Lessons from Christmastime plane crash still save lives today
The pilot got so caught up in trying to figure out what was wrong with the landing gear, the plane ran out of fuel — while the flight crew bit their tongues for fear of being insubordinate. A new crew management system was the response.
By Finn J.D. John — December 24, 2017
It was well after dark — 6:15 p.m. on a Thursday night, three days after Christmas in 1978, in a quiet suburban neighborhood of southeast Portland. Theresa Salisbury was having supper with her two-year-old daughter in their home, located on Burnside Street near 157th Avenue, when the ground shook.
“My windows shaked and rattled,” Salisbury told the Portland Oregonian’s reporter. “The door flew open. So I grabbed my kid and ran to the back of the house. When I didn’t hear anything else I walked out to the front. I couldn’t see the house across the street because of all this blue smoke. It was choking me. When I walked outside, the house next door was completely flattened.”
The third-worst commercial airplane crash in Oregon history had just happened — right outside Salisbury’s dining-room window.
Soon Salisbury’s quiet neighborhood was alive with emergency responders, curious locals, and dazed-looking crash survivors. The nearby Community Free Will Baptist Church was quickly set up to treat survivors, and the Red Cross put the call out for blood donations; two hours later, several hundred people had put their dinner forks down and hurried in to give a pint.
And nearly everyone on the scene echoed the same thought: A fully-loaded airliner, with 189 people on board, had crashed in the midst of Oregon’s largest city. Yet although there were some people badly hurt, and 10 deaths, the vast majority of passengers and crew, along with everyone on the ground, was uninjured. All in all, were it not for the deaths of those unlucky 10, the crash would have been something of a Christmas miracle.
United Flight 173 was a McDonnell-Douglas DC-8-61, a stretched version of the four-engine jet airliner that was McDonnell-Douglas’ answer to the Boeing 707. The flight had started out in New York City earlier that night, and following a stopover at Denver, it was scheduled to land at PDX, its journey’s end, at 5:13 p.m.
And all was going completely according to plan until just before the scheduled landing, when the landing gear was lowered.
When that was done, something went wrong with the right main landing gear, and instead of lowering into place in a controlled fashion, it dropped into place with a boom that shook the airplane. The impact destroyed the sender that lit the “landing gear locked in place” light on the dashboard. The crew, flying around the landing strip, had no way of knowing if the gear was locked in place or not, and was faced with the possibility that it would collapse when they tried to land the plane on it.
The pilot in command of the plane, Capt. Melburn McBroom, got permission to spend a little time circling the airport to try to diagnose the problem and give the stewardesses time to prepare the passengers for a possible rough landing. And for the next hour or so, the big bird flew a pattern around the airport while the crew tried to figure it out.
Meanwhile, unnoticed by McBroom, the fuel was burning at an accelerated rate, because the plane was trimmed for landing and the gear was down.
The first sign of trouble came at 6:06 p.m., just after McBroom announced they would be landing in about five minutes.
“I think you just lost number four,” said First Officer Rod Beebe. And, a few seconds later, “We’re losing an engine.”
“Why?” McBroom said.
The crew scrambled to open cross-feeds from the other fuel tanks, to get the dead engine started again. This worked, and, realizing now how perilously low fuel stocks were, McBroom started preparing for an emergency landing at the Troutdale airport.
But seven minutes later, flight engineer Forrest Mendenhall said, “We just lost two engines, guys.”
A few seconds later, Capt. McBroom said, “They’re all going. We can’t make Troutdale.”
“We can’t make anywhere,” replied Beebe.
“OK. Declare a mayday,” said McBroom.
Beebe got on the radio: “Portland tower, United 173 heavy, mayday. We’re — the engines are flaming out. We’re going down. We’re not going to be able to make the airport.”
That was the last radio transmission from Flight 173. Captain and crew had other things to worry about. The big airliner was left ghosting through the air over Portland, a high-speed glider, its pilots desperately scanning the light-strewn cityscape below for a safe place to land ... or crash. And, because it was dark, the best they could do was aim for a dark spot below, and hope any trees weren’t too big.
As it turned out, they probably couldn’t have picked a better spot.
The final death toll in the ensuing crash-landing was 10: eight passengers and two crew members — flight engineer Mendenhall and senior flight attendant Joan Wheeler. Another 23 passengers and crew members were seriously injured, including Capt. McBroom. And 156 passengers and crew members were unharmed or suffered injuries too minor to require treatment.
The crashing airplane snapped off trees, tore out power lines and flattened two houses on the ground. Both houses were vacant and dark. It’s interesting to contemplate that if one of the vacant houses had had its porchlight left on, McBroom would probably have picked a different place to land, and the death toll might have been different — probably higher, possibly much higher.
Investigators determined that the initial problem was a maintenance one — the one that caused the loud landing gear. Ironically, the landing gear was just fine, locked in place and ready for service; but, by flying around for an hour troubleshooting it, the crew had lost track of time and fuel, and had come up about five minutes short on both.
The other lesson that investigators took from the crash was a big one, and it has unquestionably saved lives in the years since this crash — probably hundreds of them: The lesson was that commercial jetliners are too complicated to be flown according to a strict chain-of-command hierarchy, in which the pilot barks orders and information only flows back to him if he asks for it. Instead, a more collaborative team approach was needed, so that one person’s momentary weakness or distraction would not be deferred to by members of the team who happened to be in a position to know better.
The result was an initiative called Crew Resource Management, or CRM, developed several months after the crash by NASA psychologist John Lauber, who had extensively studied cockpit communication under even more complicated flight conditions. The most important element of CRM is a recognized way for authority to be respectfully questioned.
CRM was adopted by United in 1981, and other airlines quickly followed suit. By the mid-1990s its benefits were so obvious — especially in contrast with certain other countries that at that time were still following the old model — that the FAA made it mandatory.
(Somewhat controversially, Malcolm Gladwell actually cited and described the Flight 173 crash and the ensuing adoption of CRM in his wildly successful book Outliers, in which he compared the accident rates for American and Korean airlines and attributed the lower accident rate among U.S. planes to CRM.)
So the family members of the 10 victims of the Flight 173 crash have that much consolation for their loss: their loved ones’ deaths on that winter night continue to save uncountable others from a similar fate.
(Sources: “United Airlines, Flight 173, MD DC-8-61, N8082U,” lessonslearned.faa.gov; National Transportation Safety Board report AAR79-07; Portland Oregonian archives, 29 Dec 1978-01 Jan 1979)
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