Gambling with Fate: The crash of Galaxy Airlines flight 203
On the 21st of January 1985, a chartered Lockheed Electra carrying football fans back home after a trip to Reno, Nevada crashed into city streets just one minute after takeoff. The plane struck vehicles and buildings before bursting into flames, incinerating the occupants in a massive explosion. Remarkably, one person survived: 17-year-old George Lamson Jr., who was thrown from the plane still strapped into his seat while 70 others perished. As Lamson gave hospital-bed interviews to the incredulous media, investigators began to examine the crash with expert eyes, and uncovered some worrying details. Numerous setbacks and technical difficulties plagued the flight while it was still on the ground. Once airborne, trouble started immediately as an unknown vibration rocked the plane. But the cause turned out to be much more insidious. The vibration itself was harmless and did not directly lead to the crash; rather, the effect it had on the crew would turn out to be the key to the disaster.
In January 1985, American football fans from around the country tuned in to watch the 19th Super Bowl, the final match-up that would determine the winner of the 1984 football season. The match between the San Francisco 49ers and the Miami Dolphins was to take place at Stanford University in Stanford, California on the 20th of January, and as was tradition, Super Bowl parties were organized across the US. One group of football fans from Minnesota decided to go all-out: the plan was to fly the whole group to Reno, Nevada, where they could spend the weekend gambling and skiing, while those who wanted to watch the Super Bowl in person could take a bus onward to Stanford to attend the game. After the match, they would fly back to Minneapolis, arriving home in the early hours of the morning — just in time to catch a couple hours of sleep before returning to work on Monday. To carry the group, a broker agent working for Caesar’s Tahoe, the casino which sponsored the trip, hired Galaxy Airlines — a small company specializing in charter flights aimed mostly at gamblers traveling to and from Las Vegas, Reno, and Atlantic City, New Jersey.
Among the planes in Galaxy’s fleet was an antiquated Lockheed L-188 Electra, a large four-engine turboprop designed in the 1950s. By 1985, the Electra was something of a curiosity, having long since been phased out of the fleets of all major carriers; now, most of the remaining Electras belonged to obscure airlines like Galaxy, which were able to buy the planes at bargain basement prices.
By the evening of the 20th, the Electra had already been all over the country. A couple hours before the big game, it was scheduled to arrive in Seattle, Washington with a load of passengers; however, by the scheduled arrival time, it was nowhere to be seen. Waiting in another airline’s crew lounge at SeaTac Airport (Galaxy lacked a lounge of its own) were the crew who would fly it to Reno: Captain Allan Heasley, First Officer Kevin Fieldsa, and Flight Engineer Mark Freels. Heasley was a veteran Electra captain with more than 14,500 flying hours, extensive knowledge of aircraft systems, and excellent marks in training. In contrast, Fieldsa and Freels were both new hires; Fieldsa had only 172 hours on the Electra out of more than 5,000 total hours, and Freels had only 262 hours total, all in the Electra. By the time the plane finally arrived in Seattle — more than an hour late — Heasley had grown noticeably displeased with the delay. After the passengers disembarked, the crew boarded the empty plane and ferried it to Oakland, California, where they hurriedly boarded another group of passengers and rushed them to Reno.
Meanwhile, the group from Minnesota reunited at Reno-Cannon International Airport. The Super Bowl had ended some hours earlier with a victory by the 49ers, and now those who went to see it had finally returned to Reno and rejoined those who stayed at Caesar’s Tahoe to gamble and watch the game on TV. When the plane finally arrived at the terminal in Reno and disembarked the passengers from Oakland, the 20th of January had ticked over to the 21st, and everyone was itching to get moving.
Among the passengers boarding that night were Minneapolis residents George Lamson Sr. and his son, 17-year-old George Lamson Jr. As they filed onto the plane, the Lamsons sat down in a row of their choice, but were soon confronted by another pair of passengers who insisted that the seats belonged to them. There was no seating chart, so they thought this was strange, but not wanting to fight it out, they elected to move somewhere else. George Lamson Jr. sat down in seat 6A, directly behind a bulkhead, while his father took the adjacent seat 6B.
