How to crash an airplane – Nickolas Means | The Lead Developer UK 2016

[Applause] so good afternoon everybody hope you've enjoyed the first day of lead dev I know I certainly have it's quite the honor to be able to share this stage with so many amazing speakers so thank you to the organizers and to Mary the committee chair and all the speakers with President to us today I like Mary said my name is Nicolas means I'm VP of engineering at well match health I work with a lot of really smart people to help make the US healthcare system better if you want to know more about what I do come talk to me because with a British audience it's going to be a conversation it's not not something I can explain from stage but another thing you need to know about me is that I am a student of plane crashes I know that's a weird thing to say but if you want to if you want to nerd tonight me come up to me and ask me about a plane crash that I can't tell you the details about right off the top of my head Joe one of the members of the conference staff did this to me last night at the speaker's dinner and so instead of going home to the hotel and rehearsing my talk I went back and looked up the details of British Airways incident where the windscreen got sucked out of an airplane and the pilot got sucked out halfway and they still managed to land and everybody survived it was British Airways flight 53 90 if you want to go look it up yourself but it's not it's not the morbidity of plane crashes or the spectacle that fascinates me it's the dynamics of what happens in the cockpit what the flight crew goes through from when an incident starts to when the plane gets to the ground one way or the other there's two kinds of ways this go there's some flight crews that take tiny incidents and through poor reactions or poor decisions take tiny system bolts and make them in a giant disasters then there's other incidents where flight crews take giant problems insurmountable obstacles and somehow managed to eke out a better outcome than they ought to be able to and the story I want to tell you today is the story of one of the latter it's a story of a flight crew who takes a plane that's struck with almost insurmountable peril and manages to save more than half the people on board that's what I think is one of the most fascinating plane crashes aviation history the story of United 232 so July 19th 1989 was an absolutely beautiful day in Denver Colorado the highways summer in the mid-80s scattered clouds there was a wonderful breeze blowing in off the Front Range of the Rocky Mountains was the kind of day if you've ever been to Denver in the summer it's the kind of day that just begged you to go outside and do something go for a hike play around a golf it was also a wonderful day for flying at Denver's Stapleton International Airport planes were leaving on time everything was running smoothly and about 10:30 or 11:00 in the morning the first of the 285 passengers and 11 crew members that would eventually be on board United flight 232 started arriving at the gate their flight that day would take them from Denver staple an airport to Chicago O'Hare or so they thought when they cross the jet bridge if you were in the boarding lounge that day you would have seen something like this through the window it's a bit of an unfamiliar sight to a modern traveler back in these days it was forbidden for planes to fly extended distances with only two engines they had to have more redundancy than that so Airlines invested heavily in what they called tri jets engines that had planes that had two engines one of the wings and one mounted through the tail and that's what you had been getting on this day specifically a dc-10 series 10 aircraft tail registration number November 1819 uniform that picture is the actual plane you had been getting on that day it was an old but proud plane delivered United in 1971 and had been in service since then for about 18 years now 18 years seems kind of old for an airliner but it's really not United would actually fly their dc-10 flight fleet well into its 30s and you can still see these planes around the world today carrying packages and FedEx delivery a lot of them are still operating as you got on board you'd have seen something like this if you've been on board of Boeing triple7 recently this cabin is just a little bit wider than that it was a wide and roomy cabin was a quiet plane and pilots love to fly it they referred to it as the Cadillac Fleetwood of the skies because it was such a comfortable ride and the three engines gave it way more power than it needed so they loved love being able to put their hand in the throttles and push them forward for takeoff and let the power of that plane slam them back in their seats if they took the skies around to 10:00 in the afternoon that day that's exactly what happens it was a textbook takeoff out of Denver Stapleton they turn east-northeast out of the airport toward Chicago and if you'd been in the cabin at that point you'd have smelled chicken strips United was running a promotion that summer they called their picnic lunch so if you were flying at lunch time they would bring you a little basket cover to run white check paper with picnic lunch in it and that day it happened to be