The legacy of Flight 191 When an engine ripped off a DC-10 at O’Hare it killed 273 people, and changed air travel forever

All 271 on board, along with 2 on the ground, were killed.

Seconds later it slammed into the ground and burst into flames.

After losing an engine on the runway, the DC-10 banked sharply after takeoff.

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Share this on Email As 258 passengers filed on to American Airlines Flight 191 at O’Hare International Airport the Friday before Memorial Day in 1979, nothing suggested that they would never reach Los Angeles. They would have listened to the flight attendant instruct them how to buckle the seat belt and where to find the emergency exits. None of that would matter. As the three-engine McDonnell Douglas DC-10 accelerated down the runway, reaching takeoff speed, the left engine broke away, vaulting over the aircraft’s wing. The pilots heard a thunk. “Damn,” one of the pilots said. It would be the last word captured by the cockpit voice recorder. The plane continued to rise, its wings level, despite the nearly 13,500 pounds suddenly missing from its left side. But as it reached 300 feet, the plane slowed and rolled left until it began to overturn, its nose tipping down. After just 31 seconds of flight, the plane plunged back to earth, killing all the passengers and 13 crew members on board. The wreckage strafed an open field and mobile home park, scattering debris and erupting into flames. Bodies were burned beyond recognition.

American Airlines Flight 191 leaves the terminal at O'Hare International Airport and rolls out to a runway on May 25, 1979. Minutes later, it crashed. All 271 aboard the DC-10 and two people on the ground died. These photos were taken by Michael Laughlin, 24, a student pilot on a layover at O'Hare. (Michael Laughlin/for the Chicago Tribune) Image p2p slug: chi-hist-flight191taxi20110823161854 Smoke billows from the wreckage of Flight 191 after it crashed in a burst of flames less than a mile away from the runway at O'Hare in 1979. Elk Grove Village firefighters were at the scene of the crash in four minutes, but "it was total devastation," one firefighter recalled. (Michael Laughlin/for the Chicago Tribune) Image p2p slug: chi-110823-flight-191-memorial-pictures-002

