United Airlines Flight 173
| United Airlines Flight 173 | |
|---|---|
 A United Airlines DC-8 similar to the one involved in the accident |
|
| Accident summary | |
| Accident type | Crash due to lack of fuel |
| place | 7 miles southeast of Portland Airport |
| date | December 28, 1978 |
| Fatalities | Crew: 2, passengers: 8 |
| Survivors | 179 |
| Injured | 23 |
| Aircraft | |
| Aircraft type | Douglas DC-8-61 |
| operator | United Airlines |
| Mark | N8082U |
| Departure airport | New York JFK Airport |
| Stopover | Denver-Stapleton Airport |
| Destination airport | Portland (Oregon) airport |
| Passengers | 181 |
| crew | 8th |
| Lists of aviation accidents | |
On the United Airlines flight 173 , which led from New York JFK Airport via Denver-Stapleton , Colorado to Portland, Oregon , the Douglas DC-8 used here crashed on December 28, 1978 near Portland . The accident was triggered by a lack of fuel, the cause of which was due to an inadequate division of tasks or cooperation between the crew ( Crew Resource Management ).
Flight history
The flight crew consisted of experienced people. Flight Captain Malburn McBroom (52 years old), First Officer Rodrick 'Rod' Beebe (45) and Flight Engineer Forrest Mendenhall (41). McBroom had been with United Airlines for 27 years and was one of the company's most experienced pilots with 27,600 flight hours. He also spent about 5500 hours as a captain on the DC-8. Beebe had been with United for 13 years and had more than 5,200 flight hours behind her. The flight engineer had 11 years of service and over 2500 flight hours.
The plane took off from Denver at 2:47 p.m. with 189 people. The calculated flight time was 2 hours and 26 minutes and the landing in Portland was scheduled for 17:13. According to the flight plan, the minimum amount of fuel required for the flight was 14,470 kg; in fact, at 21,183 kg, the aircraft actually had significantly more fuel in its tanks than it left the gate in Denver.
Two of the crew members were killed, flight engineer Mendenhall and flight attendant Joan Wheeler. Another two were seriously injured and four were not injured or only slightly injured. Eight passengers died, 21 were seriously injured, and 152 had either no or minor injuries. Fortunately, the 304th Air Rescue and Salvage Squadron of the Air Force Reserve was at Portland Airport and was conducting routine training flights when the accident occurred. HH-1H helicopters were dispatched immediately to the site of the crash and transported many of the survivors to nearby hospitals.
Accident investigation
The investigation by the National Transportation Safety Board (NTSB) revealed that a loud thump was heard when the landing gear was extended at around 5:10 p.m. on the approach to the destination Portland International airport. This unusual noise was followed by vibrations and movements around the vertical axis . The mechanism for retracting the right main landing gear was defective due to corrosion and allowed this landing gear to fall down unhindered. (This freefall of the landing gear is not a problem in itself, because the freefall is intentionally triggered if the extension mechanism is defective .) The landing gear was now extended and locked, but the violent freefall damaged the sensor, which confirms the correct extension of the landing gear in the cockpit . These unusual phenomena - vibrations, the loud thud, the non-glowing green light for the right landing gear - induced the crew to abort the approach and investigate this problem. This also gave time to prepare the crew and passengers for an emergency landing. The consultations with Douglas engineers and the tower about possible causes and measures to remedy the landing gear malfunction dragged on until 18:15, when the crew finally realized that a landing was inevitable due to a lack of fuel. On the approach, however, several engines failed, so that the aircraft was no longer able to reach the runway and crashed into a wooded area on the outskirts of Portland. Particularly in this situation it is noteworthy that an extended landing gear increases the air resistance of the aircraft and therefore an equally increased fuel consumption must be expected.
From the investigation report:
The Safety Board believes that this accident exemplifies a recurring problem - a breakdown in cockpit management and teamwork during a situation involving malfunctions of aircraft systems in flight ... Therefore, the Safety Board can only conclude that the flight crew failed to relate the fuel remaining and the rate of fuel flow to the time and distance from the airport, because their attention was directed almost entirely toward diagnosing the landing gear problem.
Translation:
The investigating authority believes this accident exemplifies a recurring problem - a breakdown in crew management and in-flight cooperation in conditions characterized by disruption. The investigating authority therefore came to the conclusion that the crew failed to take into account the amount of fuel still available and the fuel consumption in connection with the remaining flight time and flight distance to the airport. The reason for this was that the attention of the crew was almost exclusively devoted to the chassis problem.
The causal cause of the accident according to the report 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 crewmember's 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.
The NTSB considers the likely cause of the accident to be: The master's failure to observe the fuel condition and to react appropriately to the low fuel level and to the advice of the other crew members regarding the fuel condition. This resulted in a lack of fuel in all engines. This inattention arose because the master was absorbed in the malfunction of the landing gear and the preparation for a possible emergency landing.
It was recognized as contributing causes that two other crew members failed either to assess the dangerousness of the fuel condition or to successfully inform the master about this fuel condition.
The cockpit crew was at least partially aware of the situation with regard to the kerosene - this is confirmed by the sound recordings of the flight data recorder.
The NTSB recommended to the Federal Aviation Administration (FAA) :
Issuing a bulletin […] to ensure that crews are trained in cockpit resource management, with particular emphasis on the benefits of engaging for captains and assertiveness training for other cockpit crew members.
With these words, the NTSB recommended that captains involve other crew members in the decision-making process and that other crew members should better assert themselves if they consider a condition to be dangerous.
consequences
This recommendation by the NTSB regarding crew resource management was the starting signal for far-reaching changes in the training of crew members. Just a few weeks after the accident report was published, NASA held a joint conference of aeronautical experts to discuss the potential benefits of resource management.
The introduction of what is known as Crew Resource Management (CRM) was a success story. United Airlines began such training programs in 1981, and today CRM-based training is standard worldwide.
Responsible for the accident was Captain McBroom, who lost his license and withdrew from United Airlines. He died on October 9, 2004 at the age of 77.
Similar accidents
A similar incident occurred in 1963, when a Tu-124 of Aeroflot on the Neva in Leningrad notwasserte. The reason for this was that the pilots wanted to solve a landing gear problem while they were circling near Pulkovo Airport for two hours and also ignored the fuel consumption. In this accident, however, all 52 passengers and crew members survived.
Other similar accidents:
- Eastern Air Lines flight 401 : A control lamp in the cockpit was defective and incorrectly indicated a problem with the nose landing gear. Inadvertently, the autopilot was deactivated, and the crew ignored the steady descent - until the plane hit the Everglades swamps.
- Scandinavian Airlines System Flight 933 : In 1969, a DC-8 crashed over the ocean while approaching Los Angeles . A defective nose landing gear indicator light and the request from air traffic control to significantly reduce the speed on the landing approach contributed to this. This was made more complicated by the fact that the landing flaps must be fully extended for a minimum flight speed, which in turn is only possible when the landing gear is extended. Due to the lack of division of tasks in the cockpit, nobody paid any attention to the dwindling altitude.
swell
- Accident Report DC-8-61 N8082U , Aviation Safety Network (English), accessed July 27, 2020.
- ↑ a b c d e accident investigation report: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR79-07.pdf , accessed on September 27, 2014
- ↑ Accident report on www.airdisaster.com ( Memento of the original from March 4, 2009 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ^ Cooper, White & Lauber (editors, 1980): Resource Management on the Flightdeck: Proceedings of a NASA / Industry Workshop (NASA CP-2120).
Coordinates: 45 ° 31 ′ 21 ″ N , 122 ° 29 ′ 59 ″ W.