Expectation bias and distractions lead to near disaster

Wichita, Kansas. Summer of 2010.

The ultimate irony is to have the exact headline that, decades ago permeated itself into your life, be the one that once again illustrates in living color, the front page of your Curriculum Vitae. Except this time, you not only portray the role of the victim, but demonstratively and unambiguously dress in the gowns of culpability. So, just about a quarter of a century earlier I had come oh-so close to bending metal and hurting people during a taxi-out of Frankfurt, Germany. And without remorse I could (and did) very assertively and aggressively point the finger at the captain, after all I was so innocent! Yet now 24 years later, it was me in the left seat and here we were once again confronting bad luck, a broken airplane, as well as more than our fair share of dysfunctionality…could that play a factor later on?

During the summer of 2010, I was near the zenith of my fortunate career in aviation, enjoying the privileges, rights and rewards of being a senior airline captain with my choice of days worked and routes flown. I had moved my family to the greater Salt Lake City (SLC), Utah area 12 years earlier and, in an effort to blend family time and work, I always looked forward to each and every single “SLC flight sequence” I could muster, beg, borrow or steal. Such was this afternoon flight, a repetitive Memphis to Salt Lake City and back daily sequence that would run all week.

This was midweek and I had just landed in Memphis. As a recipient of a celebratory barbeque lunch, a new and shiny jet, a load of heavy freight and a belly full of fossil fuel, I was ready once again the happiest of campers more than ready, willing and able to aviate westbound. Earlier that morning as we climbed out of SLC, a different First Officer and I had noticed that significant cloud build-ups were blooming and wondered if upon on return in the afternoon, they might pose a threat…could that play a factor later on?

Unlike the DC10 in Frankfurt, this MD10 had undergone a major transformation and now not only possessed new glass cockpit technology, but it also only required two crewmembers to fly (versus three required in the DC10). All of the aircraft systems had been incorporated, validated and automated so we no longer needed a Flight Engineer, or did we? With one set of eyes less, you would have guessed that more attention to detail should have been the soupe du jour. To make things more interesting, the First Officer who was our guest of honor, had recently been hired and their legacy on this airplane could only be measured in a single week. It was also my very first time to meet and fly with that individual…could that play a factor later on?

This MD10 had undergone a major transformation and now not only possessed new glass cockpit technology, but it also only required two crewmembers to fly.

Minutes before stepping aboard the aircraft, I took one last opportunity to check in at home and called my wife to see if she would be able to meet me for dinner at the downtown hotel that evening. Her voice was a little doubtful as she mentioned the ever-increasing dark clouds and strong winds that had hung around our house all afternoon. She hates to drive in inclement weather and as we said goodbye, it seemed to me that I’d be dining alone.

As I reviewed the maintenance records for our trusty steed, I came across a notification that the #2 autopilot was inoperative. Since the MD10 was equipped with two fully functioning, independent autopilots, this would be either a minor inconvenience or perhaps not an issue at all…could that play a factor later on?

Our takeoff, climb-out and initial high altitude cruise flight were normal and uneventful. Worth mentioning, is that initially as a team we didn’t particularly gel together. The conversations were polite, professional and certainly politically correct. Yet there was very little said that was not related to the jet and to flying. It is time like these that bring to mind the phrase, “the power of silence”. We did notice that the further westbound we flew, the worse the weather seemed. These concerns were soon validated by Air Traffic Control who began issuing significant weather notices and handed out enroute delays as quickly as red-hot playoff tickets. It became apparent in the quickest of fashions that the greater Denver, Colorado area was getting pounded by repetitive gangs of malicious thunderstorms. Yep, another typical summer afternoon in the Rockies….could that play a factor later on?

We were level at 34,000 feet with a beautiful blue sky and had just recently crossed overhead of Wichita, Kansas witnessing the airport disappear under our nose as our craft easily chewed through eight miles per minute. Things could not get any better, that is, until our Master Caution light brightly illuminated along with the unmistakable click of the autopilot switches and we unambiguously understood that our one and only serviceable autopilot had now disconnected.

