Monday, December 7, 2009
Sway: The Irresistible Pull of Irrational Behavior
Ori and Rom Brafman do a great job of captivating the reader with amazing anecdotal stories that drive home the primary message of the book: people, who normally make rational, intelligent, and calculated decisions, can and will neglect glaring evidence to make a decision that will negatively alter their lives. The wide swath of tales covers enough ground so that all readers should experience the proverbial cooking pan to the side of the head. Perhaps that is why I liked the book. The Brafman brothers state that all people do stupid things. Then, you, as a reader, give them a chapter or two to prove their point thinking that you'd never be caught doing some thing so foolish that it would alter the course of your life. You are then engulfed by the storytelling. And then, bam, the fry pan hits you square in the face because you realize that one of the stories directly describes some recent foolish action you have taken.
This book is outstanding in its own right. My interest was piqued by the book's 1st sentence which describes one of the world's most experienced and accomplished pilots in the world. Now, allow me to diverge. Aviators are an interesting set. Perhaps there are more technically difficult jobs in the world. But the confidence required to be an aviator disallows just anyone to sign up. Aviators must be relentlessly perfect. Surgeons and aviators have to have a certain swagger in their professionalism because mistakes are final. While not everyone knows an aviator, most people know surgeons and are inspired or disgusted by their approach on life and interactions with people. I feel like the same can be said about aviators.
My 9 years previous to b-school were spent flying the US Navy's largest plane that lands on the carrier. Just to reiterate the idea of finality, when landing on the carrier, I had 4 feet of centerline deviation before I started dragging my wingtip through parked planes. If not on centerline while landing, not only would I be causing literally hundreds of millions of dollars of damage as I dragged my wingtip through parked planes, but the likelihood of surviving that event would be slim at best. Plus, the 150 flight deck workers would be subjected to 150 knot flying metal shards. So my plane would be lost, 15 or so other planes would suffer severe damage, and many people would likely not survive. So it was a stressful life. But in my mind (and reality), there just wasn't a better carrier aviator. I was the best. I had to be. Each time I was on final approach to the carrier, attempting to safely crash my plane onto the deck and pray that my tailhook caught a wire, I had to have nerves of steel and the confidence to accomplish my task at hand. Raining? Didn't matter. Snowing and couldn't see? Fly perfect instruments. Windy and the carrier deck pitching plus or minus 19 feet with 9 foot listing? A varsity day, but toughen up. So as you can clearly see, that confidence is required, because beyond open heart surgery, there are few jobs in the world were you absolutely must be perfect, every time.
So I found it interesting that the Brafman brothers would start with the Tenerife disaster that killed 584 people when two planes collided on the runway. Increasing bad weather, crew rest, and a failed cockpit social structure allowed the holes of the proverbial swiss cheese to align and this horrible mishap to occur. All the safety frameworks in place did not catch the circumstances surrounding this event. Many studies were conducted to better understand what went wrong and how to plan to avoid the mistake again. The interesting piece for me is that my years of flight school incorporated these safety improvement ideas so well, that I did not even realize it was happening. Allow me to diverge again.
When you start flight school, you first fly with an instructor. That instructor has thousands of hours flying and you do what they say when they say it. If you cannot perform simple maneuvers, talk on the radio, and understand the emergency procedures, you attrite quickly. There is a knowledge base that you must acquire and prove that you can perform. However, after about 200 hours, a student knows his way around the jet and can safely get off the ground, zipp around at 300 knots, fly formation, and safely land in challenging weather environments. The confidence is building because flying a jet is a difficult task. However, this idea of crew resource management is ever present. There is always someone somewhere that has information that you need. It might be that ATC knows there is a distressed plane behind that needs to land before you--altering your fuel planning. It might be that your a fire-detection system has failed. It might be that your co-pilot sees a very small plane 20 miles out that is CBDR (constant bearing-decreasing range). It is not that anyone one of these things will cause a disaster. But add these circumstances up without the primary decision making (the aircraft commander) understanding what is happening, and the holes of the swiss cheese align. Experience, and the confidence (read arrogance) that surrounds it will never be a substitute for a lack of situational awareness. For this reason, it is imperative that the cockpit be an information depository. As an aviator, you must constantly look for new bits of information. It might be a rate of descent reading, an altitude, a radar blip of another plane, or an ATC radio call describing the weather at your destination. Flight is dynamic and constant, relevant, updated information is paramount. The most important thing to understand here is that things happen quickly and pilots get saturated. Hence, CRM. Crew resource management enables a communication environment where each crew member is incentivized to speak up concerning relevant information. Had the social structure in the cockpit of the KLM flight been different, the greatest commercial aviation mishap would have been avoided. However, the copilot (who was an amazing pilot in his own right) did not speak up when his more senior captain took an action that was reasonable, yet deserved questioning.
The interesting piece is that 20 years after the Tenerife disaster, CRM has even reached Naval Aviation. As a matter of fact, CRM was such an established standard that I didn't realize that at one point it did not exist. Even as a US Naval Aviation Safety School graduate, I did not understand that there was a generation gap between an aviator trained 10 years previous and myself. A single flight with my commodore (15 years my senior) made it painfully clear to me. I signed for the aircraft as the aircraft commanded, despite the fact that I was seriously outranked. I was the more experienced aviator in in this particular aircraft, but he had thousands more hours overall. We had an oil pressure problem and I wanted to land quickly. He thought it was a false reading and we should press 30 minutes back to base so that he could make his next meeting. My aircrewman and I both agreed that landing asap was the best plan. The commodore pressed his case. I listened to his reasoning and then listened to the aircrew thinking. Because I had signed for the plane, I had 51% of the vote. The commodore was visibly upset that I declared an emergency and landed at the nearest airfield. However, his mood changed very quickly when directly after landing, our right engine failed. His desire to take his next meeting clouded his ability to think clearly about the circumstances surrounding our flight. Because he outranked me by 15 years (a lifetime in Navy), he expected me to immediately fold to his wishes. However, CRM demanded that I accumulate as much information about our situation from all members of the crew. Had the commodore signed from the aircraft, he just would have pointed the plane towards home base and suffered an engine failure. Because I listened to the reasoning of all crew members, I was able to build my situational awareness (unlike the Tenerife disaster) and make a timely decision. It was standard protocol for me to employ CRM in this case. However, the commodore was not interested in my thoughts on the matter. I am happy this generation gap existed.
For me, CRM was a normal, necessary part of aviation. Yes, I was the best aviator to fly my aircraft--that confidence did not escape me. However, unlike the commodore, I knew that I could be better if I had complete information. Older pilots pre-CRM believed that their experience was more valid than any other entity in the aircraft. It seems criminal with hindsight, but in the commodore's era, the confidence/arrogance that was required to be a good aviator was a swiss cheese hole aligning mechanism--and it was encouraged. His willingness to employ CRM in his cockpit set up a social structure that was difficult to overcome. Had I not signed for the plane that day giving myself 51% of the vote as aircraft commander, I wonder how my world would be different.
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