How to crash an airplane – Nickolas Means | The Lead Developer UK 2016
Summary
TLDR本次演讲回顾了1989年7月19日发生的联合航空232号航班事故,讲述了机组人员如何在飞机失去所有液压系统控制后,通过卓越的团队合作和创造性的解决方案,成功将飞机降落在爱荷华州锡城机场,最终实现了185人幸存的奇迹。这一事件被视为机组资源管理(Cockpit Resource Management)的典范,强调了在紧急情况下,有效的沟通、领导和决策对团队成功的重要性。
Takeaways
- 🛫 飞行事故的教训:通过分析飞机事故,我们可以了解到机组人员如何应对紧急情况,并从中学习到宝贵的经验。
- 🚁 飞机设计的重要性:DC-10型飞机的三重冗余液压系统设计在当时被认为是先进的,但在极端情况下仍可能出现问题。
- 💡 机组人员的团队合作:在面对飞机失去全部液压控制的紧急情况时,机组人员通过有效的沟通和协作,共同应对危机。
- 🛰️ 紧急情况下的创造性解决方案:在没有标准操作程序可遵循的情况下,机组人员通过创新思维和尝试不同的方法来控制飞机。
- 👨✈️ 机组资源管理(CRM)的应用:通过实施CRM,机组人员能够更好地利用每个人的技能和知识,共同解决问题。
- 🤝 权力下放与集体决策:机长Haynes通过放权给其他机组人员,使得团队能够共同参与决策,提高了处理紧急情况的能力。
- 📣 确保每个声音都被听到:在紧急情况下,确保每个人的观点和建议都被考虑,有助于找到最佳解决方案。
- 🚫 避免个人英雄主义:在团队合作中,避免个人英雄主义,鼓励集体合作和共同承担责任。
- 🌐 多元化团队的价值:多元化的团队可以带来不同的观点和专业知识,有助于提高团队解决问题的能力。
- 📈 领导的角色转变:领导者的角色应从单一的决策者转变为确保团队中每个声音都被听到和尊重的协调者。
- 🛎️ 应对紧急情况的准备:通过模拟训练和准备,可以提高机组人员在真实紧急情况下的表现和生存率。
Q & A
飞机失事的原因是什么?
-飞机失事的原因是二号引擎尾部的风扇盘爆炸,导致飞机失去了所有的液压系统,无法正常控制飞行。
风扇盘爆炸后,机组人员是如何尝试控制飞机的?
-风扇盘爆炸后,机组人员首先尝试通过关闭二号引擎的油门和燃油切断来控制飞机,但发现控制杆被卡住。随后,机长Haynes接管了飞机的控制,并尝试通过调整剩余引擎的推力来控制飞机的飞行姿态。
为什么飞机无法使用其液压系统?
-飞机的液压系统因为风扇盘爆炸产生的碎片而被破坏。所有三个液压系统的液压油量和压力都降至零,导致飞机失去了对升降舵、副翼和方向舵的控制能力。
机组人员是如何准备紧急着陆的?
-机组人员通过与空管沟通,请求将飞机引导至最近的合适机场——苏城机场。同时,机组人员通知了乘务长Jann Brown,要求她准备客舱并告知乘客紧急着陆的信号。
Denny Fitch是如何帮助机组人员的?
-Denny Fitch是一位DC-10型飞机的检查飞行员,他在乘客中意识到飞机遇到了严重问题,主动提出帮助。在驾驶舱中,他接管了节流阀的控制,通过调整剩余两个引擎的推力来尝试控制飞机的飞行。
飞机在着陆过程中遇到了哪些困难?
-飞机在着陆过程中因为失去了液压系统,无法使用襟翼和缝翼来降低速度和增加升力。飞机以比正常着陆速度快一倍的速度接近机场,并且以极高的下降速率降落。
飞机最终是如何成功着陆的?
-尽管飞机以极高的速度和下降速率接近机场,但机组人员通过精确地控制剩余引擎的推力,成功地使飞机在苏城机场的一个关闭的跑道上着陆。
飞机失事的生存率是多少?
-在这次飞机失事中,有185人幸存,111人遇难。这是商业航空史上首次在完全失去飞行控制的情况下有乘客幸存的案例。
机组人员的表现如何被评价?
-美国国家运输安全委员会(NTSB)认为,在这种情况下,联合航空232号机组的表现非常值得称赞,远远超出了合理的预期。
机组资源管理(Cockpit Resource Management, CRM)在这次事件中起到了什么作用?
-机组资源管理强调团队合作、沟通、领导和决策。在这次事件中,机组人员通过共享信息、共同决策和有效沟通,成功地将飞机引导至机场并实施紧急着陆。
软件工程领导者能从这次飞机失事中学到什么?
