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Lessons Learned – The Flight 401 Disaster

The acronym CRM is commonly understood to stand for customer relations management. It has another meaning however in the aviation world, Crew Resource Management. The job of flying a commercial aircraft from one airport to another can be likened to a project; it has a start date (departure), an end date (arrival) and delivers a unique product or service namely the safe transport of the passengers at their destination. CRM became a hot topic and important discipline in the aviation industry after the crash of Eastern Airlines flight 401 in the Florida Everglades in 1972. The television show Mayday aired a piece on this tragedy recently and I think the lesson learned by the aviation industry is one that can be applied to the project management profession.

Flight 401 flew from JFK in New York to Miami the night of December 29th, 1972. The airplane was a Lockheed L1011-Tristar, which as state of the art at that time. The flight crew was led by the Captain, Robert Albin Loft, and included Flight Engineer Donald Louis Repo and Co-pilot Albert John Stockstill. In addition to the standard cabin crew were Warren Terry, a co-pilot, and Angelo Donadeo a maintenance specialist. These latter were “dead-heading” to Miami. Dead-heading is airline slang for hitching a free ride to return to their home base. The pilot had 32 years experience flying for Eastern, and the engineer had 25 years experience. Although the co-pilot had much less experience than Loft, he had more experience with the L1011 and previous flying experience in the air force. This was the team in control of the cabin.

Flight 401 received permission from the tower to take off at 9:20 pm that night and proceeded south over Norfolk Virginia then over Wilmington North Carolina and then out to sea for the rest of the flight. The planes navigation system would bring the plane to “Barricuda point” over the Atlantic and then it would start its turn westward over West Palm Beach and then south to Miami. Shortly after take-off Warren Terry decided to move from the cabin to a vacant seat in first class which left Angelo Donadeo the lone “dead-header” in the cabin. Co-pilot Stockstill flew the plane while pilot Loft operated the radio. This was standard procedure for Eastern and was the way in which it gave its co-pilots flying experience.

Eastern Flight 401 arrived at the Miami airport at about 11:20 pm, behind National airlines flight 607. The National plane was directed to land on runway 9 right leaving runway 9 right for the Eastern plane. Just before landing the crew on flight 607 radioed the tower that they were having trouble with the landing gear in the plane’s nose and were having to deploy it manually. They also asked that the airport have fire trucks ready for their landing in case they should experience trouble.

When it was Flight 401’s turn to land a few minutes later the signal light for their nose landing gear failed to turn on. Stockstill asked Loft if he wanted to circle until the problem was fixed. After conferring with the control tower, Loft instructed him to circle. When Stockstill asks about retracting the landing gear Loft instructs him to leave it down and then pushes on the throttles to compensate for the extra drag. Loft did this even though Stockstill was still flying the plane.

The problem light was located on the co-pilots side of the plane but Stockstill couldn’t reach the light because he was still flying the plane. The tower instructed Flight 401 to turn north and then west on a course that would take them over the Florida Everglades. The plane reached an altitude of 2,000 feet and then leveled out. Loft instructed Stockstill to put the plane on auto-pilot and then try to extract the light bulb so it could be replaced. Stockstill succeeded in extracting the panel holding the light and gave it to Repo so he could replace the bulb. Donadeo witnessed this transaction but says he did not see Repo replace the bulb with a spare. Repo attempts to replace the panel but inserts it sideways so the light is still inoperative. Loft orders Repo to inspect the landing gear visually from a small bay below the flight deck accessed through a trap door. As Repo is disappearing into the “hell hole” Stockstill is now struggling to remove the panel without success. The cockpit recorder captures the conversation which shows Loft’s frustration with the malfunctioning light and the rest of the crew’s laughter reveals that no-one is taking the incident seriously at this point. Stockstill is still struggling to extract the panel.

At this point an altitude warning is heard on the recorder but Loft and Stockstill are still completely focused on the landing gear light. Their discussion totally ignores the warning and focuses on the light, the likelihood it is merely burned out, and their certainty that the nose gear is down at this point. Repo appears through the trap door and announces that he cannot see whether the gear is down or not. Loft directs him to try again. Meanwhile, Stockstill has one hand on the steering yoke, which also controls the altitude of the plane by controlling the angle of the flaps, and one hand on the panel holding the light. Donadeo witnesses this as he moves to the bay to help Repo. Stockstill is heard on the recorder telling Loft that something has happened to the altitude. Loft’s last words are “Hey, what’s happening here?”

At this point, Flight 401 disappears from the controller’s radar screen. A hail from the controller to the airplane produces no answer. The airplane had crashed into the Florida Everglades about 18 miles west north-west of Miami. It hit the swamp at about 220 miles per hour and slid for 1/3 of a mile breaking up into 5 pieces before finally coming to rest. Out of a total 176 passengers and crew, 103 died in the crash. Due to the quick response time and heroic efforts by an airboat operator by the name of Robert Marquis, who happened to be on the scene, and the Coast Guard 73 passengers were rescued from the swamp.

