The Precision Approach

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  • How We Got Here (Part 2 of 3) – Outta Gas

    United Airlines Flight 173 – Decision Making

    Almost six years to the day after Eastern 401, United 173 also experienced landing gear problems on approach and at night, this time into Portland (OR) International Airport.

    United Airlines Flight 173, a DC-8 with 181 passengers and eight crew members, departed Denver Stapleton International Airport just after 3:45pm MST on December 28, 1978 for the two-plus hour flight to Portland. All had been uneventful until extension of the landing gear when the crew heard an audible “thump” and felt the aircraft’s nose lurch noticeably to one side. The crew received indicator lights telling them that the nose and left main landing gear were down and locked, but not the right main gear. The crew correctly discontinued the approach and asked to hold near the airport to troubleshoot the problem.

    From the Cockpit Voice Recorder (CVR) at 5:46:52pm PST —

    First Officer: “How much fuel we got…”

    Flight Engineer: “Five thousand (pounds).”

    By the time of this exchange, the aircraft had been holding for close to 30 minutes. The DC-8 burns approximately 10,000 pounds of fuel per hour at cruise altitude with the gear and flaps up. With the added drag of the extended gear and flaps, 5,000 pounds probably amounted to around 15 minutes of flying time in a best-case scenario.

    However, the First Officer and Flight Engineer continued to bring the Captain’s attention to the aircraft’s low fuel state.

    CVR at 5:48:54pm —

    First Officer: “What’s the fuel show now…?”

    Captain: “Five (thousand pounds).”

    CVR at 5:50:16pm —

    Captain: “Give us a current card on weight, figure…about another fifteen minutes.”

    Flight Engineer: “Fifteen minutes is gonna…really run us low on fuel here.”

    The Captain is asking the Flight Engineer to perform landing weight calculations for an attempt at landing in fifteen minutes. The Flight Engineer believes that is impossible and tries to articulate that. The Captain never acknowledges it.

    CVR at 5:57:21pm —

    Captain to the First Officer: “You might…you might just take a walk back through the cabin and kinda see how things are going Okay? I don’t want to, I don’t want to hurry, em but I’d like to do it in another oh, ten minutes (or so).”

    My interpretation: the crew has been troubleshooting a landing gear problem for close to 45 minutes. The Captain’s timeline for starting their approach is moving later and later. To say that the Captain is being indecisive is not accurate. He is afraid and there is nothing wrong with that except that he is a product of that time. Captains were the final and only authority in the cockpit during that era; they did not receive training on how to use their crew to help in decision making, reinforce process, and mitigate against personal perceptions of situations.

    After almost 10 more minutes of discussion and preparation for landing, things go predictably worse.

    CVR at 6:06:49pm —

    First Officer: “We’re losing an engine.”

    Captain: “Why?”

    First Officer: “Fuel.”

    Almost unbelievably, the aircraft stayed aloft for another seven minutes beyond this exchange as each of the four engines shutdown due to fuel starvation. The crew desperately tried to keep the aircraft airborne to make the airport, but the airplane came down in a suburban northeast Portland neighborhood at 6:14pm, almost one hour after the problem started. Eight passengers and two crew members lost their lives in the crash. There was no post-crash fire because the plane had no fuel on board.

    The National Transportation Safety Board (NTSB) determined that the probable cause of the accident “was the failure of the captain to monitor properly the aircraft’ s fuel state and to properly respond to the low fuel state and the crew members’ advisories regarding fuel state. This resulted in fuel exhaustion to all engines. His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency.” 

    Contributing to the accident “was the failure of the other two flight members to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain.”

    The investigation also discovered that metal corrosion in the right main landing gear caused a failure in the support structure to lower the gear into place. Instead, it just slammed into position and damaged the electrical relay that sent the indication to the cockpit that the gear was down and locked, which it was.

    So how did this incident contribute to improvements in decision making in aviation and what are the lessons that organizations can learn from it too? More to follow…

    Here is the NTSB accident report.

    The story of United Airlines Flight 173, the plane crash that launched the crew resource management revolution in airline training

    In memory of those who lost their lives aboard United Airlines Flight 173.

  • How We Got Here (Part 1 of 3) – The “Lightbulb Moment”

    Eastern Airlines Flight 401 – The Communication Dimension

    At 11:33pm EST on December 29, 1972, the First Officer of Eastern Airlines Flight 401 lowered the landing gear handle to configure the Lockheed L-1011 for landing at Miami International Airport. After lowering the handle, only the green lights for the left and right main landing gear illuminated to tell the crew that those specific set of gear were down and locked. The light for the nose landing gear did not illuminate, so the crew discontinued the approach.

    From the cockpit voice recorder (CVR) at 11:34:05pm —

    Captain: “Well ah, tower, this is Eastern, ah, 401. It looks like we’re gonna have to circle, we don’t have a light on our nose gear yet.”

    Tower granted the request, instructed the crew to climb to two thousand feet, and to switch back over to approach control. Approach control further instructed the crew to turn north and then west to hold over The Everglades to troubleshoot the problem. The First Officer placed the autopilot on so that the crew could determine the extent of the issue.

    For the next six minutes, the crew continued to troubleshoot the indicator light, going as far as dispatching the Flight Engineer to an avionics bay beneath the cockpit to look through a small portal to determine the position of the landing gear. But the crew would never get the chance to resolve the problem.

    CVR at 11:42:05pm —

    First Officer: “We did something to the altitude.”