-软件工程领导者可以从中学到团队合作的重要性,避免个人英雄主义,确保每个团队成员都有发言权,以及培养一个包容和鼓励多样性的团队文化。
Outlines
🌟 开场致辞与背景介绍
演讲者在lead dev会议上向听众问好,并表达了与众多杰出演讲者同台的荣幸。他感谢组织者和委员会主席Mary,并简短介绍了自己——Nicolas,Well Match Health的工程副总裁。他提到自己与许多聪明人合作以改善美国医疗系统,并邀请感兴趣的听众与他交流。此外,他还透露了自己对飞机失事的研究兴趣,尽管这听起来有些奇怪。
✈️ 飞机失事的启示
演讲者分享了自己对飞机失事的特殊兴趣,特别是对驾驶舱内发生的事情感兴趣。他讲述了两种类型的飞行事故:一种是小问题由于处理不当而导致的大灾难,另一种是飞行员面对巨大困难时如何取得比预期更好的结果。他强调,他将要讲述的United 232航班的故事属于后者,这是一个在几乎无法克服的困境中拯救了半数以上乘客的故事。
🌤️ 美好的飞行日与突如其来的灾难
演讲者描述了1989年7月19日,一个在丹佛科罗拉多州的美好夏日,以及United 232航班的乘客和机组人员的到来。这架DC-10型飞机是一架老旧但值得骄傲的飞机,已经服役了18年。然而,这次看似平常的飞行在飞行中突然发生了巨大的爆炸声,飞机尾部的二号引擎风扇盘爆炸,导致机组人员必须紧急应对。
🚨 紧急情况与初步应对
爆炸发生后,机组人员迅速做出反应,试图控制飞机。他们发现二号引擎失效,并尝试按照标准程序请求降低高度并继续飞往目的地。然而,他们很快意识到情况比预期的要严重得多,因为飞机的控制系统出现了问题,飞行员无法通过常规方式控制飞机。
🛫 危机中的决策与求生
面对飞机失去全部液压系统的紧急情况,机组人员必须做出快速决策。他们尝试使用飞机的发动机推力来控制飞机的飞行方向和姿态。在此过程中,一名非当班的飞行员Denny Fitch提供了帮助,他是一名DC-10型飞机的检查飞行员,拥有丰富的模拟器训练经验。尽管如此,他们仍然面临着巨大的挑战,因为DC-10型飞机没有为完全失去液压系统的情况设计应急程序。
🌪️ 飞机失控与机组人员的协作
在飞机失控的情况下,机组人员通过协作和创新的方法来控制飞机。他们尝试了各种可能的控制手段,包括使用不同的发动机推力组合来影响飞机的飞行路径。在这个过程中,机组人员之间的沟通和决策变得至关重要。他们必须共同努力,才能有机会将飞机安全降落。
🛬 紧急降落与生存奇迹
在机组人员的共同努力下,飞机最终成功降落在了Sioux City机场。尽管飞机在降落过程中发生了严重的撞击和翻滚,但令人惊讶的是,有185名乘客在这次事故中幸存下来。这次事故成为了航空史上的一个奇迹,也展示了机组人员在极端情况下的卓越表现和团队协作的重要性。
🤝 团队合作的重要性
演讲者强调了团队合作在解决复杂问题中的重要性。他提到了机组资源管理(Cockpit Resource Management)的概念,这是一种强调团队内部沟通、领导和决策的方法。通过分享United 232航班的故事,演讲者说明了在面对挑战时,团队成员之间的相互支持和合作是如何帮助他们克服困难并取得成功的。
Mindmap
Keywords
💡飞行事故
💡飞机控制
💡液压系统
💡紧急情况
💡机组资源管理
💡飞行安全
💡飞行员
💡紧急着陆
💡团队合作
💡事故调查
Highlights
Nicolas Means 分享了作为工程副总裁在健康匹配公司的经历,以及他对于改善美国医疗系统的贡献。
Nicolas Means 表达了他对飞机坠毁案例的研究热情,并分享了他对飞机事故中驾驶舱动态的深入理解。
通过英国航空公司53航班的案例,Means 强调了飞行机组在面对紧急情况时的反应和决策对结果的重大影响。
Means 讲述了联合航空232号航班的故事,这是一个在遭遇几乎无法克服的困境后,成功救出半数以上乘客的案例。
在丹佛科罗拉多州的一个美丽夏日,联合航空232号航班的乘客和机组人员经历了一次意外的飞行。
飞机在飞行中遭遇了二号引擎风扇盘爆炸的灾难,机组人员必须立即作出反应以确保飞机安全。
在飞机失去二号引擎后,机组人员发现他们无法通过常规方法控制飞机,因为所有的液压系统都失效了。
联合航空232号航班的机组人员通过创造性的思维和卓越的团队合作,成功将飞机导向紧急着陆。
在飞机接近机场时,机组人员与空中交通管制的沟通展现了他们在极端情况下的专业性和冷静。
尽管飞机以超过正常速度两倍的速度接近机场,机组人员仍然设法控制飞机进行了紧急着陆。
飞机在着陆时遭遇了严重的撞击,但由于机组人员的英勇努力,大部分乘客得以幸存。
Nicolas Means 强调了机组资源管理在这次成功紧急着陆中的关键作用,以及团队合作的重要性。
通过这次事件,Means 提醒我们,在面对挑战时,我们需要避免个人英雄主义,而是要作为一个团队共同面对。
Means 鼓励软件工程领导者采用类似机组资源管理的方法,确保每个团队成员的声音都能被听到。
在软件工程领域,Means 强调了建立一个每个成员都能够发声并共同解决问题的团队文化的重要性。
Means 通过联合航空232号航班的故事,展示了在危机中卓越的团队合作和领导力如何创造出意想不到的成果。
Transcripts
so good afternoon everybody hope you've enjoyed the first day of lead dev I know
I certainly have it's quite the honor to be able to share this stage with so many
amazing speakers so thank you to the organizers and to Mary the committee
chair and all the speakers with President to us today I like Mary said
my name is Nicolas means I'm VP of engineering at well match health I work
with a lot of really smart people to help make the US healthcare system
better if you want to know more about what I do come talk to me because with a
British audience it's going to be a conversation it's not not something I
can explain from stage but another thing you need to know about me is that I am a
student of plane crashes I know that's a weird thing to say but if you want to if
you want to nerd tonight me come up to me and ask me about a plane crash that I
can't tell you the details about right off the top of my head Joe one of the
members of the conference staff did this to me last night at the speaker's dinner
and so instead of going home to the hotel and rehearsing my talk I went back
and looked up the details of British Airways incident where the windscreen
got sucked out of an airplane and the pilot got sucked out halfway and they
still managed to land and everybody survived it was British Airways flight
53 90 if you want to go look it up yourself but it's not it's not the
morbidity of plane crashes or the spectacle that fascinates me
it's the dynamics of what happens in the cockpit what the flight crew goes
through from when an incident starts to when the plane gets to the ground one
way or the other there's two kinds of ways this go there's some flight crews
that take tiny incidents and through poor reactions or poor decisions take
tiny system bolts and make them in a giant disasters then there's other
incidents where flight crews take giant problems insurmountable obstacles and
somehow managed to eke out a better outcome than they ought to be able to
and the story I want to tell you today is the story of one of the latter it's a
story of a flight crew who takes a plane that's struck with almost insurmountable
peril and manages to save more than half the people on board that's what I think
is one of the most fascinating plane crashes
aviation history the story of United 232
so July 19th 1989 was an absolutely beautiful day in Denver Colorado the
highways summer in the mid-80s scattered clouds there was a wonderful breeze
blowing in off the Front Range of the Rocky Mountains was the kind of day if
you've ever been to Denver in the summer it's the kind of day that just begged
you to go outside and do something go for a hike play around a golf it was
also a wonderful day for flying at Denver's Stapleton International Airport
planes were leaving on time everything was running smoothly and about 10:30 or
11:00 in the morning the first of the 285 passengers and 11
crew members that would eventually be on board United flight 232 started arriving
at the gate their flight that day would take them from Denver staple an airport
to Chicago O'Hare or so they thought when they cross the jet bridge if you
were in the boarding lounge that day you would have seen something like this
through the window it's a bit of an unfamiliar sight to a modern traveler
back in these days it was forbidden for planes to fly extended distances with
only two engines they had to have more redundancy than that so Airlines
invested heavily in what they called tri jets engines that had planes that had
two engines one of the wings and one mounted through the tail and
that's what you had been getting on this day specifically a dc-10 series 10
aircraft tail registration number November 1819 uniform that picture is
the actual plane you had been getting on that day it was an old but proud plane
delivered United in 1971 and had been in service since then for about 18 years
now 18 years seems kind of old for an airliner but it's really not United
would actually fly their dc-10 flight fleet well into its 30s and you can
still see these planes around the world today carrying packages and FedEx
