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Benchmark Six Sigma - War Room

It was 17 min past 3 in the afternoon when an Airbus A320-232 departed Bob Hope Airport, Burbank, California, carrying 140 passengers and six crew members. It was scheduled to fly 2,465 miles (3,967 km) to John F. Kennedy International Airport, New York.

The problems, however began minutes after the plane took off from the Burbank airport. The pilot could not retract the plane’s nose gear (Front landing gear). The pilot announced, they had an indication that there might be some problems with the landing gear. As the passengers tried to assimilate this information, the pilot came on again, and announced that the plane was being diverted to Long Beach airport, where it would be flying low so that the crew down there could visually inspect the fault with the landing gear. Now, the passengers started becoming really nervous.This, however, was just the beginning of one of the world’s scariest landings.

The ATC at Long Beach confirmed that the plane’s front (nose) landing gear was stuck in the wrong direction. It was found that the nosewheelhad rotated ninety degrees to the left, perpendicular to the direction of the fuselage.

landing gear stuck in 90 angel

AN EMERGENCY LANDING WAS NOW INEVITABLE!!!There were three worst-case scenarios to mull over:
  1. First would be a situation where, upon impact, the nose gear would rotate partway into position, locking or sticking at an acute angle. With the tires deflected, the aircraft could be yanked from the runway.
  2. Situation two involved a collapsed or sheared strut — the force of the landing causing the entire fixture to bend backward, the nose then dropping hard onto the surface.
  3. And lastly, in combination with either of the first two events, was the slight possibility that as the wheel rims grind into the runway, the inevitable shower of hot sparks might bring on a fuel-tank explosion or ignite some portion of the plane’s structure.

The lives of the 146 people on board rest on a twisted piece of metal.

Well, the problems didn’t end here. Things were about to take an even more surreal turn for the passengers. Remember, we called it one of the scariest plane landings ever. The plane was equipped with DirecTV satellite television which gave live news coverage on aircrafts. The news channels were broadcasting live about a plane in serious trouble. Guess what, it was the same plane in which the passengers were watching the live news about their own flight in trouble (Confused! Read Again). And now, everyone slowly started realizing this and panic spread. Passengers on the flight were watching live news coverage of their flight, while the plane circled over the Pacific for hours. Imagine the plight! It’s like sitting in a car which you know is about to meet an accident. (And yes, also watching it live. Enough to give anyone goosebumps!!). Here’s where I’ll take a break in the story.

showing news broad cast

(True Image of the TV in the plane seats, showing the news broadcast)

Said that the emergency landing was inevitable, the pilot needed to ensure every measure that could save the lives of maximum passengers on board. It was very necessary for him to consider ever minuscule possible measure so that he could land without any casualties. Here is where in I bring in the fishbone diagram (Ishikawa diagram).

The fishbone diagram identifies many possible causes for an effect or problem. It immediately sorts ideas into useful categories.

Imagine you are the pilot of the plane. Brainstorm the major categories which are important for the emergency landing.

If this is difficult use generic headings:

  1. Methods
  2. Machines (Equipment)-
  3. Man (People)
  4. Materials
  5. Measurement
  6. Environment

Try to note down everything you think is important to save lives of maximum passengers on board and fit it into any of the categories above. Every point that you enlist is one of the probable X’s (inputs) which when controlled will ensure possible safe landing of the plane with no casualties. Some of these points which you might enlist might turn out to be critical X’s, which will be the most important ones, warranting safe landing. However, this is one case where all your probable X’s might be Critical. Its 146 lives at stake and if you miss enlisting some critical X’s or deprioritize some which are important, the plane might face serious consequences.   I handover the cock pit and the fate of all 140 passengers and the six crew members to you!

I put this situation to all the participants in one of my training sessions. This is how it went…

Mr. Nirmal: (Who is still caught up in the story and wants to know what happened) Can you tell us the suspense first and then we populate the fish bone.

