Remembering Captain Al Haynes

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

This past Sunday, August 25, 2019, Captain Al Haynes died a week shy of his 88^th birthday. Captain Haynes was a remarkable pilot who, 30 years ago last month, brought United Airlines flight 232 to an emergency landing in Sioux City, Iowa, with no means of control except the ability to vary the thrust produced by the airplane’s two engines (the DC-10’s third engine had experienced an uncontained engine failure). Although 111 passengers ultimately perished in the accident, the actions of Captain Haynes and the other crewmembers saved the lives of 184 others on the flight.

The sequence of events started when the airplane’s central engine in the tail failed, sending heavy, high-speed shrapnel spraying through the rear of the airplane. The shrapnel cut all three of the airplane’s hydraulic lines and all hydraulic pressure was lost. This left no way for the pilots to control the airplane—at least, no way intentionally designed for that purpose. Hydraulic pressure was needed to move the airplane’s control surfaces and allow it to turn, climb or descend in response to pilot input, and to configure the airplane for landing by extending the flaps.

After the engine failure, the airplane started banking to the right and its nose dropped. The crew tried to stop the bank and bring the nose up, but the airplane did not respond. The only controls that worked were the throttles for the remaining two engines, one on each wing. By varying how much power each engine produced—that is, applying differential thrust—the pilots were able to stop the turn and bring the airplane level.

The plane pulled right, and slowly oscillated vertically in what is called a phugoid cycle, losing approximately 1,500 feet of altitude with each cycle. Among the passengers on the flight was Captain Dennis Fitch, a United pilot and training check airman, who came to the cockpit and offered Captain Haynes any help that he could provide. Captain Haynes welcomed Captain Fitch’s help.

Captain Fitch began to apply differential thrust, and that way, regained some control of the airplane. He was able to minimize the phugoid and gain some directional control, although the airplane could only turn to the right. The decision was made to make an emergency landing at the airport in Sioux City, Iowa.

The crew was able to use differential thrust alone to control the airplane’s direction of travel and descent, and line up the DC-10 with the runway. But, with no hydraulics, the flaps could not be extended. When the DC-10 was designed and approved, the total loss of hydraulic-powered flight controls was considered so unlikely that there was no need to develop and approve a procedure to deal with such a situation. Because flaps control both the minimum required airspeed and sink rate, however, the flight 232 crew could control neither.

Just prior to landing, the airplane was going 220 knots and descending at 1,850 feet per minute, well above the normal targets of 140 knots and a 300-feet-per-minute descent. As the plane touched down, the right wing tip hit the runway first, and the plane began to break up and catch fire, ultimately resulting in the fatalities of 111 people. For 184 others, Captain Haynes and his flight crew are credited with their improbable deliverance from an unlikely accident cause.

In our investigation of this accident, we pointed out that the interaction of the pilots, including the check airman, during the emergency showed the value of crew resource management (CRM – then known as cockpit resource management) training, which had been practiced at United Airlines for a decade. Ten years before the United flight 232 accident, we recommended that CRM training be required for all airline flight crews.

Flight simulator reenactments of the accident airplane’s flight profile carried out as part of our investigation revealed that it was virtually impossible to control all parameters simultaneously needed to land safely at a predetermined point. After observing the performance of a control group of DC-l0-qualified pilots in the simulator, we concluded that Captain Haynes’s damaged DC-10 airplane, although flyable, could not have been successfully landed on a runway after the loss of all hydraulic flight controls, and that, under the circumstances, United flight 232’s flightcrew reacted commendably and beyond reasonable expectations.

But the benefits of CRM training were clear. The flight crew, lead by Captain Haynes, used CRM to deal with a situation considered so unlikely that there were no procedures or training on how to respond. When talking about the accident later, Captain Haynes said, “If I hadn’t used CRM, if we had not let everybody put their input in, it’s a cinch we wouldn’t have made it.”

Although he always denied that he was a hero, Captain Haynes was the right man at the right time for an event considered to be so unlikely that it was virtually impossible. Thirty years after that accident, and mere days after Captain Haynes’s death, we at the NTSB remember how his CRM practice saved over half the people on United flight 232. Aviation is safer the world over thanks to Captain Haynes.

Heading Back to School Safely

By Stephanie Shaw, NTSB Safety Advocate

 It’s nearing the end of August. Gone are the days of lounging by the pool or on the beach, or running around and playing outside. Soon, crowds of children will be waiting on the street corner for their school bus to arrive. It’s almost Labor Day, and the back-to-school season is upon us.

‘Tis the season for worrying about a lot of things: hunting down the best sales on school supplies and clothes, buying the right books, hoping your children will have good teachers and make new friends . . . the list goes on. It’s easy to forget about transportation safety amidst these other thoughts and concerns, but now is also the time to discuss with your kids the safest way for them to get to and from school.

