The Importance of Speaking Up
A true story illustrating the critical role of candour for effective teamwork.
On February 24, 1989, United Flight 811 left Honolulu bound for Aukland with 355 souls onboard. Sixteen minutes after takeoff, at 22,000 feet, a grinding noise was heard, followed by a loud thud that rattled the whole aircraft — one and a half seconds later the forward cargo door blew out. The pressure differential caved in the cabin floor above the door. Nine people stilled strapped to their seats were sucked out of the cabin through a gaping hole in the fuselage.
The pilots began an emergency descent to get the aircraft quickly into breathable air while performing a 180-degree turn to return to Honolulu. The crew’s emergency oxygen had failed. Debris had caused two engines to catch fire. The crew started dumping fuel to lighten the aircraft.
The engineer toured the cabins to assess the situation. On the upper deck he saw the aircraft’s skin peeling off in places to reveal stringers and on the lower deck a huge gaping hole. He thought a bomb may have gone off. He advised slowing the aircraft to 250 knots. The stall speed is 240 knots, so it was a very narrow operating envelope.
As the plane neared the airport the landing gear was extended (this is an important detail that we’ll get back to in a minute). The damaged airbrakes could only be partially deployed which meant a very high landing speed. Nevertheless, the plane landed without overshooting the runway and everyone was safely evacuated.
The critical success factor in making it back was good teamwork. The captain attributed the success largely to the CRM (Crew Resource Management) training that he had recently received. Historically, dysfunctional cockpit cultures — a “Captain is King” tradition — rendered flight officers too intimidated to question a pilot’s decisions. This culture had been attributed to many air disasters and United Airlines had rolled out a training program to teach the crew how to speak up, and the pilots to listen.
Remember the landing gear? Standard operating procedure dictated that it be lowered immediately upon decompression. But debris had severed the hydraulic lines which meant that once the wheels were lowered they couldn’t be raised again. The copilot said to the captain, “I know its procedure but are sure you want to lower the landing gear? ’Cause we don’t know if we can hold altitude.” The captain replied, “That’s a good point. We’re going down pretty fast right now. We’ll keep the gear up”.
If they had lowered the landing gear, they wouldn’t have made it back to Honolulu.
Reference: Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety. Gordon, et al. (edited for brevity)
