Case Study Analysis Accident Research United Flight 232

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1 Case Study Analysis: Accident Research United Flight 232 Mae Murch Embry-Riddle Aeronautical University BSAS 335 Mark Scharf September 24, 2023

2 Case Study Analysis: Accident Research United Flight 232 United Airlines Flight 232, with the registration number N1819U, was a tragic incident that occurred on July 19, 1989, in Sioux City, Iowa, United States. The flight was a scheduled domestic passenger flight from Denver, Colorado, to Chicago, Illinois, with a planned stop in Chicago. The aircraft involved in this incident was a McDonnell Douglas DC-10 (Federal Aviation Administration, n.d.). After a catastrophic engine failure, the airplane suffered complete loss of all hydraulic flight controls. Despite the loss of hydraulic control, the flight crew made extraordinary efforts to keep the aircraft aloft and ultimately attempted an emergency landing at Sioux Gateway Airport in Sioux City (Federal Aviation Administration, n.d.). During the emergency landing, the DC-10 suffered a violent crash landing, leading to the breakup of the aircraft and a large fire. Despite the devastating nature of the crash, a significant number of passengers and crew members survived due to the efforts of the flight crew, emergency responders, and the passengers themselves. Tragically, 111 people lost their lives in the crash, but 185 people survived. The primary causal factor was the catastrophic engine failure, which ultimately resulted in the complete loss of all hydraulic flight controls. This loss of control was the immediate cause of the crash. The engine failure was attributed to a fan disk failure, which led to the disintegration of the engine components, damaging critical systems and control surfaces (Federal Aviation Administration, n.d.). Contributing factors were inadequate maintenance practices that failed to detect and address the pre-existing issues within the engine, particularly with the fan disk. While the fan disk was undergoing the revenue service, the engine overhaul also revealed that fan disk in piece part level inspections for a total of six times. The inspections include a fluorescent pentrant inspection, which should have highlighted the fatigue crack, as it was big

3 enough (Federal Aviation Administration, n.d.). Another issue was the design of the DC-10’s hydraulic system. Due to its location and close arrangement, it’s very susceptible to a complete loss in case of engine failure (Federal Aviation Administration, n.d.). Overall, the structural and mechanical factors involved in the accident included the design of the DC-10's hydraulic system, which lacked redundancy, making it vulnerable to a total loss of control in the event of a failure. Additionally, the engine's fan disk design had weaknesses that led to its catastrophic failure, damaging critical components and systems. Some of the Relevant Human Factors and Organizational Factors Related to the Accident are Organizational Culture. The Organizational factors within the airline and regulatory bodies played a big role. There was a lack of comprehensive oversight and standards regarding engine maintenance and inspection practices. The flight crew themselves did amazing given the circumstances. Collectively they were very experienced, the captain had over 7000 hours in the DC-10. An off-duty DC-10 check captain was also onboard, and after being called in the flight deck by the captain started taking control of the throttles for the left and right engines. Asymmetric thrust was the only way to control the damaged aircraft, which was concluded in simulator studies that the NTSB later used to establish if the crew would have benefited from different training to keep control of the airplane. The result was clear, the airplane was impossible to control and even if it was semi flyable, the crew would not have been able to land the airplane safely on a runway (Federal Aviation Administration, n.d.) Resulting from the crash, the NTSB recommended improved maintenance practices, enhanced training for flight crews, and the development of emergency procedures for dealing with complete loss of hydraulic. A revision to engine inspection protocols and enhanced hydraulic system redundancy in newer aircraft was also part of the updated safety standards.

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