Planning and Teamwork: The story of United 232 crash, response and recovery.
Sioux City, Iowa
July 19, 1989
Iowa National Guardsman Dennis Nielsen carries Spencer Bailey to an ambulance. Bailey recovered. Gary Anderson Sioux City Journal.
Everything seemed to be going against United Airlines flight 232 on Wednesday July 19, 1989 at 3:16 pm, 37,000 feet above MSL over Alta, Iowa. On the McDonnell Douglas DC-10's way from Denver to Chicago, the number two engine -the one on the tail-exploded loud enough to be heard on the ground in Buena Vista County. The explosion rendered one engine gone and the hydraulics useless. The crew could not use rudders, the elevator, flaps nor ailerons. They did have something going for them- teamwork and expertise in the cockpit. 296 people were on board and far from turning into a case of 296 cases for forensic investigators, more than half lived to tell their stories.
They also had something else. Not to take anything from the crew, emergency responders on the ground before and after the crash had through training, professionalism and teamwork kept more from losing their lives and remained quick on their feet as the story changed. This paper will be the story of what the emergency managers and responders saw and learned that afternoon where a typical Summer day, how they prepared for that day and what happened as a result. July 19, 1989 became a day where tragedy met planning, teamwork and professionalism.
After the explosion, the crew – Captain Albert Haynes, First Officer William Records, Second Officer Dudley Dvorak and Captain Dennis Fitch ( who was flying as a passenger but quickly came up front to help) radioed Minneapolis FAA regional center they had lost engine 2. Kevin Bachman, the approach controller for Sioux Gateway, received a call from the FAA at Minneapolis center at 3:20 pm that a DC10 might make an emergency landing there. Bachman called an Alert 2 at 3:24 pm (Hughes) meaning emergency equipment is to be placed on the field, in this case the National Guard fire fighting equipment. It is not as serious as it sounds as this would have been called if the plane needed to land because a passenger was having a heart attack. ( Gonzales p 22) Plus, at this point captain Al Haynes was not sure if he could make the landing at Sioux Gateway. At 3:35 pm the captain determined he believed he could make it. John Bates, the supervisor in the tower, used a special hotline to the Sioux City fire department to call the alert 3. It was not without some questioning as the crash had not yet happened and that is what the alert 3s are designed for. The Alert 3 activated all Siouxland 911 police, fire and EMS, notified the hospitals, air ambulances and ground ambulances from 30 miles away. Air ambulances in Omaha, Nebraska and Sioux Falls, South Dakota where also on standby. ( Sopher: 1990) The county emergency plan was activated. 39 fire departments converged on Sioux Gateway. The emergency equipment was sent to the closed runway 22 for staging. ( Woodbury: 1990)
The explosion took place where the red triangle is located. From that point steering was done by adding and decreasing power to the engines. NTSB
The plane was making it to Sioux Gateway. Just before the landing the crew was given clearance to "land on any runway." In a now legendary response among aviation enthusiasts, Captain Haynes responded laughing "Roger. (laughing again) "You wanna be particular and make it a runway, huh?" It was the last bit of levity for awhile( Gonzalez: 2014).
A normal DC 10 lands at 300 feet of descent per minute. Flight 232 was coming in at more than 1600 feet per minute headed straight for runway 22 ( Gonzales: 2014 ) . By 4 pm some 35 emergency vehicles were at the airport ( Pine: 1989)
A quick change - a very quick change- occurred when the plane was approaching. The controllers quickly realized some of the emergency crews were on closed runway 22 where the plane was headed and they were about a minute out. The emergency equipment quickly cleared. It was close enough that Haynes could see the equipment moving off the runway as the flight was approaching ( Haynes: 1991). The captain gave the passengers the instructions that hearing "brace bracebrace" was a time to assume crash positions. At 4 pm Haynes came on the PA system - "BRACE! BRACE! BRACE!"
Physics were working against it. Due to it’s speed the plane and minimal control, one wing hit the ground, the plane flipped over in a cartwheel roll, caught fire and ended up in a cornfield planted along the runway. Now it was the responder's turn. Had all been killed, it would have been the deadliest aviation accident in the US until and since that time. Seven foot Iowa corn surrounded the runways and taxiways. (NTSB: 1990) The population of the city was about 80,500 (1990 ), 115,000 in the metro area they call "Siouxland" which also includes parts of Iowa, Nebraska and South Dakota (Census: 1990). Today anyone living in Siouxland knows the story be it because they remember that day or heard it from their parents, flight 232 defined the area and its people.
