If it hadn't played out in the nation's newspapers, the crash of American Airlines Flight 191 in Chicago 25 years ago and the investigation into its cause would be the makings of a suspense novel.
"This is the aviation equivalent of 'Silkwood,' " said Peter Greenberg, referring to the story of Karen Silkwood. Her effort to address safety concerns at a Kerr-McGee plutonium fuels plant in Crescent, Okla., was made into a Hollywood film.
"It has everything: high stakes, politics, intrigue and -- a la Silkwood -- a questionable death. The economic impact was absolutely staggering. And it had the long-range impact of killing McDonnell Douglas."
At the time, McDonnell Douglas was nipping at Boeing's heels for dominance of world aircraft manufacturing. Its three-engine long-range DC-10, which was involved in the crash, was the backbone of its fleet. Airbus, created nine years earlier, was a bit player.
After the crash, federal authorities grounded DC-10s nationwide for nearly two months. Sales of the DC-10 plummeted. Its successor, the MD-11, never caught on with the airlines. The company lost ground to Airbus during the next 18 years before its $13.3 billion merger with Boeing in 1997.
Greenberg covered the crash and investigation for CBS affiliate KNXT in Los Angeles. Travel editor at NBC's "Today Show," he has produced a documentary, "The Crash of Flight 191," which is airing this month on the History Channel.
"Imagine the economic impact of grounding the entire fleet of DC-10s," Greenberg said. "There were 138 DC-10s flying in the U.S. alone, but worldwide the fleet was essentially grounded too because the FAA wouldn't let any foreign air carriers fly them into the country either."
American Airlines, McDonnell Douglas and the airline industry lost millions of dollars a day as federal authorities searched for the cause of the crash.
Seven months after Flight 191, on Dec. 21, 1979, the National Transportation Safety Board issued its final report on the Chicago crash. The NTSB cited a faulty engine-changing procedure at American's Tulsa Maintenance & Engineering Center as the cause of the crash, which killed 273 people.
Listed as contributing causes were McDonnell Douglas' design of the engine mount on the DC-10 and deficiencies in the Federal Aviation Administration's inspection and reporting systems.
The NTSB report has value today because it focuses on how crucial FAA inspectors are to ensuring air safety, Greenberg said.
"The problem in these economic times with the FAA is they aren't properly staffed with inspectors," Greenberg said. "To what extent are airlines outsourcing maintenance and to what extent is maintenance not properly supervised? If maintenance is not properly supervised, that's a serious concern."
Flight 191 crashed on takeoff from O'Hare International Airport on May 25, 1979, when the left engine ripped away and somersaulted over the wing. The plane stalled, rolled to the left and plunged into an abandoned airfield. All 271 people aboard the plane and two on the ground were killed.
The NTSB investigators said the crash was triggered by a 10-inch crack in the rear bulkhead of the left wing engine pylon, one of the points where the pylon attaches to the wing.
When the crack gave way, investigators said, the engine ripped away, extensively damaging hydraulic fluid lines and electrical cables. Without the cables, cockpit instruments were disabled, preventing the crew from being warned that the aircraft was about to stall.
Had the engine not taken the hydraulics and electrical wiring with it, the flight crew could have flown the plane out of the stall, investigators concluded. The plane is designed to be able to fly with two engines.
In a stall, a plane's wing does not produce enough lift to support the plane and it literally quits flying.
The DC-10 was about to stall, investigators said, because the leading edge slats on the left wing, deprived of hydraulic fluid that forces them to extend, began retracting. The slats extend on takeoff and landing to expand the curve of the wing, allowing it to generate lift at slower speeds than otherwise would be possible.
When the plane stalled, the unbalanced slats caused it to roll over and dive.
The investigators said the crack that started the crash sequence was caused by American's maintenance procedure of removing and reinstalling the engine and pylon as one unit instead of removing them separately as recommended by McDonnell Douglas.
Investigators found nine DC-10s at American, United Airlines and Continental Airlines with cracks or weakened engine mountings, all of them damaged as a result of the procedure, which involved the use of a forklift to support the engine while mechanics removed mounting bolts and the pylon.
"Chapter 54-00-00 of the DC-10 Maintenance Manual . . . called for, first, removal of the engine, and then removal of the pylon," the NTSB accident investigation report found. "The pylon alone weighs 1,865 pounds . . . whereas the pylon and engine together weigh about 13,477 pounds. . . ."
Bill Fey, who at the time of the Chicago crash was manager of production of the DC-10 and 747 lines in Hangar 5 at the Tulsa Maintenance & Engineering Center, told investigators that he conceived of the "unit concept method" of removing the engine and engine pylon assemblies at one time with a forklift.
"This technique would save about 200 man-hours per aircraft, but more importantly from a safety standpoint, it would reduce the number of disconnects (hydraulics and fuel lines, electrical cables and wiring) from 79 to 27," the NTSB report found.
McDonnell Douglas executives advised against removing both the engine and pylon in one operation, but they weren't adamant about it, the NTSB investigators said.
The FAA was totally uninformed about the forklift procedure, the NTSB found.
FAA inspectors at the Tulsa maintenance base weren't aware that American had adopted an engine-changing procedure at odds with McDonnell Douglas' recommendations until May 30, 1979 -- five days after the Chicago crash.