I quickly asked the First Officer to hand fly the airplane while I assessed the situation and spoke with Air Traffic Control. It didn’t take long for us to figure out what the problem was. We had lost Hydraulic system #3 – poof, gone, squirted out a leak in some random hose at 3,000 PSI. It didn’t take but a few seconds for the system to go (since autopilot #1 is powered by hydraulic system #3) and with the loss of this hydraulic system, our only viable choice was then to use autopilot #2. The only issue was that it had been inoperative even before our flight and now we really needed it…could that play a factor later on?

Due to rules imposed by the Federal Aviation Administration, we were not legal to operate above 29,000 feet without the use of an operable autopilot – this part of the U.S. airspace is known as Reduced Vertical Separation Minima (RVSM) so being what it was, one of the first things that happened is we got evicted from 34,000 feet and ordered down to 28,000 feet. We complied while using our slow, hand-flown descent to tend to our house keeping duties in terms of checklists to be completed. Now it was time to start building “Plan B”. Thankfully the clear airspace we were presently in allowed us to clearly see ahead and what we saw we did not like…could that play a factor later on?

Even the 5 o’clock weatherman could have told you that hand flying westbound at 28,000 feet towards a sky filled with menacing anvil topped cumulonimbus that easily crested 45,000 feet would not be the most prudent or wisest of choices. Adding points for difficulty was the hydraulic dilemma. Without dissecting this beyond comprehension, hydraulic system #3 differs from hydraulic systems #1 and #2 in several ways, the most prominent being that the extension and retraction of the landing gear finds its roots here. In other words, no pressurized fluid in hydraulic system #3 means no normal operation of the landing gear (fortunately there is an emergency way of extension only). So while we would be able to utilize the emergency procedures to extend our landing gear, in our current state of affairs, once locked in place, we would not be able to retract the landing gear. Why was this a concern?

Looking at the geography of Utah, we can easily see that the location of Salt Lake City places it 500 miles from Denver, 400 miles from Las Vegas, and 350 miles from Boise. All of these are significantly distant, this is especially cogent when we understand that the amount of fuel planned for any weather diversion is factored with the landing gear in the retracted position. A gear down scenario would consume copious amounts of fuel and time, neither of which we had enough of. If we elected to continue to Salt Lake City, and upon approach extended our landing gear via the emergency system and procedures, should the thunderstorms (which I knew were assertively announcing their presence from speaking to my wife as she stood in our backyard) mount a coincidental frontal assault with our arrival and thus prevent us from landing. We would have no recourse, no way to reach an alternate airfield with our landing gear extended. Plain and simple…could that play a factor later on?

We chatted a few minutes and decided that our best and most prudent curse of action was to park the airplane as soon as possible. We had just overflown Wichita. It looked good and we studied the landing charts and saw that Runway 1L was 10,000 feet long which was plenty of distance for a long run out as we now (due to the hydraulic loss of system #3 had also lost wheel brake system #2) needed to be careful stopping the airplane. We knew we had a company ramp there with our own company aircraft mechanics and maybe they spoke MD10. We coordinated with Air Traffic Control, declared an emergency, and diverted expeditiously to Wichita International landing uneventfully. Our troubles seemed over or so it seemed, oh just how wrong this would prove to be!

As part of the standard operating procedures, anytime an aircraft declares an emergency, the airport supporting ground equipment (Police, Fire, EMS) go into action and so it was this afternoon when they all proudly and overtly escorted us to our ramp placing themselves strategically in a festive parade formation only feet away from the front of our airplane…could that play a factor later on?

Immediately after clearing the runway and starting our taxi inbound to our ramp, the First Officer and I talked succinctly and elected to shut down our #3 engine. This was due to the potential problems associated with the leaking #3 hydraulic system. That was a normal and expected procedure. (On the MD10, the #1 engine hangs on the left wing, the #2 engine lives high up on the tail and the #3 engine is found on the right wing.) In shutting down our #3, we had also mechanically rendered brake system #2 inoperative. That’s OK because we still had engine #1 powering brake system #1…could that play a factor later on?

As we approached our ramp, we were directed by the ground controller at Wichita to park our aircraft as much out of the way from normal operations as possible. This was necessary as the sheer footprint of our humongous jet would easily preclude the movement of any airplane in our vicinity. So, off we went to an unused remote penalty box and sure enough, all of our police, fire and EMS migrated as well. Unknowingly, (to us) this patch of ground had a slight downward pitch built in…could that play a factor later on?

