1: The date was July 10, 1989. United Airlines flight 232 took off from Denver headed for Chicago.
There were 285 passengers on board.
It was a gorgeous day, sunny and mild. There were light winds out of the west at thirteen miles per hour.
“For the first hour and ten minutes of the trip, everything went perfectly. Over Iowa, the crew, consisting of Captain Al Haynes, first officer Bill Records, and flight engineer Dudley Dvorak, put the plane on autopilot, ate lunch, and shot the breeze,” Daniel Coyle writes in The Culture Code: The Secrets of Highly Successful Groups.
Captain Al was fifty-seven years old. “A low-key Texan and a former Marine, he had an amiable manner appreciated by his crews,” Daniel writes. “Two years from retirement, he was planning for the next stage of life, when he would pilot an RV around the country with his wife, Darlene.”
Suddenly, at 3:16 p.m., there was a loud explosion from the rear of the airplane.
“The plane shook fiercely, then started climbing and tilting hard to the right.”
First Officer Bill took hold of one of the two control wheels, known as yokes. “I have the airplane,” he said.
Looking at the gauges, the crew realized one of the plane’s tail engines—one of the DC-10’s three engines—was gone. The airplane continued to tilt farther to the right despite Bill’s efforts to correct it.
“Al,” he said, “I can’t control the airplane.”
Al grabbed the other yoke. “I got it,” he said.
But he didn’t have it.
“He pulled with all his strength,” Daniel writes, “but the controls barely budged. The plane kept tilting to the right, until it felt like it was nearly standing on the wing.”
Investigators later determined that the explosion occurred due to a microscopic crack in a six-foot-diameter fan inside the tail engine.
“The consequences of the explosion, however, went beyond the loss of the engine, which could normally be overcome,” Daniel notes.
“Shrapnel had sliced the main and backup hydraulic control lines through which the pilots operated the rudder, ailerons, and wing flaps—in short, the explosion removed the pilots’ ability to control the plane.”
The term the National Transportation Safety Board uses to describe this type of event?
Catastrophic failure.
“Airlines didn’t bother training pilots for catastrophic failure for two reasons,” Daniel writes. “First, such failures are extremely rare—the odds of losing hydraulics and backups had been calculated at one in a billion.
“Second, they are invariably fatal.”
2: Al stopped the airplane’s roll by increasing power to the right-wing engine and decreasing power to the left-wing engine. The plane slowly tilted back to somewhere near level.
But, the bigger problem facing the pilots was that their controls did not work.
“The plane was now wobbling through the Iowa sky like a poorly made paper airplane,” Daniel observes, “porpoising up and down thousands of feet each minute.”
As Al and Bill wrestled with the yokes, the flight attendants walked through the cabin, attempting to keep the passengers calm. One family found their Bible and started to pray.
Denny Fitch was sitting in an aisle seat in first class. When the explosion happened, he had spilled coffee all over his lap.
What was Denny’s job? “He spent his days in a flight simulator, teaching pilots how to handle emergencies,” Daniel notes.
He told one of the flight attendants he was willing to help. “The word came back: Send him up.”
When Denny opened the cockpit door, his heart dropped.
“The scene to me as a pilot was unbelievable,” he later told a reporter. “Both the pilots were in short-sleeved shirts, the tendons being raised on their forearms, their knuckles were white… The first thing that strikes your mind is, ‘Dear God, I’m going to die this afternoon.’
“The only question that remains is, ‘How long is it going to take Iowa to hit me?”
Denny scanned the gauges, trying to figure out what was happening. He had never seen anything like this before.
“Tell me,” Denny said to Captain Al. “Tell me what you want, and I’ll help you.”
Al gestured to the engine throttles on the console in between the two pilots. Al and Bill were 100% focused on controlling the yokes. Someone needed to control the throttles to maintain level flight.
Denny knelt down between the seats and grabbed the throttles with both hands.
“Shoulder to shoulder,” Daniel writes, “the three men began to do something that no pilots had ever done: Fly a DC-10 without any controls.”
They began to communicate in a specific way: Through short, urgent bursts.
AL: Okay, let’s start this sucker down a little more.
DENNY: Okay, set your power a little bit.
AL: Anybody have any ideas about [what to do about the landing gear]? He [flight engineer Dudley Dvorak] is talking to [maintenance].
DENNY: [Dudley] is talking to [maintenance]. I’m gonna alternate-gear you. Maybe that will even help you. If there is no fluid, I don’t know how outboard ailerons are going to help you.
