Investigation Summary
The accident occurred during a period of rapid growth and transition for Delta Air Lines following its merger with Western Airlines. Investigators found that the cockpit atmosphere was excessively casual; the Cockpit Voice Recorder (CVR) captured extensive discussions between the pilots and a flight attendant regarding the dating habits of crew members, the 1988 presidential election, and even jokes about what 'juicy tidbits' the media would find on the CVR if they crashed. This lack of discipline resulted in the crew taxiing to the runway without extending the flaps to the required 15-degree setting. When the aircraft rotated, it lacked the necessary lift to maintain flight. The right wing dropped, striking the runway and then an ILS antenna array 1,000 feet beyond the runway end. The NTSB also discovered that the TOWS failed to activate because a throttle-actuated switch was improperly adjusted and a valve in the system was partially clogged with silicone, preventing the warning horn from alerting the pilots to their error.
Final Conclusions
The NTSB determined the probable causes were (1) inadequate cockpit discipline which resulted in the flight crew's attempt to take off without the wing flaps and slats properly configured, and (2) the failure of the takeoff configuration warning system to alert the crew. Contributing factors included Delta's slow implementation of standardized cockpit management programs and the FAA's lack of aggressive action to correct known deficiencies. NTSB member Jim Burnett issued a formal dissent, arguing that the failures of Delta management and the FAA to correct known training deficiencies should have been cited as direct causes of the accident rather than mere contributing factors.
Photographic Evidence (1)
Video Analysis
Air Crash Investigation S18E03 Deadly Distraction — A detailed dramatization and analysis of Delta 1141, focusing on how sterile cockpit violations and a failed warning system led to the 1988 disaster.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Larry Lon Davis, age 48. Fired after investigation.
First Officer
Carey Wilson Kirkland, age 37. Fired after investigation.
Flight Engineer
Steven Mark Judd, age 30. Fired but later reinstated by Delta.
Systems & Failure Modes
Takeoff Warning System (TOWS)
A safety system designed to sound an intermittent horn if the throttles are advanced for takeoff while the flaps, slats, or trim are not in the correct configuration.
Leading Edge Slats and Flaps
High-lift devices on the wings that must be extended to increase lift during low-speed operations like takeoff; on Flight 1141, these remained fully retracted.
Stick Shaker
A mechanical device that rapidly vibrates the control yoke to provide a physical warning to the pilots that the aircraft is approaching an aerodynamic stall.
Interesting Facts
- 01The total flight time from liftoff to the first ground impact was approximately 22 seconds.
- 02The Takeoff Warning System (TOWS) failed to sound because of a misadjusted switch and a clogged pneumatic valve.
- 0314 people died, including 12 passengers and 2 flight attendants (Dixie Dunn, 56, and Rosilyn Marr, 43); most fatalities were due to smoke inhalation.
- 04The NTSB report noted that the aircraft could have potentially recovered if maximum power had been applied within 3 seconds of the initial stickshaker activation.
- 05All three flight deck crew members survived the crash, though the Captain was trapped in the cockpit for over 30 minutes.
Safety Actions & Advisories
Sterile Cockpit Enforcement
The NTSB recommended that the FAA and airlines more strictly enforce FAR 121.542, which prohibits non-essential conversation during critical phases of flight.
TOWS Maintenance Procedures
Boeing and the FAA issued directives to improve the inspection and maintenance of takeoff warning systems to ensure pneumatic valves do not become obstructed by contaminants.
Known Controversies & Unanswered Questions
CVR Privacy and Public Release
Reference ↗The public broadcast of the CVR tapes, featuring the crew's casual banter just before the fatal crash, caused a massive outcry from pilot unions, leading to federal laws restricting the release of actual CVR audio recordings.