Gary Brown, Emergency Management director for Woodbury County, Iowa, had lobbied for a disaster plan when such was not common for such a small area. He became the director in 1987, and through the county now has another emergency manager he is not far away as the director of Woodbury County Emergency Services. Gonzales described him "a young, energetic bulldog of a man who believed in his mission." ( Gonzales: 2014)
"A lot of it is I was very young and I was working with seniors and some felt there wasn’t a lot of need for all these emergency plans. I got into this when I was in my late 20's and I was talking to people in their 60's telling them the way they are doing it needed to change. It was a turf issue that I don’t need someone else telling me how to run my emergency," Brown said in a 2016 interview with the author. ( Brown: 2016)
His vision prevailed. It did not hurt that the area prided itself on pulling together Resident, George Lindale, mentioned in 2011 when floods were threatening the town FEMA came to town to teach kids how to fill sandbags. "There isn't a kid born in this town who don’t know how to fill a sandbag."(Gonzales p 116) "The people of the midwest are just a little different. They don't want to admit it can happen to them but if it does they are willing to put their shoulders behind it to help when we have a disaster we don’t have to look for anything. There are always people ready to help." ( Brown: 2016)
"The Disaster Planning Committee consisted of representatives from both hospitals, the fire departments, police, disaster services, prehospital care providers, the media, the airport, Red Cross, ANG, communications centers, political offices and major industries in Siouxland." (Sopher: 1990 p 65a) At the time two disaster drills were done a year. Just this month the local agencies worked together on an active shooter drill. ( Brown: 2016)
Sioux Gateway handled about 115,000 passengers that year ( Hughes: 1989 ). It was listed by the FAA as an Index B airport, The Federal Aviation Administration required a full scale emergency exercise every three years. Sioux City Airport was compliant in this as their last full-scale exercise was held October 10, 1987 where a bus was used to simulate a downed plane and 90 people served as casualties. It was far less than the almost 300 that were aboard the DC 10, but scheduled flights their, according to the NTSB, were DC9's, 737's and 727's which contained only about 2/3rds the passengers of the DC-10 (NTSB p 20). Still the hazard vulnerability was there. Those contrails over Siouxland equaled major highways in the sky. ( Gonzales: 2014)
Another requirement for Index B airports was an annual table top drill reviewing procedures and what to do in the case of an emergency. This was last done a month to the day earlier. "During post accident discussions, emergency personnel indicated their preparedness training was a tremendous asset in this response," The accident report for the National Transportation Board said (NTSB: 1990). It also, has a way of "tearing down barriers" The 185th Iowa Air National Guard (ANG) was based out of Sioux Gateway and provided fire protection for the ANG and civilian facilities. Fire Chief James Hathaway said there were barriers set up between agencies. The training exercises mandated cooperation from the higher ups, but the cooperation among the agencies had staying power and he believed that by flight 232 those barriers had been resolved. On July 19 there were 150 on duty and during the recovery roughly 300 worked the crash site ( Woodbury:1990)
An aside on an emergency preparedness training is in order. I volunteered as an actor this past March as a victim in an active shooter exercise. The goal was having people acting irrationally, a victim running at the rescuers instead of sheltering in place. Simulated wounds in a variety of places –moulage it's called- added to the feel of a mass casualty. I was also a participant in a bombing exercise five years ago with other EMS personnel, where several victims in various states of injury needed to be rapidly triaged, in the dark with jackhammers running inside the building. The secondary explosion came as we were evacuating the victims. And in still another event where I was a reporter/observer was through Wilderness Medical Associates International with a scenario involving a biological research team caught in a flash flood. Rescuers had to deal with rain, mud and telling one of the members of the team she needed to stop the CPR she had been doing for the last hour ( Greaney: 2012). In short, exercises need to take training and throw the proverbial curve balls.
