Wall Street Journal Interactive Edition
March 19, 1999
United 747's Near Miss Initiates
A Widespread Review of Pilot Skills
William M. Carley
Staff Reporter, Wall Street Journal
As the United Airlines jumbo jet lifted off from San Francisco
International Airport one night last summer, one of its four engines lost
power. Because of poor flying techniques, the co-pilot who was at the
controls slowed and nearly stalled and crashed the plane.
"Push [the nose] down" to pick up speed, shouted two extra pilots
sitting in the rear of the cockpit. The co-pilot did, but now the jet was
off course and heading toward San Bruno Mountain northwest of the airport.
The jet's ground-proximity warning sounded, and the extra pilots shouted,
"Pull up, pull up!"
Carrying 307 passengers and crew, the plane cleared the hill by only 100
feet. The jet also barely missed apartments and houses with hundreds of
sleeping residents. A crash of the jet, which was heavily loaded with fuel,
would have been one of the worst aviation accidents in history.
The captain finally took control and flew over the ocean, dumping fuel
before returning safely to the airport. But the incident -- just now being
publicly disclosed -- has rocked the world's biggest airline and spurred
the Federal Aviation Administration to force changes in United's
pilot-training techniques. The jumbo's low flight also has alarmed local
residents, with one man declaring in a call recorded by an airport hotline:
"I thought the damn thing was coming in on my roof."
United, a unit of UAL
Corp., based near Chicago, acknowledges the incident and says that it has
spurred the carrier to take a series of steps, ranging from a safety audit
of all its 9,500 pilots to a major shakeup in its pilot training. Edmund
Soliday, vice president for safety, says the airline hasn't lost a plane
because of poor piloting for 20 years, "and we are taking this incident
very seriously." He says the airline aims to improve its margin of safety
"so we won't have to look at a hole in the ground someday."
In Washington, Nicholas Lacey, who as FAA director of flight standards
is the agency's top official on piloting issues, says United's close call
"didn't result in a tragedy -- but it was a near-tragedy." Mr. Lacey adds
that for a variety of reasons, "complacency might have set in" among some
United pilots.
The agency is now pushing United hard to improve skills of its pilots,
especially its 747-400 co-pilots, or to ground some of them. One FAA
mandate that was to become effective this month would have grounded so many
United co-pilots that it would "severely hamper" the airline's
international operation, according to a letter to United pilots from the
Air Line Pilots Association. (The union represents the carrier's pilots.)
That FAA proposal has been modified, and United says international flights
won't be cut, but the agency is still pressing for pilot improvements.
Additional United close calls in recent months -- also never publicly
disclosed -- have broadened the concern beyond the 747-400 crews. "In the
past months, we have had several operational incidents," airline jargon for
close calls, W.J. Carter, chief of United's Honolulu-based pilots, wrote in
a Feb. 23 internal memo to his flight crews. "Major accidents historically
are preceded by a series of these seemingly unrelated incidents. This
disturbing trend is cause for concern," the memo continued.
United has set up a special one-hour safety seminar which all its pilots
must attend by May 10. If they don't, they will be dropped from the flying
schedule without pay. According to the union's letter to United pilots,
"This is as close as an airline can come to a military 'stand down,' " when
military flyers are temporarily grounded because of safety concerns.
United officials declined to discuss details of the incidents because
they were disclosed to management by pilots under a confidential
safety-reporting system. But many safety analysts say that United, which
had no legal obligation to publicly disclose some of the close calls,
should be commended for alerting its pilots. "They have treated this [San
Francisco] incident like an accident to raise safety awareness among their
pilots, and for that I give them kudos," says the FAA's Mr. Lacey.
Despite the close calls, United emphasizes its safety record is
excellent, with nearly 6.2 million flights without a crash since a United
737 went down in Colorado Springs in 1991. Safety analysts agree that
United's record is strong. United has been a leader in many safety
measures, including teaching pilots in simulators how to escape wind
shears, beginning in the 1980s, and installing better ground-proximity
warning systems in jets in recent years.
The close call in San Francisco, safety analysts say, raises issues that
have been worrisome for years. Airplanes are designed to take off and climb
safely even if an engine fails. In the San Francisco episode, why didn't
the United co-pilot fly the plane properly? There is "no doubt we had a
pilot proficiency problem," concedes United's Mr. Soliday.
One factor in pilot proficiency is the enormous increase in long-range
flying in recent years. The jet in the close call was a Boeing 747-400,
designed to fly nonstop trips such as New York to Tokyo. The jumbo
routinely makes 14-hour flights. Concerned about pilot fatigue, Boeing
designed the cockpit for as many as four crew members: a captain and
co-pilot who handle flying duties, and two extra pilots sitting behind
(dubbed "bunkies" because they can rest in bunks) who relieve the others
during the flight.
