CRM and United Airlines Flight 232: A Crisis Case Study

Introduction

This paper examines the role of crew resource management (CRM) in the crash of United Airlines Flight 232. The crew on Flight 232 did everything possible to save the aircraft and lives given the circumstances, and CRM played a large part in their survival and in saving as many lives as they did.

Flying Without Controls: The Crisis Unfolds

The crew literally "flew by the seat of their pants" during this crisis on July 19, 1989. No one had ever experienced the failure of all three hydraulic systems in flight, and there had been no training or simulator instruction for such an occurrence. The crew had to develop a strategy as they discovered what the plane would and would not do.

Captain Al Haynes was in command on the flight deck that day, but the three crewmembers worked together — along with an off-duty training captain who happened to be aboard — to discover how to even remotely control the aircraft's flight path. Haynes described the process this way: "What do you want to do, I don't know, and let's try this, and you think that'll work, beats me, and that's about the way it went, really" (Haynes, 1991). The crew found they could steer the aircraft by varying thrust on the remaining number-one engine to turn the plane gently in the direction they hoped to go, but there were no hydraulics — no ailerons, no flaps, nothing else to control the flight path.

In the flight recorder transcripts, the cockpit crew can be heard working together to handle problems as they arose, which is a clear example of CRM in action during a crisis. Haynes underscored the point: "So if I hadn't used [Command Leadership Resource Training] CLR, if we had not let everybody put their input in, it's a cinch we wouldn't have made it" (Haynes, 1991).

Communication as the Cornerstone of Survival

Communication was the key that held the crew together, coordinated their efforts with the ground, and assured that at least some passengers would survive. Communication was terse but to the point. Because the crewmembers worked as a team, discussed their options and results, and played on each other's strengths, they maintained constant contact with air traffic control. Haynes noted in his post-accident comments that communication was one of the most important factors in the cockpit. The outcome — only 112 passengers and crew lost, while 185 survived the devastating crash — reflects the effectiveness of those communication efforts.

All crewmembers, including off-duty United personnel, were involved in the communication process. Flight attendants prepared passengers for a crash landing, and the captain kept them informed of the emergency and their progress. Haynes described the standard procedure: "When you're going to have an emergency preparation, you call all the flight attendants together, the aide does, the senior flight attendant — she briefs them, then they go out to their duty demonstrations and demonstrate and tell what they want done" (Haynes, 1991).

Captain Haynes also credited the ATC controllers, especially Kevin Bockman at the Sioux City center, for their efficient handling of the situation, and praised the ground and emergency crews for their excellent response to the aftermath. In short, everyone from ground crews on up worked together to create the best possible outcome from a terrible situation. Had all these pieces not come together, it is almost certain that more people would have died and the disaster could have been far worse.

Conclusion

CRM is a valuable resource for the airline industry, and continuing to use it can only save more lives in the future.