delivery a lot of them are still operating as you got on board you'd have
seen something like this if you've been on board of Boeing triple7 recently this
cabin is just a little bit wider than that it was a wide and roomy cabin was a
quiet plane and pilots love to fly it they referred to it as the Cadillac
Fleetwood of the skies because it was such a comfortable ride and the three
engines gave it way more power than it needed so they loved
love being able to put their hand in the throttles and push them forward for
takeoff and let the power of that plane slam them back in their seats if they
took the skies around to 10:00 in the afternoon that day that's exactly what
happens it was a textbook takeoff out of Denver Stapleton they turn
east-northeast out of the airport toward Chicago and if you'd been in the cabin
at that point you'd have smelled chicken strips United was running a promotion
that summer they called their picnic lunch so if you were flying at lunch
time they would bring you a little basket cover to run white check paper
with picnic lunch in it and that day it happened to be chicken strips a few
Oreos and a cup full of cherries well about an hour into the flight
most people had finished their lunches the flight crew was beginning to pick up
from lunch Jim McKay the legendary American sportscaster from ABC's Wide
World of Sports was about 20 minutes into explaining the history of horse
racing in the in-flight movie jewels of the Triple Crown sounds thrilling I know
and about that point what had become what had been a completely normal flight
up until then suddenly changed there was a tremendous bang at the back of the
airplane passengers thought maybe a bomb had gone off the flight crew across the
plane hit the deck and grabbed the nearest armrest afraid that what they
had heard was an explosive decompression and they might be sucked out of the
plane close neither of those things what had actually happened is the fan disc in
the number two engine the tail mounted engine had exploded
on the flight deck they had just finished their lunches when they heard
this explosion first officer bill records who have been sitting in that
seat on your right there immediately yells I've got it
lunges forward grabs the yoke disabled the autopilot and starts flying the
plane by hand Dudley Dvorak the flight engineer who would have been sitting at
that control console right there on the right
starts checking his gauges and immediately notices the number two
engine is failed so he radios Minneapolis st. Paul air control center
not to declare an emergency but just to ask for clearance to lower altitude but
goes on a dc-10 I mentioned the redundancy of the three engines it
actually wasn't that big a deal to lose an engine with the reliability of these
engines built in the 70s and 80s losing engine wasn't all that uncommon so
standard procedure was just to request a lower altitude slow down a little bit
and continue on to your destination and that's exactly what they intended to do
about this point captain al Haynes who was sitting in the pilot's seat that day
asks for the engine shutdown checklist from from flight engineer Dudley Dvorak
now captain Haynes at this point was primarily concerned with making sure
that whatever happened to this number two engine didn't escalate into a bigger
crisis when engines failed it's possible that it could be catching on fire or
there could be physical damage and you wanted to avoid making the situation any
worse so we asked ugly Dvorak to start in on
the checklist the first thing on the checklist was to close the number of the
number to throttle and so captain Haynes tried to do that and could the wooden
budge the throttle was stuck so he moved on to the second step of the checklist
the second step was to shut off the fuel shutoff to this engine they tried that
as well wouldn't budge and is at this point that they finally understood that
something more than a routine engine failure had befallen their beautiful
plane that day the thing you need to know about the dc-10 is that the
throttle and the fuel shutoff are both physically coupled to the engine via
steel cable if you think about how a bicycle brake works it's the same theory
so the fact that both of those controls were jammed hold the flight crew that
there must be some significant physical damage to the aircraft
so hands into work we're trying to figure out what to do next when bill
records from the copilot seat shouts ow I can't control the plane which is a
terrifying thing to hear so captain Haynes looks over and bill records with
his arms as tense as they could be has the yoke all the way back all the way to
the left there's two things about this that terrifying the first thing is you
would never give an aircraft that kind of input at cruise speed you'd be like
driving down the highway at 85 miles an hour and suddenly jerking the steering
wheel all the way to left you would lose control of the plane if you did that but
even more terrifying than that despite the fact that that records had the yoke
all the way back which would command the plane to go up and all the way to the
left which would command the plane to turn left it was doing the exact
opposite it was descending and rolling to the right so at this point captain
Haynes yells I've got it and takes the controls from Bill records and tries to
see if he can have any effect on the control surfaces of the plane meanwhile
flight engineer Dvorak is still studying his gauges trying to figure out exactly
what's happened to his beautiful plane when he something catches his attention
he glances up from his gauges momentarily out the windscreen of the
aircraft and immediately yells were rolling at this point the plane is about
38 degrees of Bank which is pretty steep for a commercial plane it'd be pretty
uncomfortable if he were back in the passenger cabin and immediately to an
instinct that he still doesn't understand to this day captain Haynes
swats the number one throttle closed opens the number three will throttle all
the way to the firewall wide open and subsequent studies showed subsequent
subsequent simulator exercises showed that in that moment captain Haynes saved
their aircraft because after he did this the point slowly started coming back to
