Sioux City

Human FactorsAircraft Accidents
Written By Adam Howey

Transcipts are approximate. Email us if you have questions.

Transcript Start

00:00

Adam Sam Sioux City. Yeah, just be clear. This isn't a podcast about the township of Sioux City, right? It's probably the best name to call it. There would have been a couple of titles we could have had such as United Airlines 232. Okay could have called it CRM. But, for me, from, from studying this years ago, when someone says to me Sioux City, it just means one thing to me.

00:28

And that's the crash of United Airlines 232 at Sioux City. So we're gonna just talk about one flight and one accident. Yeah, I guess this was kind of the first aviation accident where they attributed CRM, as an example of the gold standard of CRM and how it can work.

00:45

Effectively, even though over a third of the passengers were, sadly killed successful accident with the loss of life. So it's a bad accident but it's a successful one, but I think it's worthy of a whole podcast, rather than accident. Rather than just tagged onto the end of a CRM topic.

01:04

Definitely, because it's a stayed in my mind. Yeah, throughout my career, definitely. It was used as an example of good CRM. I guess, a disclaimer to anybody who's might be listening that we'll probably talk about loss of life. Yeah. What about the history? We talk about. How do you want to just for anybody that hasn't heard of the accident or yeah, doesn't know the background.

01:27

We should probably just bring in everything. There's plenty of stuff out there on Sioux City. Yeah, there is, I think there's a couple of reasons for that one, with it being held up as a success to the news media, we're present at the site of the crash in advance. It's actually a live video of the crashes.

01:44

Yes, it's created a kind of. Well, there's two plays even, there's a couple of films, plenty of documentaries. Yeah, and a whole book, not an aviation book. So I'll try some basic facts and see when I run out, say go 1989 and it's united airlines, you still exist and have existed with that name for a very long time.

02:07

Since the 20s, I think flight 232 Denver Colorado to Chicago, which is their home base one, those flights through their hub, but Chicago, so it was going on to somewhere else. Philadelphia, right? That's right. That's the one. Yeah. The accident started to unfold an hour and a bit into the flight in the cruise over Iowa which is a big open flat land,

02:35

plain stunning area of the United States through the central corridor of the United States that normally a lot of bad big thunderstorms blow through yep not on that day and it's a McDonald. Douglas DC 10 aircraft which you don't see anymore. No. Al Haynes. The captain described it as an old man's aeroplane because it was very easy to fly.

02:57

Apparently, that's how he described it. But how would you like it? The late Al Haynes here? Any died about a year ago? Yeah, I like him. Yeah, one likes him. Right. And it'll probably become clear like in the podcast when we touch on the CRM side of things, as to why we like him so much, right?

03:14

He's obviously used CRM or cockpit leadership and resource management as they used to call it CLR. I used it to really good effect. But you know, the DC10 and what significant about it with this accident is, it's a, it's a three engine aeroplane with the. Number two engine, being mounted to the yeah, to the rear of the tailplane.

03:35

So with some of these aeroplanes I'm guessing that when the engines weren't as powerful as they are now, they needed extra thrust to empower these wide body aircraft. And so they only need a three obviously the seven four had four engines. Yeah, so there's a tri-star as well and I always used to get the two confused for the DC.

03:55

10 has this tail. Yeah, and then, as if somebody's just stuck in the middle. Yeah. Sort of hangs halfway down the fin. Yeah, the tri-star has it. So a built into the fuselage so it can't see the engine, the ducked. Yes. Agreed. So the DC10 the engine just sort of stuck on in the middle of the fin, kind of more that I see.

04:17

We're going to talk about. It's wide body. This aircraft was and not full but 2090. So you need the passage of 284 to 84 passengers. I've been yeah, about 11 crews. That's probably where I've got. Yeah, I think I'm looking at it. I think in, you could probably squeeze a few more and maybe 300 passenger 300.

04:38

Yeah, it's in a two, five, two seating configuration. So, two on the outside, five in the middle, I didn't know that. If I was travelling long haul on that, I wouldn't like to be in the middle of five. That would be nice if you got two not if you're in the two-er, if you slide.

04:51

But in the middle of a row five this single traveller would be it. Wasn't that inflation? No. What else can we say about it? So these wide body big jets that the first one really be in the seven four seven. They were the first generation of aircraft to not have cables that connected, the flight controls to the flying surfaces.

05:11

Yeah there's no physical connection, Al Haynes, you started flying in 56. Yeah, to him, that was concerning when he first went on to the aircraft. Yeah, there's nothing physically connected. Sorry that. Yeah. There's nothing physically, almost connected between his yo. Yeah. And the aileron, the rudder and the elevator.

05:29

Yeah, what there is, is high pressure hydraulic lines, just like car breaks. Yeah. Or even your bike, your new bicycles got hydraulic brakes, right? So what happens if you lose that hydraulic fluid, then that system doesn't work anymore. So in order for that to not be a possibility, they have to on all these big jets you always hear three.

05:50

There's this three systems as that's always there. Seems to be the number for redundancy so there's three hydraulic systems. So if one goes you've still got two worst case of two goes. You can still fly the plane on one. That's the idea. Yeah. And I believe it was one in a billion chance.

06:07

Absolutely. That you would lose all three say impossible. Yeah. So that is what we're going to get on to. They lose all three hydraulic systems. So, the DC10, they're the graph that had a lift down to a space downstairs for the crew to, like, prepare meals. And these kind things, in fact, the number one as we would call it the cabin manager, the lead flight attendant Jan Brown.

06:30

Yeah, she in the early days of the DC 10 it had convection ovens downstairs, right? And she would bake a whole cake with ingredients really on the flight, okay? Take all the ingredients bake, the cake downstairs. And bring it up for the crew on quiet, flights, nice. This is, this is a generation of aircraft that a different to what we're used to.

06:49

Yeah. Yeah, that demonstrates. Yeah. Yeah. Say the captain our hands. Yeah. He's been flying. It quite a long time. Yeah. And he confesses that he was enjoying his life as a first officer for a long time flying across the Pacific to Hawaii. Yeah, it's been in 10 days on the beach, coming home, but at some point he decided he need to be a captain.

07:09

He went over to the B727, I think okay then came back to the DC 10, okay? To continue as a captain and he had a lot of time. So who else was in the flight there? So well when the flight took off there was only three in the flight deck by the end of it, there was four.

07:24

So in the flight deck, it starts the first officer was Bill Records. Yeah, and the flight engineer as they used to have in those days, was Dudley Dvorak. So let's describe that. Say else that on the left and the captain. See as you look forward and Bill is in the right seat.

07:40

He's the first officer /co pilot and they're calling the flight engineer. This second of second officer as well. He sat just behind the first office sort of to his side besides down at the panel instruments here. So this is an aircraft that still needed flight engineer due to the increasing complexity of these aircraft.

07:56

And at that time, technology hadn't caught up. So that there was no electronic systems that we'd have. Now that we tell you what's going on, there's just too many dials to fit in front of the pilots and to many switches the engineer fly engine. Also just monitor those dials basically, and there wouldn't be anything like we have now.

08:14

Like ecam that no, it would ping up. It would have to be spotted essentially by the and we have like 10 screens 10 pages on one screen, hydraulic page, electric page, fuel page. They wouldn't have that technology. So they're all steam driven as they call it gauges like old-fashioned dials.

08:34

Yeah. So the first officer had a lot of flight time 15. 20,000 hours, something like that? Yeah, a lot more. I think this seems something like 30,000 hours for the captain a lot. I know he's got a set about 7,000 other DC 10. Yeah, yeah, a real life, it's quite a lot.

08:49

I mean, that's how many I've got. I think he started flying in the 50s. So, this would be like 30 years later, 25 years later, and the engineer had a lot of time as well. However, on this aircraft, the first officer had not long been on the aircraft, right?

09:05

You don't need, just done his flight release to line, kind of flight and the engineer. He only had like 30 hours on on their aircraft. He just got off the 727, but a similar type of aircraft and we'll talk about Denny Fitch's experience, I guess in a minute. Yeah.

09:21

So you talked about the DC10 the flight. Yeah. All the normal stuff. So, basically, briefly she took about what happened? to get them into the situation. They got into. So that that number two engine, we talked about, there was mounted on the tail plane. It was actually a fan disc in that engine completely.

09:39

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Explosion

Well exploded. Essentially, it completely shattered, burst out of the side of the engine cowlink, okay? And all the sort of metal parts, cause massive damage to the tail, plane of the aircraft and that one in a billion chance, it actually, those parts of debris, severed, all three of the hydraulic lines.

10:00

So, say, essentially all the hydraulic fluid, just poured out of the back of the aeroplane , lovely. And then the flight crew were left with absolutely, no, no flight controls, no elevator, no flaps, no later ones, no rudder. Just breaking down that, that fraction of a second. Yeah, event the engineering of jet engine is insane.

10:22

You can hang like, 10, double decker buses, off, one blade, or something Rolls-Royce. Say then the disc in the middle, that holds all those blades together and a latent fault from when it was manufactured that disk in that titanium, and I've got into making titanium, and I still don't really understand it right, okay.

10:41

But it's it's a weird material, but join the manufacturer of that disk, there was a deficiency in it. Okay. And that disk had been flying for a long time, maybe, 30, 40,000, hours, or something, 12,000 cycles and then on this particular moment in the cruise, it decides that it's had enough, it cracks open causes a catastrophic failure of that disk the blades shoot out from the side, they take out the accessory gearbox and that explodes and that debris actually then it was about.

