Comments about technological history, system fractures, and human resilience from James R. Chiles, the author of Inviting Disaster: Lessons from the Edge of Technology (HarperBusiness 2001; paperback 2002) and The God Machine: From Boomerangs to Black Hawks, the Story of the Helicopter (Random House, 2007, paperback 2008)

Friday, March 3, 2017

Sully, the Movie, and the National Transportation Safety Board

The National Transportation Safety Board is never far from the news, given its broad jurisdiction over moving-vehicle mishaps in the civilian sector. Here's a link to its update on the uncontained engine failure at O'Hare last October, an event of some concern given the rarity (no docket is posted yet):
The Board's methods (complete with fictional figures) were portrayed in the movie Sully as a witch hunt attempting to find fault on the flight deck.

But anyone familiar with NTSB procedures know that Captain Chesley Sullenberger wasn't being set up. Yes, the real Board did dig deeply into whether he could have flown the airplane back to the airport. It wasn't to look for someone to blame, but for lessons to share. 

Here's the report:

Here's the accident docket:

Here's a sample document from the docket, concerning the quick reference handbook that's referenced in the movie:

During the fifteen months between the ditching and the final report, simulator trials showed it would have been barely possible to get back to the airport, but only if the crew had executed the return without any pause to sort out what had happened. (Illustration from

As the Board freely acknowledged, the return-to-airport scenario would have required perfect and instantaneous knowledge. In real emergencies, a crew must take time to stabilize the system, figure out what's happened, look at their options, reach a decision, communicate, assign duties, and execute. Short-cutting any of these steps is a fast way to disaster. 

And as the crew knew, attempting a return to the originating airport after engine failure during early climbout is, in most cases, a bad idea. It's why pilots call it the Impossible Maneuver. Flight 1549's crew made the right choice, but the Board wanted to look at all the angles, and in particular whether training and manuals were of any help. 

Anybody who's familiar with transports, as the Board is, would know what splendid airmanship the crew performed that day. For one thing, even a slight bank at the time of ditching would have sent the Airbus into a cartwheeling crash, because the big turbofans act like brakes when hitting the water.

The Board's interviews can be tough and pointed in some cases, but that's what fact-finding is like - sorry! 

For a real grilling, go in front of a murder board. That's a group of experts who do everything they can to find gaps in a plan such as a special-operations mission.

I was at the Board's offices in Washington last year and had a chance to see a bit of the process of mustering a go-team process. I had finished up a talk to the Board members and staff on what I call the Narcissistic Risk-Taking Leader, and was talking with Chairman Christopher Hart by his assistant's desk. 

At that point one of the staff came in to report a Greyhound bus had crashed in San Jose, with fatalities. They checked the schedule for which member was on call, and a go-team was assembled. Chairman Hart did take the time to walk me out of the complex, which isn't easy to get around. 

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