But those curve balls need to be realistic, Brown said. "It's not a test. it's not a fool the guesser environment. It started out that way but we quickly learned the worst you can do is put them in a non realistic scenario without the training and equipment expect them to perform and if they and criticize them if they don't. You can't have a scenario where a plane crashes into a school bus, slides across the highway, hits a tank farm and falls into the river. Most responders aren't gonna buy into that scenario if you have a scenario that is not credible." ( Brown: 2016) Today the Department of Homeland Security's Exercise and Evaluation Program gives emergency agencies a framework for an effective training exercise. ( Homeland Security: 2013)
Preparedness goes well beyond training exercises. In 1986 Iowa and all the counties developed an all hazards emergency plan. Ellen Gordon, State Director of Disaster and Emergency Services said she believed this is one of the top reasons for the success of the operation. (Woodbury: 1990). Brown believed that if there is criticism about response to a disaster one should first look to the leaders. How was the training? The facilities? Did they have access to equipment? ( Woodbury: 1990) Considering the lives at risk and all the eyes that are on the community and the emergency manager, the responsibility is difficult to overstate.
Al Haynes in the 1980's.
Air National Guard Fire
The 185th Iowa Air National Guard's (ANG) home was a Sioux Gateway. It also had its own fire department that served the civilian airport, In its fleet were
2- p2-19 Oshkosh crash trucks which carry foam and water
1- p4 Oshkosh
1- 2000 gallon water tanker
1- crash truck
1- Rescue truck ( Hughes)
All were dispatched for the alert 2. There were 150 personnel on duty that day who all helped on recovery. ANG Fire Chief Jim Hathaway was fire command. In addition another 150 personnel were active the following days at the base and helped out with the recovery. ( Woodbury: 1990)
Sioux City Fire-
Perhaps it is not fair to JUST say Sioux City fire as fire departments from three states converged on Sioux Gateway but the initial dispatch was called to Sioux Fire alarm office. Per the disaster plan the initial call from air traffic control dispatched from the Sioux City fire department
2 - pumpers
1 - aerial
1 - command car
Keep in mind the DC 10, the fire chief knew, was a large aircraft where the exit doors were 36 feet above the tarmac so the aerial truck was called because more than just standard ladders from a truck may be required to reach victims. Of course the alert 3 upped the number of fire equipment significantly. Incident command was provided by Sioux City Fire Chief Orville Thiele. ( Woodbury: 1990)
Siouxland Health Services, now called Siouxland Paramedics, had the emergency ambulance contract with Woodbury County. The alert 2 per the disaster plan mobilized an ambulance form the agency. Needless to say they would be way over capacity with a DC-10 crash and mutual aid would be the word of the day. Woodbury Emergency Management had 100 backboards on the ready the brought to the scene. Not only were 39 ground ambulances involved but nine helicopters were used to ferry the critical patients ( Woodbury: 1990.)
Triage breaks the patients into one of four categories: walking wounded, injured but stable, critical and dead. A textbook from 1984 shows the classifications were similar then as now ( Shoemaker: 1984) instructing clinicians to use – often simultaneously –mental status, respiratory rate ( between 11 and 30 is a sign of stability), respiratory effort, systolic blood pressure ( 90 and above= stable) and capillary refill ( two seconds or less = stable). Those not breathing have their airways adjusted and if there are still no breaths no further efforts are attempted. The point is that this critical step can be accomplished as effectively and quickly by any physician, RN or emergency medical technician. What was not used was the triage tags ambulances have on hand for such a mass casualty incident. Responders quickly determined applying the tags would have caused delay so instead they used flags denoting the condition of the patients by category. One flaw - due to large numbers of people those flags were hard to see and. The medical command was provided by Siouxland's Executive director Chuck Sundberg. Two paramedics from Siouxland Health Services were working as the triage and transport officers and they were also assisted by 150 personnel from the Iowa ANG( Sopher: 1990)
Once the patients were prioritized in triage, treatment was limited to IV’s, airway and circulation, that is controlling bleeding. ( Woodbury 1990)
The dispatch center was overwhelmed as word came out that a plane was in trouble and headed for Sioux City. Twitter or Facebook was a generation away so EMS systems as far away as the eastern portion of the state sent ambulances for Sioux City. "They heard a plane had crashed and they didn't know if they would be needed. I would never encourage self deployment Self deployment only adds to the confusion." Brown said ( Brown 2016)
In a moment of irony that could have been written by a screenwriter, the staff of Marian Health Center ( now Mercy Medical Center) in Sioux Falls were meeting to address an acute staff shortage when the call came in about 232 heading in for an unscheduled landing. Verna Welte, RN, was the vice president of nursing services at the hospital and reflected on that day for Nursing Administration Quarterly.