Gallery of archive images from the crash of Flight 191 and the aftermath » Forty years later, the crash of Flight 191 remains the deadliest passenger airline accident on U.S. soil. Its legacy helped spur reforms that contributed to a vast improvement in commercial aviation safety. “It had a lasting impact on how aircraft maintenance is overseen,” said former Federal Aviation Administration chief of staff Michael Goldfarb. “It was just a stark reminder those things are very important.” The changes didn’t happen overnight. A series of air disasters in the decade and a half that followed, coupled with rising demand for air travel that put more passengers on more airplanes each day, forced the industry to reckon with its safety record, aviation safety experts said. It worked. With improvements in technology, training and systems meant to flag problems before they lead to accidents, it’s been more than a decade since the last fatal crash on a scheduled passenger flight by a U.S. airline. But two months ago, weeks after that 10-year milestone was achieved, the industry faced another crisis. The second fatal crash of a Boeing 737 Max overseas within less than six months led to a global grounding of the plane — one of the only times regulators grounded an entire fleet since Flight 191 crashed in Chicago. As investigations into those two accidents continue, regulators and industry officials worldwide are conducting a reassessment of safety procedures. To some, the crashes of the 737 Max served as a necessary caution against complacency. Ralph Nader, the consumer advocate whose niece died in the March 10 Max crash in Ethiopia, likened the industry’s approach to safety to a rubber band that has been repeatedly stretched without breaking. “You get complacent about how much you can stretch it, and it snaps,” he said. How the crash happened These diagrams were originally published in the Tribune in the days following the crash. The Tribune modified the archive graphics and filled out the description of what happened with new reporting. Crash site 90 Flight path TOUHY Detail area Oasis Mobile Home Court Chicago Runway 32R O’Hare International Airport CLEARED FOR TAKOFF At 3:02:38 p.m., May 25 American Airlines Flight 191, a DC-10 bound for Los Angeles International Airport, gets clearance for takeoff. The aircraft, carrying 258 passengers and 13 crew members, begins speeding up for takeoff on the 10,000-foot long Runway 32R. LOSES LEFT ENGINE At 5,000 feet down the runway, the aircraft reaches 175 mph which is necessary for takeoff. At this time the 9,000-pound engine and pylon (the piece connecting the engine to the left wing) separate from the aircraft, flipping over the top of the wing and falling to the runway. Electrical power and hydraulic lines are severed in the left wing and white smoke or vapor appears. RADIOS THE PLANE 3:03:52 p.m.: Seeing this, an air traffic controller radios the plane: "All right, ah, American, ah, one ninety one heavy. You want to come back in to what runway?" There is no reply. ENGINE SKIDS ON RUNWAY The engine skids along the runway to the 8,000-foot mark. The flight crew, which could not see the wings and engines from the cockpit, proceeds with takeoff. Engine FLIGHT TAKES OFF The plane lifts off about 6,000 feet down the runway, reaching an altitude of about 300 feet above the ground with its wings still level. BEGINS SHARP BANK LEFT Shortly before the plane is over the end of the runway, however, it begins a sharp bank to the left due, in part, to retraction of the outboard slats caused when the engine and pylon detached from the left wing. The plane will continue to roll left until its wings are past the vertical position. BEGINS TO STALL Now over Touhy Avenue, the plane is no longer going fast enough to stay in the air. Due to the loss of electrical power, the flight crew does not receive any warning that the aircraft is stalling. It begins to descend. SLAMS INTO THE GROUND 3:04:05 p.m.: With its nose pointed downward, Flight 191 slams into the ground of an open field about 4,600 feet northwest of the departure end of the runway. It is demolished upon impact then explodes. There are no survivors. MT. PROSPECT Maine West Township High School Crash site HIGGINS MANNHEIM 90 Flight path TOUHY Oasis Mobile Home Court O’Hare International Airport Detail area YORK Chicago Runway 32R CLEARED FOR TAKOFF At 3:02:38 p.m., May 25 American Airlines Flight 191, a DC-10 bound for Los Angeles International Airport, gets clearance for takeoff. The aircraft, carrying 258 passengers and 13 crew members, begins speeding up for takeoff on the 10,000-foot long Runway 32R. LOSES LEFT ENGINE At 5,000 feet down the runway, the aircraft reaches 175 mph which is necessary for takeoff. At this time the 9,000-pound engine and pylon (the piece connecting the engine to the left wing) separate from the aircraft, flipping over the top of the wing and falling to the runway. Electrical power and hydraulic lines are severed in the left wing and white smoke or vapor appears. RADIOS THE PLANE 3:03:52 p.m.: Seeing this, an air traffic controller radios the plane: "All right, ah, American, ah, one ninety one heavy. You want to come back in to what runway?" There is no reply. ENGINE SKIDS ON RUNWAY The engine skids along the runway to the 8,000-foot mark. The flight crew, which could not see the wings and engines from the cockpit, proceeds with takeoff. Engine FLIGHT TAKES OFF The plane lifts off about 6,000 feet down the runway, reaching an altitude of about 300 feet above the ground with its wings still level. BEGINS SHARP BANK LEFT Shortly before the plane is over the end of the runway, however, it begins a sharp bank to the left due, in part, to retraction of the outboard slats caused when the engine and pylon detached from the left wing. The plane will continue to roll left until its wings are past the vertical position. BEGINS TO STALL Now over Touhy Avenue, the plane is no longer going fast enough to stay in the air. Due to the loss of electrical power, the flight crew does not receive any warning that the aircraft is stalling. It begins to descend. SLAMS INTO THE GROUND 3:04:05 p.m.: With its nose pointed downward, Flight 191 slams into the ground of an open field about 4,600 feet northwest of the departure end of the runway. It is demolished upon impact then explodes. There are no survivors. MT. PROSPECT Maine West Township High School Crash site HIGGINS MANNHEIM TOUHY Flight path 90 Willow Creek Oasis Mobile Home Court Runway 32R O’Hare International Airport Detail area YORK Chicago CLEARED FOR TAKOFF At 3:02:38 p.m., May 25 American Airlines Flight 191, a DC-10 bound for Los Angeles International Airport, gets clearance for takeoff. The aircraft, carrying 258 passengers and 13 crew members, begins speeding up for takeoff on the 10,000-foot long Runway 32R. LOSES LEFT ENGINE At 5,000 feet down the runway, the aircraft reaches 175 mph which is necessary for takeoff. At this time the 9,000-pound engine and pylon (the piece connecting the engine to the left wing) separate from the aircraft, flipping over the top of the wing and falling to the runway. Electrical power and hydraulic lines are severed in the left wing and white smoke or vapor appears. RADIOS THE PLANE 3:03:52 p.m.: Seeing this, an air traffic controller radios the plane: "All right, ah, American, ah, one ninety one heavy. You want to come back in to what runway?" There is no reply. ENGINE SKIDS ON RUNWAY The engine skids along the runway to the 8,000-foot mark. The flight crew, which could not see the wings and engines from the cockpit, proceeds with takeoff. Engine on runway FLIGHT TAKES OFF The plane lifts off about 6,000 feet down the runway, reaching an altitude of about 300 feet above the ground with its wings still level. BEGINS SHARP BANK LEFT Shortly before the plane is over the end of the runway, however, it begins a sharp bank to the left due, in part, to retraction of the outboard slats caused when the engine and pylon detached from the left wing. The plane will continue to roll left until its wings are past the vertical position. BEGINS TO STALL Now over Touhy Avenue, the plane is no longer going fast enough to stay in the air. Due to the loss of electrical power, the flight crew does not receive any warning that the aircraft is stalling. It begins to descend. SLAMS INTO THE GROUND 3:04:05 p.m.: With its nose pointed downward, Flight 191 slams into the ground of an open field about 4,600 feet northwest of the departure end of the runway. It is demolished upon impact then explodes. There are no survivors. Sources: National Transportation Safety Board aircraft accident report; Federal Aviation Administration; Chicago Tribune archives Jemal R. Brinson/Chicago Tribune The crash Dan Cirignani, a police officer patrolling the airport roads on foot that afternoon, didn’t see the plane go down. But it was impossible to miss the black smoke clouding the sky over the airport. He wondered if it was a drill. But a voice on his radio called all personnel to a “strike on the field” — a plane crash. Then he heard the sirens. Firefighters from Elk Grove Village, which borders O’Hare, were on the scene in four minutes. They’d been told a plane had crashed. But the smoke was so thick that Bill Clark, a lieutenant at the time, said he couldn’t be certain until he sliced through a fence and saw the deep furrow the aircraft made in the ground, along with debris and victims. It was obvious that no one on board could have survived, he said. “It was total devastation. There was nothing we could do to change what happened,” said Clark, now Schaumburg’s emergency management coordinator.