11:14

Yeah. Okay. The point being. Why it chose to give up at that moment when they're just making a slight right turn at 37,000 feet? I don't know. But that might be as Al says their first piece of look that it occurred at that moment not at takeoff or some other phase of flight or on a different day.

11:32

Yeah the tail was quite damaged. Yeah the explosion stay loud that workers on the ground in a factory here. It really also here something like a helicopter, spinning around landing in the field and months later. They'll they actually find all these bits and it was I gets a rewards the crops.

11:52

Yeah, that's right. Yeah, everyone in the cabin thinks a bomb has gone off. Yeah. Or there's a decompression, I read that a lot. Yeah, a few passages thought it was a bomb. Senior camera. Thought it was a decompression, like, a hole inside of the aeroplane. Yeah, she was remembering the Aloha accident out in Hawaii where there was big hole in the aircraft.

12:12

So she said she just grabbed on to something and the DC10, there's nothing wrong with the aircraft but it had history record and there was a few decompressions where flight attendants have been sucked out the aircraft. Yeah, Al captain now the first officer bill and second officer Dudley were obviously just trying to figure out what happened.

12:33

Al and Bill realising that their flight control their control. You just wasn't doing anything aircraft starts making a right bank, right turn and they can't just I mean I can't even imagine you just not being you know, having flown for so long. Now, have you had an engine failure huh I need a simulator.

12:51

So yeah, nothing in real life but I but I kind of imagine having the engine failure but just not having control of the aeroplane. I can't, you know what? Feeling to put input into your flight controls and they're not work. If we're gonna talk about CRM's role in in all this, let's break down those next few seconds.

13:10

And maybe what our training in 2021 might lead us to do and what our experience. How you react say, massive explosion In all seriousness. It's about an hour and a quarter or something, or an hour and a half into the flight. I mean that's the most chilled time top of climb certainly with the checks that way.

13:30

Yeah. A bit of time before you get to Chicago, Al Haynes is nursing a coffee right, which he spills all over himself for the remainder of the flight. Okay, the first often the engine having a conversation about fishing Als annoyed because he likes baseball, right? These kind of things.

13:48

So, extremely low workload low, stimulus, passengers probably asleep, even though it's the day cabin crew done the service. Yeah, chilled. Massive explosion. So huge surge of adrenaline. Yeah, startle and surprise we call it. No electronic engine system, but you've got Dudley, you is able to tell you what he's seeing.

14:10

Dudley essentially is the ECAM, EICAS, like, he's probably a really good one. Yeah, so in the next 14, seconds Dudley and Al using a physical checklist perform the engine to shut down procedure. Our course for it, the captain totally the fly engineer reads it. I'll first action is to retard the thrust lever.

14:33

It won't go back. It's to cut the fuel off, it won't go back. It always did in the simulator, but he's starting to realise, maybe, there's some damage and so they pull the fire handle and whether it's quintessent or not. At that time, the engine shuts down. And so, a lot of the high vibration, I think, and the noise may be disappears and I I read on that as well.

14:54

That was one of the first bits of CRM is that there's actually quite a lot of input from Dudley on that. He was the kind of instigator of how best to shut that engine down, but it was kind of hours leadership that allowed deadly to give there. And we'll come on way more into this about the captain's authority and okay.

15:10

All right, so change if we unpack that moment then, go on. What what do you mean? So I I read it was along the lines of hours. So struggling to figure out how to shut it down, right? And it was, it was like especially won't get back yet. Yeah, exactly.

15:24

But it was deadly suggestion from his experience as to think about another way. It was essentially Dudley's input. That this is a different, you know, generation because we will be able to have a conversation with the ecam. Oh yeah, that's interesting. But it's also at that time there was a lot of this.

15:40

The captain is the authority, he or she obviously knows best. But obviously, these guys have been trained in CRM. Here is a small example, but it's the first one of many, where deadly obviously feels he can concentrate and so not challenge out, but offer a suggestion to how that he might not have thought of that, that's how I read it anyway.

15:58

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CRM History

Yeah. Okay, that's interesting. So, I hadn't picked up on that. Say let's pause there, because, yeah, I don't want to go too much into CRM until well let's let's talk briefly about history CRM, crew resource management comes under the human factors, part of aviation. It's a non-technical discipline but it's training.

16:16

It's a way you can score and assess pilots. It's the way you can select pilots and it's a combination of their cognitive skills and they're interpersonal skills, if you like trying to make them objective and usually the titles are things like communication decision, making leadership teamwork situational awareness. These are their the breakdown of the skills and topics and things in CRM and it's pilots and it's cabin, crew and aviation led the way, I'd say aircraft used to crash because the wing fell off or the engine fell off or pilot error.

16:52

Yeah, and once manufacturing and maintenance and aircraft design and systems got better, and we wanted to reduce accident rates more as aviation especially was picking up and more and more people were flying pilot error became the dominant reason why aircraft were crashing. Yeah, and it's sad that to this day, the news will still say it was pilot era or some mum will say pilot error.

17:15

When all the way back in 1980, we were starting to unpack that term now. So we don't just say pilot error. We now break that down to what do you mean by that? Say, we've got humans flying aircraft, which is amazing because of what the human brain can can achieve versus just a computerised thing.

17:33

But humans to er is to human to make an error is a human thing. So it's okay. If you make a mistake, you're expected to and CRM starts to unpack tools and skills. And, and techniques, and and training for you to overcome pilot error. Yeah. So there'd been some accidents including fuel starvation, and I'm not thinking of the everglades and thinking of some idea this.

18:01

So I, so from my research, I found two sort of main aircraft accidents, which accelerated the our own process one of which was so it was US airlines 173, which I think is what you're talking about where they run out of fuel because they're trying to diagnose, a landing gear problem and a light bulb essentially.

18:17

Yeah. They all got kind of sucked into that problem. Yeah. But nobody was keeping an eye on the bigger picture which was that they're running a fuel and then the other one was the KLM Tenerife North. Okay. Where the first officer, possibly, arguably new. That there was another aircraft on the runway but didn't know how to challenge.

18:37

Yeah, the captain. Who was a very very senior almost possibly chief pilot level. Yeah, captain. And he just didn't know how to approach it. So CRM, the idea of bringing CRM in after those two accidents, but kind of before that as well, but those two accidents, sort of emphasise, the need for it was to, as well as all those skills you talked about leadership, communication, etc.

18:58

But also to try and shallow the authority gradient in the flight deck, as much as possible. And I believe that in about 1980 this is when the idea was introduced. Although there's a really good book which has written a really long time ago by a belak and an RAF pilot.

19:16

Yeah, I remember, yeah, he doesn't use the term CRM at all. It's called the human pilot (The Naked Pilot) something like that. Yeah, yeah. I've got, I'm just not on my bookshelf here. I've got it with loads of bookmarks in it and he explored what the human is contributing in the the mistakes that they're making and the things they're achieving when there's accidents.

19:38

And so this idea was out there, of course, quite early. It just took a long time. To really, I'm learning NASA and a lot more involved in the development aviation than I realised. So they they started to put it out there to the commercial industry and united perhaps as a legacy what you would call that big airline Lexi.

19:56

Hello, they took it on immediately and they called it CLR and the effect is that Al Haynes that had nine years of CLR of CRM training. By the time, this accident had occurred but he'd started flying in 55 56. So, that's, that's really interesting because it might have been the first time that we can see CRM really paying off, but certainly the crew were the ones saying that, that's what saved the day.

20:23

One early way to describe CRM was using the shell model. So it's how you see yourself as part of the bigger system. Yeah. So it's not just you. And the other pilots is you and the environment you and the hardware, you and the checklists and includes air traffic, control carbin crew.

20:43

And that's a always 100% apart of CRM, which is it's not just a flight deck thing. It's always cabin crew. In fact, the training is mandatory that you do it with cabin crew and also air traffic control, who played a big part in this. Yeah. Yeah. And the success of this, we're going back to that moment.

21:00

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Flight Controls

Yep, where there's a giant explosion, there's some Startle and surprise, al drops his coffee, they realised. It must be an engine and Dudley is able to help them shut down. Within 14 seconds, I read it quickly. Yeah, it's quite quickly, which is not a race. No, but that problem seemingly is solved immediately.

21:20

Yeah. And you failure. No, big deal. Not very nice of the passengers. Yeah. And then what happens. So then they realise the plane is starting to bank over to the right and they can't control it. Yeah their control yoke is not working, there's not working and that at that moment Dudley's having a look at his sort of instruments and he sees that all three hydraulics are empty, all the fluid and also hydraulic systems empty.

21:46

So we've got these hydraulic lines full of fluid and we have a gauge telling you how much fluid is in the reservoir and that's going down a zero. And he can't quite believe it because he's never seen that before or trained for that because it's one in a bill.

21:59

He communicates that to Al and Bill who would wrestling with the controls and successfully. And and the plane is starting to bank and bank, and back, more and more into a steeper. Always to the right, always the right and break that down for a second, then see the pilot and you've run your drill your trainings kicked in.

22:20

Yeah, I don't if it was a hand over control, but as you say, the first officer has the control. The aircraft. Yeah. So Al and Dudley are consumed in the shutting down the engine. They look back. And I think the first officer grabs the attention of the captain and says I need help here.

22:39

Yeah or something. And that's when I'll potentially for the first time realises, they're in a descending bank or they're starting to bank. Yeah. And also that the control yoke is fully back. Yeah, and fully to the left. So the opposite of what they're doing and he also points out that your yoke because I've flown a Boeing for a couple of years, but the yoke, you know, it does come right into your fay belly.

