Aviation’s worst disaster occurred on March 27, 1977, when two 747s collided on a runway in Tenerife, Canary Islands. Five hundred and eighty-three people were fatally injured in an accident that should not have happened.
The next year, a United DC-8 landed short of the runway near Portland, Ore., out of fuel. Tragically, 10 passengers lost their lives.
Neither accident should have happened because some of the crewmembers knew things were going wrong but could not persuade the captain. Both captains continued in their mistaken belief that things were going fine. Both ended in catastrophe.
On a foggy day in March 1977, KLM Flight 4805 began its takeoff roll on a flight to Amsterdam. The flight engineer and first officer were unsure if they were cleared for takeoff or only to line up on the runway awaiting further clearance. The captain was sure they were cleared for takeoff. He overruled the other two pilots and the big jet began to accelerate. They were not cleared for takeoff because a Pan Am 747 was taxiing on the runway as instructed by the controllers.
As the KLM jet neared flying speed they saw the Pan Am plane in the fog and attempted to fly over it. The airplanes collided, killing all aboard the KLM flight and many on the Pam Am jet. Aviation had just suffered its worst accident.
A little more than a year later, United Flight 173, a DC-8, was flying from Denver to Portland, Ore. As they approached the Portland airport and extended the landing gear, something went wrong. One of the main landing gears malfunctioned, causing the pilots to abort the landing. Once at a safe altitude the pilots attempted to fix the problem. Soon it became apparent there was a chance that the landing gear might not support the airplane on landing and an evacuation might be necessary. After advising the flight attendants to prepare the cabin for a possible evacuation, the captain continued to work with the first officer and flight engineer to resolve the problem. Fuel was becoming an issue.
It took longer than expected to get all the passengers prepared, and the jet consumed fuel at a high rate due to the drag of the extended landing gear and low altitude. The first officer and flight engineer were growing concerned. As the captain methodically checked with the flight attendants on their progress, the first officer and flight engineer again expressed their concern about the amount of fuel remaining. The captain overruled them, finishing the discussion with the flight attendants.
Finally, he asked for a turn toward the airport but there was not enough fuel remaining to make it. The four-engine jet ran out of fuel 6 miles from the airport. Two crewmembers and eight passengers died.
Both accidents had captains overrule other crewmembers with catastrophic consequence. Aviation had to create a way for crewmembers to effectively communicate safety concerns. Crew Resource Management (CRM) was born. The concept of CRM is that everyone is responsible for safety. While the captain is in command, he or she must take into account safety concerns from fellow crewmembers. We began to build better teams flying the airplanes.
In 1989, United Flight 232 had an engine explode, crippling the DC-10. The explosion sent shrapnel through the tail, severing hydraulic lines in all three systems. The jet was uncontrollable. Using CRM, the captain and crew, along with a DC-10 instructor that was flying as a passenger, managed to gain limited control of the badly crippled airliner. They landed in Sioux City, Iowa, destroying the airplane but 185 survived. CRM built the team that flew a nearly unflyable jet.
Today, CRM is a major component of every airline safety program. Every pilot is taught the skills of leadership, followership and effective communication. CRM is a contributor to the lower accident rate we see today.
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John Cox is a retired airline captain with US Airways and runs his own aviation safety consulting company, Safety Operating Systems.