On August 31, 1988, the flight, using a Boeing 727-200 series aircraft, crashed during takeoff at DFW, resulting in 14 deaths and 76 injuries among the 108 on board.
[1]: 102–103 The cabin crew consisted of four flight attendants: Dixie Dunn (56); Diana George (40); Rosilyn Marr (43); and Mary O'Neill (57).
[1]: 2 The aircraft was instructed to line up on the runway and hold for one minute due to the possibility of wake turbulence from an American Airlines McDonnell Douglas DC-10 that was departing.
The takeoff was normal until the main wheels left the ground, at which point the aircraft commenced a violent rolling motion and the right wing dropped.
[1]: 14 The aircraft developed compressor surges (due to breakdown of the airflow through the engine), and was unable to gain altitude or maintain stabilized flight.
[1]: 30 The National Transportation Safety Board (NTSB) investigation into the accident attempted to reconstruct the aircraft's performance based on reports from witnesses and survivors.
[1]: 5 Based on examination of the wreckage, the NTSB determined that collision with the instrument landing system (ILS) localizer antenna array approximately 900 feet (270 m) beyond the departure end of the runway 18L led to the breakup of the aircraft.
Delta officials quickly reacted to questions about the 727's operating and maintenance condition by pointing out that the original factory engines from 1973 (when the plane was initially purchased by the airline) had been replaced in the last few years by a newer model that ran more quietly and used less fuel.
After conducting airplane performance studies, the NTSB determined that the events of Flight 1141 could only be explained by the aircraft attempting to take off without its flaps and slats extended to the proper take-off configuration.
[1]: 70 The captain continued to pull back on the control column in an attempt to keep the plane's nose raised, which created turbulence over the rear-mounted engines and caused the compressor surges.
[1]: 71 Based on the lack of warning sounds on the CVR, the NTSB also determined that the plane's take-off warning system (TOWS), designed to alert the crew if the engines are throttled to take-off power without the flaps and slats being correctly set, failed to alert the pilots to their improper takeoff configuration.
[1]: 36 A fleet-wide Boeing 727 inspection, ordered by the Federal Aviation Administration following the Flight 1141 crash, identified 35 anomalies in the TOWS out of 1,190 aircraft examined.
[1]: 73 FAA regulations require a sterile cockpit before takeoff, which prohibits conversation unrelated to the aircraft and the pending flight.
[1][13][14] In it, the NTSB ultimately determined that there were two probable causes for the accident: (1) inadequate cockpit discipline that resulted in the flight crew's failure to extend the aircraft's flaps and slats to proper take-off configuration, and (2) the failure of the plane's TOWS to sound and alert the crew that their plane was not properly configured for takeoff.
[1]: 94 Contributing to the accident was Delta's slow implementation of changes to its flight crew management programs, a lack of sufficiently aggressive FAA action to compel Delta to correct known deficiencies, and a lack of sufficient accountability within the FAA's air carrier inspection process.
[1]: 96–97 Burnett's dissent proposed a probable cause statement that included the two probable causes named in the main report, while adding a third probable cause:[1]: 99 Also causal to the accident was the failure of Delta Air Lines' management to provide leadership and guidance to its flightcrews through its training and check airmen programs to promote and foster optimum cockpit management procedures, and the failure of the Federal Aviation Administration to correct known deficiencies in the training and check airmen programs of Delta Air Lines.Although the NTSB specifically faulted the captain and first officer for the accident, and did not fault Judd (the flight engineer), Judd was unable to find work as a commercial pilot after being fired from Delta.