Sunday, August 09, 2020

Three tips to help you make it through the day!

 We all have hidden strength - the trick is to claim it!   Here's some hints and thoughts that might help. They might not be totally accurate but they're close enough to be helpful!

Tip #1 - Don't drive on your starter engine!

Humans are like cars.   All gas-powered cars have two engines - a small electric one to get the big engine going, and the big one.    When you wake up in the morning you are running on your starter engine.   You need to get your main engine started with a totally different source of power. 

Some ways people do that are prayer,  rituals,  meditation,  and music.  

One quote I like as near as I can recall is by Martin Luther, the guy who started the Protestant reformation and the Lutheran church.   He said "Work, work, work - from early morning till late at night! I have so much to do I shall spend the first 3 hours in prayer.!"

  Martin Luther

 Tip #2 - Act from love

My favorite paraphrased quote from Boys Town's motto is "He ain't heavy, Father -- He's my brother!"

Tip #3 - Don't travel alone!

Studies show that hills seem easier to climb if you walk with someone else. There are about a zillion other reasons why partnering up during a crisis is a great idea.

==============

More stuff:

U. of Michigan "teach-out" on how to thrive in these hard times:

  https://online.umich.edu/teach-outs/thrive-in-trying-times-teach-out-fl/?

Music:

He ain't heavy, he's my brother ( the Hollies )

Hands ( Jewel )


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Thursday, April 30, 2020

Smart Meeting Rooms, a concept for Second Life

Here’s what I’m working on 

and I'm looking for collaborators!  

 
“Smart meeting rooms” in Second Life


Here's the concept:
* Current teams and meetings in RL are often not very productive



        Either mind-numbing or hostile


* In almost all cases,   remote meetings via Zoom, etc. are worse. Every day there's a new article in the news about how "remote meetings" are a massive drain on our energy.   The major reason is that they are not designed to manage the "emotion channel",  the non-verbal clues and cues we send each other constantly in Real Life interactions and meetings -- all those little grunts, twitches, shifts of body positions, tension in the face, etc. add up -- a lot!





* Linden Labs Virtual World Second Life has affordances that RL doesn’t, and that many-faced "remote conferencing" system such as Zoom or GoToMeeting or Skype lack, so possibly the whole “meeting” User Experience ( UX ) could be crafted to boost the odds of having a great meeting. 


 How could that be done?


Answer:  tilt the emotional playing field! 

 

 What can be "tilted"?  In a virtual world essentially everything can be changed, from the "room" if there is even a room,  to the avatars.  It can be changed in real-time, and potentially managed as effectively with a control panel as the lighting is for a stage play, or the audio in a recording studio.

Why meet in "rooms" anyway?   Would comfortable chairs around a fire-pit make for a better conversation?


  Every aspect of a meeting space in Second Life could in principle be controlled dynamically by a wise facilitator using a sophisticated dashboard and controls:    seating arrangement, environment ( ambient or response-sounds, lighting, spot-lighting, weather, size of room,  walls, fog , table shape/size, jungle?, city?, mountain vista? )



*  Since permissions can be given to a Second Life “Experience”, every aspect of avatars themselves could be dynamically controlled:   age, sex, size, muscles, clothing, species,  ambient and responsive-gestures.

*  In practice humans are exquisitely aware on an unconscious level of  subtle changes in other humans’ expressions, body language, or echoing behavior, etc.  As the book Nudge points out, the clues we respond to may all be both gentle-touches and not even consciously noticed to have a measurable impact on behavior.  Participants may not even realize their emotions are being manipulated.

* Someday a human DJ emotional-channel facilitator could be replaced with an AI expert system, relieving the chance that the additional person was a security risk or had an agenda that favored one “side” or another, and lowering the cost and thereby increasing availability of such “smart meeting rooms” to the public.

* side benefit - the changes in concepts, self-image,behaviors, and relationships created in SL may in fact persist once logged out into RL, so a great UX in SL could have downstream benefits as well that compound over time.

You can read more of my ponderings on what's wrong with meeting rooms and why, in my mind, that is potentially the most important question of the decade in terms of addressing how to make better decisions come out of the same groups of people, in a billion small ways, every day, as we actually learn how to work together and put our heads together and solve problems together.

