The Accident that Launched Crew Resource Management

First, I will say that there is really no such thing as a "good" airline accident, no matter how few the casualties. However, given the "tombstone mentality" of some aviation regulators, often the only way to get change effected is in response to a fatal accident. In that sense, an accident may have consequences that contribute to safe operations going forward. This does not diminish the tragedy, but it might prevent any lives lost or injuries from being in vain.

In December 1978, United Flight 173, a DC-8 jet, was enroute from New York to Portland, Oregon. Nearing the airport, the landing gear was lowered. The crew felt a thump and a yaw. They noticed that the indicator light for the right main gear was not illuminated.

Rather than attempting to land, the Captain decided to ask for a holding pattern near the airport while the crew diagnosed the problem. For the next hour, the DC-8 flew around the holding pattern.

Virtually all flights on airlines in the U.S. operate under Instrument Flight Rules, or IFR. Among other requirements, aircraft on an IFR flight plan must carry sufficient fuel to their destination, then to their alternate airport, then an additional 45 minutes. Despite this substantial fuel cushion, this crew overran that safety margin.

The voice recorder indicated that there was confusion among the crewmembers about the actual fuel level shortly before the accident. It also showed that the First Officer and Flight Engineer made some efforts to draw the Captain's attention to the fuel state. Unfortunately, they were not able to divert the Captain's attention away from the landing gear problem in time to comprehend the low fuel levels and act.

The aircraft ran out of fuel with not enough time left to glide to an airport. The aircraft impacted a wooded hill at such an angle that it was able to slide along rather than coming to an abrupt stop. Since there was no fuel, there was no fire. Out of a total of 189 passengers, eight were killed, and many injured. Two crewmembers died also.

The National Transportation Safety Board (NTSB) investigated the accident. The probable cause was found to be "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." A contributing factor was "The failure of the other two flight crewmembers either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain."

By the mid-1970s, NASA, the FAA, and the NTSB had begun to recognize that a major contributing factor to many airline accidents was a breakdown in the management of cockpit resources, including hardware, software, and "liveware", or other crewmembers.

Of particular concern were accidents where one crewmember observed a problem developing, but either did not report it to the other crewmembers, or did not draw their attention to the problem forcefully enough. With many pilots being military veterans at that time, there was a reluctance to challenge the commanding officer, or Captain. And Captains did not always welcome crew input concerning the Captain's performance. To say the least.

There were also accidents in which the entire cockpit crew became focused on a single problem, such as a landing gear indicator light, with the result that no one was flying or monitoring the aircraft. The present accident was in that category.

In this accident, we see several of the most common breakdowns in cockpit management. First, the preoccupation of the entire crew on the landing gear problem, violating the age-old maxim of "Aviate, Navigate, Communicate."

In any situation, the first focus has to be on the safety of the aircraft and its continued operation in the air. Then the pilots must focus on navigating the aircraft. Finally, although no less importantly, there must be clear and unambiguous communications between the cockpit crewmembers, the cabin crewmembers, and Air Traffic Control, with each crewmember's inputs and observations taken into account.

It was also apparent that the crew lost Situational Awareness. Situational Awareness can be defined as "the perception of environmental elements and events with respect to time or space, the comprehension of their meaning, and the projection of their status after some variable has changed." This crew demonstrated an almost total lack of Situational Awareness until it was too late.

Government and industry at least reacted quickly to this most preventable of accidents. (The gear was actually down and locked in place. They could have landed safely in Portland.) NASA convened a conference several weeks after the NTSB final report, bringing together representatives of airlines, the manufacturer, and academic experts, many of whom had already been studying various aspects of cockpit management.

The conference was highly successful, resulting in recommendations that became the basis of modern-day Crew Resource Management (first called Cockpit Resource Management.) In addition to the need for good Situational Awareness, one of the most important findings stressed the need for all crewmembers to practice inquiry, advocacy, and assertion in their communications with other crewmembers.

First Officers and Flight Engineers (and Captains) need to speak up (inquiry) if they observe an anomaly that others might not have seen. They need to advocate a recommended course of action to the Captain, in a way that does not challenge his authority (a neat trick with all the ex-military pilots back then.) Finally, if the recommended course of action is not followed or is not understood, these same crewmembers might need to assert their positions to be certain that they are taken seriously.

As an aside, those who are familiar with the Eastern Airlines Flight 401 accident in 1972 might see the same dynamic at work as in this accident. In both cases the crew became fixated on a landing gear indicator and lost their Situational Awareness. Flight 401 did not run out of fuel, but in their somewhat disorganized maneuvering around and under the cockpit, with no one really in charge, the autopilot was somehow disengaged without the crew noticing. By the time they became aware of their mistake, it was too late to recover. The nearly-new L-1011 crashed into the Everglades. 96 of the 163 passengers died.

In more recent times, CRM has played at least some role in the enviable safety record of mainline air carriers. According to the Aviation Safety Network, 2017 was reported to be the safest year in aviation history worldwide, with zero fatal accidents, not counting airliners that were the victims of terrorism.

This safety record has been equaled by no other form of public nor private transportation.

Because of its contributions to the development of Crew Resource Management, and the consequent saving of lives, United Flight 173 has been called one of the most important accidents in aviation history, fortunately with a relatively low loss of life.