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c h a p t e r 17

U N I T E D A I R L I N E S

F L I G H T 2 3 2

O n July 19, 1989, while en route from Denver to Chicago, flying

debris severed all three hydraulic systems on United Airlines

Flight 232, leaving the pilot without any control of the DC-10 aircraft.

Through the courageous effort of the cockpit crew and a highly coordi-

nated emergency response, the plane was able to make a crash landing

at the Sioux City, Iowa, airport. Due to these exemplary risk manage-

ment practices, both in the air and on the ground, of the 296 passengers

and crew onboard, 184 people survived the crash (see Exhibit 17.1).

In the early afternoon of July 19, 1989, passengers began boarding a

United Airlines DC-10 aircraft at Denver’s Stapleton Airport. One of

the passengers, Denny Fitch, introduced himself to the flight crew as he

entered the plane and made his way to the first-class section. Fitch, an

off-duty DC-10 instructor pilot, settled into his seat, looking forward to

an uneventful flight. He was entirely unaware that an unthinkable dis-

aster was about to occur, one that he would help turn into an equally

improbable success.

United Airlines Flight 232 departed Denver for Chicago at 2:09 PM.

In the cockpit was Captain Al Haynes, a 33-year veteran with nearly

30,000 hours of flying time. Beside him sat First Officer William Re-

cords and Flight Engineer Dudley Dvorak, with 20,000 and 15,000

hours of flight time, respectively, on their resumes.

237

Abkowitz, Mark D.. Operational Risk Management : A Case Study Approach to Effective Planning and Response, John Wiley & Sons, Incorporated, 2008. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/broward-ebooks/detail.action?docID=335777.<br>Created from broward-ebooks on 2017-11-28 11:28:13.

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About an hour into the flight, the 8 attendants onboard began serving

lunch to 285 passengers. The plane had climbed to 37,000 feet and had

just crossed the Iowa border when the crew began executing a gentle

right turn toward Chicago. Suddenly a deafening explosion shook the

entire aircraft. The sound was so loud that the captain initially feared

that the passenger compartment had decompressed. A quick scan of the

flight controls, however, revealed that one of the engines had failed.

Haynes gave the order to begin shutting it down.

The DC-10 is a three-jet engine aircraft with one engine under each

wing and one in the tail. The failed engine on Flight 232 was the tail,

also referred to as the number two engine. The plane still had its right

and left engines available, however, which normally would be sufficient

to carry the aircraft to a safe landing.

Haynes left Records to fly the plane while he and Dvorak carried out

the shutdown procedure for the damaged engine. Dvorak read the first

item on the procedure list: ‘‘Close the throttle.’’ Haynes pulled the

throttle lever, but it would not move, a problem he had not encountered

before. When Dvorak continued to the second item, ‘‘Turn off the fuel

supply,’’ Haynes could not move the fuel supply lever, either. Haynes

E X H I B I T 1 7 . 1 Crash site of United Flight 232

Source: www.airdisaster.com/special/special-ua232.shtml.

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and Dvorak had just devised an alternate way to shut off the fuel to the

number two engine when Records spoke up: ‘‘Al, I can’t control the

airplane.’’

The explosion of the engine had shot more than 70 pieces of shrapnel

into the horizontal section of the plane’s tail. These projectiles severed

all three of the independent, redundant hydraulic flight control systems

onboard. With hydraulic fluid completely drained from the aircraft, the

crew seemingly had no means of controlling the plane.

Upon realizing the severity of the situation, Dvorak began contacting

maintenance and air traffic control (ATC) centers to notify them of his

circumstances and to seek advice. The maintenance experts had never

encountered a similar problem. In fact, the probability of all three hy-

draulic systems failing at once was considered so low that the aircraft

manufacturer, the Federal Aviation Administration, and United Airlines

had no established a procedure for addressing such a scenario. Accord-

ing to the manufacturer’s specifications, steering a DC-10 under these

conditions would not be possible. Maintenance could offer no sugges-

tions and, unknown to the flight crew, decided that Flight 232 was

doomed.

Meanwhile, the plane continued its slow right turn and began de-

scending. Haynes took over the controls as the plane began to roll over

onto its back. As the tilt of the plane increased and the crew ran out of

options, Haynes desperately throttled the left engine and reduced the

thrust in the right. The plane then began to level out.

ATC directed Flight 232 to Sioux City Gateway Airport to attempt

an emergency landing. Haynes then notified the passengers that the

number two engine had been lost and instructed the flight attendants to

prepare for the landing.

After about 15 minutes of manipulating the throttles in an attempt

to steer the plane toward Sioux City, a flight attendant brought Finch

to the cockpit. Although Finch was unable to provide any new infor-

mation, he offered to assist in whatever way he could. Finch first went

to the rear of the aircraft to confirm the damage. He then took over

control of the throttles, affording the crew more freedom to work on

United Airlines Flight 232 239

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the problem. For the next 30 minutes, Finch steered the plane with a

throttle control in each hand, responding to commands from the

crew.