chicken strips a few Oreos and a cup full of cherries well about an hour into the flight most people had finished their lunches the flight crew was beginning to pick up from lunch Jim McKay the legendary American sportscaster from ABC's Wide World of Sports was about 20 minutes into explaining the history of horse racing in the in-flight movie jewels of the Triple Crown sounds thrilling I know and about that point what had become what had been a completely normal flight up until then suddenly changed there was a tremendous bang at the back of the airplane passengers thought maybe a bomb had gone off the flight crew across the plane hit the deck and grabbed the nearest armrest afraid that what they had heard was an explosive decompression and they might be sucked out of the plane close neither of those things what had actually happened is the fan disc in the number two engine the tail mounted engine had exploded on the flight deck they had just finished their lunches when they heard this explosion first officer bill records who have been sitting in that seat on your right there immediately yells I've got it lunges forward grabs the yoke disabled the autopilot and starts flying the plane by hand Dudley Dvorak the flight engineer who would have been sitting at that control console right there on the right starts checking his gauges and immediately notices the number two engine is failed so he radios Minneapolis st. Paul air control center not to declare an emergency but just to ask for clearance to lower altitude but goes on a dc-10 I mentioned the redundancy of the three engines it actually wasn't that big a deal to lose an engine with the reliability of these engines built in the 70s and 80s losing engine wasn't all that uncommon so standard procedure was just to request a lower altitude slow down a little bit and continue on to your destination and that's exactly what they intended to do about this point captain al Haynes who was sitting in the pilot's seat that day asks for the engine shutdown checklist from from flight engineer Dudley Dvorak now captain Haynes at this point was primarily concerned with making sure that whatever happened to this number two engine didn't escalate into a bigger crisis when engines failed it's possible that it could be catching on fire or there could be physical damage and you wanted to avoid making the situation any worse so we asked ugly Dvorak to start in on the checklist the first thing on the checklist was to close the number of the number to throttle and so captain Haynes tried to do that and could the wooden budge the throttle was stuck so he moved on to the second step of the checklist the second step was to shut off the fuel shutoff to this engine they tried that as well wouldn't budge and is at this point that they finally understood that something more than a routine engine failure had befallen their beautiful plane that day the thing you need to know about the dc-10 is that the throttle and the fuel shutoff are both physically coupled to the engine via steel cable if you think about how a bicycle brake works it's the same theory so the fact that both of those controls were jammed hold the flight crew that there must be some significant physical damage to the aircraft so hands into work we're trying to figure out what to do next when bill records from the copilot seat shouts ow I can't control the plane which is a terrifying thing to hear so captain Haynes looks over and bill records with his arms as tense as they could be has the yoke all the way back all the way to the left there's two things about this that terrifying the first thing is you would never give an aircraft that kind of input at cruise speed you'd be like driving down the highway at 85 miles an hour and suddenly jerking the steering wheel all the way to left you would lose control of the plane if you did that but even more terrifying than that despite the fact that that records had the yoke all the way back which would command the plane to go up and all the way to the left which would command the plane to turn left it was doing the exact opposite it was descending and rolling to the right so at this point captain Haynes yells I've got it and takes the controls from Bill records and tries to see if he can have any effect on the control surfaces of the plane meanwhile flight engineer Dvorak is still studying his gauges trying to figure out exactly what's happened to his beautiful plane when he something catches his attention he glances up from his gauges momentarily out the windscreen of the aircraft and immediately yells were rolling at this point the plane is about 38 degrees of Bank which is pretty steep for a commercial plane it'd be pretty uncomfortable if he were back in the passenger cabin and immediately to an instinct that he still doesn't understand to this day captain Haynes swats the number one throttle closed opens the number three will throttle all the way to the firewall wide open and subsequent studies showed subsequent subsequent simulator exercises showed that in that moment captain Haynes saved their aircraft because after he did this the point slowly started coming back to level pushing the number three throttle all the way up and pulling the number one all the way back increased list