What happened next cannot be more appropriately choreographed, except perhaps in a recreation of a Shakespeare’s Comedy of Errors – sad but true. To start out, as mentioned the Deputy Barney Fife and cohorts’ circus parade of siren blaring, light flashing, were still standing around and pointing ever closer to our jet. Their presence, covertly deposited a shadow-like vapor trail around our immediate perimeter to our 12 O’clock position, leaving us with the feeling that big brother was watching and they were watching downhill from us…could that play a factor later on?

As we initially tried to communicate with our mechanics that had come out to meet us, we quickly found out that their intercom headsets would not work properly. We could hear them but they could not hear us. We then reverted to hand signals and attempts at writing a note and holding it to the window. The plan was simple in origin and design – secure the aircraft via either chocks against the wheels or via a tractor and towbar. Attach it to the airplane thereby rendering it immovable. Simple, right?

The mechanics preferred the use of a tow bar and tractor so off they went on their latest scavenger hunt. And poetically enough, just before their departure, they asked us to move the airplane one more time and just a few feet to a further corner of the tarmac. During this last center stage act, with a definite loss of communication, unfortunately we (mostly I) lost situational awareness and did not confirm that chocks were indeed back in place. I also did not verify that the parking brake had been set once again – after all we had moved the airplane several times and somewhere in those sequences the parking brake ended up being off and the wheel chocks tragically remained in a different zip code. The search for the towbar and tractor continued…could that play a factor later on?

Time passed and those standing in front of our jet grew bored. Just the loud whine of the jet engines broke the monotony of a hot summer Kansas afternoon. This entire time, two of our engines were still operating to provide electrical/pneumatic and hydraulic power. That is, until I decided to reduce the noise level by electing to shut down another engine leaving us with only one operable engine to provide the necessary mechanical needs. This is where the rubber met the road, as the saying goes.

Once again, without dissecting this beyond comprehension, engine #1 (left wing) powers a number of things, one of which is extremely important at this particular time and that is wheel brake system #1 which provided us with the ability to hold the airplane in position by depressing the brake pedals (which I was subconsciously doing). My natural selection was to shut engine #2 (high on the tail) as it had no direct effect on our only remaining brake system #1. Was this discussed with the First Officer? No, it was not. I just assumed he/she would have agreed with my choice of which engine to shut down.

To this day, I clearly remember my exact words to the First Officer, “Let’s go ahead and shut another one down and reduce the noise level for those folks out there”, expecting the whole time to feel/hear the #2 engine securing itself. Our company flight manual has very specific, detailed procedures to shut down an engine. These procedures ensure that things are done and steps followed in the correct order to achieve the goals intended. Was this done? Obviously not…could that play a factor later on?

As a personal side note, just how difficult is it to be truly introspective? To admit to yourself that you have indeed fallen short of the mark. What are the thoughts, perceptions, realities, admissions, reflections, rationalizations, excuses and feelings that come into play? Are they immediate? Yep, some are, yet their first cousins soon show up and commence that never-ending finger pointing. There is an old saying in Naval Aviation, I’d rather die than look bad. Perhaps a bit extreme, but certainly germane. What made all of this much more damming is that in a past life I had been the Dali-Lama of human factors. I was the individual in charge of instructing all the other pilots at my airline exactly how NOT to do what I had just done. What would my reputation be? How could I walk through the pilot operations center? Would they all point and whisper…there HE goes, did you hear? Not to mention the potential audience with federal authorities, all the while standing on the wrong side of the long green table without a simple glass of water…could that play a factor later on?

In retrospect what happened next can, in hindsight, be easily predicted yet to me, it was The Mother of all surprises. Following my command, the First Officer did indeed secure/shut down another engine except instead of engine #2 coming to a spinning stop, it was engine #1. I had not been specific as to which engine to secure. I had just directed him to shut down another engine. In defense of the First Officer, whose limited experience awarded them a bit of latitude for potential error, in his mind there would be less noise if a wing-mounted engine was secured rather than the one up high, way back in the tail…could that play a factor later on?