As Flight 232 approached Sioux City Gateway, Fitch was unable to

keep the airplane from completing a number of wide right circles as it

continued descending (see Exhibit 17.2). Meanwhile, Haynes commu-

nicated with the Gateway airport air traffic controller to make prepara-

tions for landing. The crew then dumped the plane’s excess fuel and

worked in concert with the controller to steer the aircraft away from

populated areas around Sioux City.

Rescue and firefighting vehicles gathered as Fitch attempted to line

up the plane with the longest of Gateway’s three runways. As the plane

completed its final circle, however, Fitch was only able to align the air-

E X H I B I T 1 7 . 2 Flight path of United 232 over Iowa

Source: National Transportation Safety Board, Aircraft

Accident Report—United Airlines Flight 232, McDonnell

Douglas DC-10, Sioux Gateway Airport, Sioux City, Iowa,

July 19, 1989. Report No. NTSB/AAR-90/06, November

1990.

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craft with a shorter, 7,000-foot runway that was no longer in use. The

controller cleared Flight 232 to use the shorter runway and scrambled

rescue equipment that had been positioned there out of the way.

Fitch and the crew were able to straighten the plane out for landing,

but they could not control the speed and descent rate. Whereas a speed

of 160 miles per hour at a descent rate of 300 feet per second is the

normal condition for landing a DC-10, United 232 was traveling at al-

most 250 miles per hour and dropping at more than 1,850 feet per

second.

The plane touched down 45 minutes after the explosion, at approx-

imately 4:00 PM. Although the aircraft landed just off of the runway

center line, the left wing dipped at the last moment, striking the ground

and spinning the plane to the side. The right landing gear ripped a large

hole in the concrete runway as the plane broke apart and then burst into

flames.

The center section of the aircraft, where most of the passengers were

located, ended upside down in a cornfield 3,700 feet from the site of

initial touchdown. Firefighters approached the wreckage cautiously in

order not to injure the victims who had begun walking across the run-

way. The tall corn in the field, just one of the many obstacles responders

faced, made it difficult for firefighters to see the wreckage and locate

survivors. The limited number of available radio frequencies for the size

of the recovery effort also hindered communication among responders.

Additionally, a critical water delivery system malfunctioned as fire-

fighters fought the flames. Despite these challenges, the firefighters were

able to reach the plane, cut through seat belts to remove survivors

trapped inside, and extinguish the blaze.

Crash victims were moved from the wreckage site to a well-organized

triage area for transport to local hospitals. When the scale of the

disaster became apparent, rescue workers requested additional vehicles.

Thirty-four ambulances, some from as far as 60 miles away, responded

to the call, along with 9 helicopters. All critical patients were evacuated

from the scene within an hour of touchdown, with the remaining vic-

tims removed within another 45 minutes.

United Airlines Flight 232 241

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At the time of the crash, the two local hospitals activated their mass-

casualty plans, assembling resources and personnel. By the time the first

patients arrived, they encountered an orderly and efficient medical dis-

aster response system.

Of the 296 people on board United Flight 232, 185 survived the

crash and fire. Following an accident investigation and simulator testing

of the event, a federal review board declared that a safe landing under

such circumstances was essentially impossible, making the survival of

any of Flight 232’s passengers all the more extraordinary.

The failure of the number two engine was caused by a material defect

and wear in an engine fan. The six-foot fan developed a crack and dis-

integrated during the flight, spraying fan blades and pieces of metal that

severed all three independent hydraulic lines. The crack, which had oc-

curred very early in the life of the engine part, had never been detected,

despite six detailed inspections of the fan over its 18-year life.

That the Flight 232 crew was able to save the lives of 185 people is

considered remarkable. This positive outcome can be attributed in part

to the crew’s experience; the four airmen had been flying for a total of

103 years. It can also be attributed to at least one crew member having

trained on the use of unconventional aircraft control methods after the

hydraulics-related crash of a Japan Airlines jumbo jet in 1985. Another

critical factor was the crew’s preparedness for handling in-flight emer-

gencies. This preparation, referred to as Crew Resource Management

(CRM) training, enabled the crew to communicate effectively, cooper-

ate with one another, and carry out necessary tasks in the face of almost

unimaginable adversity.

CRM training, which was adopted by the airline industry following a

series of potentially avoidable mishaps in the 1970s and 1980s, aimed

to increase the effectiveness of communication among cockpit teams in

emergency situations. Poor communication had been a major factor in

more than 70% of all airline accidents, and teamwork often suffered

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when stress levels were high. Thus, CRM sought to foster a group ap-

proach to problem solving and communication, in stark contrast to the

previously accepted paradigm in which the captain was the unchal-

lenged leader of the flight. According to CRM, in emergency situations,

this kind of inclusive, efficient communication is even more important

than skill in flying the aircraft.

