This paper examines the crash of United Airlines flight 232, discussing and analyzing the human factors and crew resource management elements, successes, and failures surrounding the accident.
On July 19, 1989, as the DC-10 plane cruised over Iowa, the fan disk of its tail engine broke apart, and the debris cut through all three of the jet’s hydraulic lines. The extent of the damage caused the flight crew to lose surface control of the plane.
Captain Alfred C. Haynes, the flight’s commander, discovered by luck how they could still maneuver the plane by using the throttles to adjust the power on engines 1 and 2. However, flying the plane was one thing; developing a strategy to land the plane and saving at least some of the passengers was another.
Captain Haynes credits Crew Resource Management as being one of the factors that saved his own life, and many others. The crew had about 45 minutes, from the time of the engine failure until touchdown, and not a single minute of it was wasted. The crew managed to utilize all available resources aboard and on the ground with excellent communication, good situational awareness, and dynamic problem solving and decision making processes.
In the cockpit, the flight team exhibited an incredible degree of communication and situational awareness. Captain Haynes communicated in a way that created an atmosphere that this was a team effort, that his crew would not hold any vital information
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After waiting many hours in the airport lobby, the plane finally was ready at gate 42. I took one last look at where I had been sitting for the past two hours. As I walked toward the plane, I thought about all the terrible things and accidents that I had been through at my summer trip. Shake once I boarded the plane and tuck myself comfortably in the seat, the plane took off and started the ...
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from him out of fear of upsetting him. Captain Haynes made his goals and intentions known to his them through constant communication with them and, as a result, he had a crew that backed him up. On the ground, the flight team also maintained constant communication with ATC. When they finally came to the conclusion that a horrific crash was inevitable, they immediately contacted for help. The ground was thus well informed of the situation aboard the plane. Consequently, all resources that a crash of the scale would need were prepared and made available prior to touchdown.
Captain Haynes also immediately had the cabin crew informed of the situation. This gave flight attendants ample amount of time for preparation.
They team, further, did not have problems with following SOPs. Captain Haynes did not stop at the engine shutdown checklist but also asked for visual inspections of the plane’s condition. This helped them consider all options that may be available to them on how they could fly and land the plane better. In fact, there was nothing that the experts from the ATC suggested that the flight crew hadn’t already done.
The pressure of the situation, with 297 lives at stake, a lot of them are children, did not seem to affect the problem solving process of the team. Tasks such as flying the plane and communicating to the cabin crew and the ATC were efficiently delegated. Everyone was welcome to take part in the decision making. A DC-10 instructor, who happened to be onboard as a passenger, was even invited even if he was already minutes behind what
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was going on in the cockpit. The team was ahead of the situation and made sure that those on the ground are with them on it such that ground resources were following the plane in case it had to crash-land in the city.
With 185 of the 297 total passengers and crew surviving the devastating crash, the UA Flight 232 accident was considered a success. The industry and the investigators of the crash are one in saying that the flight crew’s management of the situation was perfect. Factors that could have helped save more lives are those that are already beyond the crew’s control such as the human errors made in the inspection of the plane and in one of the water pump vehicles.
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Halfway There People. Droves of them, hustling off to their appointed gates with seventeen suitcases strapped to themselves like pack mules. All scowling, furrowing their brows. Hoping to get to where they want to go, and with all seventeen suitcases they came with. Me I only had two bags, but one of them was large enough to be a body bag. Beside me was my cousin, a tall 16-year old, the jock ...
The miracle of Flight 232 became the most cited case in the use of CRM techniques. It provided a clear example on how a near uncontrollable situation could be managed with successful results through good CRM application.
References
Krey, N. 1996-2005 Industry CRM Developers Situational Awareness Management Course. from http://www.crm-devel.org/resources/misc/transcan/transcan1.htm
NTSB Report AAR-90/06 (pdf)”. NTSB. Retrieved on 2006-08-02.