Click to read; We need Serious R&D On How to Improve Meetings

The Baha'i concepts of "consultation" are quite relevant to how meetings should happen and this technology in my mind is only a way, using socio-psycho-biofeedback,  to have groups get there in a week, not 20 years, the same way biofeedback can help a person locate their alpha-rhythm in 15 minutes instead of 20 years in a cave in Tibet.     The end goal is that the people, once they grok and latch onto the idea, can carry on without the training wheels of technology

It can be compounded, so that those who grok the concept can act as guides to bring new people on-board, and if it can be done in virtual reality,  then distance is no barrier and the entire globe can tap into this way to vastly improve the outcomes of their own organic processes of decision-making.



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Monday, April 20, 2020

Covid-19 pandemic response - Reprise

I believe that our personal and social responses to the covid-19 pandemic have some gaps that I wanted to address.  Here are the main risk factors for you dying from the pandemic virus:


[click the picture to enlarge it ]

In order to die from covid-19, you have various risk factors that policies like "social distancing" are supposed to address.     Briefly, left-to-right, you have odds of being exposed, which "social distancing" is supposed to improve. If you're exposed you have odds of being infected, and if infected you have odds of it becoming serious.   Most of us, 80% of us in fact, if we get infected,  will not have a serious illness requiring hospitalization.    If we were that serious, we have some odds of not getting admitted to a hospital, because it's already full,  or even if we get into a hospital bed, of the hospital not having the resources they need to care for us -- those two are factors, again, that social-distancing and "shifting the curve" are supposed to improve.   Finally,  even with the best of care, you could die anyway.   No one is looking at changing that factor right now.

What I do not see addressed in social media are the two important boxes on the left -- the ones that protect 80% of us already!    What factors would make it less likely that we would be infected by the virus if we were exposed to it?   And,   even if we got infected, what factors prevent the infection from becoming life-threatening and requiring a hospital visit?   

It's become increasingly clear that the human immune system can be depressed by many social determinants.   Here's a scholarly paper on what's known about how simply reducing stress can improve resistance to infection:

Effectiveness of Stress-Reducing Interventions on the Response to Challenges to the Immune System: A Meta-Analytic Review

Many studies show that these psycho-social,  non-medical interventions can affect both of two boxes I highlighted above -- resistance to being infected if exposed,   and,  resistance to developing serious complications if infected.

The effect of this sort of non-medical intervention is real,  evidence-based,  and in some cases quite powerful.  

So, why aren't we talking about doing something about those two things?    Studies have shown that there are many "social-determinants" of health,   such as exercise and eating right,  or overcoming stress, anxiety, and depression, which can have a strong impact on increasing our immune system.

One of the most powerful impacts on our immune system is the least understood -- the power of social connectivity and emotional intimacy to increase our odds of living.  [  That's "intimacy" as in deep friendship or closeness,  not "intimacy" in a sexual way! ]     Perhaps anxiety about things even remotely sounding sexual as research topics is a good thing -- but if it is blocking us from having a powerful boost to our immunity that doesn't require quarantines or shutting down the economy,  it's a bad thing!

I have a deep suspicion that if a company could figure out how patent and package such intimacy we'd be flooded with ads and everyone would be buying it.   As it is, no one can patent it -- its not only a power boost to our immune system, it's absolutely free, no health insurance required. 

Maybe that's why it, like the "placebo effect" -- the impact of our brain on our body which is so powerful it's the gold standard for clinical trials -- there is no commercial interest in the "product" and it slips from our attention.

The exact route by which human intimacy improves our immune system is unclear, but no one knows how aspirin works either but we use it all the time.  The effect of intimacy is not easily controlled and may sometimes be counter-productive -- but for drugs we take every day the original discovery was almost certainly a small,  perplexing effect that we spent billions of dollars on studying in order to enhance it, clean it up,  remove unwanted side-effects, etc.     Right now we're spending two thousand billion dollars on this virus problem, with more yet to come.  

You might think one billion dollars would not be out of line to spend on an effect that has shielded 80% of us successfully from dying,  wouldn't you?   Heck if we could make that number 85% of us instead of 80%, that could equate to 2 million lives saved even without needing a quarantine or social distancing.

I'm bringing our attention back to it.  If we want to reduce deaths even more than the 80% due to such factors already,   we should focus more attention on it, and maybe more dollars on advertising and advocating it, and on research to make it even more effective.

One big plus for more attention on such psycho-social factors is that, unlike vaccines or other specific drugs,  an improvement in the immune systems and general fitness of Americans provides protection against all future pandemics as well as against Covid-19.   

In fact, if you could do the math, an improvement in the mental and physical fitness of American workers probably more than pays for itself with fewer sick days and higher morale and productivity during days when employees are at work.   This kind of improvement and improved social cohesion may in fact help people, companies, and the country deal with other crises besides pandemics. 

