How to Crash an Airplane

by Nickolas Means

The video 'How to Crash an Airplane' by Nickolas Means, presented at RubyConf 2015, explores the harrowing story of United Airlines Flight 232, which faced a catastrophic failure during a flight from Denver to Chicago on July 19, 1989. This case study highlights the critical role of teamwork, communication, and leadership in high-stress situations.

Introduction to Flight 232: The flight took off smoothly on a beautiful day, enjoying a normal altitude and conditions, until about an hour into the flight when a massive explosion occurred at the back of the plane, caused by the failure of the number two engine.
Immediate Response: The flight crew's initial reactions—First Officer Bill Records grabbing the yoke and Captain Al Haynes trying to stabilize the aircraft—set the stage for the dire circumstances they faced. Despite their training, the crew quickly realized they were dealing with a severe malfunction.
The Effect of Engine Failure: The flight's engine failure was more than just a shutdown; the crew discovered that they could not control key throttle mechanisms, indicating significant physical damage to the aircraft. This escalated the crisis as they struggled to maintain control.
In-Flight Chaos: As the plane began to roll to the right uncontrollably, the crew was forced to grapple with the chaotic situation. The flight engineer recognized their dire angle of bank, which compounded the challenges they faced.
Lessons on Teamwork: The presentation draws parallels between the aviation team's response and best practices in software development teams, emphasizing how effective communication and collaboration can lead to successful problem resolution in crisis scenarios.
Key Takeaways: The video imparts valuable lessons on resilience, effective communication, and the importance of maintaining composure during emergencies. While this talk will not equip viewers with flying skills, it offers insights into enhancing team performance in any field. The narrative of Flight 232 underscores how even in critical failures, leadership and teamwork can yield incredible outcomes, saving more than half of the passengers onboard despite the odds.

00:00:15.000 Good afternoon, everybody. I have been a student of plane crashes for as long as I can remember. I know that sounds like a weird thing to be fascinated by, but there's no faster way to get me into a Wikipedia Safari than mentioning a plane crash that I don't know the details of. I feel compelled to immediately go read about that crash and figure out what it is that I might have missed.

00:00:27.800 It may sound a little morbid to say that you're fascinated by plane crashes, but it’s not the morbidity that fascinates me; it’s the human interaction in the cockpit. In these situations, the flight crew sometimes takes a tiny system fault and turns it into a gigantic catastrophe through a cascading series of events. At other times, the flight crew is able to take a catastrophic system failure and get some people back safely on the ground when they probably shouldn’t have been able to.

00:01:04.119 The flight I want to tell you about today is one of the most fascinating in American aviation history: United Flight 232. On July 19, 1989, it was an absolutely beautiful day in Denver, Colorado. If you’ve been to Denver in the summer, you know exactly what kind of day I’m talking about—80 degrees out, light scattered cloud cover, and a light breeze blowing in off the front range; a day that just begs you to get outside and have fun. It was a beautiful day for flying, and flights were running on time at Denver Stapleton Airport.

00:01:51.759 A little before lunchtime, people began showing up for United Flight 232, which was scheduled for a push back from the gate at about 1:45 in the afternoon. If you’d been at the airport that day looking through the window, getting ready to board the plane, you would have seen something unfamiliar to modern travelers. You see, that engine peeking up over the back of the plane indicates that this is a McDonnell Douglas DC-10 series 10 aircraft.

00:02:09.560 This picture illustrates the actual aircraft you would be getting on that day, tail registration number November 1819 Uniform. It was delivered brand new to United Airlines in 1971 and had been flying as part of their fleet for 18 years since. Now, while 18 years may sound old, it’s not; airplanes regularly fly much longer than that. In fact, United would fly most of their DC-10 fleet well into their 30s, and many of these planes can still be seen today flying as cargo planes for FedEx.

