By Alexa Dunn, Correspondent
Image Credit: Cockpit Voice Recorder Database for Horizons
As the halfway point of the semester passes, fatigue sets in. After all these snow days, it’s easy to get behind and lose motivation. For those like myself who are about to graduate, the dreaded feeling is looming overhead … the Senioritis. But in all disciplines, especially aviation, it’s important to keep our focus and not let distraction set in.
With that in mind, let’s take a look at Delta Flight 1141. This was a routine flight between Dallas, Texas and Salt Lake City, Utah on Aug. 31, 1988. At about 9:00 a.m., just after liftoff from the runway, the Boeing 727-232 rolled to the right, experienced a brief tail strike, struck the navigation systems at the end of the runway with its wing, and eventually hit the ground over 3,000 feet from the end of the runway. The impact quickly sparked a post-crash fire. Of the 108 people onboard, 14 were killed, and almost twice that were seriously injured. The total flight time was 22 seconds.
What happened to make this flight so tragically short?
The answers came from two places: the aircraft’s flight path, which was reconstructed by the National Transportation Safety Board (NTSB), and the cockpit voice recorder (CVR) tapes. The flight data revealed that the aircraft’s inability to climb, along with the right roll, was consistent behavior for that aircraft during takeoff with the retracted flaps and slats. During this phase of flight, these are supposed to be extended. This discovery led to further analysis of the CVR tapes, which revealed that the pilots announced the extension of the flaps, but there was no sound of the lever inside the cockpit being pulled to do so. Additionally, the aircraft’s takeoff warning system, which will sound a horn if engines are set to takeoff power without the flaps and slats being set correctly, did not go off and failed to alert the pilots to the hazardous situation.
As always, let’s dig a bit deeper. Why did the pilots fail to extend the flaps and slats as required for the takeoff procedure? Well, this goes into the concept of Crew Resource Management (CRM). CRM is the training and philosophy of using all possible resources to mitigate human error while also maintaining a safe and professional environment. Ineffective CRM comes not just from one pilot’s actions but typically from a systemic, company-wide attitude. In this case, even the Federal Aviation Administration (FAA) had previously noted “deficiencies” in performance among Delta’s flight crews, naming issues in discipline especially. But this all came to a head with what they found in the CVR tapes.
FAA regulations require a “sterile cockpit” during critical periods of flight, takeoff and landing in particular. This means that there is to be no nonessential conversation, or discussion of anything unrelated to the topic at hand. Despite this, flight attendants were heard on the recordings repeatedly talking with both pilots, mostly with the first officer. Their conversations ranged from their dating habits, to politics, drink mixes, and another airline crash a year prior.
Despite all of this, the captain made no effort to correct the first officer or manage the situation.
The NTSB established two probable causes for the accident: first, the lack of discipline in the cockpit that likely led to distraction and the failure to properly configure the aircraft for takeoff. Additionally, the failure of the takeoff warning system. While this was not officially published, other board members from the NTSB also blamed Delta and the FAA, for their lack of action regarding CRM – Delta for failing to provide training and adequate leadership, and the FAA for failing to correct known deficiencies in Delta’s programs.
So what lessons can we take from Delta Flight 1411? While fatigue and distraction may set in, discipline – in education, in the workplace, in life – is essential. We are halfway through the semester: keep flying the aircraft.
Throughout the semester, I hope to cover a wide range of accidents, from large to small, from famous to obscure, from fixed-wing to helicopter. If you have an accident in mind that you’d like me to cover, please reach out to me at [dunna8@my.erau.edu]. I’d love to hear any feedback and ideas you have.
