Flight 3407: deviance and dangerous complacency

May 15, 2009

Miles O'Brien

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.”

RUSSIAN ROULETTE

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 milesobrien@mac.com

40 comments

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It’s time to fix the real problems. First of all, you can’t pay a FO 16K and expect to get a 20-year veteran who can handle most situations. Secondly, when the break-room is a convienent way for someone to catch a nap, rather than a good night’s sleep, you will have problems. Last, but certainly not least, you need to have strict test standards, and then enforce them. You can’t continually lower the bar and then expect optimum results. FAA, NTSB, all airlines, time to wake up. Pay people what they are actually worth, enforce the standards, and safety will improve!

Thanks for an informative and insightful article. I have only one thing to add. I get the feeling that First Officer Rebecca Shaw, because of her training made obvious attempts to make Captain Renslow aware of her concerns regarding icing, in a respectful, polite manner. Perhaps because of her youthfulness, lack of experience and respect for the captain and the chain of command, she acquiesced for a couple minutes longer than she should have. I can’t help thinking that if she had it to do over again, she would have reacted much differently.

Posted by Glenn | Report as abusive

Why think the FAA and AIR TRAFFIC CONTROLLERS know whats right for the events a PILOT IS LIVING many miles away? Why is it PILOT IN COMMAND not FAA IN COMMAND? Why think a Lawmaker knows what laws will give a pilot the expertise to keep his airplane in one piece. Why forbid spin entry and recovery training, for instance.
I received my pilot certificate #517868 in November 1948, I have over 2,600 hours pilot in command time, SEMELI CFI. I quit in March 1983 and went to AIR TRAFFIC CONTROL in Washington Center then Jacksonville Center. I retired in 1994. I am afraid while flying on commercial airliners. I know the pilot up there, Ex military? is just a computer operator who thinks if anything happens it will be the FAA`s fault. The public thinks the Government is protecting them. WRONG, the pilots Knowledge of non routine events is ALL there is and the pilot will be the first to arrive at the results of HIS actions

Posted by george w. barfield | Report as abusive

What’s wrong with the airline industry is that it must seek profits in a declining economy or go bust. The offshoot of this is that you get the pilot with the least experience, and the lowest paid – union or no-union – to fly the airplane that you’re on…..

Posted by Edgy | Report as abusive

Once things started to go bad it got real bad real fast. Pilots should get emergency / aerobatic training FREQUENTLY so they REACT quickly to a deteriorating situation before it’s too late. I don’t have time in this type of aircraft, but it seems like once the nose started pitching up into a stall, there was sufficient altitude to apply max power to regain enough airspeed to recover, even after a pretty bad roll. But the stall was so bad the aircraft lost lots of altitude and airspeed with the nose up so by the time the nose finally came down and the airspeed came up there was not much room left. It looked to me like the pilots reverted to instinct and held the yoke back while fighting with the rolling instead of counterintuitively going with the roll and pushing forward to get the nose down as quickly as possible to regain maneuvering airspeed at altitude….a common non glider / non aerobatic trained power pilot mistake when things get nasty

Posted by Larry Witherspoon | Report as abusive

There are 4000 deaths per year due to truckers; 7000 deaths per year due to teenage drivers. Virtually every weekend, someone dies in a general aviation accident. 13 people get killed each year by food vending machines; the same as die in scheduled U.S. airliners.

The number one cause of death in the U.S. is mistakes by medical professionals. While we say these things about the pilots that died, there are hundreds of thousands of passenger hour, without an accident. I was a naval officer for 13 years, flew with a regional for three years, and a major airline for the last 13 years. I get a check ride every year, two physical a year, numerous spot check rides by the FAA and the company every year, and the data from my flights is monitored by the union and company through FOQA.

The public is horrified that a Captain would fail a check ride, yet a doctor can kill or maim a patient and at worst move to another state without losing a lisense? Surprise that given the pay and transient nature of airline employment, pilots chose to commute into the NY area? The starting salary of a Nassau County policeman is $34K with benefits; they advertise $92K after 8 years.

The American public has a cheap, safe, aviation system. It is conditional on, suckers, I mean investors, buying into airlines that are rigged against the common stock holder; the federal government taxing airplane tickets at rates higher than acohol, guns, and tobacco, yet returning only a small portion; and professional pilots willing to work for a smaller portion of the pie.

Posted by Charles | Report as abusive

The only solution for this is a fully automate flight, human error is inevitable.
You can put in place how many safety measures you want a 3-4 hour flight become boring at one point and people tend to do stupid thing when they are bored.