Meanwhile, a team of around ten ground personnel prepared the plane for departure. One group pumped fuel, one loaded baggage, and another hooked up the air start system. The air start system aids in starting the engines by blowing compressed air into the compression chamber, kickstarting rotation of the turbine. A ground handler parked the air start cart next to the plane, opened the air start door on the underside of the right wing’s inboard leading edge, hooked up the air start hose, and began to pump pressurized air into the system.
As the crew fired up the number 1 and number 4 engines, the ground handling supervisor attempted to make contact with the pilots via radio, but discovered that his headset had stopped working. Instead, he indicated that he wanted to communicate with hand signals, and the pilots acknowledged.
Moments later, he gave the signal to taxi, and the plane began to roll forward. But he immediately noticed that there was a problem: the ground handler operating the air start system hadn’t finished disconnecting the hose! He frantically signaled to the pilots to stop, then walked over to the ground handler and helped her uncouple the air start hose, which she had been struggling to disconnect. Once the hose was properly detached, he signaled to the pilots that they were free to continue taxiing, and the Electra departed the loading area. Neither the pilots nor the ground handlers realized that in the rush to disconnect the hose, nobody had remembered to close the air start door.
With the air start door still propped open, Galaxy Airlines flight 203 taxied to the head of runway 16R and received takeoff clearance. With Captain Heasley at the controls, the Electra accelerated down the runway until it reached V1, the maximum speed at which the takeoff can be aborted. Moments later, the air start door slammed down and back up again with a loud “thunk,” which was followed by another just as Heasley pulled back to climb.
“What is it, Mark?” Heasley asked as the Electra climbed away from the runway.
Another thunk echoed through the cockpit. “I don’t know,” said Flight Engineer Freels. “I don’t know, Al.”
By this point the open door was causing heavy vibrations that rocked the entire plane. Because of its position on top of the wing, the door acted like a spoiler, interrupting the airflow over part of the right wing. The turbulent airflow resulted in heavy buffeting that immediately occupied the attention of everyone on board.
“That’s METO,” said Freels, indicating that he had set the engines to the ‘maximum except takeoff’ power setting, the highest thrust level used during normal flight (except, of course, for takeoffs and go-arounds).
At this point it occurred to Captain Heasley that the vibration could be coming from the engines. “Okay, pull ’em back from METO,” he said to Freels, who dutifully obeyed. If the vibration ceased, then the engines must have been the problem. But there was no apparent change.
Turning to his first officer, Heasley said, “Tell ’em we need to make a left downwind to get outta here, get it back on the ground.”
To the controller, First Officer Fieldsa said, “Galaxy 203, like to make a left downwind, we gotta get back on the ground.”
Meanwhile, Freels checked the engine parameters but could see no obvious issues. “RPMs look stable, horsepowers look good,” he said.
“Galaxy 203, say again?” the controller asked.
“Ah, sir, we’d like to make a left downwind,” said Fieldsa.
“Tell him we have heavy vibration,” Heasley ordered.
“We’ve got a heavy vibration in the aircraft,” Fieldsa said over the radio.
“Jesus,” Freels muttered.
“Okay, I’ve got it,” Heasley said. “Pull the power.”
“Galaxy 203, roger,” said the controller. “Maintain VFR [visual flight rules] and a left downwind for runway 16 right, and do you need the equipment?”
Everything in the cockpit began to rattle as the vibration intensified. With engine power at such a low setting, their airspeed had dropped significantly, and the plane was in danger of stalling. But no one seemed to notice.
“Yeah,” Heasley said in response to the controller’s question.
“Affirmative,” Fieldsa replied, passing on his captain’s answer.
“Roger, how many people on board, and say amount of fuel remaining?” the controller asked.
“68, and we got full fuel!” said Fieldsa.
At that moment, flight 203’s airspeed dropped so low that the wings could no longer produce enough lift to keep the plane in the air. The Electra stalled and began to fall towards the ground in a nose-high position.
“Okay, put more power back,” Captain Heasley ordered.
The ground proximity warning system began to blare, “WHOOP WHOOP, PULL UP!”
“Pull up!” Freels echoed.