Just as if it was yesterday, I sense, I feel, I live the decreasing vibrations and noise as the engine began its final ever-slowing spiral towards silence and sleep. All seemed normal as I looked out the front windshield at the numerous rooftops of the fire engines, ambulances and police cars just feet away. That is until the general quarters alarm blasted deep inside my amygdala, instantly activating the storm trooper legions of panic, shock and disbelief. Why were both of my feet slowly rotating around compressing brake pedals? Why was that residual brake pressure disappearing? Where was it going? And more importantly, what was causing our 400,000 lbs. abode to creep forward at an alarmingly increasing rate? What was earlier yards or even feet of separation now seemed like mere inches. Those vehicles, those people, they had no way to move, no way to extricate themselves from the approaching doom.

Quickly I looked inside the cockpit and to an even greater degree of confusion I witnessed first-hand the engine indicators for engine #1 sweeping counterclockwise at the speed of light – yes sir! It was tapping out and tapping out with no way of an immediate restart. There was no way of resuscitating it back to life and no way to regain that life-saving power to wheel brake system #1…could that play a factor later on?

They say that at least once you will see your life flash before your eyes. The next minute or so played both in slow motion and in almost out of body like experience. I don’t recall hearing any sounds or feeling anything other than pure, unbridled terror as I pumped my feet as fast and as forcefully as I could – why? Not because of anything other than the raw hope of a miracle. I had to keep that purple battering ram from breaching whatever safety zone was still left. It wasn’t because at that moment I had my wits about me and remembered the emergency pneumatic brake accumulator, capable of 10 applications. It was because I could not pray more fervently. I could not light another votive candle or wish it any stronger. Yet, to our rescue came a simple system designed during the infancy of this jet for situations just like this. It did work. It did take a few seconds to activate and when it was said and done, when the jet was finally stopped once again, when the parking brake was re-engaged, we were less than 18 inches from their main fire truck.

The moments that followed the slight rocking of our jet as the parking brakes took effect and indeed demonstrated to one and all that we were once again static still seem trance-like. So much confusion, both in and out of the cockpit. Our mechanics were nowhere to be seen. The first responder quorum was now gathering anew as they had expeditiously moved out of the way. Entertaining themselves by pointing ever so excitedly at the microscopic distance between the nose of our airplane and the roof of the fire truck. Inside the cockpit, my head spun and spun. I tried to make sense of what had happened and so did the First Officer, what just happened? Was that my voice I heard 24 years earlier?

I now had a choice. I could, as in a past life, covertly obscure the facts and instantly deposit them deep inside the catacombs of denial, thereby rescuing my ego – or I could painfully man-up, belly up to the bar and put on my big boy pants. I knew that the next time I looked in the mirror, I would have to face myself. To say that the decision to follow through with what was right did not come easy, there is always (at least for me) a smidgen of self-preservation, yet how much a failure would I be if after all that I invested in teaching how and what to do, when it counted the most, I miserably flunked…could that play a factor later on?

As an epilogue, the mechanics soon showed up with a tow bar and all was secure. We exited the jet and thanked the first responders. Not much was said about our last-minute slide into home plate. We remained overnight at a hotel while a new hydraulic hose was flown in and installed. All good. The next morning we continued to Salt Lake City with a load of one-day late freight.

After a restless sleep and somewhat of a meal, I made it a point on the way to Salt Lake City to have a long, forthright, authentic chat with the First Officer. Yep, sometimes honesty is the best policy even if you know those self-inflicted wounds are sure to be the most painful.

A year or so later I saw that First Officer in Memphis. He simply smiled and gave me a thumbs up.

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Mario Jimenez

Mario Jimenez grew up in Latin America and graduated from the University of Texas, El Paso. He served in the United States Marine Corps as a Naval Aviator flying the A6 Intruder, T2 Buckeye and A4 Skyhawk.

Following his military career, he joined FedEx and flew the B-727, McDC-10 and McDMD-11 ultimately serving as a captain and check airman. At FedEx, he also served as a CRM/human factors manager and member of the pilot selection team.

He's been married to Barbara Bluth for nearly 50 years and the couple is very proud of their 3 children and 11 grandchildren.The family has resided in Utah since 1998.

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