Lessons – Flight 401 Disaster

CRM abbreviations are commonly understood as customer relationship management. However, this means that in the aviation world crew management. The performance of a commercial aircraft flight from one airport to another is comparable to a project; it has a start date (departure), an end date (arrival date) and provides a unique product or service, namely the safe transport of passengers to their destination. CRM became a hot topic and an important discipline in the aviation industry after the crash of 401 Eastern Airlines flight to the Florida Everglades in 1972. The TV show “Maiday” told the story of this tragedy quite recently, and I think the lesson of the aviation industry is one that can be applied to the profession of project manager.

Flight 401 took off from JFK in New York City in Miami on the night of December 29, 1972. The aircraft was a Lockheed L1011-Tristar, which is modern at the time. The flight was led by Captain Robert Albin Loft, and included pilot-engineer Donald Louis Repo and pilot Albert John Stockstyle. In addition to the staff crew were Warren Terry, the pilot, and Angela Donadea, a maintenance specialist. The latter were “dead” in Miami. The dead end is airline slang, where you can travel for free to return to your home base. The pilot had 32 years of experience flying east, and the engineer had 25 years of experience. Although the pilot had much less experience than Loft, he had more experience with the L1011 and previous flight experience in the Air Force. It was the team that controlled the cabin.

Flight 401 received permission to take the tower at 9:20 p.m. that night and headed south over Norfolk, Virginia, then over Wilmington, North Carolina, and then out to sea for the remainder of the flight. The aircraft’s navigation system would lead the plane to the Barricade point over the Atlantic, and then it would start turning west over West Palm Beach and then south to Miami. Shortly after takeoff, Warren Terry decided to move from the cockpit to a vacant seat in first class, which left Angela Danadeo a lone “dead head” in the cabin. Captain Stockstill flew the plane while pilot Loft operated the radio. It was a standard procedure for the East and became the way it gave its pilots the flight experience.

East Flight 401 arrived at Miami Airport around 11:20 p.m., following National Airline Flight 607. The national plane was directed to land on runway 9, right leaving runway 9 to the right on the east plane. Before boarding Flight 607, the crew of the radio station knew that they had problems with landing in the nose of the aircraft and had to deploy it manually. They also asked that fire engines be ready for landing at the airport if they had any problems.

When it was the turn of flight 401, a few minutes later the signal lamp for their nose failed to turn on. Stockstyle asked Loft if he wanted to spin until the problem was fixed. After talking to the dispatcher, Loft instructed him to circle. When Stockstill asks about diverting the chassis, Loft instructs him to leave it down and then presses the throttle valves to compensate for the extra drag. Loft did so even though Stockstyle was still flying the plane.

The problem light was on the side of the pilots of the plane, but Stockstyle was unable to reach the light as he was still flying the plane. The tower instructed Flight 401 to turn north and then west on a route that would carry them through the Florida Everglades. The plane reached an altitude of 2,000 feet and then leveled off. Loft instructed Stockstill to land the plane on autopilot and then try to retrieve the light bulb so it could be replaced. Stockstill got the light on the panel and gave it to Repo so he could replace the light bulb. Donadeo witnessed the deal but says he did not see Repa replace the spare bulb. Repo tries to replace the panel, but inserts it on the side so that the light still does not work. Loft orders Repo to inspect the landing gear visually from a small compartment under the flight that passes through the trap door. As Repo disappears into “hell,” Stockstill is now struggling to remove the panel without success. Cab recordings record a conversation that shows Loft’s frustration with the wrong light, and the rest of the crew’s laughter shows that at the moment no one takes the incident seriously. Stockstill is still trying to retrieve the panel.

At this point, the dictaphone sounds a height warning, but Loft and Stockstill are still fully focused on the chassis light. Their discussion completely ignores the warning and focuses on the light, the likelihood that it just burned out, and their confidence that the transmission carrier is omitted at this point. The turnip appears through the door of the trap and announces that it does not see whether the gear is coming down or not. Loft directs him to try again. Meanwhile, the Stockstill has one hand on the steering oppression, which also controls the height of the plane, controlling the angle of the flap, and one hand on the panel that holds the light. Danadeo testifies to this when he moves into the bay to help Repa. A tape is heard on the tape recorder telling Loft that something has happened to the height. Loft’s last words: “Hey, what’s going on here?”

At this point, Flight 401 disappears from the radar screen of the controller. The hail from the dispatcher to the plane is not responding. The plane crashed into the Florida Everglades about 18 miles northwest of Miami. He hit the swamp at a speed of about 220 miles per hour and slid 1/3 mile, breaking into 5 pieces before finally calming down. Out of a total of 176 passengers and a crew of 103, the crash killed 103. Due to the rapid response time and heroic efforts of an aircraft operator named Robert Marquis, who happened to be at the scene, and the Coast Guard rescued 73 passengers from the swamp.

