Delta Air Lines Flight 1141 - Investigation

Investigation

On September 26, 1989 the NTSB (National Safety Transportation Board) published the accident report. Two causes were primarily blamed for the accident: (1) The crew had not ensured that the wing's flaps and slats were properly positioned for take-off, and (2) the plane's takeoff warning horn, designed to alert the crew if the engines are throttled to take-off power without the flaps and slats being correctly set, was not operating correctly. The airplane did not gain sufficient speed to climb in a flaps-and-slats-retracted condition, causing a loss of lift. The continued high angle of attack combined with a lack of lift resulted in a configuration where disturbed air flowing over the wings disrupted the air flow into the engines causing compressor stall. Subsequent collision with the instrument landing system (ILS) localizer antenna array approximately 1,000 feet beyond the departure end of the runway 18L led to the breakup of the aircraft.

FAA regulations require a sterile cockpit before takeoff, which means there is to be no conversation unrelated to the aircraft and pending flight. The cockpit voice recorder (CVR) tapes recorded extensive talk about the CVR itself and how on Continental Airlines Flight 1713 crew discussions were recorded about the dating habits of the flight attendants. Media broadcast of the CVR tapes, which demonstrated why the crew mistakenly mispositioned the flaps, provoked such an outcry by pilots that subsequent releases of CVR data have been restricted by law and carefully vetted by the NTSB.

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