on the right wing and pulled it up counteracted the drag that the failed engine was having on the tail and with the point now under relative control Dudley Dvorak makes the first announcement of passengers now something I need to tell you is that this particular dc-10 only had a 30-minute loop cockpit voice recorder and the actual accident sequence is about 47 minutes from when the fantasy ruptures to when the plane gets to the ground in Sioux City so the first 17 minutes of the crash were really lost to history but according to accounts from the flight crew and from passengers on board what Dvorak said when a little something like this Wow waited there there we go ladies and gentlemen we've lost our tail engine but this aircraft can fly fine with the two remaining engines we're going to descend and continue on to Chicago perfectly reassuring thing to say to the the people in the back of the airplane but almost immediately after making this announcement Dvorak finally spots the thing in his gauges that he's been looking for so intently and realizes that they they have a much bigger problem on their hands and what any of them thought he notices that on his hydraulic gauges hydraulic quantity and hydraulic pressure across all three hydraulic systems are at zero so he has no hydraulic pressure and no hydraulic fluid and that means that he's not going to be able to control the plane so at this point bill records radios Minneapolis st. Paul air traffic control and declares emergency this time and asks for a diversion of the closest suitable Airport and they send into Sioux City Iowa about this point in flight back in the passenger cabin the overhead chimes ringing in Jann Brown section Jann Brown is the one there on the far left in the turquoise suit and she's the head flight attendant on this flight that day she looks around the cabin she can see the rest of the flight crew nobody has their phone off the hook she knows it's not anybody in the cabin she knows it must be from the cockpit and she also knows that getting a call from the cockpit during the cruise flight there's going to be nothing but bad news sure not Dudley Dvorak asked her to report to the cockpit and she knows if she's being asked to report to the cockpit that it's certainly not good news and telling this story later Jan Brown says my whole world change when I open that door there was no panic but the sense of crisis was absolutely palpable in here captain Haynes told her we've lost all of our hydraulics we're having trouble controlling the plane we're going to try an emergency landing in Sioux City in about 30 minutes so I need you to prepare the cabin and brief the passengers my signal when we're about to land will be brace brace brace and I need all the passengers in brace position at that point Jan I don't know how this thing's going to turn out so good luck all right so Jan brown mustard and meager thank you and then ducks into the lavatory to compose herself before making the rounds and briefing all the flight attendants on the plane and beginning the preparations for this emergency landing meanwhile captain Haynes ask Dudley Dvorak to look in the flight manual and find the procedure to handle complete hydraulic loss the FAA mandates yeah the all our Academy so so the Federal Aviation Administration in the u.s. mandates that any likely failure modality that's going to strike an aircraft has to be documented in one of these checklists you have to have a set of failure procedures for where anything goes wrong well there's no checklist of course there's not because nobody ever expected a dc-10 to lose all of its hydraulics and it's at this point that Minneapolis st. Paul Center finally hands the flight over to Sioux City Iowa and captain Haynes makes this initial contact with the tower in Sioux City ok so you know we have all our social abilities very little elevators and also not we're all experienced by power I mean we can only penetrate every level today and 232 heavy understand sir you can only make right turns of the hood sounds fun done it so you to understand what Catholic means of saying there you need to know a little bit about how airplanes are controlled he says we have very little elevator and almost no aileron so the elevator is the control surfaces here on the horizontal stabilizer at the back of the plane and that controls the planes movement up and down so in saying they have no elevator he's saying they have no ability to control their altitude he also says they have no ailerons now ailerons are these surfaces on the back of the wing that control roll going into turns they would use the smaller inboard ailerons at high speed cruise and the larger outboard ailerons when they were going slower close to the ground they had neither set so they couldn't control the altitude of the plane they can control the roll of the plane he doesn't say it but they don't have any rudder either so they can't control it they can't even control the off the plane they're literally only controlling the plane by the thrust from the two engines well shortly after this exchange with air traffic control Jan Brown has composed herself and she's making her way back through the first-class section and she's briefed Jan Murray who's in the pink there on