Lessons learned: Flight disaster 401


It is commonly understood that the acronym CRM means managing relationships with customers. However, it has another meaning in the world of aviation, Crew resource management. The work of flying a commercial aircraft from one airport to another can be compared to a project; It has a start date (exit), an end date (arrival) and provides a unique product or service, that is, the safe transport of passengers to their destination. CRM became an important issue and an important discipline in the aviation industry after the fall of the 401 Flight of Eastern Airlines to the Florida Everglades in 1972. The Mayday television show presented a piece about this tragedy recently And I think the lesson learned from the aviation industry is one. which can be applied to the profession of project manager.

Flight 401 flown from JFK to New York in Miami on the night of December 29, 1972. The plane was a Lockheed L1011-Tristar, which was the state of the art at that time. The flight crew was headed by captain, Robert Albin Loft, and included flight engineer Donald Louis Repo and co-driver Albert John Stockstill. In addition to the standard cabin crew, there were Warren Terry, copilot, and Angelo Donadeo, maintenance specialist. These last ones were "without exit" towards Miami. The dead game is an airline jargon to get a free trip to return to your home base. The pilot had 32 years of experience flying by the engineer and the engineer had 25 years of experience. Although the copilot had much less experience than Loft, he had more experience with the L1011 and previous flight experience in the Air Force. This was the team that controlled the cabin.

Flight 401 received the permission of the tower to take off at 9:20 a.m. that night and headed south on Norfolk Virginia, then over Wilmington, North Carolina, and then to the sea during the rest of the flight The aircraft navigation system would take the plane to the "Barricuda Point" on the Atlantic and then start turning west on West Palm Beach and then south to Miami. Shortly after the take-off, Warren Terry decided to move from the cabin to a vacant first-class seat that left Angelo Donadeo the only "cabezal" dead in the cabin. The Stockstill copilot flew the plane while the Loft pilot operated the radio. This was the standard procedure for Eastern and was the way it provided its co-pilots with the flight experience.

Eastern Flight 401 reached Miami airport at 11:20 a.m., behind the 60th national flight. The national aircraft was directed to land on track 9 on the right, leaving track 9 to to the right for the Eastern plane. Just before landing the crew during flight 607 emitted a radio to the tower that had problems with landing on the nose of the plane and had to deploy it manually. They also requested that the airport dispose of fire trucks ready for landing in case they could suffer problems.

When he wanted to fly the flight 401 on the ground a few minutes later, the light from the landing unit of his nose did not light up. Stockstill asked Loft if he wanted to make turns until the problem was resolved. After delivering himself to the control tower, Loft ordered him to circulate. When Stockstill asks how to pull off the landing gear, Loft instructs him to let him down and then press the accelerations to compensate for the additional drag. Loft did it even if Stockstill continued to fly the plane.

The problem light was next to aircraft pilots, but Stockstill could not get to the light because the aircraft was still flying. The tower ordered flight 401 to turn north and west into a course that would take you over the Florida Everglades. The plane reached an altitude of 2,000 feet and then leveled it. Loft ordered Stockstill to put the plane on an autopilot and then try to extract the light bulb so it could be replaced. Stockstill managed to extract the panel that held the light and gave Repo so he could replace the light bulb. Donadeo witnessed this transaction, but says he did not see Repo replace the bulb for a replacement. Repo tries to replace the panel but insert it aside because the light still does not work. Loft orders that Repo visually inspect the landing gear from a small bay below the flight deck to which it is accessed through a trap door. As Repo is disappearing into the "hell hole", Stockstill is now fighting to eliminate the panel without success. The cabin recorder captures the conversation that shows the frustration of Loft for the light that does not work and the rest of the creatures of the crew reveals that no one is serious about the incident at this time. Stockstill still struggles to remove the panel.

At this point, an altitude warning is known on the recorder, but Loft and Stockstill are still completely focused on the light of the gear. His argument completely ignores the warning and focuses on the light, the probability of only burning and its safety that the nose gear has dropped at this time. Repo appears on the trap door and announces that he can not see whether the gear is down or not. Loft directs him to try again. Meanwhile, Stockstill has a hand to the steering yoke, which also controls the altitude of the plane by controlling the angle of the flaps, and one hand on the light-fitting panel. Donadeo testifies when he moves to the bay to help Repo. The recorder Stockstill is listening to Loft saying that something has happened at altitude. The last words of Loft are "Hey, what's up here?"

At this time, flight 401 disappears from the driver's radar screen. A haul of the driver on the plane does not produce any response. The plane had crashed into the Florida Everglades about 18 kilometers west of northwest Miami. He hit the swamp at about 220 miles per hour and slid for 1/3 mile in 5 pieces before finally resting. Of a total of 176 passengers and crew, 103 died in the incident. Due to the rapid response time and the heroic efforts of an operator of aircrafts under the name of Robert Marquis, who went on stage, and the coastal guard was rescued from the reservoir to 73 passengers.