Posted by andrei | Report as abusive

The cutthroat competition on costs is an issue, particularly given the limitations of oversight. Perhaps it would make more sense if fa– res were (gasp) regulated and the airlines competed on quality of service, with adequate margins for pilot salaries, training, etc – or would that represent the evil of ‘socialism’?

Do we really prefer the present approach? Underpaid, undertrained, overworked, pilots? I don’t question the fundamental dedication of these two pilots – but such an insane structure and ‘system’ of regulation and oversight is courting disaster. The only surprise is that it isn’t more frequent.

Posted by Super Tortoise | Report as abusive

The FAA is too political. The administrator is appointed by the President, always as a campaign favor or political payback. They appoint retired admirals , wives of Senators, airline execs, and not one knows anything about how Air Traffic Control works or how to fly an airplane. The FAA ‘s sole responsibility should be aircraft and atc safety . Both in training , maintenance, and regulation period. They look the other way all the time when airlines or politicians getting contributions from airlines put pressure on them to ease up on enforcement , put off air worthiness directives when they should be issued and not hire enough controllers. Alaska Air signed off maint on a dc9 and it crashed with a bad worm screw in the tail when it should have been changed. Air Tran crashes in the everglades and then it comes out they had all sorts of problems the FAA let slide.
2 years ago a Comair flight takes off on the wrong runway and crashes because the pilots didn’t know the layout of the field they were in and they are supposed to , plus the control tower instead of 3 controllers had only 1 doing 3 jobs. Now we have undertraining in commuter planes and salaries you cant live on. We have pilots commuting from 2000 miles away to work and guess what , it’s in the majors too. . Yeah they fly 80 hours a month and spend how much time delayed on the ground and no sleep but no the FAA looks the other way. Fatique , flight hours worked without breaks and airlines cutting corners in training and hiring have been a problem for years and yet evrey time we have a crash we all point to the FAA and they give out their usual BS and nobody changes anything. It their job to run things and if an airline can’t make money with properly trained pilots proper top notch maintenance and properly rested experienced crews in this economy with oil at $50+ a barrel then they should be out of business period
Want to fix it , re regulate the airline industry , today in the so called free market they all try to take route share away from each other even if it means they lose money doing it .Well guess where they cut corners when they do that. The cheapest airfare isn’t always the best and smartest thing to do when it reduces safety. I’ve been in this business for 40 years as a Commercial Pilot, Instructor and Air Traffic Controller retired . The deregulation in the 70′s destroyed a great industry, We went from a safe clean well run system to a cattle car business where your treated like a steer , crammed in with no space and put thru a sensleess useless security system , that doesn’t make anything safer.

Posted by david robertson | Report as abusive

Harold, you are what is wron with the West. Mr. O’Brien is right to point out what is wrong with NASA or any organization. You are part of these poeple who think other should not say anything wrong about organizations,because it might effect their profit or whatever. WE should be able to point out what is wrong instead of being politically correct.

Posted by Kenny | Report as abusive

They are cheap operations and carriers that put safety last. The consumer assumes the risk because the seats are cheap. Add poorly trained (read cheap to pay, my fantastic domestic helpers make a better salary) pilots, an aging fleet and poor visibility and you have a recipe for disaster.

The pilot failed five flight exams, that should bar him from the industry, not get him employed.

This country has gotten into the horrible habit of rewarding systemic failure. We see the tragic results of that wrongheaded policy in a situation like this.

Being a pilot and an engineer who has flown in some pretty bad weather I put forth my opinion.

1. If a pilot has not been trained to fly in severe icing conditions then he, or she, is unprepared for what happens. This is the same as flying an overloaded aircraft or one that is unbalanced. When the aircraft stops flying, it stops flying. In any of these conditions you have to fly it into the landing and the gear comes down at the last moment. There is no flaring at the runway. One also has to have plenty of runway and a good set of brakes. I call this type of landing a “controlled crash”.

I have been on commercial flights with good and bad pilots. I lived in Alaska for 22 years and they get sorted out real quick up there. Coming into Kuparuk on the charter 737 and landing on a 3500+ foot gravel strip is quite an experience. I think all commercial pilots ought to have some Alaska training before they get their ticket. You can’t teach bad weather conditions in a simulator, nor can you program it into a computer. “You have to be there”.