the left with her arm in a sling and Jan Murray begins walking through the first-class cabin picking up leftovers from lunch and starting the emergency preparations for landing when Denny Fitch is on your right there gets her attention now Denny is another United Airlines dc-10 pilot and he's commuting home from Denver to Chicago he likes to say about himself that he has a radar for people in distress and that Jan Murray was clearly in distress so he gets her attention and he says Jan don't worry about this this thing flies fine on two engines we simply have to get to lower altitude Jan Murray leans down so as to not be heard by overpass other passengers and says oh no Denny the pilot and co-pilot are flat trying to fly the plane that they've told us we've lost all our hydraulics well as a dc-10 captain Denny Fitch knows there's no way that's true because in addition to being a dc-10 captain Danny Finch's a dc-10 check pilot and he actually spends his days in Denver at United Airlines flight simulation center torturing other pilots through full motion flight simulators he's literally been through every emergency scenario that they expect to occur on a dc-10 he's taken pilots to it to see how they react and he's never heard of a dc-10 losing all of its hydraulics so he tells Dan Murray would you please go let the captain know that he has a dc-10 check pilot riding back here and I'd be happy to come up and offer any assistance that I could well captain Haynes upon hearing this readily agrees hoping that this dc-10 check pilot will have some magic incantation or know about some secret switch that will fix their plane and give them control but when Fitch gets for the cockpit he looks over Dudley Dvorak shoulder at the gauges he sees no hydraulic quantity no hydraulic pressure he checks the busbars to make sure there's not an electrical fault that might explain loss of flight instrumentation there's not he knows he's never seen anything like this he says at that point the only question I had was how long was going to take Iowa to hit me so I've alluded to this several times but losing all hydraulics in a dc-10 was considered an impossibility the reason for that is the dc-10 is built with three redundant hydraulic systems one powered by each engine and each control surface on the plane was controllable by at least two of those hydraulic systems once more the dc-10 was one of the first generation of aircraft along with the Boeing 747 Milwaukee 1011 Tristar that had no manual reversion and what that means is if you're flying on say a Boeing 737 a smaller plane you lose all your hydraulics the flight crew can still wrestle the yokes and get some response out of the flight control surfaces be like going down the highway and losing your power steering you can still steer the car it's just going to be a lot more work not on the dc-10 the control surfaces are so large and the forces acting on them are so strong that it would be of no use to provide manual reversion you can only move the flight control surfaces if you have hydraulic systems so without any of their three hydraulic systems the research that had been done indicated that one of two things would happen one the plane would go into an uncontrollable flutter and fall of the earth like a leaf or like this plane had tried to do it would roll over on its back and go into a descent so fast that it would actually tear the wings off the plane before it ever got to the ground but neither of those things happened United 232 stayed in the air at this point since Denny Fitch didn't have any magic fixes captain Haynes asked them to take over the throttles because it was much easier for someone to kneel down between the two seats and control the throttles at the same time than for him and Bill records to control the number one and number three independently and try to coordinate their actions meanwhile captain Haynes radios Sioux City again to reiterate the darkness of their condition we have no hydraulic fluid which we have no elevator control almost done and under the later on control I have serious doubts about like a shear force it just got to some places here there that we might be all the ditch and I don't get to throw it if I want to put it down wherever it happens to be and then in the air traffic control audio there's this really uncomfortable pause for Kevin Bachman tries to figure out what in the world to tell this flight crew and he comes back with a really strong answer united 232 heavy registers pick up a road or something up there Brooke let's go up anywhere from 2,000 feet up 15 her downhill waves ha John can you pick up a road thanks Captain Obvious so in that bit of audio you can hear one of the things that the flight crew is fighting about this plane and it's called foo Boyd oscillation it's actually one of the default flight modes of an aircraft no flight control services what happens is plane without flight control surfaces will immediately dip into dive and slowly it'll build air speed over the wings which will build lift and the plane will return to an ascent and it will go up for a little bit until it loses airspeed until it loses lift on the wings and start to descend again the plane is trying to find equilibrium between the lift on the wings and