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Safety Recommendation Details

Safety Recommendation A-79-047
Details
Synopsis: ON DECEMBER 28, 1978, UNITED AIR LINES FLIGHT 173, A DC-8-61, CRASHED NEAR THE PORTLAND INTERNATIONAL AIRPORT AFTER CIRCLING IN THE VICINITY OF THE AIRPORT FOR ABOUT 1 HOUR WHILE THE FLIGHTCREW ATTEMPTED TO RESOLVE A LANDING GEAR PROBLEM AND PREPARE PASSENGERS FOR THE EMERGENCY LANDING. OF THE 181 PASSENGERS AND 8 CREW MEMBERS ABOARD, 8 PASSENGERS AND 2 CREWMEMBERS WERE KILLED AND 21 PASSENGERS AND 2 CREWMEMBERS WERE INJURED SERIOUSLY. THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE PROBABLE CAUSE OF THE ACCIDENT WAS THE FAILURE OF THE CAPTAIN TO MONITOR PROPERLY THE AIRCRAFT'S FUEL STATE, AND TO PROPERLY RESPOND TO THE LOW FUEL STATE AND THE CREWMEMBERS' ADVISORIES REGARDING FUEL STATE. THIS RESULTED IN FUEL EXHAUSTION TO ALL ENGINES. CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF THE OTHER TWO FLIGHT CREWMEMBERS EITHER TO FULLY COMPREHEND THE CRITICALITY OF THE FUEL STATE OR TO SUCCESSFULLY COMMUNICATE THEIR CONCERNS TO THE CAPTAIN.
Recommendation: ISSUE AN OPERATIONS BULLETIN TO ALL AIR CARRIER OPERATIONS INSPECTORS DIRECTING THEM TO URGE THEIR ASSIGNED OPERATORS TO ENSURE THAT THEIR FLIGHTCREWS ARE INDOCTRINATED IN PRINCIPLES OF FLIGHT DECK RESOURCE MANAGEMENT, WITH PARTICULAR EMPHASIS ON THE MERITS OF PARTICIPATIVE MANAGEMENT FOR CAPTAINS AND ASSERTIVENESS TRAINING FOR OTHER COCKPIT CREWMEMBERS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Portland, OR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA79AA005
Accident Reports: United Airlines, Inc., McDonnell- Douglas, DC-8-61, N8082U
Report #: AAR-79-07
Accident Date: 12/28/1978
Issue Date: 6/7/1979
Date Closed: 3/21/1980
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Crew Resource Management, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/21/1980
Response: In your letter you indicated that the faa was preparing an air carrier operations bulletin (8/22/79 ltr) to satisfy the recommendation. We note that the air carrier operations bulletin 8430.17, chg 11, dated 11/3/79, has since been issued. Paragraph 957 on page 945 deals with resource management and interpersonal communications training for air carrier flight crewmembers. This action fulfills the intent of recommendation a-79-47 which is now classified in a closed--acceptable action status.

From: NTSB
To: FAA
Date: 8/30/1979
Response: We are pleased to note that the faa is preparing an air carrier operations bulletin instructing all principal operations inspectors to urge their assigned carriers to include resource management training in their flight crewmembers training programs. Pending the issuance of the bulletin, recommendation a-79-47 will be classified in an open--accpetable action status.

From: FAA
To: NTSB
Date: 8/22/1979
Response: FAA LTR: WE ARE PREPARING AN AIR CARRIER OPERATIONS BULLETIN INSTRUCTING ALL PRINCIPAL OPERATIONS INSPECTORS TO URGE THEIR ASSIGNED CARRIERS TO INCLUDE RESOURCE MANAGEMENT TRAINING IN THEIR FLIGHT CREWMEMBER TRAINING PROGRAMS. 11/3/79 - AIR CARRIER OPERATIONS BULLETIN 8430.17 CHG 11 ISSUED. PARAGRAPH 957, PAGE 945 IS REGARDING "RESOURCE MANAGEMENT AND INTERPERSONAL COMMUNI CATIONS TRAINING FOR AIR CARRIER FLIGHTCREW MEMBERS."