The Dangers of Fixating on Small Issues

On 28th December 1978, United Airlines flight 173 took off from John F Kennedy International Airport in New York, making its way to Portland International Airport in Oregon.  It made a scheduled stop in Denver, Colorado before flying on towards Portland.

The flight crew on that day consisted of Captain McBroom, first officer Beebe, and flight engineer Mendenhall. Captain Malburn McBoom was a hugely experienced pilot.  One of the most senior pilots with United Airlines.  He had clocked up some 27,600 hours flight time over his 27 years with the airline, 5,500 hours in this particular DC-8 model.  First Officer Roderick Beebe was an equally qualified first officer.  He had been with United Airlines for 13 years and logged 5,200 hours.  Finishing off the flight crew was flight engineer Forrest Mendenhall who had close to 3,900 hours flight time, and 11 years service with United Airlines.

As flight 173 was making it’s approach to Portland the landing gear was lowered into place when the crew felt an abnormal vibration.  Unusual sounds, coupled with the lack of an indicator light led Captain McBroom to request a holding pattern to allow the problem to be investigated.

During the next 23 minutes in the holding pattern, the experienced crew discussed and carried out numerous checks on the landing gear to ascertain that it was, indeed, down and locked in place.  All the signs suggested that the landing gear was, indeed, down and locked in place, but Captain McBroom just couldn’t be sure.  He could land without landing gear, and statistically the risk of fatalities would be low.  The United Airlines flight manual confirmed this and training was given to captains to do this, but it was not a risk Captain McBroom was willing to take.

Flight 173 had taken off with 46,700 lbs of fuel.  The journey should have used 31,90 lbs, but this extra flight time was going to put a strain on that reserve.  While Captain McBroom had become fixated on the problem of the landing gear, he failed to notice that this was fast becoming the smaller of his problems.  With fuel rapidly depleting they could no longer make it to the airport.

As fuel got to a critical level, flight 173 lost one engine, and then another.  Even at this stage, Captain McBroom was still fixated on getting the landing gear problem sorted.  He had become blinded by what he considered a major issue, while much larger issues were unfolding around him, but couldn’t see it.

At 1813 hours on 28th December 1978, first officer Beebe declared a Mayday on United Airlines flight 173, almost a full hour after the initial problems with the landing gear.  Two minutes later, they crashed into suburban Portland, killing 10 people (including the flight engineer) and seriously injuring another 23.  Two unoccupied homes were destroyed in the 1500 foot wreckage path.

All too often we become so involved in a minor issue, so obsessed that we simply fail to notice the real issues.  That’s exactly what had happened to Captain McBroom.  He had simply become fixated on a problem, and failed to properly recognise other greater problems growing.  How often in business have we done the same thing?  How often have you become so fixated with a problem, that you have failed to notice the real issues around you?  What can that fateful flight teach us about our own business?

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