# NTSB DCA88MA072: Boeing 727-232, N473DA, Dallas/Ft Worth, TX, August 31, 1988 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: August 31, 1988, 09:01 local (14:01 UTC) - Place: Dallas/Ft Worth, TX - Location: 32.8972° N, 97.0377° W: Placed by OpenAirDocs at DALLAS-FORT WORTH INTL (DFW), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=32.8972&lon=-97.0377&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 14 fatal, 26 serious, 50 minor, 18 uninjured - Status: Completed, report April 24, 1990 - Report: Approved by Office Director - Investigation class: Class 1 - NTSB office: Major Investigations Division - Safety recommendations: Yes - NTSB case key (mKey): 15900 - NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA88MA072.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15900/pdf - Board report AAR8904 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR8904.pdf - Page: https://openairdocs.org/ntsb/DCA88MA072 ## Probable cause (1) THE CAPTAIN AND FIRST OFFICER'S INADEQUATE COCKPIT DISCIPLINE WHICH RESULTED IN THE FLIGHTCREW'S ATTEMPT TO TAKEOFF WITHOUT THE WING FLAPS AND SLATS PROPERLY CONFIGURED; AND (2) THE FAILURE OF THE TAKEOFF CONFIGURATION WARNING SYSTEM TO ALERT THE CREW THAT THE AIRPLANE WAS NOT PROPERLY CONFIGURED FOR THE TAKEOFF. CONTRIBUTING TO THE ACCIDENT WAS DELTA'S SLOW IMPLEMENTATION OF NECESSARY MODIFICATIONS TO ITS OPERATING PROCEDURES, MANUAL'S, CHECKLISTS, TRAINING, AND CREW CHECKING PROGRAMS WHICH WERE NECESSITATED BY SIGNIFICANT CHANGES IN THE AIRLINE FOLLOWING RAPID GROWTH AND MERGER. ALSO CONTRIBUTING TO THE ACCIDENT WAS THE LACK OF SUFFICIENTLY AGGRESSIVE ACTION BY THE FAA TO HAVE KNOWN DEFICIENCIES CORRECTED BY DELTA AND THE LACK OF SUFFICIENT ACCOUNTABILITY WITHIN THE FAA'S AIR CARRIER INSPECTION PROCESS. ## Analysis THE FLIGHTCREW REPORTED THAT THE TAKEOFF ROLL APPEARED TO BE NORMAL IN ALL RESPECTS, WITH NO WARNING LIGHTS, AUDIBLE WARNINGS, OR UNUSUAL ENGINE INSTRUMENT CONDITIONS. THE CAPTAIN STATED THAT THE ROTATION WAS INITIALLY NORMAL, BUT AS THE MAIN GEAR WHEELS LEFT THE GROUND HE HEARD 'TWO EXPLOSIONS.' HE SAID IT FELT AS THOUGH THE AIRPLANE WAS EXPERIENCING 'REVERSE THRUST.' THE CAPTAIN STATED THAT THE AIRPLANE BEGAN TO 'ROLL VIOLENTLY.' THE AIRPLANE STRUCK THE INSTRUMENT LANDING SYSTEM (ILS) LOCALIZER ANTENNA ARRAY APPROXIMATELY 1,000 FEET BEYOND THE END OF RUNWAY 18L, AND CAME TO REST ABOUT 3,200 FEET BEYOND THE DEPARTURE END OF THE RUNWAY. INVESTIGATION DETERMINED THAT THE WING FLAPS AND SLATS WERE NOT PROPERLY CONFIGURED PRIOR TO THE ATTEMPTED TAKEOFF. (FOR FURTHER INFORMATION - SEE NTSB/AAR-89/04.) ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - preflight planning/preparation - improper, pilot in command (cause) - overconfidence in personal ability, pilot in command (cause) - procedures/directives - not followed, copilot/second pilot (cause) - procedures/directives - not followed, pilot in command (cause) - procedure inadequate, company/operator management (contributing factor) - insuff standards/requirements,operation/operator, faa(organization) (contributing factor) - inadeq method of compliance determination rcrdkpng, faa(organization) (contributing factor) - lowering of flaps - not performed (cause) - lowering of slats - not performed (cause) - safety system(other) - inoperative (cause) - In flight collision with terrain/water, descent - uncontrolled ## Aircraft - Registration: [N473DA](https://openairdocs.org/deregistered/N473DA-1989-07-27), registration cancelled 1989-07-27, S/N 20750 (OpenAirDocs) - Reported make and model: BOEING 727-232 - Registry model: [Boeing 727-232](https://openairdocs.org/model/boeing-727-232) (registry code 1384082) (OpenAirDocs) - Category: Airplane - Serial number: 20705 - Airframe hours: 43023 - Engines: P&W JT8D-15 15500 lbs thrust turbo fan - Damage: Destroyed - Fire: On-Ground - Flight: Part 121 - Registered owner: Delta Airlines, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, August 11, 1988, 166 hours before - Destination: SLC, SALT LAKE CITY, UT - Flight plan: IFR - Airport: DFW, Dallas/Ft. Worth Intl, runway 18L, 11,387 × 200 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; commercial, airline transport; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 17,000 total, 7,000 in this make and model, 119 in the last 90 days, 62 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 57 °F - Altimeter: 29.00 inHg ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19880831036229A](https://openairdocs.org/incident/19880831036229A), Aug 31, 1988: Boeing 727232, Dallas-Ft Worth, TX, Destroyed, 14 fatal. Crew failed to ascertain flaps set for takeoff and flap warning horn failed, lack of lift caused settling and crash ## Other investigations on N473DA (2) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB NYC77IA025](https://openairdocs.org/ntsb/NYC77IA025), Dec 27, 1976: Boeing 727 (N473DA), Bangor, ME, incident, minor damage - [NTSB NYC75AN068](https://openairdocs.org/ntsb/NYC75AN068), Nov 25, 1974: Boeing 727 (N473DA), Flushing, NY, substantial damage From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.