A Salt Lake-bound jet probably crashed last year because its inattentive, distracted crew failed to properly set wing flaps and slats, the National Transportation Safety Board ruled Tuesday after a 13-month investigation.
On top of that, the board said a warning system that should have sounded alarms to point out those improper settings was broken on Delta Flight 1141, which crashed Aug. 31, 1988, at the Dallas-Ft. Worth International Airport.The Boeing 727-232 jet only climbed to an altitude of 20 feet and was airborne just 22 seconds before a fiery crash. It killed 14 of the 108 people on board and injured 76 - and the high number of survivors is considered a miracle.
Meanwhile, the Air Line Pilots Association criticized the board's conclusions, saying they were based only on circumstantial evidence. It said it will petition for "a thoughtful and careful" reconsideration of the findings.
After an eight-hour discussion of federal investigators' reports on the crash, the board laid most the blame for the crash squarely on Capt. Larry Davis and First Officer Cary Wilson Kirkland.
"This crew was not representative of professional airline crews in general in the way they ran the cockpit," said board member John Lauber.
Investigator Gerrit J. Walhout said the captain "was completely out of the loop" in cockpit decision-making, leaving responsibility for checklists and ensuring flight readiness to the first and second officers.
Cockpit tapes showed the captain and first officer also had extended, non-flight-related conversations with a flight attendant - who was in the cockpit for 18 of the 26 minutes spent waiting for takeoff.
Investigators said while the captain, first officer and flight attendant were chit-chatting, the crew missed a transmission informing that it was higher in the lineup for takeoff than it thought.
Investigators said when the crew finally discovered less than two minutes before takeoff that it was next in line to leave instead of No. 4, the crew raced through checklists.
Even though the first officer called out that he checked the flaps, investigators said he was rushing too fast through the list and didn't check it closely enough - and that subsequent flight patterns and lack of other causes suggest flaps were not set.
The board said the captain also reacted incorrectly when it was discovered the plane had a problem while rolling down the runway.
When the captain felt a "stick shake," indicating problems might force the plane to stall, maximum power should have been called for, according to Delta Airlines procedures. The captain failed to call for that until an instant before the crash, and instead tried to raise the nose of the plane - which reduced its lift, the board said.
Investigators said other test flights and computer simulations show that if full power had been called for quickly, the plane likely would have achieved enough altitude to escape the crash.
The board also said a warning system that should have sounded alarms warning that flaps were set incorrectly was broken.
It said Delta pilots using the plane in previous weeks had warned of intermittent problems with the system. Mechanics thought they had fixed the problem two weeks before the crash. But a post-crash examination showed a bent lever - and not dirty connections that mechanics had cleaned - likely caused the system not to work.
Besides the "probable causes" of the crash listed by the board, it also listed two "contributing factors."
The first was Delta's slow implementation of operating procedures, training and crew standards and manuals during a period of fast growth and the merger with Western Airlines.
The changes were urged by the Federal Aviation Administration after the airline experienced a series of near-mishaps in the summer of 1987.
The other contributing factor was the FAA's "lack of sufficiently aggressive action" in correcting Delta deficiencies it had discovered.
Board member Jim Burnett unsuccessfully sought to have both Delta and the FAA cited in the more serious "probable cause" category, contending more vigilance could have prevented the crash.
But Acting Chairman James L. Kolstad talked members out of it. Especially defending the FAA, he said, "I don't see the federal government is to blame any more than a New Jersey highway patrolman is responsible for a death on a New Jersey highway."
The pilots association said it is not convinced sufficient evidence was found to blame the crash on the improper setting of flaps, and said the "board takes great liberty in criticizing the attitudes and personalities of the cockpit crew without greater input" from them.