Not surprisingly, the former US Surgeon General recently declared that the number one health problem in America is "loneliness".   You can read about this or listen to the 3/23/20 talk here.
"Long before coronavirus spread around the world, former Surgeon General Vivek Murthy was sounding the alarm about a different, quiet epidemic: loneliness. We’ll talk to him about why so many Americans are suffering from loneliness and what we can do to take better care of each other even as we’re asked to be physically apart."
I should comment that I have no stock in any company that would benefit from such investment, no "skin in the game" other than my own.  I just don't see what's wrong with the logic above.  Please feel free to comment in the comment section and enlighten us all!  I welcome comments, even critical ones, or new directions, if they help us make better decisions now, when it matters the most.

Finally,  it's a little rough around the edges, but I recently published in this blog some thoughts on how to operate in crisis conditions,  when the normal rules no longer apply and nothing is where it used to be, in this post:  Tips for Reliable Operation During the Covid-19 Crisis.   These are suggestions such as "buddy up with someone", "don't trust your memory", and "be tolerant of other people who are near their breaking point and having trouble concentrating."   Please feel free to add your own gems in the comments.

Anyway...

Here's a tweet chain from this morning,  slightly amplified and annotated:

===============================
Do Americans ever stop to think what they're doing? Would you call on an IT guy to fix your car? Drill your teeth? Fix your plumbing? So why on earth do we trust every idiot with a computer background to expound on epi?
Quote Tweet
All I don't wanna do is zoom-a-zoom-zoom-zoom
@hypervisible
·
“While neither man has a background in health or epidemiology, the same statistical modeling that applies to fast company growth might also be useful for tracking virus growth.” Stop bros. Just stop. bloomberg.com/news/articles/
7:38 AM · Apr 20, 2020Twitter Web App
 -----

Replying to
Great point, Karen! The pandemic has exposed a loss of American social systems which place the most qualified experts into respected leadership roles. Epi modelers are one such group. 

 



That said, the entire complex adaptive social system is way larger than modeling a virus, or the collective responses to it, or recursively, to prior models, responses, etc. The risk of unjustified predictions is about 100%.
Mixing ABM and policy...what could possibly go wrong?
Invited talk at 19th International Workshop on Multi-Agent Based Simulation at Stockholm on 14th July 2018. Mixing ABM and Policy ... what could possibly go wrong?


 -----

Meanwhile, fixation on huge system-wide actions from FEMA to social distancing to hospital systems neglects a key intervention point -- what can be done on a personal level to reduce: (a) odds of becoming infected if exposed, and (b) odds of becoming serious if infected.

 -----


Obvious candidates are stress-reduction, exercise, enough sleep, nutrition, micro-scale mutual-support networks, all of psychoneuroimmunolgy including clinical-trial supported power of social connection to boost our immune system more than drugs.
 -----

"Love and intimacy are [ crucial] ...If a new drug had the same impact ...it would be malpractice not to prescribe it. ... the breakdown of the social structures that used to provide us with a sense of connection and community ...are [the key.]
The Medical Basis for the Healing Power of Intimacy 
We all know that intimacy improves the quality of our lives. Yet most people don't realize how much it can increase the quality of our lives -- our survival.

In this New York Timesworld-renowned physician Dean Ornish, M.D., writes, "I am not aware of any other factor in medicine that has a greater impact on our survival than the healing power of love and intimacy. Not diet, not smoking, not exercise, not stress, not genetics, not drugs, not surgery."

He reveals that the real epidemic in modern culture is not only physical heart disease but also what he calls spiritual heart disease: loneliness, isolation, alienation, and depression. He shows how the very defenses that we think protect us from emotional pain are often the same ones that actually heighten our pain and threaten our survival. Dr. Ornish outlines eight pathways to intimacy and healing that have made a profound difference in his life and in the life of millions of others in turning sadness into happiness, suffering into joy.
 

Note - UCLA launches New Ornish Lifestyle Medicine Website
UCLA Health has launched a state-of-the-art new website to support their Ornish Lifestyle Medicine program. Dr. Dean Ornish’s Program for Reversing Heart Disease is the only scientifically proven program to stop the progression and even reverse the effects of heart disease.