The National Transportation Safety Board (NTSB) is responsible for investigating all air accidents. Naturally more attention is paid to the investigation of accidents in which lives are lost, like the crash of “Flight 401”, and the NTSB has brought all its significant resources and experience to this disaster. Their investigation began at the crash site, and they found the control panel almost completely undamaged, so they were able to determine the exact time of the fall (11:42 p.m.) so that the panel containing the nasal transporter indicators was clogged sideways in her dishes and that the two light bulbs did burn . Using a dictaphone, they were able to determine that the plane’s speed was 198 knots when the plan crashed and the throttles were in full upright position, suggesting that the crew may have realized their situation at the last minute and tried to lift the plan. The NTSB also assisted Angela Danadeo, who survived the disaster.

Through the cabin registrar, physical evidence and testimony of Danade NTSB were able to recover the accident. The plane approached the landing and deployed the landing gear. The nasal transmission indicator does not light up, which may indicate that the nasal transmission is not deployed or the light is not working properly. The Flight Tower orders them to move on their way through the perpetual fruit and maintain an altitude of 2,000 feet, while Loft orders the Rap to visually inspect the landing gear. Okay so far. Next, Loft informs Stockstill (which has control of the aircraft) to turn on autopilot. The plane maintains its altitude, then drops 100 feet, leveled and maintains that altitude for 2 minutes. After that, the plan begins a gradual descent. This descent is so gradual that the crew does not notice, and after 70 seconds the plane lost only 250 altitudes. 250 feet is enough to trigger warnings that are well heard on the dictaphone, but have been ignored by cabin staff who are completely focused on trying to replace the burned-out indicator lights.

The speed of the descent, which began so gradually, is gaining momentum. Another 50 seconds and the plane drops below 101 feet, which triggers another alarm that the crew notices, but so far the plane is sinking at 50 feet per second. Stockstill responds by giving the plane full throttle, but corrective action is too late and the plane falls.

The autopilot is turned on by two switches on the control panel, but you can turn it off by pressing the control column (or oppression). The NTSB believes that when Loft turned to Rap to order him to visually inspect his nose, he accidentally turned off the autopilot by clicking on the column. At this point, the autopilot does not turn off completely, but will maintain the independence of the altitude that the pilot selects forward by pushing forward on the column. Accidental strikes against the column explain the further descent of the aircraft.

The NTSB report recommends a number of technical improvements that could prevent the tragedy. The visual inspection device in the inspection department proved to be too complicated to operate. Turnips contributed to the confusion in the cabin. The board recommended changing the device so that it worked with one person (the pilot had to switch the light on which the overhead was located, and Loft did not testify to this). The altitude warning system sounds once and then flashes orange. At altitudes above 2,500 feet this light flashes continuously, below 2,500 feet it flashes only once. The board recommended flashing constantly at any height. The NTSB report noted the attention the cabin staff focused on the burned-out lights, but at the time there were no further recommendations. Subsequent incidents in which a pilot and / or crew error resulted in a crash or imminent crash caused the creation of Crew Resource Management (CRM) and a mini-industry emerged to teach pilots to maintain control over their crew and aircraft.

By this time you will be asking yourself, “in what in the world is all this related to me or any other project manager?” In a nutshell, the answer is this: the same lack of emphasis on the part of the leader that led to the 401 plane crash could lead to the collapse of the project. Project managers can learn some lessons from this tragedy and use some of their own CRM management strategies.

What stands out most about this tragedy is the attention of the entire crew of the cockpit of this plane, including the pilot, on two burnt out light bulbs: the total cost is 12 dollars. The cost of insufficient attention on the plane’s flight: the plane is $ 15 million plus 103 lives. The lesson is clear; the project manager cannot lose focus on the overall goals and objectives of the project due to the abandonment of a minor task or for its implementation. The pilot on the aircraft is jointly responsible 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 rarely extends to personal safety. The pilot owns the cockpit crew team and is responsible for the task of that crew so that the aircraft reaches its destination safely. The pilot cannot afford to escape this responsibility because the crew is struggling to solve a relatively minor technical problem. As it turned out, the landing gear dropped, and the plane could land safely. The crew either knew about it, or strongly suspected it, as they studied ways to change the light bulbs. Had Loft appointed a replacement for Stockstyle or Donade’s light bulbs (he was engaged in Loft), he could have focused on the flight of the plane and prevented the crash.

Project managers must take responsibility for fulfilling the overall goals and objectives of the project. This means that if the build doesn’t work, or problem reports are mounted, or a new app doesn’t meet performance expectations, we can’t be so confused in fixing the situation that we lose sight of the overall project. We must use wisely the resources that are given to us to achieve the goals of the project. Assign reasons for rejection to someone on your team who has the necessary experience and knowledge, and then trust them. If you do not have such a person on your team, contact the sponsor and ask for a resource. Don’t let yourself feel responsible for solving all the problems of your project so as not to distract you from your primary responsibility: the overall success of the project.

If you ever find yourself in a position of wanting to go down into a trench and get your hands dirty by solving a technical problem that plagues your project, remember the experience of pilot Robert Loft. Don’t let stakeholders down and disrupt the project by focusing on the $ 12 portion rather than the million-dollar project.

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