On Flight 232, the superb team interaction and coordination demon-

strated by the crew was a product of CRM training. A case in point was

the discussion that took place among crew members on how to lower

the landing gear in the absence of hydraulic power. Each airman offered

suggestions, which were then discussed by the group, eventually leading

to an agreed-on approach. In another instance, as Dvorak took Fitch’s

place at the controls to land the aircraft, he realized that Fitch was more

proficient at using the throttles. He then suggested that Fitch perform

the landing and returned to his supporting role. According to Haynes,

without this kind of team-oriented approach and open communication,

Flight 232 would likely have been a complete loss.

Effective communication also extended beyond the cockpit door.

The captain reported that communication with the flight attendants

was as good as could be expected while the officers attempted to fly the

damaged aircraft. Flight attendants, in turn, were able to explain the

situation to passengers and provide instructions in preparation for land-

ing. Interaction between the flight crew and Gateway air traffic control

was similarly solid. The radar worker speaking with Flight 232 re-

mained calm throughout the ordeal, lowering the tension level in the

cockpit and helping the crew maintain its composure.

Preparedness for the disaster was not limited to air personnel, how-

ever. Local officials in Sioux City had formed a disaster planning com-

mittee that met each month and held two simulated disasters exercises

every year. In one such exercise, response personnel practiced for the

emergency landing of a DC-10 aircraft at Gateway Airport, although a

DC-10, like United Flight 232, had never landed at the airport before.

Ironically, the exercise was held on the same runway used by the

crippled plane.

United Airlines Flight 232 243

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The airport itself was also well equipped to handle the disaster. Sioux

City Gateway was categorized as a ‘‘Category 6’’ airport according to

National Fire Protection Association standards. This classification,

based on the largest plane scheduled for landings at the airport, re-

quired one less rescue vehicle and half the amount of extinguishing

agent than Gateway kept on hand.

Before Flight 232 had even touched down, local responders issued a

‘‘Level 3 Alert,’’ which indicates that a plane has already crashed. This

allowed early activation of Sioux City’s crash response plan in anticipa-

tion of the emergency landing. As Flight 232 approached, airport re-

sources were prepositioned along the runways, while Sioux City

responders had mobilized to the south, in case the plane fell short of its

target. This preparation allowed firefighters to respond quickly and ef-

fectively, saving many passengers’ lives.

While credit belongs to preparation and training by the crew and

responders, according to Captain Haynes, disaster mitigation also de-

pended on a confluence of events almost as unlikely as the circumstan-

ces that set the episode in motion. For example, the engine failure

took place on the only day of the month in which the 185th Iowa Air

National Guard was on duty, making available 285 additional res-

ponders. The timing of the accident was similarly beneficial in that it

coincided with shift changes at local hospitals. As a result, these hospi-

tals had enough personnel on hand to allow for a doctor and assisting

staff to be assigned to each ambulance as it arrived. Good afternoon

weather, which can be unusual over the Midwest region of the United

States in July, was critical in controlling the aircraft. Finally, the pres-

ence of an off-duty instructor pilot as a passenger on the plane pre-

sented the crew of Flight 232 with an invaluable additional resource

for managing the crisis.

Haynes, Fitch, Records, and Dvorak all suffered varying degrees of in-

jury in the crash, but each returned to work within 11 months of the

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accident. Haynes went on to speak publicly about the accident and the

virtues of CRM training.

In 2003, a large cargo jet departing Baghdad International Airport

was hit by a surface-to-air missile, destroying the plane’s hydraulic sys-

tems. Fortunately, the captain of the aircraft had recently attended one

of Haynes’s lectures and was able to employ Flight 232’s method of

throttle control to land the jet safely.

The crash of Flight 232 also had a direct effect on the future design of

DC-10 hydraulic systems. Following the accident, several fuses were in-

stalled in the tail section of the number three hydraulic line to prevent a

complete loss of hydraulic fluid in the event of an accident. The close

proximity of the three hydraulic lines within the plane’s tail still makes

their simultaneous failure a possibility, however. This was nearly the

case in 2002, when a tire exploded on a DC-10 taking off from San

Salvador, rupturing the first two hydraulic lines and nearly severing the

third.

Researchers at NASA have recently developed Intelligent Flight Con-

trol (IFC), a software system that allows pilots to control aircraft when

conventional controls are partially or completely damaged. The system

registers the pilot’s commands and compares how the plane responds to

the way it should react if all flight controls were normal. By adjusting the

plane’s engines to make its actual response increasingly closer to the

theoretical response, the plane becomes progressively easier for pilots to

maneuver. In simulations, pilots aided by IFC were able to land damaged

aircraft every time, while only 50% of pilots without the software

achieved a similar outcome. The system was successfully tested aboard a

military jet in February 2006 but is not yet available for commercial use.

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