the gravity acting on the plane if you throw a paper airplane off of a tall enough building you'll see it do exactly the same thing it'll flutter to the ground going up and down at a food-grade oscillation all the way to the ground but captain Haynes gets a crucial fact wrong in this call to Sioux City tower he said that they were going up 2,000 feet and down 1,500 in each wave those numbers are backwards flight 232 was actually losing about 500 feet of altitude for every food boyd cycle that they went through you can see it when I add that dotted line so captain captain Fitch is sitting there with the throttles you've already heard that the plane wants to turn right so he's trying to mitigate the plane's tendency to turn right in addition to that with just the two throttles he has to mitigate the tendency of the plane to go into these food oscillations try to get it to fly level because if they can't control the fugu fugu it oscillations they have no chance of getting this thing to the ground they will fuga way to oscillate their way straight into the earth you can hear how well this is going in the next air traffic control transmission with your forces now jump up and down here in at 232 I have assisted airports about 12 o'clock and three six past okay we're time to go update I have my club we're trying to go straight but we're not having much luck Denny Fitch is getting the food oscillations under control but he's not having much luck with the right turns if I show you the radar track of the flight you can see what I'm talking about so you can see the plane enters this chart at the bottom and it's going up and it enters a turn towards Chicago and right at that triangle in the upper right corner is where the fan disc on the number two engine fails and after it fails the plane enters into a very wide sweeping turn and about the bottom of that turn is where Denny Fitch takes over control of the plane and you see it wanders a little bit as he tries as he figures out how to control the turning but then as he starts to work to figure out how to control the food wide oscillations they go into a series of very sharp right-hand turns this would actually prove to be fortuitous because it's the only thing that allowed them enough time to descend and to be able to land in Sioux City about this point Jann Brown is walking from the back of the plane when a passenger told her to take a look at the rear stabilizer this passenger had seen a big piece of metal sticking up out the window so she looks sure enough she can see it she goes to the cockpit she tells Dudley Dvorak the same thing and Dvorak comes back to take a look there's a picture of this flight taken from the ground as its approaching Sioux City Airport that you can see exactly what they were seeing if you look closely at that rear stabilizer you can see there's some places where daylight is peeking through where it shouldn't be if I put a normal dc-10 tail next to it you can see a little bit more clearly specifically this holes punched in the rear stabilizer it's missing the exhaust exhaust cone on the engine and the plane is missing its tail cone there's actually 70 separate pieces of shrapnel that pierced the tail section of this plane and they all came from this an object they found in a cornfield in Alta Iowa about three months after the crash they didn't find it intact so you can see on the right of this disk there's clearly a crack they actually found the two halves of the disc in separate places and they found each of those fan blades in a separate place this had completely separated what you're looking at here is the front intake fan of the GE CF six six turbofan engine that powered the dc-10 if you look at an aircraft sitting on the tarmac at any Airport and you see the fan in the front of the engine this is that fan you can see that there's a containment ring around it but that containment ring is designed only to contain the weight of one of those fan blades letting go those fan blades weigh about two pounds apiece the fan disc about 350 so there was absolutely no chance to that containment ring was going to contain this fan disc and if you look at the placement of the engine in the tail of a dc-10 you can see it's perfectly mounted to cause a ton of damage to that rear stabilizer not intentionally that's where it needs to be mounted for the aerodynamics of the plane for that engine to be efficient but when this fan disc failed and was uncontrolled all of that fan disc went flying through the tail of the aircraft the reason that's important is because the tail of a dc-10 is the one place in the entire plane where all three redundant hydraulic systems come together of course it is so when they lost the number two engine they lost the number two hydraulic system because the number two hydraulic pump is attached to that engine the shrapnel knocked out the number one and number three hydraulic systems immediately after the explosion some of the passengers on the plane reported hearing a siren like sound what they were actually hearing was the hydraulic pumps attached to engine number one and engine number three working as hard as they could to bring the hydraulic system back up to pressure but actually pumping every last bit of hydraulic fluid they