But not everyone had passively accepted the new engine-changing regime.
Joe L. White, supervisor of a DC-10 engine-changing crew at the Tulsa base, began submitting memos to his supervisors in 1978. White warned that the forklift procedure was damaging bearings and engine mounts on the wings of the aircraft and violated the manufacturer's written recommendations. His memos were read and filed by supervisors, he said, but nothing ever came of it.
American mechanics continued removing the engine and pylon with the forklift.
After the NTSB report was issued, the legal maneuvering began. All the parties to the case were being sued by the relatives of the deceased.
Lawyers for McDonnell Douglas and American sparred over who was liable. American's lawyers thought the manufacturer should bear most of the liability for the accident. McDonnell Douglas' lawyers strongly disagreed.
In late spring 1981, McDonnell Douglas investigators swarmed into Tulsa to find out which of American's mechanics had participated in the forklift procedure. They learned that American had used the forklift on Flight 191's DC-10 between March 29 and March 31, 1979. Eight weeks before Flight 191 lifted off in Chicago, mechanics had replaced the engine pylon's spherical bearings.
McDonnell Douglas' attorneys notified American that they wanted to take depositions from White and 150 American mechanics and supervisors. The pressures were building on everybody.
On March 25, 1981, the night before he was to be deposed by McDonnell Douglas' attorneys, Earl Russell Marshall, 47, a supervisor at the Tulsa base, committed suicide.
Although American spokesman Art Jackson said Marshall had no involvement with the accident aircraft, his wife, Marilyn, said her husband was haunted by the Chicago crash.
"He had very bad guilt feelings, and the accident gave him something to attach his feelings to," Marilyn Marshall said. "He was a casualty of that crash. It says something about the pressure an aircraft mechanic works under."
Before White could be deposed, he was directed by his superiors to meet with American's attorney in the case, David Wheeler of Los Angeles. Wheeler was concerned about White's memos concerning the engine-changing procedure, White said.
Wheeler told him, White later testified, that White "was not to recall when I wrote the memo, what it contained, what happened to it or whether anyone had ever seen it.
"He started telling me I was never to remember I authored the memos . . . (that) the procedures we were using were not safe," White testified.
In meetings with American executives following his conversations with Wheeler, White said that his superiors accused him of claiming overtime for hours he didn't work and not following company procedures.
When he refused to deny knowledge of his criticism of American's DC-10 maintenance procedures, the company fired him, White said.
American executives said White's firing had nothing to do with the Chicago crash. White was fired for absenteeism, neglecting his responsibilities and poor performance, company executives testified.
White testified about the legal maneuvering in the 1987 trial of his $9.5 million civil lawsuit against American for denial of due process. A U.S. District Court jury in Tulsa awarded White a $1.5 million judgement against American in October 1987.
American appealed and the judgment was overturned by the 10th Circuit Court of Appeals, which said the judge in the case erred in his jury instructions. Before the case could be retried, American and White reached an out-of-court settlement.
According to his records, White testified, he wrote his last memo to the company on May 1, 1979 -- 24 days before the fatal crash.
At trial, American was able to produce only one memo from White, which was stamped as received by the company on May 29, four days after the Chicago crash.
Although the company denied the existence of any other White memos, the U.S. District Court for the Northern District of Illinois sanctioned the company on June 23, 1981 -- six days after the company notified White he would be fired -- for destroying memos and documents related to the Chicago crash.
"Do I feel vindicated? No, not really," White said last week. "The case eventually exposed the maintenance errors, but let's just say it's not something I would ever like to go through again.
"It was a terrible time in my life. I lost a 230-acre farm, my children were told horrendous stuff about me. The company tried everything to discredit me, and they did it all over this town."
Now practicing law in Collinsville, White said his experience taught him about corporate ruthlessness.
"Big business goes unchecked," he said.
American spokesman John Hotard said the NTSB investigation of Flight 191 had a profound impact on the company.
"We haven't had a maintenance-related accident since then -- 25 years," Hotard said. "No one ever designs a procedure or a program who doesn't think the procedure or program is sound or safe.
"One of the things that NTSB investigators tell you is that you learn from accidents. And we learned a lot from this one."
Greenberg, the documentary producer, said the Flight 191 investigation served as a wake-up call for the FAA. The agency needs periodic wake-up calls, he said.
In July 2003, the Department of Transportation's Office of Inspector General issued a report, "Review of Air Carriers' Use of Aircraft Repair Stations."
The IG report found inadequate FAA oversight of third-party and foreign repair stations, which account for 47 percent of air carrier maintenance expenses.
"Even though air carriers are currently outsourcing close to half of their maintenance expense, FAA has continued to focus its surveillance on air carriers' in-house facilities with no comparable shift toward increased oversight of work performed at repair stations," the IG investigation concluded. "These vulnerabilities all relate to a lack of effective FAA oversight and, if not corrected, could lead to an erosion of safety."
Greenberg said the ValuJet crash in the Florida Everglades in 1996 and the US Airways Express crash in Charlotte, N.C., last year were both maintenance-related.
"The underlying cause was poor oversight," Greenberg said. "The problems you have to solve are systemic. Safety is no accident."
D.R. Stewart 581-8451
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