Human remains are marked with numbered flags for identification as emergency workers sift through debris from Flight 191, which crashed after takeoff from O'Hare on May 25, 1979. The intensity of the blaze made it hard to identify victims. (Bob Fila/Chicago Tribune) Image p2p slug: chi-flight14overall-ct0094943075-20190514

In addition to the passengers and crew, two people on the ground were killed and two more suffered second- and third-degree burns when hit by burning jet fuel, Clark said. An old aircraft hangar, several cars and a mobile home were also destroyed. Cirignani, 76, who retired in 2005 and now lives in Barrington, had worked fires and crashes before. But the first time he saw one of the victims, he didn’t immediately recognize it as a body. “I had to ask the pathologist,” he said. “They looked like black coal.” For a while, he refused to light a grill, and remains cautious when it comes to anything to do with fire. “The carnage, it was just one of the most horrible things you’ve ever seen,” he said. The intensity of the blaze and sheer number of people on board made identifying the victims unusually difficult, said Edward Pavlik, an orthodontist and chief of forensic sciences for the Cook County sheriff’s office, who was part of a team of forensic dentists that worked to identify victims of Flight 191. High-pressure hoses used to extinguish the blaze left a crater in the ground filled with “a tangled mess,” said Pavlik, 76, of Homer Glen.