Me: No let’s complete the exercise first. Again, you all are in the cockpit. Start listing everything that you think can ensure safe landing with no casualties.

(The pilot was actually talking to the ATC and other pilots for inputs.)

Mr. Dishan: The weather, especially the winds and rain. I know there is something called cross winds.

Me: Very good. Yes, crosswinds are winds blowing across one’s direction of travel. In aviation, a crosswind is the component of wind that is blowing across the runway, making landings and take-offs more difficult than if the wind were blowing straight down the runway. Watch the first 5 min of the video below to understand what do we mean by crosswinds.

If the aircraft encounters such winds while landing it become very necessary to use the front landing gear early to get back in position, which was not possible in our case. However, there was no rain that particular day. Also, the weather, the day earlier of this incident was stormy, but it was clear and without strong winds the day of the incident. But, Mr. Dishan there is a problem with your point!

Everybody thinking…

Me: The cause you mentioned, crosswinds, is an important factor in safe landing but it is not actionable. We cannot control the crosswinds since it is an environmental factor. Good that we brought the point, but there is nothing much the pilot can do about it. More, points please.

Mr. Nazim: The temperament of the pilot. His experience, his training and flight hours etc.

Me: A very good point. Very important but again it is not actionable. The pilot may himself crumble under such pressure and lose his wits. You cannot change the pilot! Let us park this for now and we will discuss this points afterwards.Why are we not talking about the plane?

Ms. Shweta:I know we cannot control this but the sturdiness of the plane is also very important. We must know whether it will be able to bear the impact of an emergency landing and possible fire, etc. If not then they can land it in water and ensure maximum people are saved. It will be better than the hard ground emergency landing. Also, as you mentioned the flight is near Long Beach airport. So, they can land the plane in water. (The class breaking into laughter)

Me: (Smiling and happy she brought the point) The phrase “water landing” is also used as a euphemism for crash-landing into water in an aircraft not designed for the purpose. Also called “ditching” in aviation accident coding manual,it is defined as “a planned event in which a flight crew knowingly makes a controlled emergency landing in water. Such water landings are extremely rare for commercial passenger airlines. Actually, ditching is the last resort. The probability of people remaining alive after ditching is very less as compared to a ground emergency landing. The images below along with the video will highlight the risks of ditching.

aircraft ditching analysis

(Image Source: aviationclub.aero/group/incidents-accidents/photo/2938/)

It is very difficult to achieve the ideal ditching. Even if you do, you have the next problem of flooding of the airplane. Let us not go out of the scope of the discussion.

Me: Anything more about the plane?

Mr. Shalin: Weight of the plane when it comes down.

Mr. Gaurav (The person sitting next to him): Even this is not actionable. We cannot reduce the weight of the plane.

Mr. Shalin: We can, if we utilize the fuel in the aircraft we can actually reduce the weight.

Me: Excellent point. Mr. Shalinbrought up two important factors in one go. The pilots flew the aircraft, which had 46,860 pounds (21,255 kg) of aviation fuel, in a figure eight pattern between Burbank and Los Angeles International Airport (LAX) for more than two hours in order to burn fuel and lower the risk of fire upon landing. This also served to lighten the plane, reducing potential stress on the landing gear and dramatically lowering landing speed as well.

Ms.Trupti: Los Angeles International Airport (LAX) Airport? When did the plane reach there?

Me: We will know how LAX came in picture when we list all important points.

Mr. Dishant: (As soon as he got the hint)Emergency facilities at the airports! They took the plane to LAX airport because the airport has the most modern emergency and safety equipment. Also, it would have been the best choice in the possible airport options, considering the fuel in the plane.

Me: Very good. Yes availability of emergency response facilities at the airport was a very important consideration for finalizing LAX as the emergency landing site. But that was not the only and most important criteria for selecting LAX.

Mr. Arindham: The length of the Runway.

