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Why Do Planes Crash?
 

Why Do Planes Crash?

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Examples of the dangers of mitigated speech, from Malcom Gladwell's book "Outliers"

Examples of the dangers of mitigated speech, from Malcom Gladwell's book "Outliers"

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    Why Do Planes Crash? Why Do Planes Crash? Presentation Transcript

    • Why do planes crash? Michael Toppa University of Pennsylvania Perelman School of Medicine Information Services July 28, 2011
    • Why do planes crash? Itsnot like the movies “The typical commercial jetliner is about as dependable as a toaster” Poor weather Tired pilots, awake more than 12 hours Behind schedule, so the crew is hurrying Pilot and co-pilot have not flown together before
    • The cumulative effect of smallerrors Crashes are the result, on average, of 7 consecutive human errors  No single error is disastrous, but the cumulative effect is Studies show this is typical in disasters involving any complex system  The 3 Mile Island nuclear disaster was the result of 5 minor, consecutive human errors  I believe there are lessons here for our work as well Poor communication among the crew is a key factor
    • Mitigated speech Whenwe try to downplay or sugarcoat the meaning of what we say, because were  Being polite  Feeling embarrassed  Being deferential to authority
    • Hypothetical scenario In a research study, pilots were presented with a hypothetical scenario, and asked how they would handle it They are in the role of co-pilot, they see bad weather ahead, and they want to make sure they dont fly into it. What do they say to the pilot?
    • 6 possible responses1.Command: “turn 30 degrees to the right”2.Crew obligation statement: “I think we need to deviate right about now”3.Crew suggestion: “Lets go around the weather”4.Query: “Which direction would you like to deviate?”5.Preference: “I think it would be wise to turn left or right”6.Hint: “That return at 25 miles looks mean”
    • The responses Pilots with the rank of Captain overwhelmingly chose the “command” option Pilots with the rank of First Officer overwhelmingly chose the “hint” option This may seem alarming, because it is! “A hint is the hardest kind of request to decode and the easiest to refuse”
    • 1982 Air Florida Crash The plane had a problem with wing ice before takeoff First officer: “Look how the ice is just hanging on his, ah, back, back there, see that?” First officer, again: “Boy, this is a, this is a losing battle here on trying to de-ice those things, it gives you a false sense of security, thats all it does.” The captain doesnt get the hint, and the plane plunges into the Potomac river a few minutes after take off.
    • Avianca Flight 052 The captain is exhausted Planes are normally very low on fuel when landing, but this flight is literally running on empty  First officer to ATC: “Climb and maintain three thousand and, ah, were running out of fuel, sir”  ATC responds with a command to continue circling, and asks for confirmation its ok.  First officer to ATC: “I guess so. Thank you very much”A flight attendant enters the cockpit, and the engineer makes a throat-cutting gesture to her Two engines flame out and the plane crashes
    • KAL Flight 801 The captain is experienced, but exhausted, its night, and the weather is terrible  The captain has flown to this airport several times before  He decides on a visual approach, using the airports beacon to navigate  Hes forgotten the beacon is on a mountain near the airport
    • KAL Flight 801, continued First officer: “Dont you think it rains more? In this area, here?” Engineer: “Captain, the weather radar has helped a lot”  They are trying to tell the captain they shouldnt be making a visual approach  Korean language and culture makes it more difficult to speak directly The plane crashes into the mountain
    • Dealing with mitigated speech Crashes are more common with the Captain in the flying seat “Planes are safer when the least experienced pilot is flying, because it means the second [more experienced] pilot isnt going to be afraid to speak up” For 15 years the airline industry has trained flight crews on reducing mitigated speech  Standardized procedures for escalating communication  If necessary, temporarily relieving the Captain of duty  KAL switched to English-only in the cockpit
    • Example from The Clean Coder Mike: “Paula, I need the login page done by tomorrow” Paula: “Oh, sorry Mike, but its going to take more time than that” Mike: “When do you think you can have it done?” Paula: “How about two weeks from now?” Mike: (scribbles something in his daytimer) “OK, thanks”
    • Passive Aggressiveness,Saying No By not speaking more firmly, Paula is inviting doubt about her estimate What if Mike went to his boss and blamed Paula for the project being late?  Thats “morally reprehensible” passive aggressiveness Saying no can be the first step in a negotiation towards the best possible outcome