level pushing the number three throttle all the way up and pulling the number
one all the way back increased list on the right wing and pulled it up
counteracted the drag that the failed engine was having on the tail and with
the point now under relative control Dudley Dvorak makes the first
announcement of passengers now something I need to tell you is that this
particular dc-10 only had a 30-minute loop cockpit voice recorder and the
actual accident sequence is about 47 minutes from when the fantasy ruptures
to when the plane gets to the ground in Sioux City
so the first 17 minutes of the crash were really lost to history but
according to accounts from the flight crew and from passengers on board
what Dvorak said when a little something like this Wow waited there there we go
ladies and gentlemen we've lost our tail engine but this aircraft can fly fine
with the two remaining engines we're going to descend and continue on to
Chicago perfectly reassuring thing to say to the the people in the back of the
airplane but almost immediately after making this announcement
Dvorak finally spots the thing in his gauges that he's been looking for so
intently and realizes that they they have a much bigger problem on their
hands and what any of them thought he notices that on his hydraulic gauges
hydraulic quantity and hydraulic pressure across all three hydraulic
systems are at zero so he has no hydraulic pressure and no hydraulic
fluid and that means that he's not going to be able to control the plane so at
this point bill records radios Minneapolis st. Paul air traffic control
and declares emergency this time and asks for a diversion of the closest
suitable Airport and they send into Sioux City Iowa about this point in
flight back in the passenger cabin the overhead chimes ringing in Jann Brown
section Jann Brown is the one there on the far left in the turquoise suit and
she's the head flight attendant on this flight that day she looks around the
cabin she can see the rest of the flight crew nobody has their phone off the hook
she knows it's not anybody in the cabin she knows it must be from the cockpit
and she also knows that getting a call from the cockpit during the cruise
flight there's going to be nothing but bad news sure not Dudley Dvorak asked
her to report to the cockpit and she knows if she's being asked to report to
the cockpit that it's certainly not good news and telling this story later Jan
Brown says my whole world change when I open that door there was no panic but
the sense of crisis was absolutely palpable in here captain Haynes told her
we've lost all of our hydraulics we're having trouble controlling the plane
we're going to try an emergency landing in Sioux City in about 30 minutes so I
need you to prepare the cabin and brief the passengers my signal when we're
about to land will be brace brace brace and I need all the passengers in brace
position at that point Jan I don't know how this thing's going to turn out so
good luck all right so Jan brown mustard and meager thank you and then ducks into
the lavatory to compose herself before making the rounds and briefing all the
flight attendants on the plane and beginning the preparations for this
emergency landing meanwhile captain Haynes ask Dudley Dvorak to look in the
flight manual and find the procedure to handle complete hydraulic loss
the FAA mandates yeah the all our Academy so so the Federal Aviation
Administration in the u.s. mandates that any likely failure modality that's going
to strike an aircraft has to be documented in one of these checklists
you have to have a set of failure procedures for where anything goes wrong
well there's no checklist of course there's not because nobody ever expected
a dc-10 to lose all of its hydraulics and it's at this point that Minneapolis
st. Paul Center finally hands the flight over to Sioux City Iowa and captain
Haynes makes this initial contact with the tower in Sioux City ok so you know
we have all our social abilities very little elevators and also not we're all
experienced by power I mean we can only penetrate every level today and 232
heavy understand sir you can only make right turns of the hood
sounds fun done it so you to understand what Catholic means of saying there you
need to know a little bit about how airplanes are controlled he says we have
very little elevator and almost no aileron so the elevator is the control
surfaces here on the horizontal stabilizer at the back of the plane and
that controls the planes movement up and down so in saying they have no elevator
he's saying they have no ability to control their altitude
he also says they have no ailerons now ailerons are these surfaces on the back
of the wing that control roll going into turns they would use the smaller inboard
ailerons at high speed cruise and the larger outboard ailerons when they were
going slower close to the ground they had neither set so they couldn't control
the altitude of the plane they can control the roll of the plane he doesn't
say it but they don't have any rudder either so they can't control it they
can't even control the off the plane they're literally only controlling the
plane by the thrust from the two engines
well shortly after this exchange with air traffic control Jan Brown has
composed herself and she's making her way back through the first-class section
and she's briefed Jan Murray who's in the pink there on the left with her arm
in a sling and Jan Murray begins walking through the first-class cabin picking up
leftovers from lunch and starting the emergency preparations for landing when
Denny Fitch is on your right there gets her attention now Denny is another
United Airlines dc-10 pilot and he's commuting home from Denver to Chicago he
likes to say about himself that he has a radar for people in distress and that
Jan Murray was clearly in distress so he gets her attention and he says Jan don't
worry about this this thing flies fine on two engines we simply have to get to
lower altitude Jan Murray leans down so as to not be heard by overpass other
passengers and says oh no Denny the pilot and co-pilot are flat trying to
fly the plane that they've told us we've lost all our hydraulics well as a dc-10
captain Denny Fitch knows there's no way that's true
because in addition to being a dc-10 captain Danny Finch's a dc-10 check
