Flight 3407: deviance and dangerous complacency
Miles O’Brien is a pilot, airplane owner and freelance journalist who lives in Manhattan. His blog is located at www.milesobrien.com. The opinions expressed are his own.
At the Colgan/Continental 3407 crash hearing in Washington on Thursday, an expert from NASA told the National Transportation Safety Board that airliners should be equipped with a new warning system that sounds an alarm in the cockpit when the airspeed gets dangerously low – awakening the crew from its complacency.
There is a bit of irony that this advice comes from NASA, an agency that has collectively killed 14 astronauts and destroyed two $2 billion space shuttles because of complacency on an institutional scale.
And that is what troubles me about the cockpit airspeed-warning gadget. While it might be a fine idea, it does nothing to solve the real problem. It is a band-aid on a gushing artery and to the extent “solutions” like that fool us into thinking we have made things truly safer; they are insidiously dangerous indeed.
Critics often accuse the Federal Aviation Administration of having a “tombstone mentality” – meaning people have to die before things can change for the better. But the tombstone mentality is much bigger than the FAA, NASA or any other bureaucracy. It is as fundamental as human nature.
Human beings will push themselves in any number of ways – right to the brink of disaster. And here is the trap: every time we do that and get away with it, we mistakenly draw the conclusion that it might not be as risky as we thought after all. As we grow accustomed to flirting with disaster and getting away with it, our perception of the inherent risk changes – but the real odds do not. And in fact, the more we tempt fate, the more likely we are to meet our fate.
Throw a frog in a boiling pot of water, and it will jump right out. Put it in with the water a room temperature – then gradually bring the water to a boil – and the frog will sit still until it becomes an appetizer. (No animals were harmed in the writing of this column.)
And so it goes for airlines, pilots and regulatory agencies. We gradually and blithely accept greater risk without comprehending what we are really up against.
Sociologist Diane Vaughan wrote a brilliant book about this in 1996 called “The Challenger Launch Decision: Risky Technology, Culture and Deviance and NASA”. Now, by “deviance”, she is not referring to NASA workers downloading porn while on the taxpayers’ time; she is talking about how organizations come to violate their own sacrosanct rules – by collectively concluding that it is just fine to ignore them. She calls it the “normalization of deviance.”
The brilliant physicist and educator Richard Feynman, who served on the Rogers Commission (which investigated the Challenger accident), summed it up well. He compared NASA’s decision to keep launching shuttles despite growing evidence of scorched, leaking Solid Rocket O-Rings as “a kind of Russian roulette… (the Shuttle) flies (with O-Ring erosion) and nothing happens. Then it is suggested, therefore, that the risk is no longer so high for the next flights. We can lower our standards a little bit because we got away with it last time.”
It is clear the path to this crash in Buffalo is littered with a long trail of “normalized deviance”.
Captain Marvin Renslow slept in the crew room at Newark after commuting from Tampa. This is against the rules but apparently everyone looked the other way.
First Officer Rebecca Shaw flew through the night from her home in Seattle and was up all day before signing in for her final trip. She evidently had a head cold – and might very well have been on some sort of over-the-counter cold medicine. She complains about her ears in the transcript of the Cockpit Voice Recorder.
Both crewmembers yawn repeatedly during this flight. No surprise there?
The crew also did not maintain a “sterile cockpit” (meaning no chit-chat) as they descended below 10,000 feet.
But all of this is just another “normal” day at the office for flight crews in many of our regional airlines. The rules that are there are frequently ignored – and the rules that are there are too lenient.
The minimum requirements still allowed:
· A captain to flunk no less than five flight exams and still hold the “left seat”.
· Those long commutes between a pilot’s home and base.
· The airlines to pay pilots paltry wages.
· Only 8 hours of rest time (from wheel-stop to sign-in for next flight).
Reading the transcript of the cockpit voice recorder is a gut-wrenching experience for me. I can only imagine what it must be like for someone who lost a love one that February night.
The crew was shockingly disengaged and unappreciative of the ice that had built up on their craft – and had minimal experience flying safely though it.
Said Shaw: “I’ve never seen icing conditions. I’ve never deiced. I’ve never seen any— I’ve never experienced any of that. I don’t want to have to experience that and make those kinds of calls. You know I’dve freaked out. I’dve have like seen this much ice and thought oh my gosh we were going to crash.”
They also never even made mention of their rapidly degrading airspeed once they deployed the landing gear as they reached began the final stage of the approach.
And then, when the airplane warned them (in most urgent terms) that it was too slow – with an automatic “stick-pusher” designed to remind the pilot to push on the yoke, get the nose down and build up some airspeed or face imminent aerodynamic stall, they overruled it – pulling back hard – sealing the outcome. The 3-D animation is also hard to watch.
This flight’s crew has become the poster children for what is wrong with the airline industry. And the solution is not a new low-speed warning device in the cockpit.
No, what we need is a way to change the “culture” inside the industry and awaken it from its dangerous complacency. And a new gadget is not going to do that.
You can contact the author at firstname.lastname@example.org