    CVR at 11:42:07pm —

    First Officer: “We’re still at two thousand, right?”

    CVR at 11:42:09pm —

    Captain: “Hey, what’s happening here?”

    CVR at 11:42:12pm —

    Sounds of impact.

    The airplane was in a left turn when the impact sequence started in The Everglades. The left wing tip made contact with the ground first, followed by the main portion of the fuselage, and then the outer portion of the right wing section tore free from the fuselage just after the fuselage had made contact with the ground. The tail section of the airplane and its tail-mounted engine came to rest forward of the main section of the fuselage as it continued to deliver thrust through much of the breakup of the airplane. 101 of the 176 occupants – including the Captain, First Officer, Flight Engineer, and two Flight Attendants – lost their lives in the crash.

    The National Transportation Safety Board (NTSB) determined that “the probable cause of this accident was the failure of the flightcrew to monitor the flight instruments during the final 4 minutes of flight, and to detect an unexpected descent soon enough to prevent impact with the ground. Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew’ s attention from the instruments and allowed the descent to go unnoticed.” NTSB investigators believed that the Captain accidentally bumped his control yoke when he turned around to speak with the Flight Engineer during troubleshooting. By bumping his yoke, this disengaged the autopilot and placed the airplane in a very slight descent. Since it was nighttime over a featureless and unlighted area, the crew was unable to sense the descent nor have visual cues outside to indicate that the airplane was slowly headed toward the ground.

    One other discovery as part of the investigation: the nose landing gear was down and locked. The lightbulb on the indicator panel had burned out.

    So how did this incident contribute to effective communication in aviation and what are the lessons that organizations of any type can learn from it as well? More to follow…

    Here is the NTSB accident report.

    In memory of those who lost their lives aboard Eastern Airlines Flight 401.

  • In Memory of Antoine Forest and Mackenzie Gunther

    To the cockpit team of Jazz Air Flight 646, you will be missed and it was privilege to share the airspace with you both.

  • Crew Resource Management – What Is It? And What Is A SADCLAM?

    Crew Resource Management, at one time known as Cockpit Resource Management, or now just known as CRM, was and is the operations excellence process that the aviation industry adopted about 45 years ago. It was after a series of accidents marked by insufficient or inadequate communication, breakdowns in decision making, and misapplications of leadership that CRM implementation became an enterprise revolution, providing needed support to operations in high-consequence environments and in some instances, time-critical situations.

    At its core, CRM does not ignore hierarchical structures – the captain is the still the final authority in the airplane. Just the same, the CRM process requires the leader and the team to pursue all available resources to create effective outcomes. And CRM extends beyond the cockpit now as it also involves the flight attendants, air traffic controllers, maintenance personnel, first responders, and others who contribute to safe operations. CRM also accepts that human error is inevitable and creates structure to mitigate that.

    To create this structure, CRM teaches the soft skills of flying and teamwork. Navy and Marine Corps Aviation use(d) the acronym “SADCLAM” to itemize the fundamental elements of CRM (odd name, but true). “SADCLAM” stands for Situational Awareness, Assertiveness, Decision Making, Communication, Leadership, Adaptability/Flexibility, and Mission Analysis. Annual CRM analyses of Naval Aviators include feedback on all of these elements oftentimes during challenging situations, usually in the simulator.

    In posts to come, I will discuss three incidents – Eastern Airlines Flight 401, United Airlines Flight 173, and the Tenerife Accident – that defined the pre-CRM era of flying and how each of those incidents contributed to the creation and integration of CRM. I will also discuss incidents like Air France Flight 447 to show how even decades later, breakdowns in CRM can still occur.

    So how does your organization communicate? How does it make effective decisions, even in time-critical situations? And how does your organization cultivate leadership? Is it time for your organization to do a little SADCLAMming?

    More to follow…

  • Welcome to The Precision Approach

    Every day, around 44,000 airline flights take off and land in 29 million square miles of American airspace. All of this translates to around 3 million domestic airlines passengers transiting the national airspace system daily. By and large, all of these flights happen without incident. And when incidents do occur, there are procedures, protocols, and tools to in place to mitigate or abate the effects of the incident.

    This blog is designed to highlight those effective practices in the aviation industry for organizations of all types. While these practices of the aviation industry may not have complete applicability to non-aviation organizations, the intent here is to discuss them in an easily understandable manner to support organizational goals of excellence in operations and preparedness / readiness for obstacles to operations.

    I will discuss all of these effective tools under the disciplines of Communication, Decision Making, and Leadership in an effort to articulate everything in a way that may prove useful or insightful for your organization. If your objective is to become a “High Reliability Organization,” the content here will prove useful in support of that – more on “High Reliability Organizations” later.

    Between February 13, 2009 and January 28, 2025, there was only 1 passenger fatality on commercial air travel in the United States. This blog will explore the why and how of this statistic. If you have ever watched the United States Navy Blue Angels or the United States Air Force Thunderbirds fly the precision shows that they do so often, this blog will explore the why and how they do it. How do planes land on aircraft carriers at night, in bad weather, and in rough sea conditions? This blog will explore the why and how of that. And lastly, if you have ever wondered how many “stakeholders” there are invested in the safe operation of an aircraft in flight from Point A to Point B, this blog will explain this network of stakeholders and how they work together to send airplanes with a few hundred people more than seven miles above the earth moving at not too far below the speed of sound effectively several thousand times a day.

    Welcome.