pilot and he actually spends his days in Denver at United Airlines flight
simulation center torturing other pilots through full motion flight simulators
he's literally been through every emergency scenario that they expect to
occur on a dc-10 he's taken pilots to it to see how they react and he's never
heard of a dc-10 losing all of its hydraulics so he tells Dan Murray would
you please go let the captain know that he has a dc-10 check pilot riding back
here and I'd be happy to come up and offer any assistance that I could well
captain Haynes upon hearing this readily agrees hoping that this dc-10 check
pilot will have some magic incantation or know about some secret switch that
will fix their plane and give them control but when Fitch gets for the
cockpit he looks over Dudley Dvorak shoulder at the gauges he sees no
hydraulic quantity no hydraulic pressure he checks the busbars to make sure
there's not an electrical fault that might explain loss of flight
instrumentation there's not he knows he's never seen anything like this he
says at that point the only question I had was how long was going to take Iowa
to hit me so I've alluded to this several times but losing all hydraulics
in a dc-10 was considered an impossibility the reason for that is the
dc-10 is built with three redundant hydraulic systems one powered by each
engine and each control surface on the plane was controllable by at least two
of those hydraulic systems once more the dc-10 was one of the first generation of
aircraft along with the Boeing 747 Milwaukee 1011 Tristar that had no
manual reversion and what that means is if you're flying on say a Boeing 737 a
smaller plane you lose all your hydraulics the flight crew can still
wrestle the yokes and get some response out of the flight control surfaces be
like going down the highway and losing your power steering you can still steer
the car it's just going to be a lot more work not on the dc-10 the control
surfaces are so large and the forces acting on them are so strong that it
would be of no use to provide manual reversion you
can only move the flight control surfaces if you have hydraulic systems
so without any of their three hydraulic systems the research that had been done
indicated that one of two things would happen one the plane would go into an
uncontrollable flutter and fall of the earth like a leaf or like this plane had
tried to do it would roll over on its back and go into a descent so fast that
it would actually tear the wings off the plane before it ever got to the ground
but neither of those things happened United 232 stayed in the air at this
point since Denny Fitch didn't have any magic fixes captain Haynes asked them to
take over the throttles because it was much easier for someone to kneel down
between the two seats and control the throttles at the same time than for him
and Bill records to control the number one and number three independently and
try to coordinate their actions
meanwhile captain Haynes radios Sioux City again to reiterate the darkness of
their condition we have no hydraulic fluid which we have no elevator control
almost done and under the later on control I have serious doubts about like
a shear force it just got to some places here there that we might be all the
ditch and I don't get to throw it if I want to put it down wherever it happens
to be and then in the air traffic control audio there's this really
uncomfortable pause for Kevin Bachman tries to figure out what in the world to
tell this flight crew and he comes back with a really strong answer united 232
heavy registers pick up a road or something up there
Brooke let's go up anywhere from 2,000 feet up 15 her downhill waves
ha John can you pick up a road thanks Captain Obvious so in that bit of audio
you can hear one of the things that the flight crew is fighting about this plane
and it's called foo Boyd oscillation it's actually one of the default flight
modes of an aircraft no flight control services what happens is plane without
flight control surfaces will immediately dip into
dive and slowly it'll build air speed over the wings which will build lift and
the plane will return to an ascent and it will go up for a little bit until it
loses airspeed until it loses lift on the wings and start to descend again the
plane is trying to find equilibrium between the lift on the wings and the
gravity acting on the plane if you throw a paper airplane off of a
tall enough building you'll see it do exactly the same thing it'll flutter to
the ground going up and down at a food-grade oscillation all the way to
the ground but captain Haynes gets a crucial fact wrong in this call to Sioux
City tower he said that they were going up 2,000 feet and down 1,500 in each
wave those numbers are backwards flight 232 was actually losing about 500 feet
of altitude for every food boyd cycle that they went through you can see it
when I add that dotted line so captain captain Fitch is sitting there with the
throttles you've already heard that the plane wants to turn right so he's trying
to mitigate the plane's tendency to turn right in addition to that with just the
two throttles he has to mitigate the tendency of the plane to go into these
food oscillations try to get it to fly level because if they can't control the
fugu fugu it oscillations they have no chance of getting this thing to the
ground they will fuga way to oscillate their way straight into the earth you
can hear how well this is going in the next air traffic control transmission
with your forces now jump up and down here in at 232 I have assisted airports
about 12 o'clock and three six past okay we're time to go update I have my
club we're trying to go straight but we're not having much luck Denny Fitch
is getting the food oscillations under control but he's not having much luck
with the right turns if I show you the radar track of the flight you can see
what I'm talking about
so you can see the plane enters this chart at the bottom and it's going up
and it enters a turn towards Chicago and right at that triangle in the upper
right corner is where the fan disc on the number two engine fails and after it
fails the plane enters into a very wide sweeping turn and about the bottom of
that turn is where Denny Fitch takes over control of the plane and you see it