“WHOOP WHOOP, PULL UP!”
“Pull up!” Freels said again. He added engine power, but it wasn’t enough.
“Sixty eight people and 1,200 pounds of fuel?” the controller asked, seeking clarification. He never got it.
“A hundred knots!” Fieldsa said, calling out their speed. This was nowhere near enough to remain airborne.
In the cabin, passengers screamed and braced themselves for impact. George Lamson Jr. pulled his legs off the floor and cradled his head in his knees to try to protect himself from the crash — perhaps a futile gesture, but it was all he could do.
In the cockpit, the panic-stricken flight engineer uttered, “God, god!”
“A hundred knots!” Fieldsa said again.
“Max power!” Heasley roared.
“Max power!” said Freels, slamming the throttles as far forward as they would go. But it was too late.
At 1:04 a.m. and 31 seconds, barely one minute after it took off, the plane slammed into a field just short of South Virginia Street on the outskirts of Reno. The brutal impact shattered the fuselage and breached both fuel tanks, triggering a massive explosion. Pieces of the plane slid into a furniture store and an RV dealership, obliterating seven RVs and setting the buildings ablaze. George Lamson Jr. was thrown straight through the bulkhead and out of the plane; still strapped into his seat, he skidded down the street ahead of the wreckage, just barely escaping the enormous fireball that consumed his fellow passengers. Upon coming to a stop, shaken but alive, he undid his seatbelt and ran away from the plane — unaware that of the 71 people on board, he would be the only survivor.
Within 30 seconds of the crash, the controller alerted emergency services, and firefighters rushed to the scene. They arrived to find a grisly tableau of destruction: pieces of the plane were strewn about an area stretching from US highway 395, across a field, and onto South Virginia Street, where a huge fire had taken root in the aircraft wreckage, the furniture store, and several RVs. Propane tanks and gasoline in the RVs continuously exploded as firefighters struggled to put out the blaze and search for survivors. In addition to George Lamson Jr., his father and one other passenger had also been ejected from the plane on impact; both were found clinging to life and were rushed to hospital. But while George Lamson Jr. had suffered relatively minor injuries — in fact, he never even lost consciousness — the same could not be said for the others. While members of the media interviewed the heavily bandaged teenager in his hospital bed, the other two survivors, including his father, lost their respective battles. George Lamson Sr. died 8 days after the crash due to a head injury; the other survivor passed away after 14 days due to severe burns.
The first priority for National Transportation Safety Board investigators after arriving at the scene was to find the black boxes. Both were quickly located, but there was an immediate problem: the flight data recorder, an older model which recorded aircraft parameters on a rotating spool of foil, had run out of foil more than 100 flight hours prior to the crash, and nothing from the accident flight was recorded. This immediately raised red flags for investigators. Pilots were required to check that the recorders were functional before every flight, but clearly nobody had done this for at least a week. If crews were routinely skipping this important step, that suggested that other procedures might have been violated as well. What else might be wrong with Galaxy Airlines?
Before answering that question, the NTSB had to figure out why the plane crashed in the first place. After extensive examination of the cockpit voice recording and the wreckage, as well as several test flights, the basic outline of the sequence of events became apparent. The ground crew accidentally left the air start door open, resulting in heavy vibrations upon takeoff. The captain thought the vibrations could have been coming from the engines, so he ordered a reduction in power; however, the crew did not restore thrust quickly enough to avoid a stall, and the plane fell out of the sky. This left three main questions: why was the door left open, why did the pilots allow the plane to stall, and how could the crash have been prevented?
Regarding the door, the NTSB identified several factors affecting the ground crew that led to the mistake. The ground handling service was provided by Reno Flying Services, a company which provided ground personnel at Reno-Cannon International Airport for a large number of airlines. Reno Flying Services normally gave both classroom and on-the-job training to its employees, but an examination of training records revealed that the ground handler who had trouble disconnecting the air start hose had received on-the-job training only. And the supervisor who failed to close the air start door had never serviced a Lockheed Electra before. But the most important factor had nothing to do with training at all, and everything to do with psychology. Normally, ground handlers stick to clear routines, where one step automatically follows another — such as closing the air start door after disconnecting the air start hose. In this case, however, the routine was interrupted when the supervisor’s headset failed, and again when the pilots tried to start taxiing while the ground handler was still struggling to disconnect the hose. These interruptions threw the ground handler and her supervisor off of that automatic routine, making mistakes more likely.