23:06

Yeah, that's how far it goes back. Yeah, it's right there. Yeah, you know, you can't mistake where it is and it's to the left is the opposite way. Yeah, owl says something. Then I've got this, which we would say, I have to try. I have control. So in modern day, I think all fleet share FNC or ANC navigate, navigate communicate way of instantly prioritising your workload, or your tasks, the first one fly or Aviate.

23:35

So what that means, make sure the aircraft's flight path is safe. Just speed the bank. And we look at like FMA's and it tells us what auto what automatically have now, the autopilot drops out, but just before all the fluid leaves, the aircraft the autopilot tries to stop the effect that the explosion has had on the aircraft, okay, so it moves the stabiliser a bit, then the autopilot drops out in the first officer, he puts the nose up or down, it makes movement and they do actually control it just for a few seconds until the fluid is leaves.

24:11

And then it's then it's set. Okay, where it is? Yeah, which will become important. When we talk about what the aircraft starts to do next, those is funny that in those few seconds, the horizontal stabilisers have run in a certain direction and then set that. So it happens to be set.

24:27

I think reasonably neutral the, you can read like, what the degrees are so the other pilot drops out. So I'd say, although does quite well because somebody else is flying the aircraft, it would seem and he's able to then go into narrower beam of situational awareness with Dudley to shut the engine down and the first officer is able to speak up as well as Dudley is already done and say something's going wrong here and get ours attention house back from what he's doing.

24:56

Yeah, I guess this is the territory which I still have a fear that it will happen to me, one day where something's happening and I don't know what it is. Yeah. Yeah. And basically the feeling of what have I done wrong? Yeah. Yeah. They're gonna, I've laughter, I've died.

25:12

They're gonna be like, why didn't he do this? Yeah. So Als looking at this thinking, I've got 30,000 hours of flying and never once in any case, has the aircraft been going down to the right when I'm pulling up and going to the left. Yeah. And I think that has a potential to send your brain into a terrible loop of data and inaction.

25:35

Yeah. Confusion like yeah a million things and that's why other people in the flight that can be helpful then. Well, that's why I think I think ultimately that helped him because if he's seen something like this before, it's hard. You know, I don't worry I now has handled. Okay.

25:48

And that could have been like more authoritative, but because he'd never seen that he was as clueless as everybody else. So, I think he sort of testaments that in that video. I know we both watched about the presentation. She doesn't NASA. Yeah, where he says. So also here in a minute, we'll talk about how Denny Fitch got into the cockpit, but he says between the four of them, they had a hundred and three years of flying experience, but none of them had seen this before.

26:11

Hence, so why should he watch it? Why should I know best? Why should I make the decisions? Why don't we throw out there to the group? Okay, and so yes, it possibly not having seen this before. Actually helped the contribution from everybody. A nice way to manage something like this would be to always prioritise aviate navigate communicate and then after that, you would go into ECAM EICAS or checklists.

26:37

And then later on you go into some analytical decision. Making using some tools but they're like stuck on the F. They're from the a they're still on the fly that aviate. Yeah. They can't. They can't do it. Yeah, yeah. Bear that in mind. As we talk about all the other problems that they had to overcome decisions that had to be made, while they never really solved, the a, well, not for a long time, did they solve the flying part?

27:01

Yeah. And they never quite got it right? But they, you know, because it was impossible, but they did eventually spend a bit of time and how guess you can onto this, like, how I'll manage to stop the say something. I'll confess that I recognise a, an Airbus pilot. I'm not as aware of is static stability.

27:22

Yeah, you know so if our aircraft loses an engine, it shouldn't ever enter a spiral dive and we're not really used to that but this DC10 is starting to bank over to the right? And descend, Ultimately, I think what an aircraft will do then is increase that spiralling descent into it, flips on its back and they're pulling up into the left, of course, nothing's happening.

27:42

So just to stay the obvious, there's no hydraulic fluid in the aircraft so they have no control over the elevator, the stabiliser, the rudder, or the ailerons, all the flaps, or other things that will come onto, say the control stick. The yoke is totally useless, but 30,000 hours of flying are telling you just do everything you can to pull up into the left.

28:05

So they can sort of keep doing that but the aircraft is to send into the right? So after hardly any time they have to do something otherwise it's always going to get out control here. So what does he do? So he uses the one tool. He's got left, really, which is his thrust on the number one.

28:23

And number three engine, which again is kind of luck that they lost a number two engine, got even thrust, you know, even distribution of trust. So he put the thrust up on the right hand engine and reduced thrust on the left-hand engine that increase in thrust on the right, managed to bring the wing back up towards level flight and actually recover them out of that, how that right-hand turn.

28:47

So I reckon if you haven't done that within a few seconds, I don't think I'm exaggerating too much. Yeah, I don't think he had long because they got up to 38 degrees angle of bank, which is quite a lot. Yes. So what would we normally do? Like normal, like even a turn never more than 25 degrees .

29:04

If you pull that passenger notice that's just notice that's a big turn and that altitude as well. You wouldn't do anything close to that 38 degrees. So again towards a steep turn and then it might be unrecoverable. So he manages to pick the wing up using asymmetric thrust yet.

29:22

So there's everything under control And not really, they get it back up out of that turn, but then I'm not sure how further long down the line, but they suffer from like a few go ahead as well. I think that comes a bit later, right. So in terms of the aviate but navigate communicate, you've got to break it down into roll.

29:41

Yeah, yeah. So they've got the roll under control but not necessarily the pitch, Does that they're still descending. There's descending. Imagine that. I mean your brain must be screaming at you like you're going down. Yeah. Yeah. And at the moment you haven't figured out how to stop that happening.

29:56

Well it's you're gonna hit the ground there at 37,000 feet. Yeah. Just a matter of time. Well that was this might be a nice time to bring in Denny Fitch because that was his first thought when he entered the cockpit was I'm gonna die today when I when he saw what happened.

30:10

So, so okay, so should we bring in Denny Fitch? I say, Denny is a good time for Denny. Yeah, no. I think so he said they've, they've got some of the aviate under control navigation, isn't too much of a problem because else not as concerned about finding an airport yet.

30:30

Yeah. Throughout most of the flight he states we're gonna be in a field and he thinks that's gonna be a great outcome basis. As long as they're not going those first. Yeah, there's no weather one year after the accident on the anniversary, they visited Sioux City and it was heavy thunderstorms.

30:48

Yeah. So that day was ten miles vis or more scatered at four and a half, you know, almost just the perfect. Perfect day. Yeah, so navigation, the terrain isn't so much of an issue. Like Al says, they went over the Rockies and they went over the ocean and they went over Manhattan.

31:04

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Communication

Yeah. Communication, some communication starts before. Then he comes in yes. The flight engineer makes to appear to passengers quite calm that they're going to have lost an engine. They're going to continue to Chicago, take a bit longer because there'll be a lural student slower speed, but the cabin crew started to become aware that this isn't?

31:23

This is kind of bad. Yeah, but they haven't visited the flight deck. No, at that time. Communication starts with the company. Yes. Yeah, I think that's the first thing. The first person as you contact. Yeah. So maybe we were a bit premature on on Denny Fitch. So yeah, the contact company so they obviously have got some sort of stability.

31:43

The aircraft is flying. Okay with this asymmetrics through us. So I think it Dudley, if I engineer contacts the company to say, hey we've got three. I said this is another example of using your resources. You've got, you know, a company line here. Yeah, a team of engineers with manuals and computers in front of them, who might be able to help you.

32:02

So, hey, we've got three hydraulic empty hydraulic systems. What do we do for this? And the hours? I remember I'll say in the in they were coming back saying what you've lost their number three, like no, we've lost all three. What one and two or you know they couldn't believe all three are gone but there was no procedure.

32:22

No, no. So I'll just talk about how we got really pissed off with the engineers. They call SAM, I can't still figure out why they call them SAM because it's almost a referring to a person called, Sam something area maintenance. Oh, okay. Okay. But they're in San Francisco. So maybe that's scary San Francisco area maintenance.

32:42

Yeah, well done, so say all the companies I've worked for we call it maintrol but there's always somebody on the end of a radio. He's an engineer and now they have this computerised database and they kind of had that in the 89, they also had lots of engineers and yeah, they're just not in the air, they're in a different, the environment eating biscuits and yeah, probably not wanting a call from an aircraft, you know, probably getting it all the time.

33:08

Oh, we've lost you know some in minor or not taking this aircraft unless the toilet gets fixed or I don't know if I'll write it. Yeah and then here is something they're not used to which is somebody talking to them saying save us. Basically says what's the trick and how we just help, which circuit breaker we pull to make it all okay.

33:29

Okay. Yeah, yeah, they can't even comprehend the situation. Yeah, let alone help them at that point and there's a lot of time to I think Dudley speaks to them trying to tell them what's going on. But what it does do at some point, I think maybe later on, although the engineers can't help them, the engineers are able to mobilise lots of other.

33:52

Yeah, people who will become much later on, you know, really useful. Yeah, that's it. The company are now aware. And yeah, and that spreads like wildfire, like yeah, around companies services, you know, everybody becomes aware that this is, yeah, there's an aircraft in the, a major problem. Well, let's talk about communication then to air traffic control.

34:12

So we haven't talked about that. They're talking to Minneapolis area controller. Yeah. And they established that Sioux City Airport is reasonably close by, and eventually they get transferred to Sioux City and Sioux City is in today's population. It's less than a hundred thousand I think. Okay. So that's the size of the the city and it's got four states around it.