When the 3:24 pm alert came in, existing non critical patients were moved to free up the areas that were needed for the severely injured. It was shift change about that time but no one was going home. Triaging, they knew, would prioritize the dead and dying from the critical, to the serious to the less severely injured. ( Welte: 1991).
At 4:17 pm in came the first patient, Harlond "Gerry" Dobson, to Mercy ( Gonzales p 208) via helicopter. The first arrival at St Luke's was that of two pediatric patients at 4:35 pm and both hospitals had a "steady stream" of arrivals ( Sopher: 1990)
A physician "from every specialty" ( Sopher: 1990 p 62) and a nurse- they came in from doctors offices, retirees, schools, people who happened to be visiting there- would be teamed up with an emergency tech. The patient would arrive and the emergency department and the team would be assigned to him or her until the patient was admitted or discharged ( Welte: 1991) They would quickly determine to what treatment areas the patient should be taken ( Sopher: 1990). If the patient was unstable, the patient was stabilized in the Emergency Department. Many were unconscious and in shock. Nine went directly to the burn unit at St Luke's. The post anesthesia unit received the walking wounded. Some, including walking wounded had conditions aggravated by the incident. It was noted there were few moderately injured people because most had either major or minor injuries. The last arrival was a bus with 32 minor injuries. About 8 pm to 8:30 pm the emergency departments were returning to normal ( Sopher: 1990) The last patient left the hospital was discharged 72 days after the crash ( Welte: 1991)
The totals: 105 went to St Luke's, 88 went to Marian. 59 people required hospitalization with about half being listed in critical or serious condition. Nine died while in the hospital. ( Sopher: 1990)
"Response to this disaster was an en example of empowerment. Staff immediately responded as needs were identified. Decisions were implemented in a short time frame. Vendors responded by bringing additional medications and solutions," (Welte: 1990).
Empowerment was going on in the cockpit over Iowa. After a 1978 DC 8 crash in Portland, Oregon, there began an effort to give all in the cockpit a voice and ownership for the flight in a term called "crew resource management" where the captain listens to the crew and the crew first and second officers are expected to be assertive in speaking up rather than everyone just deferring to the captain (Killen: 2014). Lately that has become a term used in fire and EMS where all those on a scene use their skills and knowledge of knowing what needs to be done and how to do it and acting without direct orders. Yes, there is a chain of command that must be followed. But Brown said in 2012 "I had been in this mode of I'm the disaster preparedness guy and I gotta prepare for every possible thing that we need to do-food, water, porta pods, traffic control, medical, blood- oh my God, I got all these parts to make sure they're gonna come into motion but what you really do is get the hell out of the way and let them things happen." ( Gonzales: 2014)
Dr Elizabeth Murray, forensic anthropologist from Mount St. Joseph University, discussed in a Great Courses class her academic work in forensic sciences and, as a member of The Greater Cincinnati and Northern Kentucky International Airport's Mass Disaster Committee, she worked the October 31, 1994 crash of American Eagle flight 1484. "You can be as prepared as you want but each situation comes with its own set of unique demands." (Murray: 2012)
"The first thing is you have to determine who is in charge and you'd be surprised how complicated that can be at times. Did it go down on airport property or in the city?" she said. Like Sioux City, Her agency's committee and have developed a call-out system for such an event." ( Murray: 2012)
On the American Eagle investigation they kept one hotel for investigators and a hotel across town from the investigators was the hotel for the families. It helps to keep a mental distance as well as the saying the wrong thing in front of a family member. Within the morgue the bodies – most of which were not readily identifiable – were kept away from their personal effects found at the scene and investigators working in one area were discouraged from going to the other. Wedding dresses, luggage and even children's toys were among the victims belongings and seeing both humanized the victims in a way that could prove more stressful to the investigators than even the already mentally taxing job at hand.(Murray: 2012))
Toxins, bodily fluids can be a danger that may be need to be dealt with. Necessary equipment needs to be procured. Who is going to pay disaster workers? Such is part of a disaster plan. (Murray: 2012)
Another issue is how to design a morgue. Gurneys were sent in, and a hanger at Sioux Gateway was drafted as the morgue with it's concrete floors and easy drainage but bodies must be put on a table or gurney. Leaving them on the floor leave smells that may not come out for some time. Refrigeration trucks were also brought in as well. ( Gonzales: 2014 )
Human/ Psychological Services
The family assistance center requires social workers and clergy and a hotel for the family. Needless to say well after the crash was cleared from the airport, the last survivor left the hospital and the last victim buried the survivors kept their mental battle scars. When interviewing survivors for the book over twenty years later. , Gonzales just asked one about what he did when hear heard the words "brace bracebrace." The man froze briefly as if three words transported back to that summer afternoon. Some were mentally unable to fly again. Intellectually they knew that even if they flew every day for the rest of their lives, the odds were greatly in their favor for NOT having a crash, but those primitive parts of their brains that control fear overruled the intellect.