wanders a little bit as he tries as he figures out how to control the turning
but then as he starts to work to figure out how to control the food wide
oscillations they go into a series of very sharp right-hand turns this would
actually prove to be fortuitous because it's the only thing that allowed them
enough time to descend and to be able to land in Sioux City about this point Jann
Brown is walking from the back of the plane when a passenger told her to take
a look at the rear stabilizer this passenger had seen a big piece of metal
sticking up out the window so she looks sure enough she can see it she goes to
the cockpit she tells Dudley Dvorak the same thing
and Dvorak comes back to take a look there's a picture of this flight taken
from the ground as its approaching Sioux City Airport that you can see exactly
what they were seeing if you look closely at that rear stabilizer you can
see there's some places where daylight is peeking through where it shouldn't be
if I put a normal dc-10 tail next to it you can see a little bit more clearly
specifically this holes punched in the rear stabilizer it's missing the exhaust
exhaust cone on the engine and the plane is missing its tail cone
there's actually 70 separate pieces of shrapnel that pierced the tail section
of this plane and they all came from this an object they found in a cornfield
in Alta Iowa about three months after the crash they didn't find it intact so
you can see on the right of this disk there's clearly a crack they actually
found the two halves of the disc in separate places and they found each of
those fan blades in a separate place this had completely separated what
you're looking at here is the front intake fan of the GE CF six six turbofan
engine that powered the dc-10 if you look at an aircraft sitting on the
tarmac at any Airport and you see the fan in the front of the engine this is
that fan you can see that there's a containment ring around it but that
containment ring is designed only to contain the weight of one of those fan
blades letting go those fan blades weigh about two pounds apiece the fan disc
about 350 so there was absolutely no chance to that containment ring was
going to contain this fan disc and if you look at the placement of the engine
in the tail of a dc-10 you can see it's perfectly mounted to cause a ton of
damage to that rear stabilizer not intentionally that's where it needs to
be mounted for the aerodynamics of the plane for that engine to be efficient
but when this fan disc failed and was uncontrolled all of that fan disc went
flying through the tail of the aircraft the reason that's important is because
the tail of a dc-10 is the one place in the entire plane where all three
redundant hydraulic systems come together of course it is so when they
lost the number two engine they lost the number two hydraulic system because the
number two hydraulic pump is attached to that engine the shrapnel knocked out the
number one and number three hydraulic systems immediately after the explosion
some of the passengers on the plane reported hearing a siren like sound what
they were actually hearing was the hydraulic pumps attached to engine
number one and engine number three working as hard as they could to bring
the hydraulic system back up to pressure but actually pumping every last bit of
hydraulic fluid they had overboard
well while Dudley Dvorak is at the back of the plane looking at the stabilizer
damaged Denny Fitch finally pulls off something that they had thought was
impossible up to that point he makes a left turn this is the only left turn the
plane was going to make all day that date it was a crucial left turn they had
to turn left in order to get pointed back towards Sioux City Airport if they
missed their approach to Sioux City there was another airport anywhere
within range that they would be able to make it to so they desperately wanted to
get to Sioux City in order to attempt the landing and in congratulations
immediately after they make this left-hand turn
Kevin Bachman Bachman radios them with this in a 230 mm after one out just
slightly to your left sir tonight the trying to final and also I'll take you
away from the city whatever you do with your public money can you widen out a
little bit to the left do that do that impossible thing again for us but you
can hear the desperation and captain Haynes is voiced there he's still not
very hopeful of their journey of this day the crews still fighting to suppress
the fuga way to keep the plane lined up with the airport they're working as hard
as they can to try to bring this plane to Sioux City Iowa and you can hear the
relief in captain Haynes voice when they finally spot the airport united 232
heavy roger and a dust at the airport today the runway in sight we'll be with
you very shortly thanks a lot your help sounds pretty
really finally has a little bit of hope a few minutes later Kevin Bachman calls
back with their landing clearance which is probably my favorite air traffic
control exchange in this whole sequence k9 232 heavy the West currently 361 1
360 11 you're cleared to land on any red line you want to be bigger than I get
around Lee
so in the midst of this crazy incident I don't this is Pilate gallows humor or if
it's him actually being this controlled but he has to wear with all the crack
that's a joke with air traffic control about landing on any runway well it
turns out they actually do get lined up with the runway but it's a runway that's
been closed since World War two and it happens to have all of the emergency
equipment sitting on it and there is a runway it's closed sir that could
probably work to the south it runs a northeast to southwest pretty well lined
up on this one I think we will be fine
united 232 heavy a Roger sir that's a closed runway that'll work so we're
getting equipment off the runway and a line up for that one is it 6 to 600 feet
six thousand six hundred and the equipment's coming off so they get lined
up to runway it's a closed world war two runway it's not in great shape all the
emergency equipments on it they're in there five mile final at this point so
they're really close to the airport when they're having to scramble all of this
emergency equipment off of this closed runway to other places on the airport