had overboard well while Dudley Dvorak is at the back of the plane looking at the stabilizer damaged Denny Fitch finally pulls off something that they had thought was impossible up to that point he makes a left turn this is the only left turn the plane was going to make all day that date it was a crucial left turn they had to turn left in order to get pointed back towards Sioux City Airport if they missed their approach to Sioux City there was another airport anywhere within range that they would be able to make it to so they desperately wanted to get to Sioux City in order to attempt the landing and in congratulations immediately after they make this left-hand turn Kevin Bachman Bachman radios them with this in a 230 mm after one out just slightly to your left sir tonight the trying to final and also I'll take you away from the city whatever you do with your public money can you widen out a little bit to the left do that do that impossible thing again for us but you can hear the desperation and captain Haynes is voiced there he's still not very hopeful of their journey of this day the crews still fighting to suppress the fuga way to keep the plane lined up with the airport they're working as hard as they can to try to bring this plane to Sioux City Iowa and you can hear the relief in captain Haynes voice when they finally spot the airport united 232 heavy roger and a dust at the airport today the runway in sight we'll be with you very shortly thanks a lot your help sounds pretty really finally has a little bit of hope a few minutes later Kevin Bachman calls back with their landing clearance which is probably my favorite air traffic control exchange in this whole sequence k9 232 heavy the West currently 361 1 360 11 you're cleared to land on any red line you want to be bigger than I get around Lee [Music] so in the midst of this crazy incident I don't this is Pilate gallows humor or if it's him actually being this controlled but he has to wear with all the crack that's a joke with air traffic control about landing on any runway well it turns out they actually do get lined up with the runway but it's a runway that's been closed since World War two and it happens to have all of the emergency equipment sitting on it and there is a runway it's closed sir that could probably work to the south it runs a northeast to southwest pretty well lined up on this one I think we will be fine [Music] united 232 heavy a Roger sir that's a closed runway that'll work so we're getting equipment off the runway and a line up for that one is it 6 to 600 feet six thousand six hundred and the equipment's coming off so they get lined up to runway it's a closed world war two runway it's not in great shape all the emergency equipments on it they're in there five mile final at this point so they're really close to the airport when they're having to scramble all of this emergency equipment off of this closed runway to other places on the airport now their emergency planning procedures called for them to be on this runway because it was in proximity to the other runways at the airport it was a convenient place to respond from so they had to try to figure out how to get out of the way of this plane that they had no way of predicting where it was going to go shortly after this Haines gives the brace brace brace command and the flight attendants begin shouting brace in unison over and over again a couple of passengers stick their head up to look out the window to see how close they are to the ground and the flight attendants immediately I'll get your head down and as 232 lined up the tower got excited they were actually lined up with a runway they were going to make the airport Kevin Bachman at one point stood up and scream they're going to make it but then people started noticing that 232 wasn't floating like arriving airliners normally appeared to do it's coming in very fast and the reason for that is because without hydraulics they had no slats or flaps slats our flight control surfaces on the front of the wing and flaps around the back of the wing and they extend them when the plane is flying slow because it gives the wing more lift the plane needs that extra wing surface when it's flying slow low to the ground in order to have enough lift to not stall without slats or flaps if they slow down for landing they're literally going to stall out of the skies they're not going to have enough airspeed to make it to the ground so as a result of this 232 that day was traveling at 250 miles an hour as it came in for landing normal speed for a dc-10 about 125 so going twice as fast as they ought to be going the sync rate of the plane is even more alarming they're descending at 1,800 feet per minute now the structural integrity of the landing gear was rated for 600 feet per minute but that would have been the hardest landing you've ever experienced a normal landing at a dc-10 was 200 to 300 feet per minute so they are absolutely plummeting out of the sky a few minutes before they hit the ground you can hear the ground proximity warning system tell them to pull up that their planes in danger and captain Haynes says our luck ran out about 50 feet above the runway the plane went into one last goo-goo-eyed oscillation and the wing dipped right right