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00:00It was so dark, so black, so thick. I could not breathe. I was on my last breath.
00:12Paul Verheiden fights for his life inside a burning plane.
00:18I was on the GOAT team. It was terrible when I got there. The wreckage was strewn over a large area.
00:28The plane is going down the runway, but it can't get in the air.
00:35Investigators must now solve the mystery of what went wrong aboard Delta Flight 1141.
00:42Is this it? It won't be easy. This FDR is outdated.
00:47It makes it difficult when you don't have many parameters to work with.
00:51It will require all their insight, expertise, and determination.
00:55We had to do a lot more digging.
00:58D. D. D. D. D.
01:03Pull up.
01:05D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D. D
01:35in America American 1056 fly heading 185 runway 18 left clear for take-off
01:42controllers here handle more than 670,000 take-offs and landings every year
01:501141 push-off at 15 let's go tail straight back prepare to taxi call me when you're ready
02:05okay
02:12brakes off and tail straight back
02:16the pilots of Delta Airlines flight 1141 started their day together in Jackson Mississippi
02:29after a brief stopover in Dallas they're now getting ready to pilot their Boeing 727
02:36to Salt Lake City Utah captain Larry Davis has been a Delta pilot for 23 years
02:44I forgot to get my paycheck to get yours yeah I got mine first officer Wilson Kirkland has been with
02:54the airline for nine years Larry and Wilson knew each other very well and they were very comfortable
03:00with each other I also have to check what my upcoming schedule is
03:04excuse me can I have a coffee I'm sorry you'll have to wait until we're in the air
03:14Paul Verheiden is an architect flying to Utah on business
03:20I had a project just outside Salt Lake City I had to go up there to make some field surveys and
03:27measurements basically on a routine trip
03:31clear start engines
03:33beacon
03:36it's on parking brake
03:38it's off
03:3940 psi
03:40the third crewman is the newest Delta employee on the team
03:44oil pressure rising flight engineer Stephen Judd
03:49start valve closed
03:5040 psi
03:53the engineer has his start sequence which is a little complicated so he's busy with his switches and his gauges
04:01start valve open
04:03oil pressure rising
04:06start valve closed
04:0940 psi
04:16brakes set
04:16you guys have a great trip
04:20brakes are set thank you
04:25as the flight attendants begin securing the cabin the 727's progress onto the taxiway is stalled
04:34Delta 1141 give me a right turn bring it between south ramp to 30 hold short of inner
04:381141 roger
04:40they have to wait for other planes to pass
04:57hopefully we'll get out of here while we still have teeth in our mouths
05:00grow engraved the south ramp
05:03that's Delta 1141
05:05I guess we should shut down engine number three
05:10save a few thousand dollars
05:12shutting down one of the 727's three engines will save fuel while they wait
05:19ask him to give us a two-minute warning to start our engines
05:23okay
05:24I should have brought something else to read
05:28finish this before we get off the ground
05:30it's very common to be trapped on a taxiway for long periods of time
05:35frequently it's ten twenty thirty minutes on the taxiway
05:40especially during the big push at the big airports where they schedule the airplanes to go out at the same time
05:47Dixie Dunn is a senior flight attendant with more than 30 years in the job
05:54gentlemen how's it going in here
05:58we're gonna go all the way down there and once all those planes are gone we can go too
06:04what kind of birds are those
06:11egrets or whatever you call them
06:13are they?
06:14think so
06:15they're cousins to the ones by the sea
06:171141 come south on the inner until taxiway 21 then move to the outer hold short of 19
06:301141 roger
06:32now cleared to taxi
06:34the 727 will have to join a long line of planes waiting to take off
06:39so what else are we gonna talk about?