Me: Bulls eye! Yes. The length of the runway was very important. This is because the pilot had been advised to perform a modification in the landing technique. He was advised to keep the plane on the back landing gears after touchdown for as long as possible without letting the nose gear touch the ground. In an attempt to keep the nose gear off the ground (as long as possible), reverse thrust was also not used to slow the aircraft.

avoid touchdown

Because of such a method, the pilot might not use the brakes effectively. So, the pilot-in-command made the decision that the aircraft should land at Los Angeles International Airport (LAX), in order to take advantage of its long, wide runways. He thought it was the most critical X of all probable X’s. At Long Beach the longest runway is 3.05 km. While at LAX, the longest runway is about 3.7 km.

Me: Anymore points? Well, let me tell that, there is data from crash investigations about the impact at different locations in the plane. So based on historic data analysis, the front three rows in the plane were shifted behind before the emergency landing.

Also, brace position is itself based on extensive analytical work. Brace or crash position is an instruction that is given to prepare for an aircraft crash. There are many different ways to adopt the brace position, with many countries adopting their own version based on research performed by their own aviation authority or that of other countries. There is commonality among all brace positions despite these variations.

(You can read more on http://en.wikipedia.org/wiki/Brace_position)

Brace-Positions

(Image Source: air21.se/paxsafety.htm)

The last thing you want to hear on a flight from the pilot is these 3 words “Brace for Impact”.

The panicked crowd was instructed to select their suitable brace positions which terrified them even more. The live TV relay was cut down in the plane since the sensational commentary on the news channels was scaring everyone on the plane.

(The whole training session was curious now. I stop the story again).

Me: Let us plot a fishbone.

(They cannot wait for the suspense anymore and timidly start drawing the fishbone diagram in their books).

Most of them drew a similar kind of diagram. I have represented it below:

cause and effect diagram

Now though most of them could enlist everything we discussed and also could classify them correctly, there were few corrections.

  1. The weight of the plane is dependent to a good extent on the fuel in the plane. These two are not mutually exclusive. (‘Mutually exclusive’- A statistical term used to describe a situation where the occurrence of one event is not influenced or caused by another event). We should populate reasons which are mutually exclusive.
  2. Also the speed of the aircraft while landing may be affected by the weight but there are many other factors (Reverse thrust, spoilers/”lift dumpers, drag flaps etc.). So, it can be enlisted.

Me: Now that we have understood the fishbone, let us find out the suspense of our story.

Me: The name of the flight is JetBlue Flight 292. You can read more. The plane survived the Emergency landing with all 146 on board, safe and sound. What do you think was the most important decision (Critical X’s) from all probable options (Probable X’s). It was the length of the runway which the pilot deemed to be most important. The plane stopped at 3.382 km. which is about 90% of the runway at LAX. Do you remember the length of the longest runway at Long Beach? Yes it was 3.05 km. Had they decided to land at Long beach……..

Well, we don’t want to discuss this but the learning here is important. The learning about how important is to list out all possible causes (Probable X’s) for an effect. The decision of finding out most important causes(Critical X’s) should be further justified by suitable techniques which we will learn next.

The class is happy that the plane landed safely and they have learned the fishbone as well.

Me: Wait, didn’t I tell Mr. Nazim to park his point for a while. Yes, the temperament of the pilot was the most important thing in this whole situation. Moments before safely landing the crippled JetBlue aircraft, the pilot was calm and even joked with a colleague. He also joked that he was sorry he put the plane down 6 inches off the center line off the runway. See, even for him, being in the center of the specification is so important 😉

The above case has been presented by Parag Mehta, the scientist in our team. The question below is posed by VK (Vishwadeep Khatri). We shall continue the debate for next few days.

Question by VK

Does the above description provide a good example for problem solving?

Please respond with Yes, or a No below and provide the reason for your answer in the comment box at the bottom of this post.

Yes

or

No

Parag Mehta