34:34

So calling Sioux Land just seems like the most amazing place. Yeah. People maybe we should go that one dollar thinking about it. I guess at the airport was a world war two air base. Yep. The air national guard who and we get this wrong kind of like a voluntary but I think they get paid like standby air force.

34:53

Yep. Our base there or some of them are base there and it has some commercial flights but it's not big enough to take widebody like DC 10s. Yeah I think the longest runway is a three thousand two yeah. Two thousand seven hundred stays the longest. That was the wrong way.

35:09

That they were intending that kind of established with air traffic control that they can't go there, but you can hear. And the air traffic control can hear how can confused. That's not the right word that there's something is seriously wrong because the captain isn't being a hundred percent articulate and coherent.

35:27

He's busy while busy while he's trying to tell them. We've got no steering but he does establish that with them really quickly that we can't steer the aircraft, we've lost all hydraulics that there. I think he says at one point we might end up in a field. They're pretty aware there's something really?

35:42

Yes, I I read a bit into this then if you did as well but I'll like credited. A lot of the this good outcome to the guy that he spoke to control a guy called Kevin Buckman. Yeah. Who he joked had like moved to he used to work in like Chicago departures or something and he wanted a quieter life so he moved to like Minneapolis area control, okay, but he said that basically Kevin Buckman was so calm.

36:07

So helpful and All also said that the DME wasn't working right? 80c was so useful in giving them airports distances to go directions headings options. But also what air traffic control did was they organised a load of stuff on the ground. And without I don't think the flight crew ever declared in sort of any sort of really coherent ways to the scale of the emergency, but ATC took it upon themselves to upgrade it.

36:36

And I forget the levels, but they upgraded it to sort of a higher level, which basically meant all the local population, like, get get people to the hospitals. Yeah. Get like and ambulance stuff on standby. It's funny because we use the term mayday to declare an emergency. Yeah, or pan to declare an urgent situation.

36:56

All never says made a noises, we declare an emergency and he makes a big point in that NASA's talk about saying how important is to controllers, I think have a different scale of alertness. They by the time the succeed controllers were away. I have a big tower and radar control.

37:14

They assigned one person just to united, two, three, two, N1819U They reg of the of the aircraft. So there's one gentleman, which might be the one you're referring to who sees them throughout. And there's another one sat next to him. He now controls everybody else because his international guard, a sevens, and a 10 aircraft that are out, and about doing a bit of flying, right?

37:38

It tells them get back first, they have to get back together, way. Yeah, and land, and get out the way, and he's telling them they've got a live ammunition, I think, and tells him to like, yes, he down here son. So, they have a level two, which is that there's an aircraft in distress , but bear in mind on that day, they had, like three mayday already that morning.

38:02

Oh really, they weren't that excited when they first had a phone call. Okay, you can hear the Minneapolis controller, rings. You see and say I've got emergency for you, okay? There's oh yeah, right. And basically, the international guard pilots were told. If anything goes wrong, you get a little light in your flight deck.

38:18

The clarinet emergency right? Okay, they were like just getting emergency is all the time. Okay, okay, later on these two controllers that actually there the guy handling, the aircraft told the other guy that his duties were X Y and said that included the level of alertness and the controller declares they were on level two.

38:38

Level three is an aircraft has crashed. That's right. So he took it upon himself but he had a debate within his mind and slightly with the other guy that he was gonna get told off for this and that they were doing the wrong thing because still in the air at this point.

38:50

Yeah. He decided I'm gonna upgrade its level three which is aircraft. Is already crashed. Yeah. So that triggered a lot really, really good events. And it kind of goes back to Al being very honest with himself. Yeah. And the controllers. Yeah, that we're gonna crash. Yeah. We just don't know.

39:09

Yeah. It could be in a field. Could be. Yeah I think it's gonna be but I'm gonna try and make Sioux City. Yeah we're gonna crash and even later on. He says the joke, the amazing joke, he makes it. You want to, you want me to land on a runway?

39:22

Like you want to be specific? Yeah, I'm just heading for the effort here and he's like, we're definitely in the field of the other. So that was really good because it must have helped push it to level three. So as you'll know from our speech he says some amazing things were happening that day.

39:38

So not just weather and where the engine gave out the fact that the time that they accident occurred was shift, change time of the hospital. Yeah. So all their hospitals in the area. One shift was there and the other shift was arriving. So they kept everybody almost staffed. Yeah.

39:55

All the clinics were leaving work and so they were free to go to the hospitals and the one day of the month, the international guard were all at Sioux City. So hundreds of international guard trained personnel. Yeah. So, when they hit level three on that on that button or whatever they do.

40:15

Yeah. And that phone call. They mobilised all of these people. And this is all before the aircraft landed. So this, they were so prepared for this crash. Yeah, essentially that that definitely factor but you could as you alluded to, you could point all that back to CRM and how and the crew declaring putting their hands up are saying, I don't, I don't know else.

40:37

Sharing with everyone. This is a 10 out of 10 in terms of how bad this is. Yeah, yeah. We're gonna crash. Yeah, yeah, Denny like you say walks in later. Yeah. Why that point is thinks he's gonna crash. He's gonna die. He's gonna go die today. Alright, this is first.

40:50

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Disaster Plan

Now, there's a gentleman just to honour him. I wish I could remember his name. He lived in Sioux City who was an advocate for a disaster plan for the area. Yeah, so see city sits on a river. It was used to a lot of flooding. There's a lot of chemical plants in the area because there's so much farming in in the surrounding counties and he wanted a disaster plan and he advocated it for years.

41:14

A disaster plan being that everybody involved the hospitals, emergency services, the communities, all had an interwork in relationship. If, if something happened, would you have guessed it that only 18 months ish before in 1987, they decided to practise that a 747 had crashed at Sioux City. And there was a hundred survivors.

41:40

Yeah, I that's menta;, with the international guard. All the fire engineers all the house petals. That's crazy to imagine and they learn a lot from that practise run. Yeah, ultimately will have definitely saved lives in there in the sort of do you imagine Sioux City is like I think today it's like 80 or 90,000 population.

42:00

That's not a big place and they've got themselves ready. If the important thing here to remember is that aircraft fly between places and then you'll have a buildup of traffic flying across the Atlantic or across the Pacific and taking on similar routes because great circle tracks. So aircraft converging into Chicago, converging into into New York City had very, very few commercial flights.

42:30

Yeah, but it's that right under this very busy flight path. So somebody had the presence of mind to think. Yeah, we're very small, but there's a lot of aircrafts out there above us who might have trouble who might come down here and crash, yep. Like these tiny tiny airfields in Alaska or tiny islands in the middle of the oceans and, and so on.

42:51

Yeah, to think outside the box, almost like, look, we're just a sleepy town, but to get everything. Get the momentum and get everybody organised to be prepared for something like this has obviously saved a lot of lives on that day, and it's just incredible to think that's what happened.

43:09

Just so, they push it to level three. Yep. And all these things start to mobilise, but I'll still sat in the air troubleshooting. Yep. The aircraft with the rest of the crew. Another good example of this is probably testament to the senior cabin crew really. So she gets called in at this point.

43:26

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Jan Brown Senior

This is if this is after they've kind of spoke to us all manages to say to us. Essentially prepare for an emergency landing these, she would have had her own CRM training etc. Etc. And what I found interesting was that she she could sense what was going on in the cockpit.

43:44

This wasn't just a an emergency. This was like a crisis, she she described it. Yeah. So she recognised how busy the, the three of them were and she just left the flight there because she could have said, oh, where are we going, right? How long are we gonna have?

43:58

But she just knew that they hadn't got the capacity to kind of do that. She just sends the scale of the problem and went and used her initiative. Took it upon herself to go and manage the cabin and prepare the cabin based on those words of emergency line. So I thought that was a nice.

44:12

Well, communication, it doesn't necessarily need more the better. Yeah, exactly, exactly. So we walked in and thought. Yeah. You know, I mean, did I'll even get to turn around? Probably not. Oh yeah. All I, all I read was that he just said, prepare the cabin for the emergency landing.

44:27

Yeah, so you know, five or six words and she got she gleaned everything she needed to know from that and from what was going on. And from the non communication that was that was going on. So I read a bit about her and I try not to talk about too much, but I I love Cabin Crew because I work so closely with them but they're different job role towards and but we work alongside and you get all different types of cabin, crew and the cabin manager whatsoever, the senior, the number one, and one, the cabin manager, the cabin crew member the flight attendant who's in charge has a big impact on the conduct of the flight and often the it's not all about the captain but the captain the cabin manager can set the tone.

45:13

Yeah, for the day and Jan, Brown is the ultimate professional. I mean, she wore trousers. She says, just because she knew if there was a fire that they offer more protection then wearing a skirt, the more I learn about the more you realise that she's the right, the right calving crew for the, for the job day.

45:35

I've obviously had, you know, incidents and currencies when you've had different types of cabin crew. Yeah. And, you know, don't you whether how much attention they need and how much you can rely on them? And yeah, definitely she points out that. I'll she was gonna go and said so they were on the flight and they'd done a layover somewhere, the cabin crew and the flight group got on that, often happens, whereby the cabin crew and the flight crew are interchanging between sectors and on a big aircraft, you know?

46:08

There could be I don't know on an A380 was there like 15 crews and more? Yeah. More than that. More close to 2023. Yeah. One of those phrases that sticks in my mind from my first ever CRM training was just a throwaway comment from one of the trainers, which was, oh, I always walk up the back steps when I get to the aircraft by which he meant.