06:45well we could discuss the dating habits of our flight attendants
06:48that way we have it on the recorder you know in case you crash
06:52we gotta leave something for our wife and children to listen to
06:58good morning ladies and gentlemen
07:04we are number 4 for departure
07:07flight attendants
07:08prepare the cabin please
07:10we are ready
07:11thank you
07:12might as well start
07:1540 PSI
07:24number 3
07:25start valve open
07:26in preparation for takeoff the pilots restart the third engine
07:31as the air traffic controller juggles the many flights he's handling this morning
07:38he spots an opportunity to get delta 1141 back on track
07:421141 taxi to position runway 18 left and hold
07:48ok 1141's position and hold
07:52it's an unexpected but welcome change of plans
07:56instead of having to wait for 3 other planes to take off
08:00delta 1141 is told to move to the head of the line
08:08shoulder harness
08:09they're on
08:10flaps
08:111515 green line
08:12flight control
08:13tops and bottoms checked
08:14nav instruments
08:15they're set
08:16takeoff briefing
08:17is complete
08:18ok
08:19oh
08:20finally
08:25delta 1141 fly heading 185 runway 18 left cleared for takeoff
08:351141 185 cleared to go
08:39power set
08:46engine instruments look good
08:48finally
08:49delta flight 1141 is on the roll
08:58before we took off it was pretty normal
09:01uh...
09:02don't remember anything
09:03unusual
09:04air speeds coming up on both sides
09:06the most difficult part of being an airline pilot
09:09eighty knots
09:12it's that last five seconds before the decision speed
09:17tension grows up to that moment
09:21vr
09:22v2
09:28something's wrong
09:32didn't get an engine field
09:33as the plane got off the ground it kind of dipped
09:38and then it kind of went up and then
09:40there was a big bang
09:42kind of tilted one side and then the other
09:49we're not gonna make it
09:52full power
09:55captain davis and first officer kirkland struggle to get their plane in the air
10:03and then it just dropped
10:05and hit the ground
10:12shaking you know shaking shaking and everything kind of flying around and people hollering and screaming
10:33it then stopped
10:35you know i thought
10:50we have crashed
10:51108 people are now desperately trying to get out of a plane that's filling up with smoke and fire
10:58every passenger and crew member including the pilots on board delta flight 1141 have survived a crash on takeoff at Dallas Fort Worth Airport
11:13and now they're fighting for their lives inside the burning cabin
11:16and then i looked over the aisle there was all these people and the cabin was filled with smoke and fire i could see outside the window
11:25so i thought i may not get off of this thing because all these people
11:32and i was just feeling people's back and they were moving so i just followed along
11:47was feeling people's backs and they were moving so i just followed along oh god oh god it was so
11:56dark so black so thick i could not breathe i was on my last breath flashing through my mind was
12:09my wife and two kids and this is it please
12:13and then the smoke cleared and there was sky and we were at the door
12:33an airport rescue team is at the crash site in less than five minutes news crews aren't far behind
12:40i looked back and i could see tattered clothes and some blood on some some of the stewardesses
12:48meanwhile you know the plane was burning up along with the pilots paul verheiden is one of 94 people
12:56who make it off the burning plane alive 14 others including flight attendant dixie dunn die
13:04unable to escape the smoke and flames something that i realized was life is
13:12not guaranteed none of us really know what's going to happen
13:26investigators from the national transportation safety board are quick to arrive on the scene
13:31the smell is the first thing that jumps out of you and it's the smell that gets to you most
13:37more than anything specialist jim cash is one of the first investigators to get to dallas fort worth
13:43airport i was there while it was still smoking i've never been to an accident that early on before
13:51i was on the go team so my instructions were to just go to the accident site it was terrible when i got there
14:01the wreckage was strewn over large area
14:10investigators begin examining the scorched remains of the boeing 727. they need to understand why it
14:17failed to fail to get airborne it is a long runway there was no weather at the time there's was no
14:24reason he shouldn't have gotten off so we knew there was something wrong with either the airplane or
14:31configuration now we're getting somewhere within hours workers recover the plane's black boxes and send
14:39them to an ntsb lab make sure you get those to dc asap the flight data recorder or the cockpit voice