In addition the responders had issues. Working a scene they were in "get the job done" mode but eventually everything that could be done was. Sleep issues and some deciding to leave their chosen profession due to the emotional trauma of the accident happened later (Woodbury: 1990).
Critical stress management was a new field at the time Brown said. It is designed to help those police, fire, EMS and hospital personnel deal with traumatic issues such as a disaster, death of a child or particularly gruesome crime. "A lot thought they were mental health debriefers but they were ministers, psychologists psychiatrists and therapists and they had not been through the CSM training." Brown said. "You can use therapists and ministers and others for the victims and families but the emergency managers need Critical Incident Management trained teams to debrief them." ( Brown: 2016) The responders have to be dealt in a particular area. They need trained CISM to debrief them." ( Brown
Dwight Birkley, Nursing director of Ambulatory Services of Sioux City, said in a 1990 Journal of Emergency Nursing article:
" We also learned the importance of debriefing sessions with anyone involved in such a disaster. The time staff spent in either a group or single sessions was a genuine stress reliever and was essential for continuing with the day-to-day tasks of patient care. The counselors for the hospital and local clinics brought a variety of experiences and expertise. Post disaster debriefing sessions have now been incorporated into our disaster protocols since the July 19 crash." ( Frank: 1990 )
Gregory Clapper was chaplain for the Air National Guard. He stayed with the law officers and ANGthat night as they guarded the plane. He kept watch that night at the aircraft along with Sheriff's deputies, FBI and ANG. He would talk to anyone who wanted to. Police remembered bad traffic accidents, firefighters recalled fatal fires. "We carry all of our brokenness and tragedy with us and when you open the door on tragedy, perhaps because a new tragedy has come into your life, all those old tragedies come spilling out" he said( Gonzales: 2014. P 225).
25 years later to the day, Captain Haynes reflected. "Your never going to get over it. I don’t believe in the word closure. You just learn to live with it. My wife died, I lived with that. My son died, I lived with that. and my daughter needed a bone marrow transplant I lived with that, but we talked about it and that's what you have to do is talk. And people don’t want to talk about their troubles. Finally they learned in the military the only way to deal with PTSD is to talk." ( Sioux City Journal: 2014)
And now people were descending on the city for recovery, investigation, news media, family plus those people on the plane who did not need hospitalization. Here is where the locals stepped up. Colleges offered dorm space for families and for those who were stuck in Siouxland. ( Welte: 1991)
There was no guarantee the plane would land at the airport. Interstate 29 was on the flight path so law enforcement blocked traffic. The Woodbury report after the disaster said city, state and county police were more recent to disaster planning than other agencies. The crash was treated as a crime scene. Those declared dead on the scene were, for the most part, left where they were found.
Security was a concern. Leo Miller and the Woodbury County Sheriffs Department provided security. The corn was chopped low around the aircraft so as not to be used for cover by trespassers and scavenging animals. Some did purchase response agency uniforms at uniform stores and at least one dressed as a priest attempting to gain entry. Still another claimed to be a University of Delaware Disaster Research Program but after talking his way in was discovered not to be genuine and was ordered out. (Woodbury pp 16-17). No looting was reported. Fortunately for the integrity scene the temperature got down to 59 degrees that night so decomposure could have been worse.
In addition the FBI showed up. Among other things, they took custody of a large amount of $100 dollar bills the rescuers were finding blowing around the runway and ramp, presumably being shipped in the luggage area bellow . ( Gonzales 2016)
Back to the emergency:
Crash site, facing Southwest. Associated Press
The fire was approximately 1800 degrees. Oxygen and fire extinguishers were exploding. Fire crews put foam on the fire which the NTSB credited with facilitating the evacuation of the ambulatory survivors. (NTSB : 1990)
Jim Walker was a Iowa National Guard lieutenant who saw the explosion was surprised when a few minutes later another pilot pulled up in a pickup truck and said "get in we're gonna pickup survivors," When he arrived he saw several people lying presumably dead between the crops and the runway. That is, until several of them started getting up and walking. A man in a business suit picked up his luggage and walked away. One walked directly to the airport bar for a beer (Gonzalez : 2014).