After the flames were doused, firefighters and rescue teams set out May 25, 1979, on the grim task to find the remains of victims amid still-smoldering debris from the wreckage of Flight 191. (Val Mazzenga/Chicago Tribune) Image p2p slug: chi-hist-planecrash_420110823161929 Firefighters examine wreckage near a mobile home park after the crash of Flight 191 near O'Hare International Airport on May 25, 1979. An old aircraft hangar was destroyed, along with a mobile home and several cars. (Bob Fila/Chicago Tribune) Image p2p slug: chi-hist-planecrash_320110823161857

Faces of the victims Among the 273 people who died in the crash of Flight 191 were families going on vacation, business travelers returning from meetings and passengers who were visiting friends or going to family events. Here are some of their stories. Click here to read Several of the victims had been headed to the American Booksellers Association convention in Los Angeles, including local author Judith Wax and her husband, Playboy Magazine Managing Editor Sheldon Wax. Other travelers came from as far away as Australia, Austria, Belgium and the Netherlands. The wreckage was too badly damaged to give investigators much useful information, except for the engine that broke away from the wing. It would provide important answers to both questions facing investigators: Why had the engine and structure attaching it to the wing broken off? And why had pilots lost control of a plane that, though badly damaged, was designed to fly even if an engine failed? The investigation Within days of the crash, the Federal Aviation Administration ordered other carriers to inspect their DC-10s, focusing on the area where the engine attaches to the wing. Ernie Gigliotti was one of the night shift mechanics United Airlines tapped at O’Hare. As he did the inspection, “I just had the feeling there was something not right,” said Gigliotti, 71, who retired in 2002 and lives in Pittsburgh. He pushed on the engine nose and felt it move side to side rather than up and down, and heard an unusual metallic noise. He and his partner removed more panels and found obvious damage: fractures, and bolts with the heads sheared off. When American and Continental Airlines also found damage to their DC-10s during the ordered inspections, the FAA grounded the DC-10 fleet on June 6, 12 days after the crash. The National Transportation Safety Board traced Flight 191’s damage to American’s decision to ignore McDonnell Douglas’ instructions during a maintenance procedure that required removing the engine and the pylon connecting it to the wing.

A DC-10 engine lies on the grass just east of runway 32R where it came to rest after falling from Flight 191. Investigators are examining the engine on May 26, 1979, while lift equipment, top right, stands by to remove the engine. (Karen Engstrom/Chicago Tribune) Image p2p slug: chi-flight14runway-ct0094939734-20190514 A DC-10 engine is seen just east of runway 32R where it came to rest after falling from American Airlines Flight 191 during takeoff. Investigators examine the engine on May 26, 1979. (Karen Engstrom/Chicago Tribune) Image p2p slug: chi-hist-planecrash_1520110823161442