14:47recorder are the most important things both of them provide pieces to the puzzle that the investigators
14:53need to kind of get the whole picture of what's going on with the recorders on their way for analysis
15:01investigators continue searching for clues at the crash site we want to walk the accident site
15:07because we want to see if there's any evidence that that would help us understand what happened
15:17take a look at this
15:21back of the wing here really ground down get some shots of that skid shoe looks like it hit the ground too
15:30this paint from the runway along with a scraped wing section they find that the plane's tail skid shoe
15:43also suffered damage on the boeing 727 it has a tail skid in the very aft part of the fuselage and it's a
15:52little metal shoe that rides below the fuselage in case the airplane's nose is rotated up too high
15:58you would actually hit this tail skid before you would hit the bottom of the fuselage let's find out where it hit
16:09what we're really interested in is what was going on before the airplane got to its final resting point
16:15bingo
16:27first impact with the skid shoe right there
16:32mark and measure please
16:33if you just look at the geometry of the 727 to strike the tail skid it works out to roughly a 10 degree
16:44nose up pitch attitude so when we looked at that mark we knew that the airplane was at a 10 degree
16:50nose up pitch attitude at that point along the runway
16:53it's a puzzling discovery 10 degrees nose up should allow a 727 to climb out safely
17:02why didn't it this time
17:17looks like we have a match
17:21wingtip there barb glass nav light beside it
17:25fact number two we found where the right wingtip had actually struck the runway and it had deposited
17:35quite a bit of aluminum along a segment of the runway and so that told us that there was a problem as
17:41far as the attitude of the airplane okay let's take some measurements get this runway open
17:49we knew that the pilot was having some kind of controllability problem at that point
17:55okay so
18:00the plane is going down the runway it can't get in the air
18:05its tail starts to drag and the right wing hits the ground
18:11as they wait for crews to recover all the aircraft wreckage
18:15investigators try to eliminate as many possible causes for the failed takeoff as they can
18:20what was the weight of the plane one of the critical things for departure of an airplane is to get
18:30the weight calculated if the calculations are wrong say two three thousand pounds
18:36the airplane may rotate but it may not fly
18:43the actual weight was 157 683 pounds well below maximum records show that flight 1141 was 18 000
18:52pounds below its maximum takeoff weight well within the limits for the runway at dallas
18:58okay so if weight wasn't an issue maybe they had a fuel imbalance
19:06let's check the fuel logs the boeing 727 is equipped with three fuel tanks
19:13by managing how the fuel is consumed during flight the pilot is able to properly balance the aircraft
19:20initial information that our guys got was that there might have been a fuel imbalance
19:25that the refueling numbers were a little bit confusing if the 727 was fueled improperly it may
19:34have been dangerously unbalanced on takeoff if there was more fuel in the right wing that might account
19:40for the right wing scraping the runway that we saw in the accident so if we go check the refueling records
19:48to see how many pounds how many gallons of fuel were put on when they run the numbers so what do we got
20:00it's all fine no imbalance in the fuel tanks they can find nothing out of the ordinary the weight and
20:07balance was correct it was not a factor in the takeoff accident it's another dead end
20:18air crash investigators in dallas are trying to figure out why delta airlines flight 1141 crashed on takeoff
20:35there was a lot of traffic at dallas fort worth
20:40we could be looking at a wingtip vortex
20:42wingtip vortices are spirals of air that trail off the tips of an airplane's wings
20:51the heavier the plane the bigger the vortex these tornado-like winds can sometimes be strong enough to
20:58pose an invisible hazard to other planes one of the things that can cause an accident on takeoff such as
21:051141 as if it's behind another aircraft and it happens to encounter the wingtip vortices
21:12fly into those that can upset the airplane
21:17did the plane in front of delta 1141 create dangerous vortices
21:24was flight 1141 cleared for takeoff too soon bringing it too close to the plane ahead
21:30air traffic records show that the plane that took off just before flight 1141
21:37was delta airlines flight 1486 another boeing 727 they get takeoff clearance at 8 59 17.