There was a call from fire service for a bus for the walking wounded. The walking wounded were taken to the National Guard mess hall.
ANG Fire Chief Jim Hathaway was fire commander wearing a red jumpsuit marked "FIRE CHIEF." ( Woodbury p 5 ) which under normal circumstances may have been a bit ostentatious but in this situation let everyone know who was in charge of fire suppression and rescue ( Woodbury: 1990). Responders knew who was fire command and surviving passengers knew who to follow. Being deep in the corn, several passengers went to a hill higher ground just northwest of the crash site ( Gonzales: 2014). The runway was strewn with debris so Chief Hathaway ordered subsequent fire equipment to a staging area before running immediately to the crash site and a firefighter was there to walk in front of the apparatus so a flat tire did not make the equipment useless. ( Woodbury: 1990) They were also there to make sure no one was hit by the emergency equipment.
The NTSB pointed out the 7-foot-tall corn stalks did interfere with the operations not only in making it hard for the fire department to reach the crash site but for passengers to know which way to go. Keep in mind the corn was growing on, not near, the airport property. The cockpit, which was separated from the passenger areas ended up in a soybean field also on airport property. ( NTSB p 94)
To rescue the four in the cockpit- which was barely recognizable until they heard a voice say "It's the cockpit. There are four of us in here"- the rescuers tried the jaws of life but that was inadequate. They used the ANG's forklift. All four survived. ( Gonzales p 150-151)
Woodbury County Emergency Management director Gary Brown. Tim Hynds. Sioux City Journal
The training sessions helped solidify who was in charge of what and when. But some conflicts did happen. During the fire fighting/rescue operation "Bodies adjacent to a pumper were bothering fire fighters during fire rescue operations. Chief Hathaway ordered the bodies removed." ( Woodbury p 6). An unnamed FAA official said they needed to remain for the investigation. Hathaway politely informed him "I am in charge while the fire is in progress and the FAA could be in charge later." Hathaway prevailed.
One of two Oshkosh P-19 fire engines,was operating atfull capacity when the water and flame retardant stopped flowing. A water tanker was quickly sent to resupply. The water pump however had failed giving ten minutes of no water on the burning aircraft. An investigation revealed a design flaw in the suction hose assembly causing the suction hose to collapse. (NTSB p 94) .
United sent its team quickly to the crash site and arrived that night. At 10 pm the team for United with CEO Stephen Wolf arrived and told pathologist Brand Randall the bodies needed to be removed. Keep in mind the FAA ordered them NOT to be moved. The first protest against United's request was complaining about how late it was. Gary Brown was getting calls from his boss, the county administrator, about the same thing. He called to the terminal building, getting nowhere, then he headed over to the building himself, walked to the basement office and said "Who the f*** is Stephen Wolf?" The room was shocked. United’s CEO introduced himself and asked what he could do. "You're making my life miserable and you need to stop," Brown said. Wolf assigned Brown a liaison and Brown later said think went smoothly after that. ( Gonzales p 123-124)
Helicopters were initially landed near the crash site, but they were moved further away as they tended to stir up debris and disrupted triage operations. ( Woodbury 8)
Donovan McCulley, Executive Director of the Siouxland Mental Health Center, said they were not integrated into the Incident Command System and there was communication issues. They did not know where to check in, where to assemble. "People converged and just ran around," he said. ( Woodbury: 1990 p 23). The 1990 Woodbury County report suggested preplanning mortuary, human and CISD personnel for future needs. The EMS responders did call for a bus to transport the walking wounded, but the Woodbury County report said they should have arranged for transport sooner ( Woodbury : 1990)
There can also be too much of a good thing. The national American Red Cross sent people into Sioux City without checking with the local chapter. 200 counselors showed up which made things difficult for the meeting room which held 80. ( Woodbury: 1990)
There was some confusion between ANG and civilian rescuers when it came to triage. ANG was using the military naming systems which used I, II, III and IV and the civilian system which used green, yellow, red and black. In the future color coded flags will be used with the numbers. Siouxland was seeing the plus of interagency interoperability more than 10 years before it became the issue it is today. There was also put in place a plan to have taller flags for triage as so many people made them hard to locate. ( Sopher: 1991)
Another issue involved the radio communications. When one looks at the response it seems communications would be an issue and it was, according to Brown which called the system “terrible”. ( Sioux City Journal) There were three states involved, 37 volunteer fire departments, 45 law enforcement agencies, 37 ambulances, 400 EMS personnel, 4 military helicopters, 5 civilian helicopters, 300 Iowa National Guard personnel, 200 mental health personnel and 300 total agencies ( Woodbury: 1990). In addition Brown noticed people kept talking when it was not necessary. "Just stay off the radio. Everyone thinks they have something to say so they tie up the radio traffic. There's no making it perfect but you can try to make it better," he said ( Brown 2016).