as they got to the ground and they made first contact with the right engine may sell and it spun the plane around the impact was hard enough that it knocked the number of the damaged number 2 engine completely out of its mount and without that weight in the tail of the plane the lift of the rear horizontal stabilizer was enough to pull the back of the plane up and over in a cartwheel down the runway because of the 30 minutes advance noticed that they had that this plane was going to crash there actually is news footage of this plane coming in and crashing and I do have that video I'm going to show it now I will warn you if you're squeamish you might want not want to watch there is a good bit of fire and smoke so you can see how fast that plane is coming in it's not floating it's coming in really quick and somewhere behind these trees and buildings that right wing makes the first contact with the ground and you can see it come sliding through with fire and smoke about here you see the rear come and cartwheel over and it continues sliding down the runway with the jet fuel leaking out of the tanks they had they ditched as much fuel as they could but they had to have enough to get to the ground and you can see what's remaining in the plane catching on fire with that acrid black smoke that's rising up from the wreckage here's the crash site they slid across the airport and ended up in a field of soybeans that patch of concrete sits at an angle at the top of the screen is the closed world war two runway runway 22 the plane actually hit hard enough that it drug a six-foot ditch in that runway with its landing gear just tore the concrete right out of the ground Kevin Bachman at this point left the control tower to weep because he had just watched the crash and he knew everybody had died because how could anybody live through that but his rescuers arrived at the plane a strange things started to happen people started to emerge from the wreckage some of them without a scratch there's a story of one passenger who was walking away from the plane seemingly on her turned around walked back to the wreckage got his suitcase and they would later find him in the airport bar drinking a glass of whiskey so 232 was still absolutely a tragedy 111 people died that day but of 296 people on board a hundred and eighty five of them survived now there's a bit of context I need to give you so you can understand the significance of that 185 number up until this point in the previous 25 years of commercial aviation no one had ever survived the complete loss of flight controls of an airliner nobody 185 survived this day the National Transportation Safety Board is the the US government body that investigates plane crashes there's a telling line in their report as well they say the Safety Board believes that under the circumstances the United flight crew performance was highly commendable and greatly exceeded reasonable expectations reasonable expectations this day would have been nobody surviving the NTSB in the process of developing their report did extensive simulator exercises they configured dc-10s and simulators for exactly the flight conditions at 232 fat-faced that day very few flight crews they put through the simulator exercise got the plane anywhere close to the airport nobody was successful as this crew it's how they do it what made this flight crew different let me let captain Haynes tell you himself in a speech that he gave at NASA's Ames Research Facility the preparation that paid off for the crew was something that United Airlines started in 1980 called cockpit resource management up until 1980 we kind of worked on the concept that the captain was the the authority of the aircraft whatever he said goes and we've lost a few airplanes because of that we had 103 years of flying experience up there in the cockpit trying to get that airplane on the ground not one minute of which we had actually practiced any one of us so why would I know more about getting that airplane on the ground under those conditions than the other three so if I had not used CLR if we had not let everybody put their input in it's essentially wouldn't emit so what captain Haynes is talking about there is modernly referred to as crew or cockpit resource management and it's focused on the human dynamics of the cockpit a United 232 is actually considered one of the first big success cases of crew resource management it's focused on interpersonal communication leadership and decision-making it's actually based on research that was done by NASA's Ames Research Center so it's interesting that that's where he was giving this the speech there were a couple of crashes were stubborn captain's not listening to their flight crews had caused tiny problems turn into big disasters one of the most notable was United flight 173 that cry outside of Portland Oregon and what the crew was facing that day was an indicator indicator that told them that one of their landing gear was not down now it turned out their gear was down the whole time it was a faulty switch in the wheel well but they spent so much time flying around trying to troubleshoot the problem and despite the urgings of the copilot and the flight engineer that they were about out of fuel and they should return to