21:48in this case we did calculate the probable location of the wingtip vortices for the airplanes that were
21:55nearest to the accident airplane by then the other delta plane was off the ground
22:02and already 7 000 feet ahead of them investigators know that the minimum federal aviation authority
22:09requirements for separation between flights is 6 000 feet we found that even assuming the vortices
22:16stayed as strong as they could possibly stay and that they moved in a in a manner that put them as
22:22close as possible to the accident airplane that they would still be a significant distance away from
22:27the accident aircraft more than enough clearance so it wasn't wingtip vortex
22:38we determined there was no effect of the wake vortex on this airplane to cause it to crash
22:43excess weight fuel imbalance and wingtip vortices three potential causes are now off the table
22:52the failed takeoff of delta 1141 is still a mystery hey take a look at that photo
23:10it looks like the flaps weren't extended
23:14all commercial airliners must have their wing flaps extended for takeoff without the flaps the wings
23:26cannot generate enough lift to carry the plane skyward we had to do a lot more digging
23:33investigators investigators now have their hands on critical performance data the readouts from the plane's
23:43flight data recorder they hope these can confirm their suspicion that the flaps on this flight were not
23:50extended on takeoff
23:57is this it
24:02but as they scan the numbers they soon realize the data they need simply isn't there
24:09this fdr is outdated the flight data recorder is an older model a lockheed 109d it captures very
24:18little information the recorder is kind of basic and just has your basic flight parameters airspeed
24:25altitude heading basic engine parameters there's no information regarding the flaps at all
24:33the data available can't help them prove the only working theory they have
24:37it makes it difficult when you don't have many parameters uh to work with
24:44we need to speak to the crew
24:52human factors interviews when you're fortunate enough to have surviving pilots
24:56in a serious accident we hope to uncover something that's more intuitive than was evident
25:01on the flight data recorder or the cockpit voice recorder investigators meet with delta captain larry
25:08davis and his lawyer along with a representative from the pilots union
25:15thank you for coming everyone as a delta person i was terribly embarrassed that we had let down the
25:22traveling public with this accident so i can only imagine what the pilots of 1141 must have felt like
25:32must have been terrible
25:43okay everyone ready
25:47let's try and figure this thing out
25:55part of the union reps job is to defend the pilots from any unjust accusation
26:02captain davis just tell me what happened back in the 80s airline pilots association had had seen
26:10many of the investigations quickly dismissed as pilot error why would you want to blame it on the pilot
26:17it's real simple we're the cheapest guys to nail if you had an engine or an airframe
26:25that was found to be at fault airlines could go bankrupt manufacturers could go bankrupt the the price would be untold billions
26:36we've been waiting for some time trying to get permission to taxi
26:54hopefully we'll get out of here while we still have teeth in our mouths growing gray the south brand
27:00that's delta 1141.
27:07investigators want to get as many details as they can from the captain
27:12including what he recalls about the wing flaps
27:17lots of traffic waiting to get out definitely a hurry up and wait kind of day
27:22now do you remember if you uh
27:30extended the flaps of course we did okay great
27:34now is there anything else you might remember
27:44there was something
27:48just when the main gear left the ground i heard two explosions
27:51a revelation from the captain of delta flight 1141 about hearing explosions on takeoff takes the
28:05investigation in a new direction
28:13explosions that's right it felt like we were experiencing reverse thrust
28:18engine thrust reversers are devices deployed on landing to slow the plane
28:26if a reverser were somehow to activate on takeoff the results could be catastrophic
28:33that'll cause an airplane not to fly and it'll stagger down the runway and crash because the wings stall
28:41okay uh i think we're done for today thank you all very much for your time
28:48there have been cases where a thrust reverser has come out inadvertently there's been a malfunction
28:54and so this is always in the back of our mind this is a possibility
29:01investigators are chasing a new lead the possibility that a faulty thrust reverser brought down the plane
29:09show me that thrust reverser
29:12what they need now is hard evidence that can prove or disprove the theory
29:19we were able to look at the engine thrust reversers in the wreckage after the accident
29:26we thoroughly examined the mechanisms to make sure
29:30what position they were in when this airplane crashed
29:34what they find leaves no doubt
29:36still stowed
29:40they were all stowed in their proper position and could not have been extended and then pushed back
29:48in by the impact that was ruled out totally captain davis must have been mistaken about the sound he heard on takeoff
29:57the thrust reversers had nothing to do with the accident