Captain Haynes on the 25th anniversary of the crash. Jim Lee, Sioux City Journal
Sioux City Airport today. The closed runway in the middle of the map is the location of the crash. Flightaware
Crash site and Sioux Gateway, 1989. NTSB
111 perished, according to the NTSB. Harlon Dobson died of his injuries on August 19, 1989 but was not counted in the report making the total 112 dead and 184 survivors which works out to just over a 62% survival rate. 35 died of asphyxia due to the fire, 76 from blunt force trauma. Of the survivors, 47 had serious injuries ( one of whom died a month later), 125 had minor injuries and 13 had no injuries. (NTSB: 1990)
The corn growing on the airport was seven feet tall and made rescue a challenge. The NTSB report did not specifically recommend removing the corn or soybeans but did recommend airports make sure it does not interfere with rescue operations. The most recent photos from Google maps show only grass. The FAA also ordered the inspection of suction hoses on all Kovatch A/S32P-18 water trucks to avoid similar failures like the one that delayed getting water to the burning aircraft. (NTSB: 1990)
After the incident, Siouxland agencies began to work on interoperability with the Starcomm radio network. Brown stated that inter agency communications were "horrible" in 1989 but speaks highly today of their radio system (Sioux City Journal: 2014) that has the ability to communicate through emergency responders throughout the tri state areas.
Brown advised emergency managers:
"You’ve got one chance to get it right. The mistake a lot of people make is they think when a crisis happens they think they can fix what's broken or they can catch up with the emergency and tackle it. Neither is true. You'll never be able to unring that bell. You'll never catch up with that event. It's ahead of you and you need to step in manage it. Don't get down in the weeds. Stay at the 40000 foot level and you manage the event not the event not individual things. There are people who work alongside of us can manage individual things. People who are in command manage the event. Where some make a mistake is they get caught in the weeds and can't see the big picture, they struggle and the emergency goes on longer than it needs it to be with worse consequences. I never do that. I stay at the 40,000 foot level." (Brown: 2016)
July 19: ( all Central Daylight Time. Note Denver is in Mountain time so departure was at 2:09 pm)
3:09 pm – UAL 232 Departs Denver
3:16 pm – Engine two explodes
3:22 pm- Siouxland Gateway gets a call for a DC-10 in trouble
3:24 pm- Alert 2 is sounded and hospitals are informed. They begin freeing up beds and keeping staff on duty at the normal shift change time. It is still not known where the jet will land
3:29 pm- Dennis Fitch joins the cockpit crew
3:34 pm – Sioux Gateway advises responders the plane will land South of the airport. An alert 3 is called. Per the disaster plan, most of Siouxland area fire and EMS head for the airport
3:38 pm – Responders informed by air traffic control the plane will attempt a landing at Sioux Gateway
4:00 pm – Flight 232 crash lands
4:01 pm – rescue heads towards the largest area of the plane in the cornfield
4:04 pm – 1st fire apparatus runs out of water
4:17 pm – 1st patient, Harlon Dobson, arrives at Marian
4:30 pm – all critical patients evacuated from the crash site
4:35 pm – First patient arrives at St Luke's
5:40 pm – all patients evacuated.
August 19, 1989 – Last person to die from the crash, Harlon Dobson, dies of his injuries
October 1, 1989 – Last flight 232 patient released from the hospital
April 6, 1990- NTSB report released.
Siouxland will never forget but world's attention moved on. Hurricane Hugo hit the Carolinas in September and the Bay Area earthquake hit in October. United 232 became more of a "hey I remember now that you mention it" moment as the year of the Exxon Valdez, Tiananmen Square and the fall of the Berlin Wall along with the decade came to a close less than six months later.