the airport they crashed four miles short of the airport because the captain wouldn't listen he was insistent there was landing your problem and they needed to fix it there's a couple of tenets of crew resource management that are very relevant to how we spend our days as software engineering leaders first of which is no heroes see cockpit resource management emphasizes cooperation over heroics one of the things that struck me as I was doing the research for this talk is captain Haynes deliberately uses the word we' when he's talking about the sequence of events he says things like we were at 38 degrees of bank and increasing so we closed the number-1 throttle and firewall the number three now he uses the word we there to talk about the moment that he captain Haynes saved flight 232 he lets Denny Fitch stay on the throttles long after it's obvious that that's all that's controlling the plane it'd have been really easy for him to go okay this is the only control we got then he get out of the way it's my ship but instead he recognized that Dennis Fitch had been sitting at the throttle long enough and had developed that rhythm I had developed an intuitive understanding of how the airplane was operating under these conditions and that it was best to let Denny Fitch continue to do that job rather than him asserting his authority as the captain of the plane now do we do that as soccer leaders we need to encourage our teams to work together to find solutions to hard problems and we need to sell like celebrate success as a team and learn from failure as a team as well we shouldn't look for individual heroes and individual scapegoats we should live as a team and die as a team one of the best ways to do that is to make sure that everyone has a voice you heard captain Haynes say it if everyone on the plane hadn't had input it's a cinch we wouldn't have made it it's an obvious clear connection to Soph or teams here as leaders we desperately have to avoid allowing our teams to develop dominant voices we especially have to make sure those dominant voices are in our own because it's really easy to get into that cycle it's really easy to forget as either an explicit or implicit leader on your team the weight that your comments have you can guide your team's effectively because of the authority that your voice carries but it's a double-edged sword you can also create conditions where you're the only voice that's guiding your team and other people are afraid to have input this is especially true with new engineers you need to give new engineers space to develop their identity and software to assert their their growing authority and to make the mistakes they need to make to learn and grow if there's only one dominant voice and it's constantly correcting new engineers on the team they're never going to make the mistakes that they need to make in order to learn the lessons they have to learn it's also essential if you're building a diverse team and you absolutely should be because of the diversity of perspective and expertise that it brings to your team but if you allow dominant voices to take over the conversation of your teams you'll find it very hard to subtract and keep diverse talent on your team because voices that are used to being marginalized will pick up on that pattern very quickly and they won't hang around to give you the benefit of the doubt and see how it's going to turn out so if you want to build diversity on your teams you have to make sure that everybody on your team has a voice you have to cultivate that team culture what are the interesting things about cockpit resource management is that the captain is still the captain every decision that's made in the cockpit still comes down to him so as a team lead you do still have authority but in cockpit resource management the captain's job is to ensure that he uses his authority to make sure that every voice on the cockpit is heard everybody has input that he's heard every idea available without that it's really doubtful that this crew could have gotten this outcome out of United flight 232 they wouldn't have made it to Sioux City Airport they wouldn't have gotten to the first responders who got every survivor to the hospital in under 45 min they would have been crashed in the middle of a cornfield somewhere in Iowa and it would've taken the response much longer and the outcome that they would have been far different so remember that software is a team sport building software takes technical skill but building the right software takes human interaction and lots of it so make sure you're building that kind of culture on your team a lot of our teams tend to look like those flight crews that brought planes down let's work together to look more like the crew of flight 232 if we do that if we focus on building that kind of culture on our teams we will do amazing things together thank you [Applause]

Channel: White October Events

Views: 128,252

Rating: 4.8781915 out of 5

Keywords: Nickolas Means, nick means, How to crash an airplane, The Lead Developer UK, The Lead Developer UK 2016, lead developer, lead dev, the lead developer, white october events, tech lead, lead developer conference

Id: 099cHWSbAL8

Length: 43min 13sec (2593 seconds)

Published: Wed Apr 26 2017