30:02what if the captain's wrong
30:04what if he just thinks they extended the flaps wing flaps are still a possible culprit
30:10time to see what that recording has to offer
30:19crash site wreckage suggests the 727 may not have been properly configured for takeoff
30:25okay you ready but is there anything on the recording that can back up that theory
30:33i forgot to get my paycheck did you get yours
30:38yeah i got mine they should be focused on the flight not talking about paychecks
30:42when we finally listened to the voice recorder that that afternoon
30:48there was some extraneous conversations on their long taxi out
30:52hopefully we'll get out of here while we still have teeth
30:54we still have teeth in our mouths growing gray at the south ramp that's delta 1141
31:02the conversation sounds casual investigators are surprised to hear it continue
31:11is that the flight attendant and what is she doing in there now
31:15what kind of birds are those egrets or whatever you call them are they
31:22i think so the presence to the ones by the sea sitting in the cockpit talking about birds
31:29the pilots are not allowed to have non-pertinent conversations from taxi takeoff up to 10 000 feet
31:37in this case we were pretty amazed at the lack of discipline in the cockpit during taxi prior to takeoff
31:46that way we have it on the recorder you know in case we crash we gotta leave something for our wife
31:51and children to listen to
31:56good morning ladies and gentlemen we are number four for departure
32:00flight attendants prepare the cabin please we are ready thank you
32:06so far they've heard nothing about the flap configuration but what they hear next is another surprise
32:13we might as well start number three start by our boat
32:181141 taxi to position runway one eight left and hold okay 1141 position and hold hold up a minute stop
32:27here's where the controller bumps them into first position and they've just restarted the engine
32:32they're gonna have to rush to get airborne in the course of about 90 seconds they were to start the
32:43engine finish the taxi checklist do the before takeoff checklist and take off that's a rush
32:53play it were the pilots so rushed that they overlooked an essential item on their checklist
32:59extending the flaps
33:03investigators need to know if the pilots of delta flight 1141 missed a critical item on their takeoff
33:10checklist
33:11shoulder harness they're on flaps 15 15 green light wait stop clear as day flaps extended to 15 for takeoff
33:24what's going on here so they did get a little rush there and and it was attributed to having the flight
33:31attendant in the cockpit and the casual conversations that were going on and they hit all the items on
33:36the checklist you could go right down the checklist and they they got them all once again the no flaps
33:42theory is in question but investigators may have a way to resolve the flap issue once and for all
33:49let's dig up the jack screws
33:50a device called a jack screw is an integral part of the flap system
34:03as it turns it moves a nut that extends or retracts the flaps we like those because most
34:11of the time they don't move during impact if we want to determine the position of flaps
34:15we go measure the jack screw if the flaps were extended this nut would have been here we find
34:21the jack screw we can determine where the flaps were at takeoff that seals it those flaps were never
34:29extended everything that we examined on the flaps all the mechanisms and everything reveal that they
34:34were all in the retracted position at impact it's the conclusive proof they need the flaps were not
34:42extended before takeoff but the finding leaves them with another puzzling question so why did the
34:49pilots think they were extended let's go back to the start of the takeoff checklist the team returns to
34:57the cockpit recording hoping to hear something that might explain the discrepancy
35:02the
35:06shoulder harness they're on
35:09flaps 15 15 green light flight controls tops and bombs are checked
35:14nav instruments they're set takeoff briefing is complete that was fast
35:21shoulder harness they're on flops 15 15 green light is he is he checking or just answering
35:39when you have a crew going through the checklist and you can listen to it on the cockpit voice recording
35:44one of the things that you don't typically know is whether they're just confirming a setting that's
35:50already been made or if they're actually moving say the flap handle to a position that it needs to be in
35:58flaps 15 15 green light there was less than one second between the flaps call and his response
36:05there's no way he had time to check and see if the flaps were actually out
36:09no way the speed of the first officer's response is an important clue it would have been very
36:16difficult to actually move the flap lever from say zero to 15 degree detent that rapidly
36:24investigators are convinced despite his response the first officer could not have extended or even
36:30checked the flaps in the time available flaps 15 15 green light we didn't hear the flat panel being
36:37moved i don't know what he was doing when the flight engineer read the challenge for flaps
36:43he gave the correct response that's all i can tell you is he gave the correct response you have to be
36:49totally focused on the task at hand if you're doing the checklist in the middle of other conversations