now their emergency planning procedures called for them to be on this runway
because it was in proximity to the other runways at the airport it was a
convenient place to respond from so they had to try to figure out how to get out
of the way of this plane that they had no way of predicting where it was going
to go shortly after this Haines gives the
brace brace brace command and the flight attendants begin shouting brace in
unison over and over again a couple of passengers stick their head up to look
out the window to see how close they are to the ground and the flight attendants
immediately I'll get your head down
and as 232 lined up the tower got excited they were actually lined up with
a runway they were going to make the airport
Kevin Bachman at one point stood up and scream they're going to make it but then
people started noticing that 232 wasn't floating like arriving airliners
normally appeared to do it's coming in very fast
and the reason for that is because without hydraulics they had no slats or
flaps slats our flight control surfaces on the front of the wing and flaps
around the back of the wing and they extend them when the plane is flying
slow because it gives the wing more lift the plane needs that extra wing surface
when it's flying slow low to the ground in order to have enough lift to not
stall without slats or flaps if they slow down for landing they're literally
going to stall out of the skies they're not going to have enough airspeed to
make it to the ground so as a result of this 232 that day was traveling at 250
miles an hour as it came in for landing normal speed
for a dc-10 about 125 so going twice as fast as they ought to be going the sync
rate of the plane is even more alarming they're descending at 1,800 feet per
minute now the structural integrity of the landing gear was rated for 600 feet
per minute but that would have been the hardest landing you've ever experienced
a normal landing at a dc-10 was 200 to 300 feet per minute so they are
absolutely plummeting out of the sky a few minutes before they hit the ground
you can hear the ground proximity warning system tell them to pull up that
their planes in danger and captain Haynes says our luck ran out about 50
feet above the runway the plane went into one last goo-goo-eyed oscillation
and the wing dipped right right as they got to the ground and they made first
contact with the right engine may sell and it spun the plane around the impact
was hard enough that it knocked the number of the damaged number 2 engine
completely out of its mount and without that weight in the tail of the plane the
lift of the rear horizontal stabilizer was enough to pull the back of the plane
up and over in a cartwheel down the runway because of the 30 minutes advance
noticed that they had that this plane was going to crash there actually is
news footage of this plane coming in and crashing and I do have that video I'm
going to show it now I will warn you if you're squeamish you might want not want
to watch there is a good bit of fire and smoke so you can see how fast that plane
is coming in it's not floating it's coming in really quick
and somewhere behind these trees and buildings
that right wing makes the first contact with the ground and you can see it come
sliding through with fire and smoke about here you see the rear come and
cartwheel over and it continues sliding down the runway with the jet fuel
leaking out of the tanks they had they ditched as much fuel as they could but
they had to have enough to get to the ground and you can see what's remaining
in the plane catching on fire with that acrid black smoke that's rising up from
the wreckage here's the crash site they slid across the airport and ended up in
a field of soybeans that patch of concrete sits at an angle at the top of
the screen is the closed world war two runway runway 22 the plane actually hit
hard enough that it drug a six-foot ditch in that runway with its landing
gear just tore the concrete right out of the ground
Kevin Bachman at this point left the control tower to weep because he had
just watched the crash and he knew everybody had died because how could
anybody live through that but his rescuers arrived at the plane a strange
things started to happen people started to emerge from the wreckage some of them
without a scratch there's a story of one passenger who was walking away from the
plane seemingly on her turned around walked back to the wreckage got his
suitcase and they would later find him in the airport bar drinking a glass of
whiskey so 232 was still absolutely a tragedy 111 people died that day but of
296 people on board a hundred and eighty five of them survived now there's a bit
of context I need to give you so you can understand the significance of that 185
number up until this point in the previous 25 years of commercial aviation
no one had ever survived the complete loss of flight controls of an airliner
nobody 185 survived this day the National Transportation Safety Board is
the the US government body that investigates plane crashes
there's a telling line in their report as well they say the Safety Board
believes that under the circumstances the United flight crew performance was
highly commendable and greatly exceeded reasonable expectations reasonable
expectations this day would have been nobody surviving the NTSB in the process
of developing their report did extensive simulator exercises they configured
dc-10s and simulators for exactly the flight conditions at 232 fat-faced that
day very few flight crews they put through
the simulator exercise got the plane anywhere close to the airport nobody was
successful as this crew it's how they do it what made this flight crew different
let me let captain Haynes tell you himself
in a speech that he gave at NASA's Ames Research Facility the preparation that
paid off for the crew was something that United Airlines started in 1980 called
cockpit resource management up until 1980 we kind of worked on the concept
that the captain was the the authority of the aircraft whatever he said goes
and we've lost a few airplanes because of that we had 103 years of flying
experience up there in the cockpit trying to get that airplane on the
ground not one minute of which we had actually practiced any one of us so why
