Post-Crash Survey Faults Delta for Continued Cockpit ‘Lapses’

Federal investigators report that significant “lapses” were found in cockpit procedures followed by Delta Air Lines flight crews during inspections that followed the crash of a Delta jetliner at Dallas-Ft. Worth International Airport Aug. 31.

The report, a follow-up to an Federal Aviation Administration investigation last year that found communications breakdowns, poor crew coordination and inadequate discipline in Delta cockpits, was introduced Thursday at the third day of hearings by the National Transportation Safety Board into the crash that claimed 14 lives.

Delta Given Credit

The latest report credited Delta management with taking “strong and effective action” during the last year to correct the problems found in the initial probe.

“Both line operations and training were found to be improved over last year’s audit,” the new report said. “However, deficiencies identified in the previous audit were observed. . . . “A failure to follow established procedures (was) observed in line operations . . . the acceptance of minimum standards (was) observed on proficiency checks. . . .

“The (inspection) team observed lapses in crew coordination and discipline in a small but significant percentage of cockpits.”

The NTSB says it is still too early to determine what caused the crash of Flight 1411 last August, but attention has continued to focus on the possibility of a cockpit lapse--forgetting to lower the wing flaps that provide extra lift on takeoff.

The pilot, co-pilot and flight engineer all say they are sure the flaps on the Boeing 727 were deployed properly before the jetliner made the unsuccessful takeoff attempt. However, after the crash, the flaps were found in the fully retracted position, as was the cockpit lever that controls them.

After reviewing a transcript of the cockpit voice recording recovered from the wreckage of Flight 1411, Delta Vice President Harry C. Alger disputed an NTSB questioner’s suggestion Thursday that pilot Larry L. Davis, 49, co-pilot Carey W. Kirkland Jr., 37, and flight engineer Steven M. Judd, 31, seemed “complacent.”

However, commenting on personal conversations the crew had during engine start-up and a cockpit chat with a stewardess the crew allowed during taxiing, Alger said he was “disappointed at the deviation from standard practice. . . .

“I see actions by the crew that are disappointing,” he said.

Marion B. Dittman, leader of the teams that conducted the investigations of Delta in 1987 and 1988, explained during her testimony Thursday that the initial inquiry was ordered by her FAA superiors in response to “a series of incidents” that had plagued Delta a few months earlier.

These incidents included a near-miss between a Delta plane and another jetliner over the Atlantic, an instance in which a Delta plane went into a dive over Santa Monica Bay when the pilot accidentally cut off the jetliner’s fuel supply after takeoff from Los Angeles International Airport and an occurrence in Kentucky in which a Delta pilot accidentally landed his plane at the wrong airport.

In her testimony Thursday, Dittman attributed many of the problems found at the airline to the “Delta management philosophy” of giving its captains “maximum discretion as to how they manage their cockpits.”

Many of the recommendations made by Dittman’s team involved tightening controls that limited this discretion.