This nationally-recognized program has been so effective that the Centers for Medicare & Medicade decided to make it available to Medicare members under a new benefit category called “Intensive Cardiac Rehabilitation Programs.” UCLA Lifestyle Medicine is the first integrative medicine treatment program of its kind to receive this level of support.
-----
[ it seems appropriate here to insert a slide-show I mashed up over the weekend with a range of tips and suggestions for how to thrive in a time of crisis.
Here's the link to the GoogleDoc with the full slide-show,
and here's some excerpts from that slide show with the hot-links a little easier to follow if you are so inclined:










Learn tips for community organizing and maintaining well-being during COVID-19

The COVID-19 pandemic is challenging individuals, communities, and businesses across the globe to work together like never before.

On this course – led by experts from the Center for Positive Organizations at the University of Michigan – you’ll learn how to develop practices to help you get through this crisis.

You’ll discover the scientific grounding behind terms like thriving, resilience, and compassion.
You’ll also consider the value of gratitude and staying connected in a time of social distancing, including tangible steps to take as an individual or part of a larger community

This course is designed for anyone interested in learning more about how to thrive during difficult times and how to respond to crisis effectively.

Jewel - (song)   Hands
If I could tell the world just one thing
It would be that we're all OK
And not to worry 'cause worry is wasteful
And useless in times like these
I won't be made useless
I won't be idle with despair
I will gather myself around my faith
For light does the darkness most fear
My hands are small, I know
But they're not yours, they are my own
But they're not yours, they are my own
And I am never broken

Suzanne - by Leonard Cohen, sung by Judy Collins:

...And Jesus was a sailor when he walked upon the water
And he spent a long time watching from his lonely wooden tower
And when he knew for certain only drowning men could see him
He said all men will be sailors then until the sea shall free them...


Suzanne [ song ]

sung by Judy Collins:
If men do not build how shall they live?   ( T.S.Eliot)
The men you are in these times deride
What has been done of good, you find explanations
To satisfy the rational and enlightened mind.
...
They constantly try to escape
From the darkness outside and within
By dreaming of systems so perfect that no one will need to be good.
I will show you the things that are now being done,
And some of the things that were long ago done,
That you may take heart. Make perfect your will.
Let me show you the work of the humble. Listen. 
...
In the vacant places
We will build with new bricks
There are hands and machines
And clay for new brick
And lime for new mortar
Where the bricks are fallen
We will build with new stone
Where the beams are rotten
We will build with new timbers
Where the word is unspoken
We will build with new speech
...
The river flows, the seasons turn
The sparrow and starling have no time to waste.
If men do not build
How shall they live?
When the field is tilled
And the wheat is bread
They shall not die in a shortened bed
And a narrow sheet. In this street
There is no beginning, no movement, no peace and no end
But noise without speech, food without taste.
Without delay, without haste
We would build the beginning and the end of this street.
We build the meaning: 






https://www.goodreads.com/en/book/show/39346786-walking-each-other-home

Walking Each Other Home: Conversations on Loving and Dying ( Ram Dass)


( goodreads)

We all sit on the edge of a mystery. We have only known this life, so dying scares us—and we are all dying. But what if dying were perfectly safe? What would it look like if you could approach dying with curiosity and love, in service of other beings? What if dying were the ultimate spiritual practice?

Ram Dass and Mirabai Bush began their friendship more than four decades ago at the foot of their guru, Neem Karoli Baba, also known as Maharaj-ji. He transmitted to them a simple philosophy: love everyone, tell the truth, and give up attachment to material things. After impacting millions of people through the years with these teachings, they have reunited once more with Walking Each Other Home to enlighten and engage readers on the spiritual opportunities within the dying process. They generously share intimate personal experiences and timeless practices, told with courage, humor, and heart, gently exploring every aspect of this journey. And, at 86 years old, Ram Dass reminds us, “This time we have a real deadline.”

In Walking Each Other Home, readers will learn about: guidelines for being a “loving rock” for the dying, how to grieve fully and authentically, how to transform a fear of death, leaving a spiritual legacy, creating a sacred space for dying, and much more.

“Everybody you have ever loved is a part of the fabric of your being now,” says Ram Dass. The body may die, but the soul remains. Death is an invitation to a new kind of relationship, in the place where we are all One. Join these two lifelong friends and spiritual luminaries as they explore what it means to live and die consciously, remember who we really are, and illuminate the path we walk together.
 
In the Google-doc slide show I go off into more emotional, philosophical, and religions directions from there,   possibly or probably leaving many readers behind.

In my understanding,  extending our  emotional and psychological self out to our neighbors,  perhaps in a metaphysical or spiritual sense, making them true friends,  has a clinically proven measurable effect, a very large effect it turns out,  on our own physical well-being.