00:02:35.280 As you got on board the plane, you would have seen a nice wide cabin and big seats. It’s actually a little bit wider than a Boeing 737 if you've flown on one of those. Pilots loved the DC-10; they referred to it as the Cadillac Fleetwood of the skies—a big, roomy airplane that was fun to fly and quiet. They especially loved taking off in a DC-10 because the three engines on this plane gave it way more power than it needed to get off the ground. When they placed their hand on the throttles, it would slam you back in your seats as you accelerated up to V2 and rotated to take off.

00:02:54.120 Around 2:10 p.m. that afternoon, a very normal takeoff occurred. This plane took off and turned east-northeast towards Chicago. If you had been on the plane at this point, you would have smelled chicken strips cooking in the onboard ovens. United was running a special in the summer of 1989 called their picnic lunch, which included chicken strips, Oreos, and a cup of cherries served in a basket with red-and-white-checked paper.

00:03:39.080 About an hour into the flight, most passengers had finished their meal, and Jim McKay, the legendary host of ABC's Wide World of Sports, was about 20 minutes into telling everyone onboard about the history of horse racing in the jewels of the Triple Crown. At this point, you would have heard an incredible explosion at the back of the plane. Most passengers thought that a bomb had gone off. The back of the plane dropped out from under it, people were slammed back in their seats, and the plane climbed 300 feet almost immediately before beginning to roll to the right.

00:04:08.879 If you were looking around the cabin, you would have seen the flight attendants hit the deck. They dove to the ground, grabbing the nearest armrest and holding on, afraid that they might experience an explosive decompression and be sucked out of the airplane. Fortunately, it wasn't an explosive decompression, nor was it a bomb. What had actually happened was that the fan disc in the number two engine in the tail of the airplane had exploded.

00:05:00.160 In the cockpit, the crew didn’t know what had happened either. They had just finished their lunches, the flight attendants had cleared them away, and brought them second cups of coffee when the explosion occurred. Immediately after the explosion, First Officer Bill Records lunged forward, grabbed the yoke, yelled "I've got it!" and turned off the autopilot. Meanwhile, Flight Engineer Dudley Dvorak looked at his instruments, trying to figure out what in the world had happened to their beautiful aircraft. The gauges told a clear story: the number two engine had failed.

00:05:34.560 Following procedure, Dvorak radioed Minneapolis Center, the flight control center managing them at that point, but didn’t declare an emergency because losing an engine on a DC-10 is not a big deal. They would just descend to a lower altitude and continue on to Chicago. That’s what he radioed for; he asked for a lower altitude assignment. After that, Captain Al Haynes, who you see on your screen, requested the engine shutdown checklist and asked Dvorak to read it out loud to him. This was the first hint that something might be very wrong with the aircraft.

00:06:04.400 The first step on the engine shutdown checklist was to reduce the throttle to idle, but Haynes tried to do that and found the throttle lever wouldn’t move. The second step was to cut off the fuel supply—he tried that as well but it wouldn’t move either. You need to know that for the DC-10, these controls are physically connected by steel cables to the engines, so the fact that these control levers wouldn’t move told Captain Haynes that something serious had happened to that engine. It was more than just an engine flameout; there was physical damage to the plane.

00:06:35.440 Haynes and Dvorak were trying to figure out what to do next when Bill Records spoke up, saying, "I can’t control the plane!" Captain Haynes looked over and saw something terrifying: Bill Records had the yoke all the way back and turned to the left. To understand why that was such a surprising sight, imagine driving down the highway in your car, going 80 mph, and jerking the steering wheel to the side. You would never do that to an airliner flying at cruise speed, but even more alarming to Haynes than that was the fact that even though First Officer Records was commanding the plane to go to the left, the plane was doing the opposite—it was going down and rolling to the right.

00:07:00.640 So, Haynes grabbed the controls and said, "I've got it!" and began fighting the controls himself, but the outcome was no different. Meanwhile, Dvorak was studying his gauges, still trying to determine what had happened to the plane, when he glanced up and noticed that the horizon was tilted. The plane had assumed a bank angle of about 38 degrees, which is way beyond the limit for any commercial airliner. Dvorak immediately yelled, "We're rolling!"