Hypnotized in high places - Northwest Flight 188

( picture of vulcan cockpit from u07ch on flickr -- Click for larger view.)

So, yesteday, it seems that a Northwest flight #188 overflew its destination city as the FAA attempted desperately to reach it. According to the NY Daily News,

Crew members aboard Northwest Airlines Flight 188 told the Federal Aviation Administration they were distracted during an intense discussion over airline policy and lost track of their location in the bizarre Wednesday night error.

I wrote a comment to ABC News, after reading the other 200 or so comments, as follows (spacing put back in for clarity and ease of reading).

====

There are always multiple levels of contributing factors, from personal to procedural to crew interaction to cockpit design to job design to corporate policy to FAA policy.

For safety, versus lawsuits, it's worth looking at each level of that nested hierarchy of contexts to seek ways to reduce the odds of this type of thing recurring. If we do that, we don't need to know for sure what happened -- only what might have happened that we are now aware of is a gap in our current system that is relatively easy to fix without side effects.

I think the context of the discussion could be expanded in two ways, both of which involve asking "What other events is this event like?" in a much larger framework.For example, I note an uncanny resemblance between this situation and the behavior of CEO's and government regulators as the nation financial situation flew up to the red line, and past it, while thousands of people screamed and called for attention below, and those above seemed to be ... asleep? ... arguing?... out to lunch?

This is not just situational unawareness, it is unawareness or a shared-delusional-mesmerized state that cannot be broken into by repeated efforts from outside and below, in the corporate and governmental boardrooms.

I'm not saying that just to b####, although b####ing can be fun -- I'm saying that human beings, even those with superb qualifications in isolation, can manage, collectively, to get themselves set up so that those "above" are completely and thoroughly "cut off" from input and flying blind or simply not flying at all anymore.

Again, not as legal blame for this accident, but as a route to understanding "what goes wrong with human interactions", this event could spur us to look at that much larger question, asking seriously, "No, seriously, how could THIS KIND OF THING ever actually happen?"

The truth is, socially, it happens A LOT.

There is something structurally seriously wrong with our mental model of how a hierarchical command structure ACTUALLY functions versus how we IMAGINE it to function.The lives destroyed and lost on a corporate and national level from THIS KIND of error are far more than the lives lost in this latest incident (zero).

Wade_AA

====
(picture by aeneastudio on Flickr)

Other observations I've made about structural blindness and delusional-mesmerism in high places:

Why we have so much trouble seeing

Why are so many flights delayed? The circle of blame


Model induced blindness and FEMA

It's a year since Katrina made it obvious that people watching CNN knew more about what was going on top government officials.

We have to ask how that is even possible. It defies our intuition, although not our experience, which is interesting.

While the "blame-game" remains in high-gear, Systems Thinking leads us to discount the obvious "bad people" and look for deeper root-causes in the social structure. FEMA Director Brown has been replaced, but the systems problems are harder to see and may still be there....

The power of delusion

It is an astonishing fact of life, which the Times article reveals, that the desire for life to be simpler is so powerful that it can cause 10,000 "trained" scientists, with PhD's, to take 30 years to finally collectively observe what others outside their mutual-blindness-field already knew.

As I've said, textbooks such as "Feedback Control of Dynamic Systems" are in their 5th editions in Control System Engineering, but biologists, and much of public health's biomedical research community, discount that literature to the point of invisibility and effectively treat it with contempt. To them, this literature does not exist. When seen, it "comes as news to them", and is promptly forgotten, because it conflicts with the shared myth of their culture, and cultural myths always win out over boring contrary evidence.

The Way Things Are (The "Yarn Harlot" tells it like it is, beverage alert!)

There are some truths. Things that just are the way they are, and no amount of desperate human optimism will change them. Allow me to demonstrate.
The guys showed up with the new stove. I went out front to meet them....

OK, Seriously... WHY didn't we see it coming?

High-reliability human systems have been studied extensively, from Chernobyl to The Bay of Pigs to Challenger to aircraft cockpit teams to hospital surgical teams to the US Army Leadership Field Manual. The answer always comes down to the same thing -- dissenting views need to be heard, and dissenters need what Harvard Professor Amy Edmondson calls "Psychological Safety" or they will wilt and become ineffective. This is how humans always behave and unless steps are taken it always breaks along this fault line.

The right question then should be, who is going to take charge of seeing that those steps are taken and that level of social literacy achieved?

I can't emphasize enough how much more important this is than more math and science, in the absence of this. As T.S. Eliot said, we repeatedly get burned "dreaming of systems so perfect that no one will need to be good, but the man that is will shadow the man that pretends to be."

Much of my weblog is about what we really need to do to avoid such errors in judgment.

