Written by 00:00 Idea Blender, Linkinbio, Risk Management

What you can learn from an aviation disaster

On July 19, 1989 the unthinkable happened on flight UA232. Thanks to an unlikely team and exceptional preparation they made the impossible landing

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Today’s story took place in summer 1989. Denny Fitch was a United Airline (UA) pilot instructor. As he boarded the flight UA232 in Denver, inbound for Philadelphia via Chicago, he was expecting – like all 284 other passengers – an uneventful flight. He was not flying in the cockpit, but in first class as he was off-duty. Before taking his seat, he went introducing himself to his three colleagues sitting at the front of that flight. Yes, at that time, it was common to have two pilots – the captain and the first officer – assisted by the flight engineer, also called the second officer.

The plane, a DC-10, departed Denver on time. An hour into the flight the heavy three engine airliner reached its cruising altitude. The eight flight attendants had just started serving lunch, when suddenly the whole aircraft was shaken by a loud bang. Then the plane started entering into a right descending turn. Denny knew immediately that something serious had happened. Without hesitation he offered his help to the flight attendant who instantly advised the pilots. A couple of minutes later he was called into the cockpit.

A scenario so unlikely that no one was prepared for

The aircrew had already identified the problem. The tail engine had failed. More worryingly, it appeared that all three independent hydraulic systems had failed as well, which made the plane uncontrollable. That explained the right descending turn. If they won’t not find a way to recover control, the plane would crash with all 296 souls on board.

That scenario was so improbable that it had never been trained in the simulator. There was no emergency checklist either to help the pilots. As Denny entered the cockpit, the crew was already desperately trying to solve the problem.

The three-engine DC-10, with the failing engine 2 at the center of the aircraft

Asking for help and accepting it

The voice recorders (a.k.a. the black boxes) revealed that the four airmen discussed the procedures and possible options to deal with the loss of the hydraulic system. If they wanted to attempt an emergency landing they needed to find a way to control the plane. The investigators of the National Transportation Safety Board (NTSB) later considered the captain’s acceptance of the pilot instructor to assist in the cockpit to be key in what has later been described as the impossible landing.

In hindsight it appears to be common sense to accept help in such circumstances. But let’s reflect a bit. How likely are we to ask for assistance when we are under a great deal of stress and pressure?

Thinking out of the box

Too often we might chose to solve the issue ourselves because no one can come-up with a magical solution. Denny Fitch was less experienced than the captain, who was a 33 years veteran himself. But when he came into the cockpit he brought-in a new view. Since he hadn’t been in the cockpit in the first minutes of the emergency, his perspective was slightly different. That allowed him to assess and react to the situation differently. 

Sometimes bringing in an outsider to what first appears to be an unsolvable problem will not give you a solution per se, but it allows you to consider things differently. You start thinking out of the box. For some emergencies or tricky situations, there are specialists ready to help you. For instance take crisis communication. When your company is in trouble and makes headlines in the press, or perhaps when you have to recall a deficient product, every further mistake will fuel the crisis. What you want is efficient and prompt problem solving. 

The good practice here is not to wait to be in trouble to start looking for help, but rather to have these contacts at hand. As time is precious, having a set of disaster recovery plans ready and a list of specialists on speed dial will get you back on track.

Team Resource Management 

Another positive contribution identified in the NTSB investigation is the interaction among the pilots, the flight engineer and the pilot instructor during the emergency. According to the investigator it indicated the value of Cockpit Resource Management (CRM) training – a procedure that United Airlines was first to introduce in the industry in 1981.

As aircrews manage under high-pressure situations CRM encompasses a wide range of knowledge, skills and attitudes, including communications, situational awareness, problem solving, decision making, and teamwork. Over the years this type of training has been extended to include the flight attendants (now being called Crew Resource Management) to be used in conjunction with the pilots to provide another layer of enhanced communication and teamwork.

Studies have shown that by both work groups using CRM together, communication barriers are reduced and problems can be solved more efficiently, leading to increased safety.

DC-10 Swissair (1978) - copyright ETH Bibliothek Zürich

DC-10 Swissair (1978) – copyright ETH library Zurich

Since then, CRM training concepts have been modified for application to a wide range of activities where people must make dangerous time-critical decisions. These arenas include air traffic control, ship handling, firefighting, and medical operating rooms.

Why not imaging Team Resource Management for board rooms, or large project teams who are also facing challenging situations (not necessarily life threatening, but definitely business critical)?

Teamwork that saves lives

Let’s come back to our story. After having discussed several options it was decided that Denny would handle the throttles, allowing the captain and the first officer to manipulate the flight controls. Denny had to use the power of the two remaining engines under the wings (with one control in each hand) to maneuver the aircraft in all three dimensions. The coordination and therefore communication between the four men was key to be able to control all the remaining elements simultaneously. With this unbelievable effort the four men managed to bring the aircraft safely to the closest airport within their vicinity: Sioux City.

Sioux Gateway Airport, as it is officially called, was only an Index B airport. It means that according to the type of aircraft primarily flying there it had only limited rescue and firefighting services. Nevertheless, they mobilized all available resources and positioned them as best as they could to be ready to intervene.

Forty-five minutes after the failure of the tail engine had occured, flight UA232 crash-landed at Sioux City Airport and caught fire. Out of the 296 persons on board, 185 survived, including Denny and the three other airmen. Given the nature of the accident, many experts consider this case as a success story – not only thanks to the exceptional performance of the crew, but also to the level of preparedness of the local personnel in Sioux City.

Getting prepared for the unthinkable

Considering the type of airport, Sioux City was very well prepared. They had more firefighting equipment than the minimum required. In coordination with the local authorities they regularly conducted simulated disaster planning exercises – not once a year as the Federal Aviation Authority asked for, but twice. When interviewed for the investigation, the emergency personnel indicated that their training was a tremendous asset in this particular situation.

How prepared are you?

Reflecting one last time on general business, do we take enough time to train for crises? Do we ask ourselves what could go wrong in our daily activities, and what the consequences could be? Over the last decades the disciplines of risk management, disaster planning and business continuity management have become more and more professionalized. In some instances it is unfortunately a pure compliance or even academic exercise and completely missing the point. Instead, the goal should remain:

You can hope for the best, but have a plan for the worst.

Conclusion

The NTSB concluded that the probable cause of the accident was a flaw in the inspection carried out by United Airlines. The fan disk of the tail engine had experienced a fatigue crack that had been overlooked during inspection. In other words this accident was due to human error. On the other hand, the outstanding performance of the four men in the cockpit saved the lives of many people. We can conclude that a wise way to learn from such an accident is not only to consider what failed, but also what did work better than expected and prevented much worse consequences.

If you want to know more about the investigation, the complete NSTB report is publicly available online.

We are planning to provide you with templates and tools to assess risks in your situation, and to give you simple and practical guidance to define business continuity plans. 

Sign-up for your newsletter below and stay tuned…

Animated video of flight UA232

Animation from the beginning of the engine failure until the crash-landing at Sioux Gateway Airport including life ATC recording.

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