and crew were in the rear cabin and tail section, which separated relatively intact and landed on its side in an open field. Overall, the disintegration of the Tristar was so extensive as to render the NTSB investigation quite difficult. Survivors reported that fire broke out in the cabin prior to hitting the tanks, and had begun spreading through the aircraft's interior, which is consistent with the right wing's collision with the light pole and fuel tank ignition. Some of the people in the tail section were unable to free themselves due to impact injuries and had to be extricated by rescue crews. Most survivors were also soaked with jet fuel, further adding to the difficulty of exiting the wreckage.

Delta Air Lines Flight 191 has the second-highest death toll of any aviation accident involving a Lockheed L-1011 anywhere in the world, after Saudia Flight 163.

Investigation

Numerous public safety agencies responded to the crash, including the Dallas/Fort Worth Airport Department of Public Safety, the Texas Department of Public Safety, the Irving Fire Department, the Irving Police Department and all available third watch personnel from the Dallas Police Department's Northwest Patrol Division and the Northeastern Sector of the Fort Worth Police Department's Patrol Division.

After a long investigation, the National Transportation Safety Board deemed the cause of the crash to be attributable to pilot error (for their decision to fly through a thunderstorm), combined with extreme weather phenomena associated with microburst-induced wind shear. The NTSB also determined that a lack of specific training, policies, and procedures for avoiding and escaping low-altitude wind shear was a contributing factor.

The NTSB attributed the accident to lack of the ability to detect microbursts aboard aircraft – the radar equipment aboard aircraft at the time was unable to detect wind changes, only thunderstorms. After the investigation, NASA researchers at Langley Research Center modified a Boeing 737-200 as a testbed for an on-board Doppler weather radar. The resultant airborne wind shear detection and alert system was installed on many commercial airliners in the United States after the FAA mandated that all commercial aircraft must have on-board windshear detection systems.

The NTSB was also critical of the airport for failing to notify emergency services in surrounding municipalities in a timely manner. While the airport's on-site emergency services were notified almost immediately, the DFW Department of Public Safety (DPS) Communications Center did not begin notifying off-site emergency services until nearly 10 minutes after the crash, and did not finish its notifications until 45 minutes after the crash. During notifications, DPS also failed to request ambulances from the adjacent communities of Irving, Grapevine, and Hurst; however, Hurst responded with ambulances after personnel at its ambulance company overheard the airport crash report on a radio-frequency scanner. The NTSB concluded that the overall emergency response was effective due to the rapid response of on-airport personnel, but found "several problem areas" which under different circumstances "could affect adversely the medical treatment and survival of accident victims at the airport".

Legacy

Following the crash and the ensuing NTSB report, DFW's DPS made improvements to its post-crash notification system, including the introduction of an automated voice notification system to reduce notification times. In 1988, following the crash of Delta Air Lines Flight 1141 while taking off from DFW, DPS completed its notification of nearby emergency services in 21 minutes; the NTSB described this as a "significant improvement" over response times after the Delta Flight 191 crash. Based on the improved response times, the NTSB issued a Safety Recommendation on January 9, 1990 calling for airport executives nationwide to consider the benefits of using automated voice notification systems for their emergency aid notifications.

The crash of Delta Flight 191 resulted in the longest aviation trial in American history, lasting fourteen months during 1988 to 1989 and presided over by federal judge David Owen Belew Jr. The trial featured the first use of computer graphic animation as substantive evidence in federal court; while the use of such animation is now routine, its use in the Flight 191 litigation was novel enough that it became the featured cover story of a 1989 issue of ABA Journal, the magazine of the American Bar Association. Preparing the animated video for trial cost the Department of Justice around $100,000 to $150,000, and required nearly two years of work. The court found that both government personnel and the Delta flight crew were negligent, but that Delta was ultimately responsible because its pilots' negligence was the proximate cause of the accident, and the ruling was upheld on appeal to the Fifth Circuit Court of Appeals.

The crash of Delta Flight 191 was the subject of a television movie called Fire and Rain. Another movie which this crash was mentioned was in Rain Man. The crash was also featured on an episode of When Weather Changed History and Why Planes Crash on The Weather Channel, and the episode "Deadly Weather" of Survival in the Sky. The TV series Mayday (Air Crash Investigation or Air Emergency) on Discovery Channel Canada and National Geographic dramatized the accident in the episode "Invisible Killer" (also known as "Slammed to the Ground"). The crash was also shown and discussed in a later Mayday episode about American Airlines Flight 1420, which also occurred during landing in bad weather conditions.

Working as a reporter for the Fort Lauderdale News and Sun-Sentinel in 1986, future renowned mystery author Michael Connelly and two other reporters conducted extensive interviews of survivors of Delta Flight 191 and wrote an article detailing their experiences during and after the crash. The article explored the topic of survivor guilt and earned Connelly and his co-writers a finalist position for the Pulitzer Prize.

Memorial

In 2010, 25 years after the accident, a memorial was installed at Dallas-Fort Worth International Airport's Founders Plaza in Grapevine.

See also

• Air France Flight 358
• Aviation safety
• Japan Airlines Flight 123
• List of accidents and incidents involving commercial aircraft
• Pan Am Flight 759
• Philip Don Estridge
• Southern Airways Flight 242
• USAir Flight 1016

External links

• Pre-accident photos from Airliners.net
• DFW Delta Flight 191 – Essay from Mica Calfee, a firefighter-paramedic who responded to the crash
• NTSB executive summary report
• Delta 191 In Their Words
• Animation of the crash, indicating wind vectors and synchronized to voice recorder data (description here)
• Vanderbilt Television News Archive