AL: How do you, we get gear down?
DENNY: Well, they can free-fall. The only thing is, we alternate the gear. We got the [landing gear] doors down?
AL: Yep.
BILL: We’re gonna have trouble stopping, too.
AL: Oh yeah. We don’t have any brakes.
BILL: No brakes?
AL: Well, we have some brakes [but not much].
DENNY: {Braking will be a] one-shot deal. Just mash it once. That’s all you get. I’m gonna turn you. [I’m gonna] give you a left turn back to the airport. Is that okay?
AL: I got it.
[A few minutes later.]
AL: A little left bank. Back, back.
DENNY: Hold this thing level if you can.
AL: Level, baby, level, level…
DUDLEY: We’re turning now.
DENNY: More power, more power, give ’em more power.
BILL: More power, full power.
DENNY: Power picks ’em up.
UNKNOWN VOICE: Right turn, throttle back.
AL: Can we turn left?
DUDLEY: (speaking to Denny): Do you want this seat?
DENNY: Yes, do you mind?
DUDLEY: I don’t mind. I think that you know what you’re doing there…
Notifications are the term pilots use to describe these types of short-burst communication.
“A notification is not an order or a command,” Daniel observes. “It provides context, telling of something noticed, placing a spotlight on one discrete element of the world.
“Notifications are the humblest and most primitive form of communication, the equivalent of a child’s finger-point: I see this. Unlike commands, they carry unspoken questions: Do you agree? What else do you see? In a typical landing or takeoff, a proficient crew averages twenty notifications per minute.”
Later analysis showed that Al, Bill, Dudley, and Denny communicated at a rate of more than one notification per second. Some of the communications were big, open-ended questions, mainly by Captain Al. “How do we get the [landing] gear down?… Anybody have any ideas?”
3: What’s interesting is that these are not the type of questions we would expect a captain to ask. In fact, they are the exact opposite.
When catastrophe happens, isn’t it the captain’s job to be in command? Shouldn’t they project confidence and be calm and in control?
“Yet over and over [Al] notified his crew of a very different truth,” Daniel writes: “Your captain has no idea what is going on or how to fix it. Can you help?”
The communications that afternoon between the makeshift crew of Flight 232 “resembled a person feeling his way through a dark room, sensing obstacles and navigating fitfully around them,” Daniel notes. “We’re gonna have trouble stopping to… Oh yeah. We don’t have any brakes… No brakes? Well, we have some brakes… Just mash it, mash it once.”
Yet, in the middle of a full-on disaster, working together, the pilots solved a complex series of problems while flying at four hundred miles per hour.
“They figured out how to optimally distribute power between the two engines and how to try to anticipate the porpoising movements the plane was making,” Daniel observes.
“They communicated with the cabin, attendants, passengers, flight control, maintenance, and emergency crews on the ground. They chose routes, calculated descent rates, prepared for evacuation.”
And even maintained their sense of humor. On their approach to Sioux City, the air traffic controller cleared them to land on any of the airport’s runways. Al asked, “You want to be particular and make it a runway, huh?”
Everyone laughed.
Moments later, at twice the normal landing speed and descending at six times the normal rate, Flight 232 attempted to land.
“A wingtip dipped and dug into the runway, sending the plane into a fiery cartwheel. The crash was terrible, but 185 people survived, including the entire crew,” Daniel writes.
100 people died that afternoon. And 185 survived. “Some walked out of the wreckage into a cornfield,” he notes. “The survival of so many passengers was termed a miracle.”
Following the crash landing, the National Transportation Safety Board placed experienced crews in flight simulators to recreate the conditions faced by Flight 232.
They ran the simulation twenty-eight times.
Twenty-eight times, the planes crashed, falling to the ground without getting close to Sioux City.
“All of which underlines a strange truth,” Daniel writes. “The crew of Flight 232 succeeded not because of their individual skills but because they were able to combine those skills into a greater intelligence. They demonstrated that a series of small, humble exchanges—Anybody have any ideas? Tell me what you want, and I’ll help you—can unlock a group’s ability to perform.”
The lesson to be learned, and the one we will be looking at this week, is the power of vulnerability to create high-performing teams.
More tomorrow!
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Reflection: What strikes me about the communications between the pilots during the crash landing? What do I find surprising? What do I find reassuring? What can I learn?
Action: Journal about my answers to the questions above.
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