Posted by fbelz | Report as abusive

The cockpit transcript contains conversation about “mean” air traffic controllers and goofy ones. Both Hot1 + Hot2 express their preference for non-mean people as those to work with.

‘Mean People Suck But
Incompetent People Kill’

would be my answer bumpersticker.

Posted by Jon Olsen | Report as abusive

Yet another testament to the value that we as a culture place on money, over the value of human life and human well being.

We live in an economy that stresses “making money” over solving problems, and doing real meaningful work. Never mind that being a pilot is a highly specialized skill requiring attention to detail, the ability to “read the winds”, and understand the implications of prevailing conditions. Never mind that a pilot, a trucker, or any other long distance transporter must cultivate their powers of focus and attention to very high levels under conditions which make such stamina difficult at best.

Never mind that those who take pride in such abilities, and as such provide the best service, are replaced by people with less experience. Because in the end, the employer never cared about the worker. It’s all about the money. And here is a wonderful example of how the priorities of the employer were placed on the acquisition of fake “wealth” instead of the person. And people died. But that’s ok. I’m sure the money that will be paid out to the survivors will be more than adequate for their loss.

Put money in it’s place. It was intended to serve us. But instead, we bleed and die for it. We throw our own people into the streets for lack of it. Our exaltation of the dollar has done more to wipe out human potential than all of the abortions we’ve ever had.

I’m not saying that money is evil. Only that money should be put in it’s place. Remove profit as a motive and replace it with the drive for excellence one’s chosen field. Working for pride is so much better than working for money.

I would agree with many of the comments here, but particularly those of and David Benny: Deregulation has proven a very mixed blessing at best and has put too extreme an emphasis on \’cheap\’ fares. Cheap comes at a price, and the price is very clear, I think, from this incident. Is it really impossible to put in place sane, sensible regulation of fares, or is the only \’solution\’ we can imagine the Magical Marketplace of Ayn Rand and her followers that, along with greed, brought us the market crash and its outcome we now face? Benny makes, I think, an eloquent and a classical argument. Money is not the problem – but the love of money, as Benny rightly notes, and its being used as the sole criterion for value (whether social or individual) is contributory. \’A fool know the price of everything and the value of nothing\’. We need, I think, to get our priorities straight – or at least straighter.

Posted by Scrooge McDuck | Report as abusive

I agree that what the airline industry needs is better training practices and testing, and that better wages for such responsibility and specialization should be paramount to running the business on top of providing better rest time to the crew.
Better wages will attract more people and higher standards of teaching and testing will create a well prepared workforce, thus reducing the risk of tragedies such as this. I agree completely.
I agree also that adding another beeping (or shall I say bleeping?) instrument with another set of bleeping lights on the cockpit isn’t liable to make any exausted pilot any more awake.
If they get to be that tired while they’re flying, not even a cold bucket of water thrown at them by a robotic arm will help.
Out of curiosity, as a rule, are there any sleeping rooms for tired pilots in all airports?

Posted by Van Dan | Report as abusive

The question of sleeping rooms strikes me as well. Even physicians in training have access to rooms meant for catching a bit of sleep when possible. It wouldn’t seem impossible for airlines to make provision for sleeping areas – quiet rooms with bunks, or something along the line of the Japanese economy hotels with tiny private cubicles. Certainly it would seem to make more sense than turning an eye while the pilots catch a bit of slumber on couches where – formally, at least – they are forbidden to do so.

Posted by Atomik Seaweed | Report as abusive

Another aspect of huma nature is we tend to overlook the obvious for the sensational. More people will be killed by people yapping on cell phones while driving than will ever be killed in aircraft, and we could fix that easily.

Posted by Richard | Report as abusive

Great article, and nice way of pointing out its not just industry-specific. But in the context of the airline industry, this is a quagmire that hasn’t even seen the full light of day yet.

Many of the comments posted have presented interesting solutions, but the only one that I think holds water, at least in the near-term, is a ratings system similar to those employed by the other political puppet from the “F”-troop, the FDA. All those easy-to-read, can’t-screw-this-up information charts on food and drugs allows the consumer to control the market, if he or she actually cares to. This system of safety would surely over-ride the urge to buy the cheapest ticket, right? I mean, we all know how healthy and fit America is!

And as a side note, the airline industry is extremely overloaded. The last thing we need to do is create more airline jobs, when Americans are getting more thrifty and video conferencing is about to all but kill the business-related revenue for the industry.

Posted by Patrick | Report as abusive

Thanks for sharing, this is a fantastic article post.Really thank you!