Knowing when to stop : the investigation of Flight 191

Abstract

On May 25, 1979, an American Airlines DC-10 crashed just after taking off from Chicago's O'Hare Airport. It was the worst crash in U.S. history at the time, having killed all 271 people on board and two people on the ground. Arriving at the scene of a plane crash is akin to walking into a play during the third act: most of the story has already played itself out. The crash is the climax of a complex and nuanced plot with hundreds of characters and no clear beginning or end. Nevertheless, investigators from the National Transportation Safety Board are responsible for reconstructing the story from the evidence. They must study the characters and unearth the storyline and all of its twists and turns, and at the end determine the probable cause. The NTSB spent six months investigating the crash of Flight 191. This is the story of how investigators pieced together the smoldering wreckage, wrestled with questions of personal error and accountability, dodged political and financial influences, and in the end put forth a list of safety recommendations based on the flaws they uncovered along the way. The investigation of Flight 191 is one example of how investigators can take an otherwise hopeless situation and turn it into a platform for introspection and improvement.