36:55that aren't related to operating the airplane then it's easy to get distracted and it's easy to miss things
37:01the mystery of the flaps is finally solved a rushed checklist led to the delta pilots thinking that
37:13their plane was ready for takeoff when it was anything but they probably didn't know in a true sense
37:21that they forgot it wasn't intentional that's for sure and they just overlooked it for investigators
37:29there's still one critical question takeoff warning would have gone off
37:37the boeing 727 is equipped with a takeoff warning system specifically designed to prevent the kind of
37:43accident that killed 14 and injured dozens more in dallas
37:50if you apply takeoff thrust and you don't have the flaps and takeoff position you would get a warning
37:57horn there's no sound of the warning on the recording it should have been sounding non-stop
38:01and we didn't hear the takeoff warning or go off the alarm would have saved them
38:06why didn't it sound so that made us think that there must have been some kind of a
38:12malfunction of the takeoff warning system
38:14the ntsb wants to know why a critically important takeoff warning system failed on delta flight 1141
38:28see what happens testing the console that houses the alarm mechanism could provide an answer
38:37they focus on the electronic components that are designed to trigger the cockpit warning here we go
38:42there's a little switch that that when they advance the throttles the switch is supposed to activate the
38:48circuitry for the takeoff warning horn okay let's reset it try it again here we go
39:01so it only works sometimes what gives multiple tests reveal that what should be a fail-safe mechanism
39:09is instead intermittent and unreliable when the takeoff warning system doesn't work it is a big deal
39:16there's a reason that it exists and it's uh it's to prevent a catastrophic accident
39:25look at this they find the reason for the failure on the terminals of the alarm mechanism corrosion
39:32and this and they were able to determine that it was the switch on the throttle quadrant that
39:41when you advance the throttles didn't activate the system properly if that button slipped off
39:48the alarm wouldn't have sounded the switch failed and thus there was no oral warning
39:53so it was a technical failure that happens extremely rarely and unfortunately they needed it that day
40:06investigators finally know what happened to delta airlines flight 1141. so
40:12it's now 8 58 a.m flight 1141 is lined up behind four other planes on the taxiway
40:23the delta crew breaks cockpit protocol while awaiting their turn to taxi
40:291141 185 cleared to go
40:31instead of setting the flaps for takeoff and focusing on the job at hand they get distracted by idle chat
40:43there are still three planes ahead of them when they're suddenly told to move past them to the runway
40:50when air traffic control cleared them for takeoff in that surprise clearance somebody should have said
40:57wait a minute we're not ready we can't do that we need time to run the checklist
41:03okay 1141 position and hold now they're in a rush shoulder harness they're on investigators believe they
41:09are so rushed flaps 15 15 green light flight control tops and bottoms checked that they fail to check if
41:18their flaps were properly extended you don't want to rush through a checklist when it's vital that you
41:25methodically perform everything that's on the list or else you're going to have a problem during the flight
41:32a mechanical failure with the takeoff warning system meant that the pilots were not alerted to their
41:37mistake the takeoff warning system is a great backup system but those backup systems don't always
41:45perform as they should so it's really up to the pilots to make sure that they're operating the
41:50airplane as methodically and professionally as possible without their wing flaps extended a
41:57successful takeoff is virtually impossible one minute later at exactly 9 a.m
42:08the plane crashes
42:13following the crash captain larry davis and first officer wilson kirkland
42:19both lose their jobs at delta
42:24for many of the 94 survivors including paul verheiden what happened at dallas fort worth
42:31that day remains the most traumatic experience of their lives
42:3629 years later it still is like it was yesterday it happened and it still causes me to
42:43to really appreciate given the opportunity to survive something like that the ntsb concludes that a
42:53combination of pilot error and mechanical failure doomed flight 1141
42:58their final report calls for changes to cockpit procedures they recommend that each crew member
43:07visually confirm the execution of all checklist items to help ensure that none are missed
43:16they also call for a study of the reliability of the takeoff warning system in all boeing 727 models
43:23the reason airplanes are so good today are because of these accidents
43:29the job of the ntsb is to look at the mistakes that people have made in the past and make
43:35recommendations to to keep this stuff from happening again the lessons learned from this accident on
43:41cockpit discipline proper training proper uh leadership by the captain that was positive
43:47there are a lot of important things came out of this accident improvements in aviation safety
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