But because these flights and rest periods required between them are so
time-consuming, pilots make only a few trips each month. And with four
pilots aboard, chances of practicing takeoffs and landings -- the most
critical phases of flight -- are few.
At United, says a spokesman, captains of 747-400s average only three
takeoffs and landings a month. Co-pilots, because there are three of them
aboard each flight, get even less practice, averaging just one takeoff and
landing a month. Because of scheduling complexities and vacations, some
co-pilots don't make a takeoff and landing for months.
The problem isn't unique to United. Boeing has sold nearly 450 of the
747-400s to 30 airlines around the world, including British Airways, Japan
Airlines and Northwest Airlines. Nor is the issue confined to Boeing
planes; the Airbus Industrie A340 makes similar long flights, many with
four pilots in the cockpit.
How many jets at other carriers may have had narrow escapes similar to
United's isn't known. Because of limitations and loopholes in FAA and
National Transportation Safety Board databases, many close calls escape
public notice. But David Simmon, a former United pilot who is now a safety
consultant, says long-range flying "is known to cause proficiency problems
due to the limited number of takeoffs and landings shared among a
four-person crew." The issue, he adds, "is an ongoing industry
problem."
Another factor in the San Francisco close call may be complacency. The
latest generation of jets, including the 747-400, are so highly automated
and reliable that pilots may simply get bored. "On these long flights, it's
very hard to keep the pilots on the edge of their seats," says Cecil Ewell,
chief pilot and vice president for flight at American Airlines. "Hardly
anything ever goes wrong," says the FAA's Mr. Lacey.
The answer to these concerns was supposed to be simulators, where pilots
can drill regularly and practice emergency moves. But the simulators can't
replicate everything, and still can't replicate critical moments in
United's close call. There are also questions about how well simulators are
used for training. Asks Mr. Simmon, the consultant: "Is some simulator
training perfunctory?"
Such problems may have played a role last June 28 as United Flight 863
prepared for takeoff at San Francisco International. FAA documents and
tapes of air-traffic controllers obtained by The Wall Street Journal under
the Freedom of Information Act, as well as interviews with pilots familiar
with the incident, show the takeoff wasn't going to be routine.
Bound for Sydney, Australia, the jet weighed almost 450,000 pounds and
was carrying nearly an additional 400,000 pounds of fuel for the long
flight -- weight that would reduce its ability to climb. And as the jet
revved its engines at 11:39 p.m., ocean fog had crept in, obscuring much of
the San Francisco area -- including the hills northwest of the airport.
"United 863 ... , runway 28 right, cleared for takeoff," the San
Francisco tower controller radioed to the plane.
For reasons that remain unexplained, the co-pilot at the controls had
even less real-world practice than usual. He had made a takeoff and landing
in a real 747-400 the previous week, but that was his first in nearly a
year. (FAA rules call for three takeoffs and landings within 90 days, but
all can be done in a simulator.)
Just as the jet lifted off from the runway heading northwest, the right
inboard engine malfunctioned for unknown reasons, triggering so-called
compressor stalls in the engine. These stalls produce enormous backfires,
with fire and smoke exploding out the rear of the engine and violently
shaking the whole plane.
"It's bang, bang, bang and shudder, shudder, shudder," says the FAA's
Mr. Lacey.
The shaking was so violent that the pilots couldn't read their
instruments at first, and frantically guessed at the cause. "Maybe it's a
[blown] tire," one of the extra co-pilots shouted. But then the co-pilot at
the controls read an instrument showing problems in the right inboard
engine, and it was shut down.
With two engines at full power on the left wing and only one now
operating on the right, the left engines began pushing the plane into a
right turn. To counter that, pilots say, the co-pilot should have just used
the rudder on the tail. But he mistakenly turned his control wheel to the
left. That extended ailerons, control panels on the rear of the wings which
would tend to make the jet bank to the left. But the co-pilot's action also
extended spoilers, panels on top of the wing that increase drag and cut the
jet's ability to climb.
Unable to climb much, but with its nose still up, the heavy jet began to
slow down, so much that the dreaded "stick-shaker" warning began. In this
warning, the pilot's control column literally shakes, signaling the plane
is going so slow that it's beginning to stall and is about to crash.
"Push down, push down" the nose to gain speed, the extra co-pilots
yelled. The co-pilot did, but now there was another danger ahead. Off
course because of the right turn, the jet was headed towards San Bruno
mountain, a broad lump that rises to 1,576 feet a few miles northwest of
the airport. Densely populated areas lap at the mountain's base. The crew
couldn't see the mountain. It was bathed in dense fog.