46:27

If you've gone to an aircraft on the tarmac an their is front steps and back steps, you're never going to get to the back of the aircraft unless you make the effort to, Jan brown said that she was going to go and brief or talk to Al introduce yourself. But he came out into the gallon, she really appreciated that and said that the service might be better off earlier on because it could be turbulence later on this kind of thing.

46:47

He had already build those relationships, a team work there, positive work, and Jan, obviously, respected professionalism. I would imagine from everything I've read about her and that's what she got when she met the flight crew. So that's then set the tone for for later on when she's walked in and realised.

47:06

Okay, I've got the message now, I'll leave just quickly then normally the crew would get together and brief. She chooses not to do that, because she doesn't want to upset the passengers too much. So she briefs them a couple at a time. The crew are still making jokes to each other and they're trying to put on a brave face as the situation becomes more and desperate Jan, and Jans realising that she's having trouble making eye contact with the passengers, but she's still maintaining professionalism and she makes PAs.

47:36

I mean to be cabin crew and to not fully understand what's going on, because you wouldn't be able to must induce a lot of fear in you. Yeah. Especially at that time in aviation when she might have known people, or yeah, before in their airline, who died in accidents, were not uncommon and the kind of 70s 80s, you know, later on.

47:58

She's making, you know, she's briefing. The passengers on planned, emergency landings inside theirs. And you can hear the PAs and they're amazing. Yeah, we're talking a bit more about her in a second. Do you want to talk about then how Denny are right? Well, yes, it's kind of this point where Denny Fitchh, who is a training captain with United Airlines and he's been on a course, I think, somewhere in Denver, and is now positioning home to Chicago as a passenger.

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Denny Fitch

48:24

He obviously senses that something's wrong bang, the explosion the bank, they're kind of fear in their cabin, Crews eyes etc. So he knows something because, and from his experience, you know, somebody's wrong. And I'd, I'm just guessing. I think he's a bit of a geek. Yeah. He's like what I mean is I think he's really motivated.

48:43

Yeah. And he's a brand new training. Captain. Did you know that? Yeah, I knew he'd not been trying to come very long a month or two. Yeah. DC10 which only just had his command not long before that but that's ultimately like better in a way interest. As he knows he will of been

48:59

Have been fresh out of the books like and that's what I think in game back to the FO and the engineer is there's always that. Okay. Someone with loads of experience, that's really good but all the only had 30 hours or the flight engineer only had this amount of time but that does mean that the type rating and the training is absolutely fresh.

49:17

Yeah. You're only able to really guess but you shouldn't necessarily assume that the more experienced the better. But what I would like to think about Denny is exactly what you said, which is he's a brand new training captain and he's eager, and he's got his head in the book, probably his lack of experience as a training captain and on the DC10, or as a captain, is made up for, by his knowledge.

49:39

Probably. Right. His executives, a bit geeky. And he's, I mean, we're assuming he's geeky but he's probably. Yeah, he's probably meant to say. Yeah, he's keen, he's keen. Yeah, he's to help. Well, they films and, you know, you can see the pilots I think, is the only one with colour in his hair, haven't I?

49:56

No, I think the FO, but the other three, maybe a bit greyer, right? Yeah. And he's got like, brown hair. He's like the youngster, but he's the most senior rank if you like, is training. Captain. Yeah. Anyway, so, so he offers assistance. So he actually just want to because I didn't I found this out.

50:12

So cabin crew not Jan and he he grabs her arm, right? And they haven't exchanged. The cabin crew says, now it's gonna be all right, it's just number two, but we've lost all three. We go, he says something back. Like and well, why are we turns? This isn't exactly right.

50:28

But you can read it and she says yeah it's all three hydraulics and he says no it's not all three hydraulics. She has the luckily she says no it is all three hydraulics and he starts his mind, he lets it go and he apparently stares for a second into space thinking.

50:43

No, so that's not right. So what does she actually mean? Yeah. And that's when he says to listen, tell them there's a check on a week. On a training. Captain on the aircraft. Yeah. Jan Jan might not have gone and told them, you know, like because there was lots of other pilots on board.

50:59

Yeah, there was retired pilots but there was also other United, another United pilot say because sometimes and Jan wouldn't have fully understood. I wish you wouldn't study serious but not so sometimes you know you don't want no, too many people like offering to help. Well, this is where I, this is where I think, where we, we should match Denny's keenness.

51:20

Let's say, we're gonna assume he died about eight years ago. So, unfortunately we can't, we can't ask him but there's plenty of interviews where he seems quite enthusiastic to this day. Yeah. And match that with how he behaves. Yeah. So he takes time to think about whether he offers his services.

51:35

Yeah. And he's in civilian clothes. Yeah. And other pilots. Actually I think there was a different airline pilot who they also offered their offered help and how he behaves when he's in the fight deck. Yeah, I think like, is it? Yeah, pick up on. Yeah, definitely. So I I got that as well.

51:55

So his offer of help is passed out but by the cabin crew, all again is good leadership CRM. Skills says, yeah, and none of history have seen this before. So training, captain, check airmen on board yet. Let's have some extra experience up here. So as if still not figured it out, no, this guy was basically flying.

52:15

He's got the the fly part of the priorities, right? He's got the wing up and they can't control the altitude. Yes. So they are they are descending towards the ground. They are gonna hit the ground. Also, through all this time. Al and the first officer Bill Bill are flying the aircraft with the yoke.

52:33

Yeah. Or trying to, they're moving the yoke? Yeah. And the whole time. Yeah. Probably. A lot of force on the yoke as well between them and say they're using both arms, the forearms, the pair of them and there you having to manipulate the trolls. Yeah. Okay. It has got to a convenient point where AL thinks, yeah, I would like, I'd like something like a bit of help here.

52:58

Yeah. Yeah. So that's fortuitous. It's interesting. Like I think about today cockpit dot lock door. If someone was offering help in every depends up but it would be billion. It's very close. Would you let somebody into the flight date nowadays to help you? You know, it's interesting on the CVR that all is getting really pissed off with the door.

53:14

Yeah. Or is it deadly or both of them because see, Jan keeps knocking on the door and it's locked, right? And I don't think it's a reinforced door perhaps that we have now, but they're just annoyed that it's kind of like a. So, the last thing you want a high workload situation, is the distraction of that.

53:31

So the same thing is occurring. Basically, they say yes and he arrives and he's knocking for a while, I think? Yeah. Then he comes in the flight deck, so he comes in. He said he quickly establishes, that this is very serious and he establishes what the problem is. And I his words were, you know, I thought this is it.

53:51

This is it. I'm gonna die today. Like there is no way out of this. That's insane. Let's talk about situational awareness. So, we like to project our situational awareness ahead of any event on this flight today. I'll need, there may be turbulence two hours into the flight, something like that or on this flight today.

54:11

We're flying to your such and such an airport. You know, we're thinking ahead to the problems that might come or we're inventing problems in our mind. What if I have a engine failure now but a lot of the time, the problem that arrives you haven't thought of because there's no way to know that the hydraulics are about to fail or the electrical systems about to have a problem.

54:31

When you have an event let's call it. That pushes your SA back to to where you are. You try and rebuild your SA to a point where you're starting to think ahead. Yeah. So he first had to just pick the wing up and he did it without thinking by applying thrust.

54:48

He's now not solving the problem, but his SA starting to rebuild and then then Denny Fitch comes in the flight deck. Yep. And his SA just on. It's been sat in the first class cabin. Yeah. And then he walks in and he suddenly realises it's bad and he's got to build up his situational awareness.

55:07

Yeah, and the crew need to share situational awareness with each other. Yeah, we call it the mental model. Yeah, so we're in a DC 10. We've got this much fuel, the flaps are out the flaps. Are you the real basics? You've got a problem. This is the problem is the flight engineer or the ECAM.

55:26

So you can lying to us as we misunderstood the problem then you've got the wider system. Have we shared the situation awareness with the air traffic control whoever else, the cabin crew for example. Yeah. So that's a point to make that. Then he comes in his situation where it's different and they manage to build his up.

55:44

Yeah. And to a point but allow him to have his own thoughts. Yeah, exactly. That's really crucial. He's they're not leading him is to you know fully as to where it is. That giving him the space to kind of figure out for himself. Yeah. And yeah I'm going on a little bit here.

56:02

Again ahead maybe slightly of where you want to go. But you mentioned a little while ago about his his manner in the flight decks. Yeah. How important that was. And I, that's something I really liked on to. I don't know what in particular you found. I think the first thing he says, is he calls Al captain?

56:20

Yes, I was gonna say that exact point. Yeah. Can't say he says, captain would you like me to take your thrust levers? Yeah. So I think that's, we were talking about CRM and communication. That's such a powerful statement, because just that one word, captain means so many things to me, I'm here to help you.

56:37

I'm here to help you you're in charge. I might outrank you as a training captain, but you are very much in charge of me. I am a resource for you to use. Let's establish who work the authority. What the great, you know, who's in charge here? And can I captain, can I take the thrust levers for you and Denny shares with him?

56:56

That he knows some of the spoilers are drifting up. Yeah, say kind of shares a bit of, I'm not I'm in on it, I've been working on this already. I've been thinking about this and I'm not an idiot and established just that gradient is very polite and inviting engaging and our reciprocates.

57:13

Because at some points, Als asking everybody like what can we do? What can what's? Yeah. And now there is a point where they put the flaps out. I'm just jumping ahead, they have a little discussion which is good about, hey, should we put the flaps out? And then I'll sort of like thinks I'm stupid am I.