The National Transportation Security Committee (NTSB) is responsible for the investigation of all air incidents. Of course, more attention is paid to accident investigations when lives are lost like the Flight 401 accident and the NTSB provided all of its considerable resources and competencies to withstand this accident. The investigation began at the accident scene and found that the control panel almost completely intact, so that they could determine the exact time of the accident (23: 42 pm), that the panel containing the indicator lights of the nose train was blocked sideways in its receptacle and that the two light bulbs were really burned. From the flight recorder they could determine that the airplane speed was 198 knots when the plane crashed and that the accelerators were in full swing position, which indicated that the crew had He is currently aware of his situation and tried to move forward the plan. The NTSB also had the assistance of Angelo Donadeo who had survived the accident.

Through the cabin recorder, the physical tests and the testimony of Donadeo, the NTSB was able to reconstruct the accident. The plane had approached to land and unload the landing gear. The indicator lights of the nasal gear did not light up, which could mean that the nose gear could not be displayed or the lights worked poorly. The flight tower orders them to change course towards a road above perennials and maintain an altitude of 2,000 feet while Loft orders that Repo visually inspect the landing gear. Good so far Next, Loft tells Stockstill (who has the control of the plane) that the autopilot intervenes. The plane maintains its altitude and descends to 100 meters and maintains this height for 2 minutes. After that, the plan starts a gradual decline. This descent is so gradual that the crew does not notice and after 70 seconds the plane has only lost 250 altitudes. The 250 feet are enough to activate a warning ring that can be clearly heard on the recorder, but cabin crew are ignored, who are totally focused on trying to replace the burning indicator lights.

The speed of descent of the planes, which had begun so slowly, picks up momentum. About 50 seconds longer and the plane goes down below the 101-foot level, which triggers another alarm the crew notes, but at this time the plane goes down at a rate of 50 feet per second. Stockstill responds giving the plane the full accelerator, but the corrective action is too late and the plane crashes.

The autopilot is activated for 2 control panel switches, but it can be deactivated by applying pressure to the control column (or yoke). The NTSB supposed that when Loft went to Repo to tell him to visually inspect the grip of the nose, he accidentally deactivated the autopilot by hitting the column. The autopilot does not take off completely at this point, but will keep any height that you select the pilot in the future or return to the column. The accidental blows against the column account for the new airplane descent.

The NTSB report recommended several technical improvements that could have prevented the tragedy. The visual inspection apparatus of the Bay of Inspection turned out to be too difficult to operate by Repo contributing to confusion in the cabin. The advice recommended a change to the device that made it work by a single person (the pilot had to light a light that was on, there was no evidence that Loft did). The altitude alert system sounds once and causes an orange light to turn on. At an altitude of more than 2,500 feet, this light flashes continuously, below 2500 feet, only blinks once. The advice recommended it to flash continuously at any altitude. The NTSB report pointed to cabin crew-centered attention on burned lights, but did not make any other recommendations at that time. The successive incidents in which a pilot and / or a mistake of the crew brought about a disaster, or near disaster, triggered the creation of Crew Resource Management (CRM) and there was a mini industry to teach pilots to maintain the control of your crew and plane.

At this time, you'll ask "what does everyone have to do with me or any other project manager?" The answer, in a nutshell, is the following: the same lack of attention of the leader that caused the 401 flight to crash may cause a project to crash. Project managers can learn some lessons from this tragedy and use some CRM strategies.

The fact that it stands out above the rest of the tragedy is the focus of the whole crew of the aircraft cabin, including the pilot, in two burned fire bulbs: a total value of $ 12. Cost of the lack of focus when flying the plane: an aircraft of 15 million dollars plus 103 lives. The lesson is clear; the person in charge of the project can not lose focus in the general objectives and objectives of the project due to the failure of a minor task or of what can be delivered. The pilot of an aircraft has overall responsibility for the success of the flight and the safety of passengers and the crew. The person in charge of the project has overall responsibility for the success of the project, although the responsibility rarely extends to personal security. The pilot has the command of the cabin crew and is responsible for assigning tasks to the crew in such a way that the plane arrives safely to its destination. The driver can not afford to lose focus on this responsibility, as the crew struggles to solve a relatively minor technical problem. As it turned out, the landing gear was down and the plane could have landed safely. The crew already knew it, or strongly suspected it because they examined ways to change the light bulbs. If Loft had assigned the replacement of light bulbs to Stockstill or Donadeo (he was in charge of Loft), he could have concentrated on flying the plane and avoiding the disaster.

Project managers must accept the responsibility to achieve the general goals and objectives of the project. This means that when a creation fails, or problems reports are increased, or if a new application does not meet the expectations of performance, we can not be so angry at the time of correcting the situation that we lose sight of global project We must make intelligent use of the resources that are given to us to achieve the objectives of the project. Assign the investigation of the causes of the failure to someone in your team who has the necessary experience and knowledge, and then trust in them to provide them. If you do not have any person on your computer, come to your sponsor and ask for the resource. Do not allow any feeling of responsibility to solve all project problems to distract your main responsibility: overall success of the project.

If you're ever in the possibility of wanting to go down the trenches and get your hands dirty to solve a technical problem that plagues your project, remember the experience of the Robert Loft pilot. Do not skip your interest groups and cede the project by focusing on a $ 12 portion instead of a multi-million dollar project.