The DC-10’s manual instructed workers to take off the heavier engine before detaching the pylon. But removing the engine and pylon as a unit saved about 200 man-hours per aircraft, according to the NTSB. “That equals money,” said Anthony Brickhouse, associate professor of aerospace and occupational safety at Embry-Riddle Aeronautical University. “And that’s the battle you constantly fight in safety, it’s safety versus money.” American also decided to use a forklift, which wasn’t precise enough to remove and reattach the engine without risking damage, the NTSB said. But if damage during a maintenance check at American’s facility in Tulsa, Okla., two months earlier explained why the engine came off, it didn’t fully explain why pilots lost control. According to the NTSB, hydraulic lines that powered other critical systems were severed when the engine and pylon broke away, leaving the aircraft unusually vulnerable to a stall and disabling warning systems. The NTSB said it wasn’t reasonable to expect Flight 191’s captain, Walter Lux, and first officer, James Dillard, to have recognized what was wrong with the aircraft in time to prevent a crash. How the engine attaches to the wing Inspections of DC-10s after the crash of Flight 191 showed a maintenance shortcut caused damage to where the pylon attaches to the wing. Detail area Aft bulkhead flange: Area where small crack grew and eventually gave way. Pylon Wing Engine Thrust link assembly: Area where faulty bolt was found. Detail area Aft bulkhead flange: Area where small crack grew and eventually gave way. Pylon Engine Wing Thrust link assembly: Area where faulty bolt was found. Pylon Detail area Engine Wing Thrust link assembly: Aft bulkhead flange: Area where small crack grew and eventually gave way. Area where faulty bolt was found. Sources: Tribune archives Jemal R. Brinson/Chicago Tribune The aftermath The fallout from the accident was, if nothing else, a call to action for an industry and its regulators. The FAA slapped American and Continental with fines of $500,000 and $100,000, respectively, for improper maintenance. Airlines were ordered to inspect their DC-10s for damage and stick to the Douglas-endorsed maintenance procedure. The FAA ordered improvements to the DC-10’s warning systems and revised flight manual procedures for handling an engine failure. Elwood Driver of the National Transportation Safety Board shows a nut and bolt from the wreckage of American Airlines Flight 191. Inspections after the crash showed a maintenance shortcut caused damage to where the pylon attaches to the wing. (Don Casper/Chicago Tribune) Image p2p slug: chi-flight14bolt-ct0094941169-20190514 In addition, an Illinois law now encourages that dentures be marked with information identifying the wearer. Pavlik, the forensic dentist, said he pushed the measure after realizing it could have helped verify victims’ identities. The NTSB also called for broader changes, such as better tracking and reporting of maintenance-related damage, stricter oversight of maintenance and tougher vetting when airlines sought to deviate from manufacturer-endorsed methods. Both airlines and regulators missed opportunities to spot the risks before the Flight 191 crash, either by better vetting the hazards of using the forklift or spotting red flags, the NTSB said in the report. Continental, for example, twice caught and repaired damage similar to that found on Flight 191 before the crash, but American told the safety board that it wasn’t aware other airlines had experienced problems. The FAA declined to act on some of those recommendations at the time, arguing that existing regulations already went far enough or that the changes wouldn’t improve safety enough to justify the extra cost. American Airlines executives attend a July 30, 1979, hearing of the National Transportation Safety Board regarding Flight 191, which had crashed two months earlier. The public hearing into the tragedy was held at the Sheraton O'Hare hotel. (Carl Hugare/Chicago Tribune) Image p2p slug: chi-flight14officials-ct0094941222-20190514 But there were changes, said Robert Swaim, national resource specialist with the NTSB, who has investigated accidents including the Trans World Airlines 800 crash that killed 230 people in 1996. “We had this accident (Flight 191), and continued to have a number of accidents … and the FAA kind of came around after we investigated and reiterated some points, that we really do have to do this stuff,” he said. In a statement, American said it actively works with federal regulators and its industry officials to improve air safety. “We honor our customers, crew members and those on the ground whose lives were lost, and our hearts go out to those personally affected by the tragedy of Flight 191,” the airline said. United Airlines also said it continually works to improve safety. Major U.S. air crashes Following the crash of Flight 191 at O’Hare and a string of deadly crashes that followed, air travel has gotten safer, even as many more people took to the skies. NUMBER OF CRASHES BY YEAR WHERE AT LEAST 20 PEOPLE DIED 1979 1980 Flight 191 crash at O’Hare 1990 Sept. 11 attacks and Flight 587 crash in Queens 2000 2010 2019 NUMBER OF CRASHES BY YEAR WHERE AT LEAST 20 PEOPLE DIED Flight 191 crash at O’Hare Sept. 11 attacks and Flight 587 crash in Queens NUMBER OF CRASHES BY YEAR WHERE AT LEAST 20 PEOPLE DIED Flight 191 crash at O’Hare Sept. 11 attacks and Flight 587 crash in Queens Source: National Transportation Safety Board Chicago Tribune The reforms Fatal crashes continued in the years that followed. All the while, demand for travel was growing, meaning more passengers, more flights — and more crashes, Swaim said. “The major power players basically came to the same realization that we can’t keep going like we are,” he said. Advancements in technology helped. Engines grew more reliable and airlines adopted systems that warned pilots if they were in danger of colliding with another aircraft or flying into the ground or an obstacle, said Hassan Shahidi, CEO of the Flight Safety Foundation. Other changes targeted human errors, including improvements in training and rules barring casual conversation in the cockpit below a certain altitude. An aerial view shows the crash site of American Airlines Flight 191 after it took off from O'Hare International Airport, seen at top of photo, in May 1979. (Karen Engstrom/Chicago Tribune) Image p2p slug: chi-hist-planecrash_2020110823161617 Swaim also pointed to a change in the way the industry thought about accidents and collected data: Instead of focusing solely on an individual incident, officials tried to identify patterns pointing to reforms that could have broader benefits. Over the years, airlines, manufacturers and regulators have worked to improve the way they gather, share and analyze data to try to spot red flags before they lead to accidents, Shahidi said. The result has been a golden age of air travel when it comes to flight safety. The last time a scheduled passenger flight on a U.S. commercial airline ended in a fatal crash was outside Buffalo, N.Y., in 2009. All 49 people on board were killed, along with one person on the ground. To be sure, U.S. air travel hasn’t been without incident: There have been fatal accidents involving smaller aircraft or foreign carriers in recent years.