57:33

We haven't got any hydraulics, of course. Yeah. But it's able for him to in his brain push past. Like okay we're starting to solve the problem, we haven't. Yeah, if you're a training captain in a sim and it's the 20th time, you've run that check to see a captain, like, try and put flaps out when he has got no hydraulic.

57:51

Fluid looks stupid. But when you are, it's like an elephant sat on your brain. Yeah, when you're in a situation that and what's going on in your brain is screaming, what's happening? What's happening and it can't break through so by making that mistake but verbalizing it and sort of, you know, self or facing.

58:08

He's saying how he doesn't say this. But he's saying how stupid am I trying to put the flaps out when I've got hydraulics? Yeah, everyone is able to get in on that and be like, okay. Yeah, I'm getting this and yeah. Yeah, why stupid? Okay yeah. What can we okay?

58:20

So that happens at some point as well. And that's an example of our being very level gradient. Yeah. Flight deck showing that he doesn't know what's going on. He's and but he wants to know what's going on. They talk about the gear as well. Are we gonna land with the gear up or down?

58:35

He throws it out as what we would call an open question to everybody, and they elect to put the gear down to hopefully, absorption, the impact. They also discuss. How they're gonna get the gear down, because there's a couple of different options. Yeah, without hydraulics for lowering the gear and he says, in there, in the talks of the NASA guys, this CVR there's so much kind of showed you that.

59:00

Should we try that? What do you think about that? But that to you and me is like is brilliant. Kind of open question using all your resources throwing. So they've got you sometime. They're not thinking about the gear, just before impact, or just before landing. Yep. They are thinking ahead thinking ahead.

59:16

Yeah. And they're realising that in terms of decision making they don't have any checklist for this. Yeah, they don't do this every day. This is an analytical decision, they need so they're bouncing ideas off each other. Now, almost any airline in the world, uses decision making tools for analytical decision making, so a problem that you've not dealt with before you not routinely deal with, or you don't know how to deal with you.

59:41

Use decision, making tools, they didn't have those then, but they're using an open style, they're all involved in. And for these little problems as they think ahead and the gear is a an example of that because they think how, if we do this just kind of clever trick of using a certain way to get the gear down, there might be hydraulic fluid.

01:00:01

That would bleed into the ailerons or something along those lines. Yeah, now back to keen, Denny Fitch, right? He's so keen that he's actually thought about this situation before today. Right? What? A miracle you've got somebody on board, he's such a geek that he's thought to himself. What would I do if I lost all three hydraulic systems?

01:00:25

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Japan Airlines 123

Yeah. And I believe the reason for that was a terrible accident of a 747 in Japan. Japan airlines one, two three, right. Okay. It was a seven four seven and a similar call sign. Yeah, I know it was what that's the call sign and it was 10 years before and there is this horrible picture of a 747 that somebody took flying with no fin whatsoever, right?

01:00:53

So imagine you've got the horizontal stabiliser at the back but no fin of no vertical and it's similar cause which is that the air 747s were kind of like still new big big aircraft to pilots at that time and you can easily tail strike, big aircraft and someone had done a tail strike in their Hong Kong at Kai Tak and to repair the tail and the bulkhead the engineers had not done it properly.

01:01:17

Boeing said that the way they did it. The aircraft should last should last about 12,000 cycles of pressurization before it failed and about 12,000 cycles later, which is quite a few years later, they had a explosive decompression on that bulkhead where they'd repair the the tail. The bulkhead that took out the whole fin and understandably, then that took out three hydraulic systems, so Japan airlines one, two, three had the same problem 10 years earlier.

01:01:49

And by some miracle, they kept it flying for quite a long time. And they didn't have a lot of the look that these guys had the weather wasn't as good. It was a night flight. Japan is just just mountains. Basically. Yeah. And they also had a deep pressurization, so imagine that they've got to do emergency descent with no flight controls.

01:02:12

So they're becoming hypoxic in the end, they crashed into a mountain and the air national guard in Japan had a base and had been not the international DM air force. Anyway, they have a base there. They listened to the the radio chatter and they got all their search from rescue stuff, ready.

01:02:32

And unfortunately, the Japanese government said, and you're not allowed to go and rescue. These people off this mountain, so nobody got to them until the next morning. Like maybe 12 hours later and local said that they could hear people on the mountain screaming in pain all night and eventually died off.

01:02:49

So nobody knows how many survived the actual crash, right? So Denny had to think about flying aircraft without any hydraulic systems, okay? I didn't know that there is in the flight thing. Yeah, yeah, it's unreal, isn't it? Like again a chance to practise so the aircraft Sam you said was doing a phugoids.

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Phugoid

01:03:09

Yeah. You're not gonna ask me to explain that. I saw. I'll do it for you back in their lecture theirs. Yes. Someone would make a paper aeroplane and throw it and distract the lecture. And yeah, you had a quite big deep lecture there. Yeah. If you make a really good paper, aeroplane they sometimes fly, and then start to head towards the ground, and then fly back up and fly down.

01:03:36

And if you watch those world record ones, I think they do that. They go into a phugoid. So if you going is just basically the motion of going up as a down and then up and down and up. And so the aircraft was starting a descent and then starting a gentle climb, starting a descent.

01:03:52

Now, what I learnt was the average was a dissent So the aircraft was descending meself. If you think about it, there nearly 40,000 feet about 40 minutes later, they've got to the ground. So they're in this food grade and and any aircraft will enter a phugoid. It will try and seek the speed that it's trimmed for.

01:04:12

So where the horizontal stabiliser was last set? Yeah, which was 200, well there at Mark 8 3 and something like 260 knots to the aircraft was trying to seek that. So as it starts to descend it picks up speed and then that induces a climb line because it goes starts getting too fast, and then it stays down to 60.

01:04:34

But then it gets too slow. Yeah. Then it puts the nose down again and yes. Right. And then later on all says, doesn't he, when they put the gear down and they're in denser air, it would have been a trim speed of about 215 knots. The aircraft was seeking, and then a bit lower later on, because they also don't feel, which maybe will come on to you.

01:04:54

So, a phugoid, they learnt after this accident that if you want to null out a few good, you do what might be counterintuitive, which is as you are going up and thinking, we're going to stall. Yeah, you need to take power off there. This will stop the news rising because it under slung wing engines, they're creating a pitch up moment.

01:05:17

Yeah. And then it will start the nose coming down. And as the news, if you're in a downward part of the phugoid, you do the opposite, which is you put power on even though the aircraft's accelerating. Yeah. And okay. So so they're in a in a phugoid.

01:05:32

Yeah. And there's will hold none to the yolks In response to Denny saying what can I do for your captain is else as you can do the thrust thrusters and they thought about Dudley doing it. But they thought he's busy, he's doing well on these guys. Yeah. Okay. And what I clean is that what Denny starts to do is mimic what the pilots are doing with the yoke.

01:05:57

Okay. So he's like the autopilot. He sees he's listening to the ATC. Yeah. Although he didn't have a headset on I think I understand. So he misses a lot of. So he's a bit out, the loop there. He's probably can't see out the window either cuz he's interesting. Yeah, yeah.

01:06:15

There was a point I was gonna make. So in terms of situational awareness, communication is important and I don't think any had a headset on no. But he basically sees what the pilots want to do and he tries to mimic, that was roughly. Yeah, it's your best account. Yeah, the whole flight and the whole accident, the pilots never let of the yoke.

01:06:36

Yeah. And at some point they thought they had a bit of elevator control. Yeah. But as far as the investigators concerned there was nothing and now makes the point of saying that even today if they did it again, he doesn't think he could let go of the yoke. Yeah, imagine this you're in an aircraft and the you might as well just take the yoke.

01:06:55

Imagine driving a car that's still and every whatever you do the steering wheel. It doesn't do anything. Yeah, so you might as well just forget it. It's like unreliable airspeed where if Alston 30,000 years of staring at the instruments and then you've got a toy. So don't look at the instruments because they're lying to you.

01:07:09

Yeah, he's got to tell himself. The yoke is useless. whatever. So they try and fly at the whole, the whole time. Yeah, which must reduce their capacity, massively, because of the physical exertion. Yeah, I do believe the first officer uses his knees at some point because I haven't been in a burn yet.

01:07:27

There is a lot of if you have trim run away and things like this, you know, it's real physical activity. Okay. So what what we getting on to you now then well I say this is where my research gets patching out up until the landing. So they're obviously working towards landing at Sioux City, the planes making, right turns, and they're essentially looping around to the right because by the way it's the right part of the tail is destroyed.

01:07:52

Yeah. So yet the drag on that side, that's causing the right bank. So they're hoping that they're gonna roll out of one of these. Right turns. Essentially lined up with the wrong way, at sea city. Yeah. That's the plan. They're just working incredibly. Well, as a team, you know, and everyone on the ground is now grounded.

01:08:07

Yeah, cabin crew are and they still continue to problem. Solve eventually they give up talking to Sam. Yep. The the, the engineers the engineers have alerted everybody to the point where the union have in a meeting with yes executives. Yeah, in Chicago. So they were like oh that's all going be honestly the place I've seen out the hangar and let's you see and I'll says they were in Sioux City before he got to his hospital award.

01:08:35

Yeah basically. So they don't feel well, they can't dump all of their fuel. No. Unfortunately, because you don't want really any fuel if you need. You're gonna crash because it has an automatic cut off which you think is probably a good idea normally and they do make one left turn, which is avoiding a weather buildup.