The National Transportation Safety Board (NTSB) is responsible for conducting investigations of all air incidents. Naturally more attention is paid to investigations of crashes where lives are lost like the Flight 401 accident and the NTSB brought all their considerable resources and expertise to bear on this crash. Their investigation began at the crash scene and they found the control panel almost entirely intact so were able to determine the exact time of the crash (11:42 pm), that the panel containing the nose gear indicator lights was jammed sideways in its receptacle and that the two light bulbs were indeed burned out. From the flight recorder they were able to determine that plane speed was 198 knots when the plan crashed and the throttles were in full forward position indicating that the crew had likely become aware of their situation at the last moment and tried to pull the plan up. The NTSB also had the assistance of Angelo Donadeo who had survived the crash.

Through the cockpit recorder, the physical evidence, and Donadeo’s testimony the NTSB were able to reconstruct the accident. The plane had approached for a landing and deployed the landing gear. The indicator lights for the nose gear failed to light which could mean that the nose gear failed to deploy or the lights were malfunctioning. The flight tower orders them to change course to a path over the everglades and maintain an altitude of 2,000 feet while Loft orders Repo to visually inspect the landing gear. Good so far. Next, Loft tells Stockstill (who has control of the plane) to engage the autopilot. The plane maintains its altitude, then drops 100 feet, levels out, and maintains that altitude for 2 minutes. After that the plan starts a gradual descent. This descent is so gradual the crew doesn’t notice and after 70 seconds the plane has only lost 250 of altitude. The 250 feet is sufficient to trigger a warning chime that can be clearly heard on the recorder but is ignored by the cabin crew, who are totally focused on trying to replace the burned out indicator lights.

The planes rate of descent, which had begun so gradually, gathers momentum. A further 50 seconds and the plane descends below the 101 foot level which triggers another alarm which the crew do notice, but by this time the plane is descending at a rate of 50 feet per second. Stockstill responds by giving the plane full throttle but the corrective action is too late and the plane crashes.

The autopilot is engaged by 2 switches on the control panel but can be disengaged by applying pressure on the control column (or yoke). The NTSB surmises that when Loft turned to Repo to tell him to visually inspect the nose gear he accidentally disengaged the autopilot by bumping the column. The autopilot does not become totally disengaged at this point but will maintain whatever altitude the pilot selects by pushing forward or drawing back on the column. Accidental bumps against the column account for the further descent of the plane.

The NTSB report recommended a number of technical improvements which might have prevented the tragedy. The visual inspection apparatus in the inspection bay proved to be too difficult to operate by Repo contributing to confusion in the cabin. The board recommended a change to the apparatus making it operable by one person (the pilot had to switch a light on which was located overhead, there was no evidence Loft did this). The altitude warning system sounds once and then flashes an orange light. At altitudes above 2500 feet this light flashes continuously, below 2500 feet it only flashes once. The board recommended it flash continuously at any altitude. The NTSB report noted the attention focused by the cabin crew on the burned out lights but made no further recommendations at that time. Subsequent incidents where pilot and/or crew error led to disaster, or near disaster, triggered the creation of Crew Resource Management (CRM) and a mini-industry sprang up to teach pilots how to maintain control of their crew and aircraft.

By this time you will be asking yourself “what in the world does all this have to do with me or any other project manager?” The answer, in a nutshell, is this: the same lack of focus by the leader which caused Flight 401 to crash can cause a project to crash. Project managers can learn some lessons from that tragedy and employ some CRM strategies of our own.

The fact that stands out above everything else in this tragedy is the focus of the entire cabin crew of that airplane, including the pilot, on two burned out light bulbs: total value $12. Cost of the lack of focus on flying the plane: a $15M airplane plus 103 lives. The lesson is clear; the project manager cannot lose focus on the overall project goals and objectives because of the failure of a minor task or deliverable. The pilot on an aircraft has overall responsibility for the success of the flight and the safety of the passengers and crew. The project manager has overall responsibility for the success of the project, although the responsibility seldom extends to personal safety. The pilot has command of the cabin crew and is responsible for assigning tasks to that crew in such a way that the airplane reaches its destination safely. The pilot cannot afford to lose focus on that responsibility because the crew is struggling to resolve a relatively minor technical issue. As it turned out, the landing gear was down and the plane could have landed safely. The crew either knew this, or strongly suspected it because they were examining ways of changing the light bulbs. If Loft had assigned the replacement of the bulbs to Stockstill or Donadeo (he was in Loft’s charge) he could have focused on flying the plane and averted the disaster.

Project managers should accept the responsibility of meeting the overall goals and objectives of the project. This means that when a build fails, or trouble reports mount, or a new application doesn’t meet performance expectations we cannot become so bogged down in correcting the situation that we lose sight of the overall project. We must make intelligent use of the resources given to us to meet project objectives. Assign investigation of the causes of the failure to someone on your team who has the necessary experience and knowledge and then trust them to deliver. If you haven’t got such a person on your team, approach your sponsor and ask for the resource. Don’t allow a sense of responsibility for fixing all the problems on your project to detract you from your primary responsibility: overall project success.

If ever you find yourself in the position of wanting to get down in the trenches and get your hands dirty resolving a technical problem that is plaguing your project, remember the experience of pilot Robert Loft. Don’t let your stakeholders down and crash the project by focusing on a $12 part rather than a multi-million dollar project.

Source by Dave Nielsen



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