There was a commitment after the crash, Brown said, "so something good can come out of something so horrible" representatives from the Siouxland have gone to teach other airports and emergency responders around the world the lessons learned. "One of the messages for those who lost loved ones is we didn’t just set back on the recognition the communities received. We took this thing and made it better," Brown said at the 25th anniversary ( Sioux City Journal: 2014)
Flight attendant Jan Brown had a similar conviction and began pushing for a change in the "lap children" policy shortly after the crash. There were four lap children on the plane and one was killed in the crash (NTSB:1990) She retired nine years later and spent more time pushing for the change ( Goglia: 2013). This writer checked with a friend, flight attendant Ela Emami, this year who confirms that like in 1989 "lap children" are still permitted age two and younger and like in 1989 Jan Brown is still trying to change that. The FAA's fear, they stated publicly, is that the added expense of needing to buy another ticket would dissuade families with small children from flying and instead put them on the road where they would be more likely to face injury or death than in a passenger aircraft (Gonzales: 2014 ). No matter who is right, this is still an important issue for emergency responders to remember.
Spencer Bailey, the boy in the iconic photo, is now in New York and editor of Surface Magazine ( Quinlin: 2008 with update confirmed by his current LinkedIn profile)
Spencer Bailey was three years old in the famous photo. Courtesy National Poetry Foundation.
If this sounds like a movie, others agreed. Two of them. "Crash Landing: The Rescue of Flight 232" was a January, 1992 ABC TV movie with Charlton Heston playing a very Charlton Heston-ee Captain Haynes, Richard "John Boy Walton" Thomas as Gary Brown and James Coburn as a cigar chomping brash Chief Hathaway. It was filmed at a lot of the actual spots such as Marian Hospital and Sioux Gateway. Brown said reluctance portrayed in the film towards an implementing an emergency plan was “a bit over dramatized” though there was some reluctance ( Brown:2016). In November, 1993 "Fearless" was a fictionalized account of survivors and their lives after a plane crash that was closely modeled after flight 232. The film begins with passengers emerging from a cornfield and star Jeff Bridges holding a toddler evoking Gary Anderson's photo. Co star Rosie Perez's lap child is killed in the crash. A stage play was also recently released, which this writer had not seen. The point- the world is watching when a high profile event. People watch events and make judgement based on what they are told. We all have heard not to get history from Hollywood but many do and movies do influence public perception. Through very few tragedies make it to the movies, an emergency manager still needs to give effective public information less the public's perception becomes inaccurate.
On July 18, 2014 a 25th anniversary memorial was held at Sioux Gateway Airport. Visiting were eight of the 11 crew members. Four flight attendants were still working as flight attendants of the 25th anniversary in 2014. (Sioux City Journal: 2014) Flight attendant Rene LeBeau was killed in the crash, Captain Denny Fitch died in 2012 of cancer and another was not feeling well and could not make it. Emergency Management Director Gary Brown was there. And the star: 84-year-old retired captain Al Haynes (Sioux City Journal: 2014).
Haynes says he had at that time done about 1,700 talks. Speaking about it is a lesson for emergency managers in that it still helps him deal with the crash and speakers fees go directly to charity. "I had a lot of trouble with guilt of survival," he said. "Mike the psychiatrist from Denver and I talked about a lot and I said I just can't figure out how I was allowed to survive and others weren't. And he said 'it won't do you any good because you won't come up with an answer. Why me doesn’t work. What if doesn't work. It happened and you're going to have to accept it.' And I said maybe I survived to do these talks. He said 'good. Go with it." ( Sioux City Journal: 2104).
Was Captain Al Haynes the star? Was anyone? The TV movie had a working title of "1000 Heroes" which was changed later to the more generic "Crash Landing." Gary Brown called everyone involved "rock stars who brought together an incredible performance" (Sioux City Journal: 2014). This could be the most important lesson of Flight 232 for emergency managers – don't play hero. Play team member. Maybe a year later in The Journal of Emergency Nursing, Lavone Sopher, Rick Petersen and Marcie Talbot summed it up best:
"We cannot emphasize enough that the success of dealing with this mass casualty event is attributed to the complete community efficiency exhibited by the resources of Siouxland and the surrounding towns. In a debriefing session the comment was made that if one person or agency participating in the disaster had not been there the event would not have been as successful as it was. There are no single heroes who can be singled out. It was truly dedication and compassion by all agencies and their personnel." (Sopher: 1990 p. 66a )