01:08:55

Yeah, so that's pretty cool. But I've seen remember, like, I'll remember that or none of them remember making the left turn, but the trace, they yeah. He's surrounded by trace. So they show. They're looking ahead of the aircraft. Looking at a threat of the weather. They realise that it would, you know, potentially, you know, destabilise the aircraft.

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Landing

01:09:13

on that day. It could have been a totally different story. Yeah, okay. Now the amazing unthinkable thing here is that some point they end up just three degree glide path Sioux city, so that's again a better look, probably as well as skilled they. But they're not, they're not actually lined up on the wrong way.

01:09:31

They thought they were gonna line up onto Sioux City's. Got a couple of crossing roadways. Yeah, and I've looked on Google Maps, right? And it's terrifying. It's a few years later, it's terrifying, how close the city is to the airport. Yeah. And even verify, even our said at some point to a traffic control keep us away just keeps away from the city right?

01:09:49

No matter what because he yeah he's expecting a crash landing air traffic control at this point are managing to think outside the box offer them. So they've got they're telling them which major highway and the state highways they even shut off a highway, didn't they? Yeah. Right. As an option.

01:10:04

State troopers shut off. Yeah. I whichever interstate it was and so they could land on that. Yeah. They even send emergency vehicles off down other highways. Yeah, because they assume the aircraft is not gonna make the airfield. Yeah, someone needs to say, I found it. Yes, where the crashes.

01:10:20

Yeah. So all this incredible in in advance of them arriving at the airport. Yeah. So what what's quite famous about? This is the footage because unfortunately if you want to tell everyone that you're going to crash him 40 minutes, the most excited people in the world are going to be the news media.

01:10:38

Yeah, yeah. So they all get to see city but that's why I have these video records although the most famous one is actually a home video but okay of the crash I'm trying not to jump ahead too quickly but I was going to talk about the last few hundred feet.

01:10:53

What do you think? Yeah, I think so. Yeah because the we've established the CRM was working well and and they just continued basically until they got lined up on the wrong way. It wasn't the wrong way. They were expecting to is actually this huge wrong way. Whereby coincidence, all the emergency services were the fire trucks were already parked, so they all had to move actually like last minute on out of their way essentially.

01:11:14

So they were lining up on this disused runway. But that was the best they could do. Yeah. So runway two twos. World War two concrete. They're in since the since Pearl Harbor basically and like you say all the trucks and these A7 and A10 aircraft had like kind of taxied out the way that way.

01:11:34

So something along those lines. Yeah. And they had two minutes to get off the other way. Yeah. The other way but I did learn there at the far end. Yes. Of the runway. Yeah so yeah. Let's talk about last couple hundred feet there so it's all going reasonably. Well I think they're fast.

01:11:48

I don't know. They're fact they got no flaps. They got no way to lay down since. I guess, they're super fast and they're ready to send is high but it's it's going. Okay. So the way I plan for non-normal landing is so I want to think ahead and there's always like little things we need to do.

01:12:07

Say we're gonna have to lower the gear in a different way. We're gonna have to flare in a different way. If we go around we can't get the gear up so many pilots use and I think on approach bucket so you draw a bucket, which is like a vertical down approach, horizontal line, oh they didn't have this capacity and time and workload to think ahead.

01:12:30

But if we were to do that for them let's just think about just how other bad situation they're in. Despite the fact that they okay you've had best look possible to control the aircraft and you've had a training captain come up to handy with thresholds and all these amazing things have happened.

01:12:50

The cabin crew managed, prepare the aircraft but we haven't even got to the potential of an approach in a landion. Yeah. Right. The gear gravity extension, great, they can do that. What about flaps and slice? Yes, there's no flaps. No slats. So they're what we would naturally use to slow ourselves down.

01:13:09

I think normally they'd land about 130 knots. But but for a flapless or a slightless land in. Yeah. Probably it's going to be 180. 190 not anyway. Yeah. This is what I wanted to bring up. How long is runway, 22? It's not very long. 6000 feet.

01:13:26

I think it's 2,200 metres at 2000 closures to 2000. Metres, it has me is right. Say we fly a little at the moment 320 series. Yeah. What is 2000? Metres mean to you guys metres would be like, medium auto break, kind of not shortest. We fly to, but short enough to want to, well, anything less than 2000 metres.

01:13:47

We have just like a bit of red flag. Yeah, yeah, I don't know. That seems really sure the DC widebody DC 10. Yeah, I also wanted to look up the altitude and temperature, but I think it was pretty hot. And I think some of these states in this in America are pretty high up as well.

01:14:05

The lie IO. Yeah, this is a wide body with 300 people on and this was way a lot. Yeah 2000 metres is not longer but but I'll think in, I can't believe we've made a flat piece of runway. Basically. Yeah, I was sort of in the mindset that they would make a control crash into a field.

01:14:22

Yeah. And I don't know if there's any more I can add but somehow they roll out when I say somehow, you know this wasn't just look you're low. No they they planned it. They were working with the controller and to get themselves into this position. Yeah. And eventually they see the runway?

01:14:42

Yeah, and I think when you read the CVR, that's when you realise, I was like oh my god yes might not be quite as bad as I think but we're definitely going off the end of the runway. Yeah, so he probably thinks 2000 meters. Oh, that's just glorious. Yeah, but it's 2000.

01:14:57

Metres is really sure and they're about the right altitude as well. Yeah, but there was one last orbit they did which wasn't picked up on radar, but it's on those diagrams, you can see? Yeah, okay. I think they did on purpose because there are too high. Okay. Yeah. Makes sense and they lost the runway and then they seen it again and that's when they realised they lined up on two two, I think.

01:15:17

Yeah. Okay. I'll say controller says, you clear the land runway. Also reciprocal of three. Three. And no, it was supposed to be three. Three, I think essentially. Yeah, I can't remember and and he says, oh well we're kind of lined up on this one now and the controls are.

01:15:33

Oh runway two two. No point is control and that's not the one. It goes to too. Yeah. Okay. We got a lot of ermergency. Vehicles on that runway but we can get them off. No problem. Don't worry about it. He's so accommodating. Yeah, so he obviously realises what the situate how diverse situation is and that they can't steer the aircraft and say yeah all the emergency services had less than two minutes to get off the runway and get out the way and then lined up with two two, .

01:16:00

Yeah. Okay. So they have no flaps and slats out so the flying pretty fast. I think about 120 knots, I think, right? It's like 100 knots fast. So what they planning. How, they're gonna break Sam? I don't know. Actually, they've got a plan. I did it. Yeah, they plan they just know.

01:16:17

They haven't got any braking and I think reverses are always hydraulic. Yeah. Actually just as well say they wouldn't have any of those so they've got to get it on this runway. So the point I wanted to make was Al's mental model has gone from landing in a field somewhere to landing on airfield but they've got an airfield with the national gaurd.

01:16:37

Yeah they've got all their fire services at the airfield and they've already got all the fire and rescue services from around Sioux City. The adjacent highways been closed they've got that to land on they've got fire services about to go and look for them off the airfield but crashing an aircraft in the middle of Iowa versus an airfield is definitely too totally different outcomes.

01:17:00

Absolutely. So they've managed to crash their aircraft in the best possible place. It's like being ran over by an ambulance, here's life. You're gonna get run over by anything and there's nothing you can do about it. What would the best things to happen? Be so they give and everybody on the ground, the most best possible amount of time and information.

01:17:18

Yeah, there is this beautiful picture of where they touch down and I can't believe they basically touched down on the in the trash effectively. Yes. Incredible. Yeah, but they're starting a downward just before 200 feet. Yeah. And a slight right? Yeah, right turn and a downward phugoid which Denny tries to sort of start but it's just too late at that point this.

01:17:44

Yeah, you know, I think they've put Denny in the right hand seat so that you can strap in Denny's in Dudley seat. Now Denny's in the flight engineer. That's right. Yeah. And Dudley yeah, the observer jumpseat. Yeah. So they're all in the flight deck still but they then he would have been face to the prospect of crashing.

01:18:01

But wouldn't stood on instead of in the middle of flight that a yeah. Okay. So they unfortunately start this figured and I think Al wants him to close the thresholds but Denny's like trying to flare by adding power to power up to try and pitch the nose up to kind of flare.

01:18:18

And there is two schools of thought that Denny either put the wrong thrust. Lever up slightly earlier or not, not or not symmetrically. Yeah, which is why the start, they start even more of a right bank or one of the engine spoilt up quicker than the other, right? So they started with four degrees of bank but they touched down with 20 degrees of bank.

01:18:40

Yeah. Which is a lot. Yeah, of bank. Plus they're accelerating downhill and the thrust. Levers are up. One thing else is in in hindsight is they learnt that you only need gentle changes to thrust levers to control the aircraft using asymmetric power. Whereas most of the flight they were using big, big changes.

01:18:57

Yeah. So as he touched down one of the engines or both the engines for full power? Yeah. The to concrete is 18. A 12 inches, deep leading world or two and the whole is like 18 inches deep. Where the right main gear? Yeah. So they they impacted the ground at about 80.

01:19:17

Was it 1800 feet a minute? Rate of descent? That's right. Yeah, so very point that we fly three degree approach about six or seven hundred feet minute. And in the flare we probably touched down about 300 feet a minute. So, they impacted the ground at 1800 feet of minutes.

01:19:32

So, like six times the normal rate of decent for a say, normal landing. If you watch the footage from all these news media, and this home video and the pictures and so on of the aircraft it looks under control. And in fact, I think everybody thought oh this is gonna be alright.