As the choir sings the Lord's Prayer, a grieving relative of a Flight 191 victim hugs her daughter at Mary Seat of Wisdom Church in Park Ridge on May 28, 1979. About 1,300 people attended the ecumenical service at the church to mourn the victims of the DC-10 crash at O'Hare. (Karen Engstrom/Chicago Tribune) Image p2p slug: chi-flight191cry-ct0020485428-20190517 Mourners cry over the casket of one of the 30 unidentified victims of American Airlines Flight 191 at burial services in Rancho Palos Verdes, Calif., on July 6, 1979. Catholic, Jewish and Protestant clergy officiated the services. The DC-10 had been bound for Los Angeles. (Nick Ut/AP) Image p2p slug: chi-flight15funeral-wre0095003353-20190515

Boeing 737 Max Then came the two fatal crashes of the Boeing 737 Max. Boeing has acknowledged a system was erroneously activated on both flights and said Thursday it has updated its flight-control software. It’s not clear whether that fix would have prevented either accident. But some have questioned whether more direct oversight by federal regulators could have identified problems before the Lion Air and Ethiopian Airlines accidents. In the years leading up to the crash, federal regulators have ceded greater authority to manufacturers like Boeing to certify the safety of their own planes. The system generally works despite the apparent conflict of interest, said Shawn Pruchnicki, who teaches aviation safety at Ohio State University. “It’s a little bit like having the fox guard the henhouse because there’s so much self-policing, but they have the same interests as everyone else. They don’t want the aircraft to crash either,” he said. The FAA disputed the idea that companies were allowed to police themselves, saying it exerts “strict” oversight and is directly involved in testing and approving new features and technologies. In the case of the Max’s certification, FAA safety engineers and test pilots put in 110,000 hours of work and flew or supported 297 test flights, the FAA said in a statement. Still, the 737 Max situation raises questions about exactly how much latitude manufacturers should have and when changes are significant enough to require an outsider’s view, Pruchnicki said. “There needs to be a point at which we decide this isn’t your father’s 737 anymore,” he said. The NTSB has also pushed for stricter FAA oversight and urged the industry to be quicker to accept safety-enhancing regulations. But Swaim, who declined to comment on the 737 Max case due to the ongoing investigation, noted concerns about the industry’s inertia and the extent to which the FAA delegates authority to the companies it regulates have been around for decades — even as safety improved. “This has been going on for a long time, and for the thousands of flights that take off a day, that’s pretty phenomenal,” he said. “It cannot be luck.” But Goldfarb said the amount of oversight handed over to airlines and manufacturers has grown over the years and that he worries the industry’s excellent record can undermine the case for costly but beneficial changes. The odds of a crash grow so slim, there are “little things you overlook,” he said. “They start to add up, and you’re only as safe as your last flight.” Families reflect on those lost A son who became a pilot, a daughter who remembers seeing her mother collapse when she heard the news and two daughters who helped build the memorial in Des Plaines. Click here to read There are few public reminders of the 1979 crash today. American no longer operates a Flight 191, and for more than three decades after the crash, there was no Chicago-area site honoring the victims. Creating one took a group of Chicago sixth graders, who led the push to build the memorial in Des Plaines after learning their assistant principal, Kim Jockl, lost her parents in the crash. But there’s no danger of Fight 191 being forgotten by those connected to the crash, or in the aviation community. “Not a semester goes by that we don’t talk about it,” said Brickhouse, the Embry-Riddle professor. “To me, it’s one of the seminal moments.” lzumbach@chicagotribune.com Twitter @laurenzumbach Help support important journalism Subscribe