In a mathematical and systems sense,  the boundaries of our "self" seem to be unlimited by our skin, and can extend out to include other people,  groups of people,  entire religions and nations, or the entire planet... and perhaps, beyond that.

It would seem that we should be exploring not only how to be better friends with each other on a local scale, but on ever-larger, even a global scale as well.

We are all on one small planet,  and as our numbers increase it is also increasingly clear that we are in the same lifeboat, and our fates are inextriciably linked on a planet-wide scale.    The old boundaries of nation and culture are fading away,  as supply-chains,  zoom-meetings, and pandemics ignore them and simply form world-wide connectivity.

I think we should go with the flow, accept that, and figure out ways to preserve the best of our heritage and culture while the old boundaries dissolve and new ones form,  retaining diversity but also recognizing unity.     It makes no sense to talk about or rejoice in "holes in their end of the life-boat."       There is only one life-boat.      We are all going to sink or all going to survive together.

Eat the meat, spit out the bones.

Wade 


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Wednesday, April 08, 2020

Tips for reliable operations during the Covid-19 crisis

I read recently where a lineman was seen to reach out and touch a live high-voltage wire without his insulating gloves on and get killed instantly.  At dawn one day in 2006 an aircraft crew taxied out to the wrong runway,  one which was way too short,  and tried to take off, resulting in a crash which killed all the passengers and all but one of the crew.  ( See The Crash of Comair 5191 post   )

These "accidents" were not caused by the people involved being stupid, uninformed, or careless. They were caused by a series of factors which added up to just the wrong mix,  when the last line of defense, the awareness or mindfulness of the crew,  was brought down by overwork, fatigue,  and things not being where they always were -- an unexpected change in context.

Novices and outsiders are quick to jump on the "obvious stupidity" of the men involved, but experienced pilots, surgeons,  etc.  will tell you sadly that there are only two kind of people in their field -- people who have made a mistake like that already,  and people who will.

I want to cry as I look at the number of doctors, nurses,  first-responders,  corporate and military decision makers trying to survive a fire-hose of high-stress high-stakes decisions,  day after day after day, with little sleep,  none of their usual ways to relax,  and many of the normal things they count on being broken or absent or changed.   On top of the usual review process is a "cancel culture" that believes "one strike and you're out!" and a legal culture of blame that often ignores the context and structural features and management policies and decisions that contributed heavily to errors happening -- and the front-line worker is the one who ends up being fired, sued,  or condemned.

Novice in today's "cancel culture" believe that if a person makes a serious mistake, that should spell the end of their career.     In fields where it takes 5-10 years or more to get professionals trained for a job,  you can't simply discard them because they made a mistake.   We don't have enough of them and it won't fix "the problem" regardless how good it might feel at the time to blame and sacrifice them.

In other posts in this blog,  I go into a longer discussion of some of the theory of how errors occur in general, in the long run,  and what can be done to reduce them, including some links to literature on the subject. Some are at the end of that piece on Comair 5191.   If you search this blog for "error" or "reliability" you'll find them.

For now I want to focus on:

Some useful rules-of-thumb for operation in crisis situations,  especially extended situations where fatigue is the norm,  the stakes are high -- possibly life and death -- , and all manner of little things that one is used to are out of place, broken, unavailable,  or replaced by unfamiliar substitutes.


REALIZE that the effective IQ of a person can be seriously reduced by fatigue,  stress,  overload, and distractions so that a person with a normal IQ of 160 could end up operating at an effective IQ of 100 or maybe 80 -- below average.

* REALIZE that the effective IQ of a person goes down even more once they make a mistake and are trying to continue operating, or have to continue operating despite that.

* REALIZE that as a person becomes impaired,  typically, their judgment goes down faster than their ability.      Even people who are used to being able to self-assess correctly can end up thinking they are fit for service when they should really be taken off the front-lines for everyone' sake.  You see this in the number of people arrested for being drunk who are unaware they are seriously tanked and are offended by anyone treating them that way,   who are shocked to see the booking videos of themselves the next day.

* THEREFORE --  you have to assume that you are one of the impaired people. Even if you don't notice it. Even if you think you can man up and focus and push your way through  it.

*  If your coworkers all tell you you need to take a break,   take a break.  No one wins if you kill people by accident.