01:19:48

Yeah and but as it goes out of view, it goes out of view. Because on that the person filming with that, home recorder is on the tower and the tower can't see the threshold of tutu because the international guard have built hangers in the way and it's the issues.

01:20:03

Runway. That's why you kind of lose sight of it. All the media were parked up to get the best shots, but they're for the other runway. Yeah, yeah. So you get this idea that's quite under control, but as it goes out, of sight is where it all goes wrong.

01:20:15

It's slightly wrong. Yeah. And or as also says there, look ran out at that moment. Yeah. CVR records. They think also they can't remember somebody saying God. Yeah. Is the last word just before it? Yeah, it touches down. It's not the right phrase. Yeah. So I just critically say what I my interpretation of what I think happened.

01:20:36

Yeah. Yeah. They're not in control the aircraft anymore so yeah it might not be of worth. I was talking about too much but the touchdown right bank, the right wing, mostly then snaps off. Yeah. And the tail, the effect of the left engine and the left wing, they think then brings the aircraft back up.

01:20:57

So people watching it crash all these people that waiting for them we have to watch it. Crash say that it was incredible is, you know, it was like a ball. Yeah, bounce bounce bounce. You didn't just smash into pieces there but that starts a fire when the right wing and but some of the right-wing separates, the tail comes off with that engine stuck on it, then the effect of the left wing still be an attached.

01:21:24

The engine, perhaps is the reason that the wing lifts up it doesn't cartwheel, which is what the news says that it does. It actually goes up and knows down. So, imagine basically, as the way I'll describes it, they left, the radome left marks, so the radio and be in the very pointiest nose part.

01:21:46

Yeah. On the tarmac, bounce bounce that then shears, the flight deck off. Yeah, and then the aircraft goes on, it's back into a cornfield and I don't think I'll talk about. For example, the book I read like describes in, in great detail. Some of this sensations and the experiences of what happened.

01:22:08

But I think they grow corn on airfields and long grass deliberately. Don't they say that if you have a crash especially on light airfields, that you end up in there in cornfields it'll show you down quite quickly. Yeah, exactly. Which is what which is what happened in the passengers describe hearing this noise that was did and it's all the cool because these big pieces of corn.

01:22:27

Yeah, these big plants, one really annoyed farmer. Like yeah, I tell you, one thing they do talk about is instantly inhaling the smell of a fresh summer's day and the cornfield when the aircraft broke apart. Yeah. So the flight deck is separated and then you've got two other sections.

01:22:46

You've also got a rear section with passengers and not just the tail, which is somewhere else. There's a rear section. Okay? So there's a big fireball. A lot of passengers died due to smoking inhalation. Yeah, everybody in the flight deck, survived the four of the they didn't find them for a long time.

01:23:03

They that was the last part to be found by the rescue services because it was kind of buried in the dirt and in the core and people ignored it apparently because they thought that no one could survive because it was flattened. Yeah. And they didn't know what it was.

01:23:14

Half an hour or 35 minutes. Five minutes. Yeah till they found them and they were wrapped in the wires. The plan is lots and lots of cables that connected, the aircraft to all those hydraulic servos and so on. And that they kind of wrapped around the flight deck. Yeah.

01:23:29

And they're all squashed. Yeah, and they're all alive. And then the air national guard are, there said they had the jaws of life and they had big machinery. And to dismantle this, this flight decking and get the pilots out. Meanwhile the various experiences the passengers one business I think he's in business class but a businessman just got got his bag and walked off and went to the bar in the terminal.

01:23:57

Wow. Yeah of course there's like the very extreme other end experiences passages. So there's how many survivors have more than half so 112 died and 184 survived. Yeah, so it's hard to talk about because it's such a successful crash, they saved? Yeah, all those lives but then they lost a lot of lives as well.

01:24:21

I think that's it. And it's sad to sad because 112 died. A lot of which were children because it was children fly for a sense day, which we didn't mention earlier. But there's a lot of children on that and unaccompanied children as well. Yeah, which as well just is and they cooperation and their, from the passengers, apparently was amazing.

01:24:42

So there was, I think there's a lot of fear in the cabin, but they relocated a lot of passengers to, you know, emergency exits and made sure that there was always an adult with a child. And there was various stories of passengers, who rescued children, who weren't their own children in the most famous one, which was a gentleman.

01:25:00

He went back in for a baby and found it in the overhead locker. Yeah, but I think it's regarded as such a successful crash in that if it wasn't for the effective CRM of the crew. And the way they handled it, in the way it was handled on the ground, then it would have been 296 dead.

01:25:20

I would think for sure, you know, effectively rather than saying, 112 died 184 survived when they shouldn't have probably. And that's, I think that's why it's regarded as, as a successful crash. It was that point where CRM had been around for a while and we were able to hold it up as a yeah, example of great CRM.

01:25:38

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DHL Baghdad

Yeah, there was a Baghdad DHL aircraft that had a triple hydraulic failure in 2003, right? Do you remember that one? Not really? It doesn't have a flight number because they their vision of Iraq was like March 2003, this is November. Okay. And the act DHL had won a contract to fly.

01:25:59

I do kind of mail apparently. Yeah, into the main airport in Baghdad and a terrorist group who were annoyed that the Iraqi army had surrendered. Basically had like stolen some service to MSIles and they fired a service missile. After this a 300 took off from Baghdad. It was doing a max rate climb but it hit the left wing.

01:26:22

The missile hit the levelling, can you believe this? No doubt. Yeah, there was a triple hydraulic failure and there's a 300 as a flight engineer as well. So there's only three crew on board. It's a cargo aircraft obviously and these guys whilst the wing was on fire and also we're still being fired at not.

01:26:42

They knew about that. And the wingspar was the real wingspar was burning. They managed to fly with asymmetric thrust and land. They came around to Baghdad airport and realised that they were too high and did another circuit, right? But also the flight engineer was having to like do some thinking outside of the SAPs he was having to pump fuel in weird ways right?

01:27:09

Because one of the fuel tanks was on fire. Yeah. Yeah. And they landed with a triple hydraulic failure. Came off the end of the runway and were evacuating. When they were told they're in a minefield and they shouldn't take a step. While their aircraft was on fire, but they came away safely.

01:27:29

And there isn't much information about it in comparison to sea city because I think although it's a commercial aircraft for the commercial crew, it was working for the military. Right, okay. But there's plenty to read about and it's another example of amazing work by the crew and they had an award from the flight safety foundation, which they got to recognise their efforts.

01:27:51

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Ending

But I can't help but thinking that they would have had in their mind that the fact that somebody's done this successfully. Yeah, this has been done before. Yeah, in the aftermath, he took about the CRM. So the NTSB credited, the CRM that United Airlines introduced the early 1980s as well.

01:28:13

Really valuable to the success of the outcome. And the FAA actually made CRM mandatory for all airlines after society because of how effective it was. I thought, I thought I was interesting. Yeah, I mean this is so much talk about but we've covered a lot of the yeah, that we've managed to.

01:28:32

I wanted to generally talk to you about it, to see how you felt about it because we, we learnt about it. When we were about 18, 19. This certainly one of the most impactful things I've ever learnt in aviation. Okay? For sure anyone listening, if you want to find out a bit more, you can read.

01:28:49

As Adam said, you can read loads about it, but I told you to watch. He just so YouTube. Al Hays. Talking NASA Langley. Yeah. He's it's about an hour and 15 minute video but it's just you just hang off every word. He says he talks about the day. And yeah it's it's fascinating.

01:29:06

If if you are at an early stage of you flying career, I had you to learn about CRM because that was a real turning point for me. Having watched Topgun when I was about seven or something, wanted to be a pilot. It wasn't until I was like 10 years later that someone explains to me, that it's not about heroics.

01:29:27

Yeah. And it's not about you as a as a god, as a pilot. It's actually about this idea that you're all gonna make mistakes and we're gonna work together and we've actually codified it in this discipline of CRM. And I worked as a CRM instructor and that one of the most enjoyable roles that I had especially working with pilots and cabin crew simultaneously.

01:29:49

Yeah, and we always look at accidents to learn, but I just say as we've said before most of our training and you can correct me from wrong, Sam, most of our assessment and training is non-technical. Yeah. So, of all the things that will get scored on at the end of a simulator.

01:30:06

Most of them CRM, as in what? 90% 80% of them. Yeah, absolutely. And in my mind, it's always going to be that accident that you sorry that that event that you just can't figure out how you're gonna get out of. The only way to get out of. It is CRM.

01:30:22

I mean, when we did selection to join our airline, they kind of gave you an impossible task yet, to fly a 747 most people hadn't flamed before. Yeah manually shortflight high speed a workload and this and then there's some kind of horrible situation and the only way out of it was CRM was to, it wasn't why being an amazing pilot and holding the exact altitude and flying amazing rate.

01:30:44

One turns and yeah this kind of thing. It was your mastery of your own and non-technical skills and those of the people that you work with and so they even use it as selection tool. Yeah. Yeah, So then we'll have to do that in CRM or just parts of CRM as a individual podcasts.

01:31:04

Yeah. Agreed. But this is a good introduction as to where it came from. And what one of the first accidents that really propelled it into the forefront of people's minds in aviation, say to like all crews that have gone before as well. Done, today's on United two, three, two.

01:31:22

Yeah, because we've learnt so much from you. Yeah, it's amazing. All right. Yes. Bye.

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Adam Howey
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