CFI-to-CFI Newsletter - Volume 13 Issue 4 - 6

LEAd
" VIRTUALLY IMPOSSIBLE " TO DUPLICATE,
DETERMINED THE NTSB REPORT MORE THAN
A YEAR POST-ACCIDENT. As part of their
investigation, several flight crews participated
in an NTSB simulated re-creation. The goal was
to use the horrific crash, in which 184 of the 296
souls on board survived, as a teachable moment-
something future pilots could reference if a
complete loss of flight controls happened again.
The problem was that a total hydraulic system
failure-the subsequent cause of the DC10
accident-was deemed by the aircraft's
manufacturer, the FAA, and United Airlines
(UAL) " so remote as to negate " a standard operating
procedure (SOP) for a crew to follow. Without an
SOP, the highly skilled and experienced pilots flying
a simulator with the same configuration as the fourperson
accident crew (losing the center engine and
all hydraulic fluids) had to wing it, too.
THE SPECTACLE OF FLIGHT 232 IS NOT AN
EXAMPLE OF HOW A CREW MANAGED A
FLIGHT TO A DISASTROUS END, BUT ONE
THAT EXEMPLIFIED A RARE-IF NEVER-
EVENT THAT WAS EXECUTED AS CLOSELY
AS REASONABLY POSSIBLE TO THE
AIRLINE'S CREW TRAINING MANUAL. ITS
MEASURE IS TAKEN NOT IN ITS CASUALTIES
BUT IN ITS SURVIVORS.
The thing is, no matter what the pilots tried, every
reenactment ended the same-they could not fly the
airplane to the runway as Captain Albert Haynes
and his team did that day. So, what was so special
about the crew of UAL Flight 232?
UAL'S COCKPIT RESOURCE MANAGEMENT
(CRM) TRAINING
" The Safety Board views the interaction of the
pilots, including the check airman, during the
emergency as indicative of the value of cockpit
resource management training, which has existed
at UAL for a decade, " wrote the NTSB in its final
accident report.
From the flight deck to the cabin, the crew
followed UAL's established CRM procedures
without any significant deviation:
* No resource went untapped. The captain
made good use of every resource at his
disposal-from notifying air traffic control,
flight attendants, and UAL's flight operations
of the emergency to accepting support from a
DC-10 off-duty check airman and coordinating
the crew's collective response with the help of
suggestions from the three subordinate pilots.
* The crew maintained situational awareness
until landing. They never stopped flying the
THE CREW MAINTAINED SITUATIONAL
AWARENESS UNTIL LANDING. THEY NEVER
STOPPED FLYING THE AIRPLANE.
airplane. They were engaged and committed to
surviving the catastrophic event from when the
No. 2 engine exploded until touching down on
Runway 22 just left of the centerline at the Sioux
Gateway Airport in Sioux City, Iowa.
* Crew demeanor remained calm
interjecting humor at times, presumably to
relieve the tension.
At the time of the tragedy, CRM was an evolving
training concept about a decade deep into it.
Airlines were still picking their way through
its nuances, but a clear message was steadily
winding through airline flight departments
and landing in training manuals. United
Airlines happened to be the trendsetter for
CRM-a concept also known as crew resource
management. The spectacle of Flight 232 is not
an example of how a crew managed a flight to a
disastrous end, but one that exemplified a rare-
if never-event that was executed as closely as
reasonably possible to the airline's crew training
manual. Its measure is taken not in its casualties
but in its survivors.
https://www.ntsb.gov/investigations/accidentreports/reports/aar-90-06.pdf
CFI-to-CFI Newsletter - Volume 13 Issue 4

Table of Contents for the Digital Edition of CFI-to-CFI Newsletter - Volume 13 Issue 4