To assess the effects of leaving the air start door open on the Lockheed Electra, the NTSB conducted a series of test flights and solicited the testimony of Electra pilots who had had similar experiences. They found several pilots who reported encountering the problem in the 1970s, all of whom were able to continue the flight safely because the vibrations ceased at higher altitudes (only after landing did any of them discover that the air start door had been left open). But at the time that most of these events occurred, no anonymous reporting system existed that would have allowed the pilots to inform the FAA without fear of retribution. After such a system was set up in 1976, the submission format didn’t include this type of incident as a category, so the trend remained difficult to identify. This was especially troubling due to one particular aspect of the incidents: the vibration caused by an open air start door felt almost identical to the buffeting that accompanies a stall. In fact, in two of the reported incidents, the captain thought the plane was stalling and executed a stall recovery maneuver. This would have been taken seriously had authorities known about the incidents, but this knowledge never made it beyond the airlines involved, even though some went so far as to modify the air start door to resolve the problem.
By contrast, the pilots of Galaxy Airlines flight 203 made the opposite mistake: they identified the vibration at a point in the flight where they were obviously not stalling, and when the plane did stall, the stall buffet was indistinguishable from the vibration that was already occurring. To make matters worse, the Lockheed Electra did not have any kind of artificial stall warning; instead, the onset of heavy buffet was itself meant to serve as an alarm, since it was extremely distinctive and impossible to miss. That another problem could replicate stall buffeting so closely was deeply concerning to investigators.
However, there were other clues that could have helped the pilots realize they were in danger of stalling, such as their low airspeed. So why did no one notice their airspeed was low until it was too late to recover? Based on the cockpit voice recording, it was apparent that Captain Heasley was the driving force for the entire crew; Freels and Fieldsa simply followed his orders and took no initiative of their own. This left Heasley in charge of both troubleshooting the vibration and flying the plane, and he apparently found it difficult to multitask. Meanwhile, First Officer Fieldsa was trying to answer a series of questions from air traffic control, including the inquiry about the number of passengers and amount of fuel on board, which came right at the critical moment where the aircraft stalled. Furthermore, Fieldsa’s adherence to procedures and ability to scan the instruments were judged to be weak during training. And finally, scientific studies had shown that being thrust into a stressful situation inhibits a pilot’s ability to recognize multiple problems, identify which problems must be resolved first, and respond correctly to those problems. The pilots of Galaxy Airlines flight 203 clearly experienced this psychological phenomenon. The principles of crew resource management (or CRM), which help pilots delegate tasks and communicate under pressure, might have prevented the crash, but Galaxy Airlines had not trained its pilots in CRM strategies, nor was it required to do so.
However, the most significant error that led to the crash was the reduction in thrust below METO on all four engines and the failure to restore it in time. Reducing power on all four engines was not the correct procedure to use when trying to identify the source of a vibration. Proper protocol held that the crew should climb to a safe altitude, then decrease thrust on each engine one by one until the source of the vibration is identified. That way the plane will always have enough power to maintain altitude. But even after the reduction in thrust, the plane would not have crashed if power had been restored in a timely manner once it became clear that the engines were not the cause of the vibration.
Captain Heasley was a veteran pilot with excellent knowledge of the Electra and a stellar training record — how could he have made such a reckless mistake? In part, this error could be explained by Heasley’s inability to multitask while under stress. But it also suggested a broader disregard for standard procedures. This tied back to the problem with the flight data recorder, which had led to similar questions. Further inquiry would reveal a whole host of serious problems with Galaxy Airlines that had gone undetected for years.
