Maintenance shortcut leads to country's deadliest plane crash

Sept. 16, 2004
A simple maintenance shortcut leads to the country’s deadliest plane crash
Lisa Greenberg
By Lisa GreenbergIf you stand at the northwest corner of
Touhy Avenue
Mount Prospect Road
in Des Plaines, Ill., you’ll see a large fence surrounding what is now a retention pond. But 25 years ago, this calm, now water-covered surface became the final resting place for 271 travelers who were bound for Los Angeles by way of O’Hare International Airport in Chicago. Twenty-two years before the United States had to unravel itself from the confusion and destruction of Sept. 11, 2001, the country was dealing with its largest loss of life from a single plane crash.

As American Airlines Flight 191 descended into this field just 4,000 ft. from the runway it had departed from seconds before, two more lives were taken on the ground, bringing the death toll to 273. Now, as we are all wont to say when tragedy strikes, it could have been worse. There is a trailer park on the edge of the field where Flight 191 fell. An Amoco fuel storage facility is also in the flight path, and it’s too grisly to create a picture in your mind of the decimation that such a collision might have produced.

But if you were there to witness the inferno that occurred that day in 1979, well, you never forgot it. The chimney of choking, black smoke was visible for miles. It was, just like that day in September three years ago, one of those days where people were rooted to their TV sets with the question “why?” blinking in their minds.
In this case there were no foreign terrorists infiltrating our mighty aviation system; the cause was something plain, yet somehow equally as sinister: shoddy maintenance.
At first the swarm of FAA and NTSB investigators deduced that the cause of the crash had been a bolt or bolts that fell loose, causing the left engine to drop off. But that conclusion proved to be hasty — forced by the enormous pressure that was brought to bear on American Airlines, airplane manufacturer McDonnell Douglas and the FAA by a ravenously curious public. The bolt was just a symptom of the real problem: A maintenance shortcut led to stress cracks and fractures over time in the left wing’s pylon bulkhead.
Instead of disassembling the components to remove the engine, American Airlines’ maintenance crew had modified McDonnell Douglas’ recommended procedure and had supported the engine with a forklift to save time. Once American Airlines’ maintenance records for the DC-10 were uncovered in its
Tulsa, Okla., facility, it was revealed that the left engine had been set onto the forklift, and then the technicians who had started the procedure left because it was the end of their shift. The technicians who had just started their shift did not know about and could not see the damage that was caused by hydraulic pressure bleeding down in the forklift, which tilted and cracked the pylon.

During the following two months of takeoffs and landings, the cracks expanded. It was that final takeoff that released the plane’s left engine, causing it to tumble over the plane’s wing, severing both hydraulic lines that controlled the wing’s slats. The pilots instantly lost contact with the control tower, and not another word was recorded from that dim cockpit.

Another life was also taken as a result of this crash, but it would not happen until two years later, in 1981, on the eve of his deposition about the case. The maintenance manager for American Airlines at that
Tulsa facility lulled himself into a carbon-monoxide-induced slumber in his family’s dark garage. His wife found the body. It was after this discovery that American Airlines and McDonnell Douglas decided to put to rest their acrimonious battle, each trying to assign the other blame for the crash. They shared in paying out the settlements to the crash victims’ families for myriad wrongful death lawsuits. But the money didn’t bring back the mass of travelers who were ejected from their lives that day, leaving gym shoes, briefcases and other scattered personal reminders of who they were before on that Friday afternoon.

Maybe that maintenance manager in
Tulsa replayed the crash-scene footage in his mind and it was too much to bear. Or maybe it was the only way to escape the burden of responsibility for having overseen a shortcut that cut short 273 lives. Either way, we have a responsibility in maintenance — and in life — to make sure that the job is done well, no matter how small. 

Lisa Greenberg is Managing Editor of Plant Services and Chemical Processing magazines. E-mail her at [email protected].