would I know more about getting that airplane on the ground under those
conditions than the other three so if I had not used CLR if we had not let
everybody put their input in it's essentially wouldn't emit so what
captain Haynes is talking about there is modernly referred to as crew or cockpit
resource management and it's focused on the human dynamics of the cockpit a
United 232 is actually considered one of the first big success cases of crew
resource management it's focused on interpersonal communication leadership
and decision-making it's actually based on research that was done by NASA's Ames
Research Center so it's interesting that that's where he was giving this the
speech there were a couple of crashes were stubborn captain's not listening to
their flight crews had caused tiny problems turn into big disasters one of
the most notable was United flight 173 that cry
outside of Portland Oregon and what the crew was facing that day was an
indicator indicator that told them that one of their landing gear was not down
now it turned out their gear was down the whole time it was a faulty switch in
the wheel well but they spent so much time flying around trying to
troubleshoot the problem and despite the urgings of the copilot and the flight
engineer that they were about out of fuel and they should return to the
airport they crashed four miles short of the airport because the captain wouldn't
listen he was insistent there was landing your problem and they needed to
fix it there's a couple of tenets of crew resource management that are very
relevant to how we spend our days as software engineering leaders first of
which is no heroes see cockpit resource management emphasizes cooperation over
heroics one of the things that struck me as I was doing the research for this
talk is captain Haynes deliberately uses the word we' when he's talking about the
sequence of events he says things like we were at 38 degrees of bank and
increasing so we closed the number-1 throttle and firewall the number three
now he uses the word we there to talk about the moment that he captain Haynes
saved flight 232 he lets Denny Fitch stay on the throttles long after it's
obvious that that's all that's controlling the plane it'd have been
really easy for him to go okay this is the only control we got then he get out
of the way it's my ship but instead he recognized that Dennis Fitch had been
sitting at the throttle long enough and had developed that rhythm I had
developed an intuitive understanding of how the airplane was operating under
these conditions and that it was best to let Denny Fitch continue to do that job
rather than him asserting his authority as the captain of the plane now do we do
that as soccer leaders we need to encourage our teams to work together to
find solutions to hard problems and we need to sell like celebrate success as a
team and learn from failure as a team as well we shouldn't look for individual
heroes and individual scapegoats we should live as a team and die as a team
one of the best ways to do that is to make sure that everyone has a voice you
heard captain Haynes say it if everyone on the plane hadn't had input it's a
cinch we wouldn't have made it it's an obvious clear connection to Soph
or teams here as leaders we desperately have to avoid allowing our teams to
develop dominant voices we especially have to make sure those dominant voices
are in our own because it's really easy to get into that cycle it's really easy
to forget as either an explicit or implicit leader on your team the weight
that your comments have you can guide your team's effectively because of the
authority that your voice carries but it's a double-edged sword you can also
create conditions where you're the only voice that's guiding your team and other
people are afraid to have input this is especially true with new engineers you
need to give new engineers space to develop their identity and software to
assert their their growing authority and to make the mistakes they need to make
to learn and grow if there's only one dominant voice and it's constantly
correcting new engineers on the team they're never going to make the mistakes
that they need to make in order to learn the lessons they have to learn it's also
essential if you're building a diverse team and you absolutely should be
because of the diversity of perspective and expertise that it brings to your
team but if you allow dominant voices to take over the conversation of your teams
you'll find it very hard to subtract and keep diverse talent on your team because
voices that are used to being marginalized will pick up on that
pattern very quickly and they won't hang around to give you the benefit of the
doubt and see how it's going to turn out so if you want to build diversity on
your teams you have to make sure that everybody on your team has a voice you
have to cultivate that team culture what are the interesting things about cockpit
resource management is that the captain is still the captain every decision
that's made in the cockpit still comes down to him so as a team lead you do
still have authority but in cockpit resource management the captain's job is
to ensure that he uses his authority to make sure that every voice on the
cockpit is heard everybody has input that he's heard every idea available
without that it's really doubtful that this crew could have gotten this outcome
out of United flight 232 they wouldn't have made it to Sioux City Airport they
wouldn't have gotten to the first responders who got every survivor to the
hospital in under 45 min they would have been crashed in the
middle of a cornfield somewhere in Iowa and it would've taken the response much
longer and the outcome that they would have been far different so remember that
software is a team sport building software takes technical skill but
building the right software takes human interaction and lots of it so make sure
you're building that kind of culture on your team a lot of our teams tend to
look like those flight crews that brought planes down let's work together
to look more like the crew of flight 232 if we do that if we focus on building
that kind of culture on our teams we will do amazing things together thank
you
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