====
Various related posts:

My 40 page multilevel structural analysis of
the Crash of Comair 5191 crash in Lexington KY. August 2006
with extensive links to source materials

related webpost with links to Comair 5191 cockpit voice recorder transcripts.


Information on the investigation of the crash of Continental flight 3407 in Buffalo, NY Feb 13, 2009, from the Buffalo News.

On Thursday, Feb. 12, 2009 at 10:20 p.m., Continental flight 3407, en route from Newark, N.J., spun from the sky and crashed into a home as it made its approach to Buffalo Niagara International Airport. All 49 people on board the plane were killed, as was one man in the house in Clarence Center. It was the worst aviation accident in Western New York history.

...A moment later, the co-pilot, Rebecca Lynn Shaw, complained of her own inexperience.

"I've never seen icing conditions," she said. "I've never de-iced. 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'd 've freaked out. I'd have like seen this much ice and thought oh my gosh we were going to crash."

Moments later, the crew lowered the plane's flaps and landing gear, and the plane quickly encountered trouble.

Things we have to believe to see

Why men don't ask for directions

Pisa/OECD - Why our education stresses the wrong way of seeing

Failure is perhaps our most taboo subject (link to John Gall Systemantics)

Active strength through emergent synthesis

US - Economy of arrogance (and blindness)

Virtue drives the bottom line - secrets of high-reliability systems

High-Relability Organizations and asking for help

Secrets of High-Reliability Organizations (in depth, academic paper)

High-Reliability.org web site

Threat and Error Management - aviation and hospital safety

Failure is perhaps our most taboo subject (link to John Gall Systemantics)

The importance of social relationships.

Houston - we have another problem (on complexity and limits of one person's mind)

Institute of Medicine - Crossing the Quality Chasm and microsystems (small group teamwork)

Here's a few quotations from MIT Professor John Sterman's textbook "Business Dynamics".

Many advocate the development of systems thinking - the ability to see the world as a complex system, in which we understand that "you can't just do one thing" and that "everything is connected to everything else." (p4)

Such learning is difficult and rare because a variety of structural impediments thwart the feedback processes required for learning to be successful. (p5)

Quoting Lewis Thomas (1974):

When you are confronted by any complex social system, such as an urban center or a hamster, with things about it that you're dissatisfied with and anxious to fix, you cannot just step in and set about fixing things with much hope of helping. This realization is one of the sore discouragements of our century.... You cannot meddle with one part of a complex system from the outside without the almost certain risk of setting off disastrous events that you hadn't counted on in other, remote parts. If you want to fix something you are first obligated to understand ... the whole system ... Intervening is a way of causing trouble.

IN reality there are no side effects, there are just effects.

Unanticipated side effects arise because we too often act as if cause and effect were always closely linked in time and space. (p 11)

And, this crucial comment by Sterman, reflecting the same observation by persons such as John Maynard Keynes.

Most of us do not appreciate the ubiquity and invisibility of mental models, instead believing naively that our senses reveal the world as it is (p16).

My additional note on this crucial insight. The reality is that the world, as it shows up on the mental TV screen we watch, is NOT the world that is actually out there. It has been more than rose-tinted by our brains. It has had entire chunks of the scene edited out entirely, and other chunks that "should go there " put in their place. A whole set of things that have given us pain or conflict in the past have been summarily removed, without so much as a place-holder left where they were. A set of things we hope might be true have been "helpfully" added to the scene. People's behavior, where it deviated from what we expected, has been "corrected" to show us them acting "the way we KNOW the are", not the way they actually are.

We are, in other words, flying almost entirely blind. We have papered over the front and side windows of our cars with pictures of the way we WANT the road to be, and are driving and turning the steering wheel based on those internal delusions.

Throughout evolution, this has been useful to reduce the immense fire-hose of data to a smaller set we can live with -- and, if we do a bad job of managing it, heck, we just die off and don't reproduce and others who do better jobs have children and go on. No big deal.

The problem comes when those living in such delusional and self-confirming, often self-congratulory worlds are given the power to rule our communities, our corporations, or our governments and they continue onwards believing that what shows up on their mental TV screens IS in fact what is going on out there, and believing, therefore, that those voices of dissenting views are, in fact, some kind of misguided or enemy action that should best be suppressed, shut out by locked cockpit doors or isolated fortress war-rooms, etc.

I'm not saying that solving this problem of filtering the fire-hose of complexity down to a size we can comprehend and use as a guide for steering is an easy one -- but I am saying that it is the kind of hard, complex problem that can yield its secrets to methodical research and study, and it is THAT research we desperately need at this time in our lives on Earth.

This is where it is breaking.

This is where we need to fix it.

Well, at least, that's what MY internal mental TV is showing me right now as the "obvious truth".

Wade