One of the first issues that caught the attention of the NTSB was the fact that the crew of flight 203 had not left behind a weight and balance sheet. A copy of the sheet must be left with the ground crew or sent to the airline headquarters before every flight, but this did not occur. In fact, the CVR contained no evidence that the pilots ever calculated the plane’s weight and center of gravity (CG). Investigators decided to do the math themselves and found that the center of gravity was actually out of limits. This meant that a forward-heavy passenger loading scheme should have been used; however, George Lamson Jr. had reported that seating was random, further supporting their suspicion that the pilots never calculated the CG at all. As it turned out, the weight and balance calculation and the flight data recorder check weren’t the only procedures that the crew had ignored in the minutes before the flight. The before start checklist was not properly completed; ten items were skipped and 6 were done out of order. No predeparture briefing was heard on the CVR. The crew did not perform the before taxi checklist, and 11 items from the before takeoff checklist were not heard on the CVR, even though they were supposed to be called out by the flight engineer (it was not clear if he ever completed them). The absence of so many required checks was indicative of a casual indifference to procedures, particularly by Captain Heasley, whose vastly greater experience and age meant that he would have set the tone for all cockpit interactions. There was a clear disconnect between this behavior and Heasley’s professional reputation. This might have been because he was in a hurry: he perceived the flight to be well behind schedule, even though Galaxy Airlines had updated the schedule to reflect the delays, and he was worried about completing the flights to Minneapolis and then back to Seattle within duty time limits.
Looking into the oversight of Galaxy Airlines by the Federal Aviation Administration, the NTSB found more concerning problems. The FAA inspector responsible for Galaxy had noted in 1984 that checklist discipline was poor and that more than 50% of responses to checklist callouts were incorrect. An FAA investigation of the airline after the crash turned up several more issues: Galaxy had missed deadlines for structural inspections of its airplanes, pilots weren’t entering defects in the technical logs, and in the 5 month period leading up to the accident there had been 176 flight duty time violations, including 8 involving First Officer Fieldsa and 76 involving Flight Engineer Freels. The FAA inspector assigned to Galaxy had not detected any of these problems, apparently because he was stationed in Fort Lauderdale, Florida — the location of Galaxy Airlines’ corporate headquarters — even though most of Galaxy’s operations were conducted out of Las Vegas and Atlantic City, which made it difficult for him to monitor them. The issues uncovered during the investigation led authorities to impose steep fines against the airline, which ceased operations as a result of federal action sometime in 1986 or 1987.
In its final report on the crash, the NTSB recommended that all operators of the Lockheed Electra modify their air start doors so that they could not remain open in flight; that Lockheed ensure pilots are aware of the effects of an open air start door, until such time as the modifications are complete; that the FAA ensure measures exist to adequately monitor carriers with operations located far from the responsible FAA office; that a different method be developed to get information to firefighters so that pilots need not answer unnecessary questions during an emergency; and that all airlines be required to provide crew resource management training, a perennial recommendation that showed up dozens of times between the late 1970s and early 1990s. As a result of these recommendations, the FAA issued an airworthiness directive mandating the change to the air start door; Lockheed issued a bulletin to all Electra operators describing the problem; and the FAA put out a reminder to all air traffic controllers to avoid nonessential communication with an aircraft that is experiencing an emergency. (Crew resource management was made a requirement in the 1990s, but not as a direct result of this recommendation.)
Today, the crash of Galaxy Airlines flight 203 is perhaps best known for its sole survivor, George Lamson Jr. Saved by sheer luck, he struggled for years to come to terms with the experience, before eventually moving to Reno, settling into a career, and raising a daughter. In the early 2010s, he took the unprecedented step of reaching out to other lone survivors of large plane crashes, an effort portrayed in the 2013 documentary “Sole Survivor.” Some didn’t respond, others rebuffed him, but in the end he did manage to meet with then 17-year-old Bahia Bakari, the only survivor of the 2009 crash of Yemenia flight 626, in which all 152 other passengers and crew were killed, including her mother. Although the meeting was productive, Lamson’s struggle will probably never be over. In 2015, he elected not to attend the 30th anniversary ceremony and memorial dedication, choosing instead to visit the memorial privately after the ceremony was over. Explaining his absence to a local news station, he said, “I don’t want to be remembered as the boy who survived this accident.” Unfortunately, despite his attempts to escape it, both the crash and his improbable survival will most likely remain with him forever.
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