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Safety Recommendation Details

Safety Recommendation A-86-083
Details
Synopsis: ON AUGUST 2, 1985, AT 1805:52 CENTRAL DAYLIGHT TIME, DELTA AIR LINES (DELTA) FLIGHT 191, A LOCKHEED L-1011-385-1, N726DA, CRASHED WHILE APPROACHING TO LAND ON RUNWAY 17L AT THE DALLAS/FORT WORTH INTERNATIONAL (DFW) AIRPORT, TEXAS. WHILE PASSING THROUGH THE RAIN SHAFT BENEATH A THUNDERSTORM, FLIGHT 191 ENTERED A MICROBURST WHICH THE PILOT WAS UNABLE TO TRAVERSE SUCCESSFULLY. THE AIRPLANE STRUCK THE GROUND ABOUT 6,300 FEET NORTH OF THE APPROACH END OF RUNWAY 17L, HIT A CAR ON A HIGHWAY NORTH OF THE RUNWAY KILLING THE DRIVER, STRUCK TWO WATER TANKS ON THE AIRPORT, AND BROKE APART. EXCEPT FOR A SECTION OF THE AIRPLANE CONTAINING THE AFT FUSELAGE AND EMPENNAGE, THE REMAINDER OF THE AIRPLANE DISINTEGRATED DURING THE IMPACT SEQUENCE, AND A SEVERE FIRE ERUPTED DURING THE IMPACT SEQUENCE. OF THE 163 PERSONS ABOARD, 134 PASSENGERS AND CREWMEMBERS WERE KILLED; 26 PAS SENGERS AND 3 CABIN ATTENDANTS SURVIVED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REVIEW, AND REQUIRE IMPROVEMENTS AS NECESSARY IN, DELTA AIR LINES QUALITY CONTROL PROGRAM REGARDING INSPECTION AND REPLACEMENT OF RESTRAINT SYSTEMS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: DALLAS/FT WORTH, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA85AA031
Accident Reports: Delta Air Lines, Inc., Lockheed L-1011-385-1, N726DA
Report #: AAR-86-05
Accident Date: 8/2/1985
Issue Date: 9/3/1986
Date Closed: 8/21/1987
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/21/1987
Response: The Safety Board is pleased to learn of the improvements that have been made to Delta Air Lines' maintenance program regarding the inspection and replacement of restraint systems. Based upon the FAA's action to revise the restraint system inspection cards, Safety Recommendation A-86-83 has been classified as "Closed-- Acceptable Action." In regard to the FAA's comment that "no subject belts failed the minimum strength test conducted during the accident investigation," the Board's investigation determined that the webbing from the right side of the seatbelt for the R-4 flight attendant jumpseat failed during tensile tests at 1,300 pounds. This failure was well below the 4,000 pounds minimum strength specified by the manufacturer for new webbing and less than the 2,250 pounds specified in Technical Standard Order, TSO-C- 22f. Further, the failure at 1,300 pounds could have caused the entire seatbelt assembly to not comply with the 1,500 pound minimum strength requirements called for in the TSO or in the requirements of 14 CFR 25 and 14 CFR 121.

From: FAA
To: NTSB
Date: 7/16/1987
Response: THE FAA COMPLETED ITS REVIEW OF THE DELTA AIRLINES QUALITY CONTROL PROGRAM REGARDING INSPECTION AND REPLACEMENT OF FLIGHT ATTENDANT RESTRAINT SYSTEMS. THE DELTA PROGRAM WAS CONSIDERED AN ADEQUATE "ON-CONDITION" PROGRAM. ALTHOUGH SOME IMPROVEMENTS HAVE BEEN IMPLEMENTED. THESE IMPROVEMENTS INCLUDE: REVISION OF INSPECTION CARD INSTRUCTIONS, INSPECTION OF RESTRAINT SYSTEMS, REPLACEMENT OF RESTRAINT SYSTEM SHOULDER AND SEAT HARNESSES EVERY 4 YEARS.

From: NTSB
To: FAA
Date: 3/19/1987
Response: As mentioned in the previous evaluation, the Board believes that adequate inspection is dependent upon the development of objective guidance for determining the airworthiness of restraint systems. Therefore, while the Board believes that the FAA has made a good faith effort to comply with the intent of this recommendation, the lack of proper guidance reduces the value of the principal maintenance inspector's evaluation. Pending development of the necessary guidance and completion of the assigned principal maintenance inspector's evaluation of Delta Air Lines quality control program for the inspection and replacement of flight attendant restraint systems, Safety Recommendation A-86-83 has been classified as "Open-- Acceptable Action."

From: FAA
To: NTSB
Date: 11/18/1986
Response: THE FAA AGREES WITH THIS RECOMMENDATION. THE DELTA AIR LINES QUALITY CONTROL PROGRAM REGARDING INSPECTION AND REPLCAEMENT OF FLIGHT ATTENDANT RESTRAINT SYSTEMS HAS BEEN EVALUATED BY THE ASSIGNED PRINCIPAL MAINTENANCE INSPECTOR. APPROPRIATE ACTION WILL BE TAKEN BY THE FAA'S DISTRICT OFFICE FOR REVISION OF THE PROGRAM.