What happened to United Airlines Flight 173
United Airlines Flight 173
Category : Airlines / Posted on: January 25, 2023 / Author: Admin
United Airlines Flight 173
SUMMARY OF EVENTS
The summary extract from the NTSB official report is here:
"Around 1815 Pacific Standard Time on December 28, 1978, United Airlines, Inc., Flight 173 crashed in a densely populated area in suburban Portland, Oregon, as it approached Portland International Airport. The plane had been delayed southeast of the airport for approximately 1 hour. Flight crew dealt with a malfunctioning landing gear and prepared passengers for the possibility that a landing gear would fail upon landing. About 6 miles southeast of the airport, the plane crashed. The plane was destroyed. There was no fire. Eight passengers and eight crewmembers died, while 8 others were hurt. 21 passengers and 2 crewmembers sustained serious injuries.
According to the National Transportation Safety Board, the probable cause of the accident resulted from the failure of the captain monitor the aircraft's fuel status and respond appropriately to low fuel and crewmember's advisory regarding fuel state. Fuel exhaustion occurred to all engines as a result. Inattention was due to preoccupation with a landing gear failure and preparations for an emergency landing.
The accident was caused by the inability of the two other flight crewmembers to understand the fuel state and communicate their concerns to the captain.
UA173 Holding Pattern
The pilot's ability to land the DC-8 safely in suburban areas should be applauded. However, it could have been prevented if the pilot and his crew had worked more efficiently together. The crew remained in the same pattern south of Portland for one hour and two minutes after the landing gear malfunction. The crew knew their fuel amounts throughout the sequence of events. It was also predictable how long and how far they could travel with decreasing fuel. Several crew members raised concerns about fuel levels during United 173's holding. The captain's attention to the gear problem was enough to distract from the larger concern about fuel quantity. Portland International was now impossible to reach by the time this realization was made.
FINAL RADIO TRANSMISSIONS
Portland Approach was advised by the captain at 1809:21 that United, Seven Three is going to turn towards the airport and come in."
The captain asked that the flight engineer reset the circuit breaker temporarily at 1810:17. Let's see if we can get the gear lights." The flight engine accepted the request.
The captain asked for the distance between the airport and the plane at 1810:47. Portland approach replied, "I'd call that eighteen-flying mile." At 1812.42, the captain requested another distance. Portland Approach replied, "Twelve Flying Miles." The pilot was then allowed to contact Portland tower.
Crash Site for UA173
The flight engineer stated at 1813.21 that "we've lost two engines, guys." At 18.13.25, he said, "We just lost one and two engines."
The captain stated that they were all moving at 1813:38. Troutdale is impossible to make. The first officer replied, "We can’t make anything."
The captain informed the first officer at 1813:46 that he was okay. Declare a Mayday. At 1813:50 the captain called Portland International Airport tower. He declared that Portland tower, United one seventy-three heavy, was now ready for business. The engines are flaming out. , We’re going down. "We're not going be able make the airport." This was Flight 173's last radio transmission.
CONTRIBUTING AND CAUSAL FACTORS
Here's the final Probable Cause of the NTSB:
The National Transportation Safety Board found that the accident was likely caused by the captain's failure to properly monitor the aircraft's fuel status and respond appropriately to low fuel and crew member's advisories about fuel state. Fuel exhaustion occurred to all engines. Preoccupation with a landing gear problem and preparations for an emergency landing resulted in his inattention.
The accident was caused by the inability of the two other flight crewmembers to understand the criticality and communicate their concerns to the captain.
NTSB acknowledged that some fuel quantity gauges could be difficult to read or interpret. They recommended that all DC-8-operating aircrew receive additional training and a bulletin on this topic.
The NTSB recommended a completely new type of training, which was more important for aviation safety in the future. These are the NTSB's recommendations
"Issue an operation bulletin to all Air Carrier Operations Inspectors, directing them to encourage their assigned operators to ensure their flight crews learn the principles of flightdeck resources management with a particular focus on the merits in participative management for captains as well as assertiveness training other cockpit crewmembers. (Class II, Priority Dict) (X-79-17).
Initially referred to as Flightdeck Resource Management (or Flightdeck Resource Management), this term quickly became Cockpit Resource Management. This term was eventually replaced by Crew Resource Management (aka CRM). Both transportation companies and private sector consultants offer CRM training. United Airlines was the first to adopt CRM in 1981. It is now an integral part of crew training for major airlines, NASA, and military aviation. Similar concepts to CRM were developed for other Highly Dependable Organizations, such as medicine and nuclear.
The concepts of CRM can be very beneficial to medicine, particularly in the ED and OR where the surgeon or ER doctor may take a dominion position, preventing team members from effectively sharing important information. TeamSTEPPS is an example of CRM-like training that has been modified for medicine. The Defence Department and the Agency for Healthcare Research and Quality have joined forces to create a national support and training network for the National Implementation of TeamSTEPPS.
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