Suddenly the plane's ground proximity warning sounded, an automatic
voice calling, "terrain, terrain, pull up, pull up." The two extra
co-pilots echoed the warning, screaming "Pull up!"
Heavy with fuel, spoilers extended and still in a skidding right turn
which further increased drag, the jet could barely climb. But the co-pilot
pulled the nose up anyway. The jet cleared the top of the mountain by about
100 feet, according to both airline and FAA officials. It was so close to
the ground that air controllers' radar lost contact with the plane,
sparking fears in the tower that Flight 863 had crashed.
San Francisco controller Cynthia Grimm immediately called a controller
at another FAA radar post. "Hi, is United 863 -- oh, there he is" on the
radar scope, she exclaimed. "He scared me, we lost radar" contact.
Lurching over South San Francisco, then Daly City and San Francisco, the
jet was so low it terrified residents. At the airport, a telephone hot line
recorded a deluge of complaints. "People were running out of their houses
for fear the plane was going to crash," a South San Francisco resident
said, according to call transcripts. The identities of callers are kept
confidential. The jet set off car alarms, "it shook the whole house, we
thought it was going to take out the neighborhood," said another
caller.
In Daly City, "I thought I was going to have to go under the couch," one
man said. And a San Francisco woman said her daughter's nearby home was
shaken "like it was an earthquake."
As the jet headed out to sea to dump fuel for an emergency landing, the
FAA was already securing tapes of the air controller conversations. United
officials retrieved the jet's flight-data recorder, which saves items such
as speed, altitude and engine performance, and began their own inquiry.
FAA and United officials were shocked at what they found: The crew had
violated fundamental flying rules, such as maintaining minimum air speed.
"They didn't do the basics," says the FAA's Mr. Lacey.
The FAA, United and its pilots' union have taken a series of remedial
steps, some short-term "quick fixes," as one United pilot puts it. They
have also launched studies which in the next year or so may lead to other
changes in United's operations.
One of the more controversial moves was made in December by James
Edwards, the FAA's principal operations inspector overseeing United's
pilots. He ruled that by this month, every 747-400 co-pilot had to have
made three takeoffs and landings in a real plane within 90 days or be
effectively banned from the cockpit. That would have grounded so many
co-pilots that United would have been forced to cancel some of its overseas
flights, including as many as 30% of its Pacific flights, according to a
pilots' union estimate.
But the FAA and United have hammered out a compromise. Within 90 days of
a flight, a co-pilot now must have made at least one takeoff and landing in
a real jet, plus two in a simulator. Co-pilots who haven't met the
requirement must make their next flight with a "check captain." Check
captains are highly experienced management pilots who check other
pilots.
"The bottom line," states the Feb. 3 union letter to all United pilots,
"is the FAA, after reviewing our aircraft landing records and other items,
has determined that the simulator cannot nor was it ever intended to be the
sole method" for keeping pilots' landing skills up to date.
United has taken other short-term steps. It has retrained the crew of
Flight 863. Using data from the recorder and with other pilots playing the
role of the crew, the airline made a video portraying the close call in one
of its simulators at its Denver training base. The shaking of the real
airplane, however, was so severe it couldn't be duplicated in the
simulator. United is now trying to improve its simulators.
The carrier is showing the video to all its pilots, and re-emphasizing
certain flying rules. One rule: the rudder (not ailerons) must be used to
maintain direction when an engine fails on takeoff.
In addition, United has increased the frequency of recurrent training
for all its 747-400 pilots. Instead of getting recurrent training -- which
involves days of extensive simulator and classroom work -- once a year,
747-400 crews are now getting it twice a year.
United has spent $2.5 million on remedial measures, and "before we're
through we may be up to $5 million," says Mr. Soliday.
United and the pilots' union also have set up a joint committee composed
of 10 747-400 captains and co-pilots to study possible changes in how the
jet should be manned. At Northwest Airlines, for example, a 747-400 cockpit
features a captain and co-pilot at the controls, and a second captain and
co-pilot in the seats behind who provide relief on long flights. At United,
there is only one captain and three co-pilots, called first officers.
Captains are generally more experienced than first officers.
William Brashear, a United 747-400 captain and pilots' union official,
says the Northwest system will be one of the approaches studied. But he
says that at United, all the co-pilots are trained and rated as captains
anyway, and lack only seniority to get the captain's title.
In the meantime, says Mr. Brashear, United and its pilots "are working
just as hard as we can to make this airline as safe as possible."