Over the past 50 years, we’ve made school transportation safety a priority. For example, although the school bus is the safest method of transportation to and from school, when a bus crash does happen, we investigate to uncover any relevant safety issues so they can be fixed. Many of the most pressing back-to-school transportation issues (including impaired driving, distracted driving, and fatigue-related accidents) are currently items on our Most Wanted List (MWL) of transportation safety improvements. Our MWL contains what we believe to be the safety improvements that can prevent crashes and save lives, and these issues are among our highest priorities in our advocacy work.

So, how will your kids get to school this year? Will they take the bus? Do you have a carpool set up with another family? Do they walk or bike to school? Is your teen driving to and from school this year? Regardless of how your child gets there and home, this is a critical time for you, as a parent, to think about ways you can help keep them safe. By talking to your children about steps you can take as a family this school year to ensure a safe commute, you can do your part to help make transportation safety a priority.

Check out some of our back-to-school blog posts for some conversation starters and tips for keeping your children and their peers safe on the roads.

• Back-to-School Safety Series: A Child’s Best Teacher
• Back-to-School Safety Series: Why the School Bus is the Safest Choice
• Back-to-School Safety Series: Pedestrian and Bicycle Safety Tips
• Back-to-School Safety Series: Wake Up to Drowsy Driving
• Back-to-School Safety Series: Zero Tolerance Starts at Home
• Back-to-School Safety Series: Eyes on the Road, Hands on the Wheel, Minds on What Matters

Safe Skies for Africa Ends, but the Safety Journey Continues

By: Nicholas Worrell, Chief, Office of Safety Advocacy

NTSB staff and attendees at the Safe Skies for Africa symposium in Lagos, Nigeria

After 21 years, the Safe Skies for Africa (SSFA) program officially came to an end last week at a symposium in Lagos, Nigeria. The program was established in 1998 in part to increase direct commercial air service between the United States and Africa, which was minimal at the time. Administered by the US Department of Transportation and funded by the US State Department, the SSFA program has accomplished many of its original objectives since inception, including improving the safety and security of aviation on the African continent. Over a dozen symposia and workshops have been held over the life of the program, and we organized past SSFA symposia with the South Africa Civil Aviation Authority and Kenya’s Air Accident Investigation Department. This year’s event was hosted by the Air Investigation Bureau-Nigeria (AIB-N), who also sent a team of accident investigators and industry representative to participate.

Former NTSB Managing Director (and program pioneer) Dennis Jones spent nearly 20 years in the SSFA program, participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators. In his opinion, the Safe Skies program has done what it was created to do. At the outset of the program, few African airlines and hardly any US airlines were flying to Africa, even though it’s the world’s second-largest continent. Today, two US carriers provide direct service to Africa, and six African countries (Egypt, Ethiopia, South Africa, Morocco, Cape Verde, and Kenya) have direct routes to the United States.

Along with increased US commercial air service to Africa, air investigation quality has improved, resulting in a lower accident rate and greater safety in commercial aviation in Africa. Many African nations now have their own accident investigation agencies, and some are even developing multimodal agencies based on the NTSB model.

We were honored to again join other NTSB communications specialists and experts, as well as former NTSB Managing Director Dennis Jones, for the final symposium. The symposium focused on the following topics:

• The NTSB’s background and history
• Emerging aviation safety issues
• The investigative process and human factors
• Accident classification and substantial damage
• Helicopter operations
• The challenges of providing family assistance
• Effective safety advocacy: creating positive change in transportation safety

Our team shared lessons learned from NTSB accident investigations, as well as strategies to help our international counterparts take steps in their own aviation safety journey. The AIB-N participants were focused and receptive to our presentations, and the event was bittersweet as we parted ways with old colleagues and brought the program to a close.

Although the SSFA program has resulted in many improvements over its 21 years, more remains to be done. Safe and reliable aviation connects people all over the world, in more ways than you may realize. Aircraft components, engines, and airframes come from manufacturers all over the world. The airplanes they comprise might be flown by airlines in any country. We are all stakeholders in aviation safety, regardless of what continent we inhabit.

We look forward to more programs like SSFA that will advance international collaboration on aviation safety issues. I’m confident that new safety ambassadors will follow in the footsteps of those who participated in the SSFA program, and I look forward to working with the pioneers who participate in these programs going forward.

For our blogs on the other NTSB SSFA symposia in South Africa and Kenya, please see links below:

https://safetycompass.wordpress.com/2018/08/09/ntsb-supports-safe-skies-for-africa-initiative/

https://safetycompass.wordpress.com/2018/10/01/another-step-toward-safer-skies-in-africa/

 

Safe and Sound at Work

By Chairman Robert L. Sumwalt

Last week, I kicked off Safe and Sound Week—an Occupational Safety and Health Administration initiative—with this video message. In the video, I reminded NTSB employees that one of the things our agency does is meet with victims’ family members on perhaps on the worst day of their lives. I told my colleagues that I’d consider it the ultimate failure to ever have to sit down with any of their family members to tell them that something bad had happened to them while they were on the job at the NTSB.

Workplace safety is not included in the NTSB’s statutory mission, but it certainly is “in our lane,” just as it’s in any organization’s lane. I believe workplace safety should be built into how we think and act at the NTSB. Our agency’s Occupational Safety and Health Program team recently challenged all of us to define what safety means. My answer was, “constantly anticipating bad things that can happen and then proactively taking actions to mitigate those things so that no one gets hurt.”

That answer was based on, among other things, a particular personal experience. I remember a street crossing near my home that was adjacent to a blind curve obstructed by shrubbery. It seemed a little dangerous, but I never really thought much of it until I had to dart back to the curb to avoid being struck by a car. After that, I found another crossing point about 15 feet away that was a little safer. Why hadn’t I found that safer crossing sooner? Because I hadn’t been constantly anticipating what could happen and working to mitigate the danger.

Now, take an example of the same lack of risk assessment to a broader scale. We recently completed our investigation of an accident near DuPont, Washington, where a transit train on its inaugural revenue service run failed to slow down from 78 mph when entering a curve with a speed restriction of 30 mph. The train derailed, sending several cars plummeting to the interstate below. Three passengers were killed, and 55 people were injured—including 8 in vehicles on the road. The transit agency responsible for assessing risk on this curve had determined one mitigation prior to the derailment: implementing positive train control (PTC); however, PTC implementation was delayed, and the transit agency didn’t find another means of mitigating the risk before carrying on with the inaugural run.

Just like me crossing the street near my home, the transit agency was not constantly anticipating what could happen and taking action to mitigate the worst-case scenario. That lack of action put not only the train’s passengers at risk, but the agency’s employees, as well.

Workplace safety doesn’t fall solely on an organization’s management, though. It’s a shared responsibility between an agency and each of its employees. Ask your workplace safety experts what to look for when assessing your workplace for safety risks. In my agency, the risks vary widely from an accident scene to the office, but we strive to address all possible scenarios to keep ourselves—and each other—safe. Wherever you work, slips, trips, falls, fire hazards, and other workplace safety concerns are undoubtedly “in your lane.” It’s up to all of us to assess our workplace risk and take actions to mitigate it.

PTC, 50 Years After Darien

By Member Jennifer Homendy

Exactly 50 years ago today, two Penn Central commuter trains collided in Darien, Connecticut. Four people died and 43 others were injured. The collision led to our first recommendation related to positive train control (PTC). Today, I joined Senator Richard Blumenthal at a commemoration of the accident in New Haven. The senator and I share the same goal: to see PTC implementation completed.

In the past half century, we have investigated more than 150 PTC-preventable accidents that have taken the lives of more than 300 people and injured 6,700 others. PTC was on our first Most Wanted List in 1990, and it’s still on our Most Wanted List today.

In 2008, when it became clear that, even after a series of deadly crashes, the railroads and the Federal Railroad Administration (FRA) weren’t going to voluntarily implement PTC, Congress took action and made PTC implementation mandatory. The railroads have made progress—albeit slowly—in the past 11 years. Some have almost fully implemented PTC, but others lag far behind. The deadline for PTC implementation was extended to the end of 2018; however, if a railroad met certain benchmarks, it could qualify for a 24-month extension. Nearly all railroads satisfied the criteria to extend the deadline, which is now set for December 31, 2020.

The December 2020 extended deadline is fast approaching, yet a lot of work remains to be done. Some railroads are still installing equipment—which is a task that should’ve been completed by now. Railroads should be providing ongoing PTC training and actively working toward interoperability with other railroads on their lines. They should be getting their safety plans to the FRA for final certification and approval. Although there is a lot to accomplish over the next 16 months, our message is simple: No more extensions, no more excuses, and no more delays. It’s time to finish the job!

From the day that President Kennedy urged America to put a person on the moon to the day that Neil Armstrong took those historic steps, it was only 8 short years. Think about that—8 years to get a human to the moon. Yet, it’s been 50 since the accident in Darien, and we still haven’t managed to get PTC up and running on our country’s rails.

As I stood in my native Connecticut today, I thought about the four people killed there on August 20, 1969, a half century ago. It’s been over a decade since Congress mandated PTC, and the traveling public is still at unnecessary risk. It’s time for the railroads to finish the job.

In this photo, taken August 20, 2019, at Union Station in New Haven, Connecticut, NTSB Member Jennifer Homendy is with Connecticut Senator Richard Blumenthal at a press event to mark the fiftieth anniversary of a fatal train collision in Darien, Connecticut, and to call for the full implementation of Positive Train Control. NTSB photo by Stephanie Shaw