* Anywhere you possibly can,  buddy up.    Work in pairs.  Never work alone. Get a second person to spot for you, and you for them.   It's amazing how many stupid things a truly exhausted person might do which could be caught by a second person watching and going "Wait -- what are you doing?!! "

Buddies also can cover for you, or cover you,  or help you get back off the street if you tripped and broke your ankle while relocating across the street in a rush. 

Some people protest that buddying up makes a shortage of staff worse, because now you have only half as many people.  Possibly not true!  In software development,  such arguments are raised against "peer-programing" where a team of two people write code together, side by side, working on thesame screen with one driving and one watching.    Studies show that pairs of people can often write good systems much faster than twice the speed that one person could, and with much higher quality.

* Checklists are your friends -- use them!

It takes way less time to check items off as you go,  regardless how compulsively anal that might seem, than to pick up the pieces after a disaster because you missed a step.

The way humans work very often we use shortcuts, so the way you remember to do some report is that the mail-cart comes by, and that triggers your action.      If the mail-cart doesn't come,  its very likely nothing else will trigger your action,  and you won't do something you should have.  You may not even realize how you cue up triggers and use them, but when many things are out of place, all your normal triggers may be broken.

*  Don't punt.   As the surviving pilots say:  Plan the flight, then fly the plan.  And along with prior comments,  have a second person vet the plan and tell you what you forgot.   It takes way less time to get a review than it does to get part way somewhere and realize you forgot something.


* Don't trust your memory for anything.   Have some way to write things down and check them off.  You will be subject to far more distractions than you are used to.     Things you put in short-term memory will be long gone by the time you get back from the interrupt.   Even walking through a  door frame may cause a complete blanking out of what it was you came there to do.


* Don't assume things will be where they should be.    Someone probably moved them. Or they've all run out when you weren't looking. Or someone stole the whole bunch of them since the last time you checked.

* Don't assume you will be where you should be.   Your whole base of operations may suddenly get shifted,  and things you counted on being in the cabinet or just down the hall won't be.    Get a go-bag of your critical resources and be prepared to grab it and go in an instant if everyone has to relocate.  Figure out in a calm time what should be in it.

 * Hard as it is -- leave extra time for everything.   Its faster to do things right the first time, even if it seems to take longer, than to do them over.   Nothing will burn up staff time faster than having to do things over.

* IF the computer is working at all,
expect the system or network or database to be really, really slow.

* In a widespread crisis, if the cell-towers are still operational,
expect a long wait for a dial-tone or a long-distance connection.

* Don't assume communications are received.  

Never assume someone got your message.   Lost and never-received messages are a classic cause of large scale disasters and massive short-term arguments between people, one of which thinks the message got through and the other of which didn't even know there was ever a message.  If it matters that the message gets through,   request or demand an acknowledgement, and check those.

* Never assume someone correctly interpreted your message.  In fast changing circumstances,   vague references to "this", or "that",  or "the plan" or "the latest directive" etc. may have shifted between the time you wrote the letter and the time the recipient receives it or reads it. Take the extra 30 seconds to be specific.

* Never assume the recipient is even there anymore.    Stuff happens.

* WHEN you make a mistake,  tell your team and your boss as soon as possible!  Don't compound things by waiting. Get if over with.  It doesn't get better -- it only gets worse, especially if someone else can fix things up right away but no one can fix things up if you wait.  More people end up being fried for cover-ups than for the original problem.

The guideline for private pilots who make the mistake of getting lost, or flying into deteriorating weather, is CCC :   Climb, Communicate, and Confess.

Of all of the above,  I suspect a guideline of never operating solo and always having a buddy is the most valuable if you can possibly pull it off.

OK - your turn- what did I miss?  What other rules of thumb do you find invaluable? Do you have links to some great other sources of rules of thumb for crisis situations for civilians?   Share your ideas here in the comments section !!  Please !!

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The crash of ComAir 5191 - a multi-lelvel systems analysis of how things go so wrong


The Crash of Comair Flight 5191

A worked example from the current [2006] news
using Systems Thinking to find intervention points that can  reduce similar errors in the future.
 
by R. Wade Schuette
Sept 7, 2006

Background

Early Sunday morning, August 27, 2006,  a commuter airliner departing Lexington, Kentucky crashed on takeoff, killing 47 passengers and 2 crew members, and seriously injuring the copilot.

The intended and actual paths of the plane, after departing from the terminal area, are shown in the photograph below.[1]



Normally, the plane would have taxied through the area marked with the X in the photograph, taken the only available left turn,  and then taken off in a southwesterly heading, down the long runway, in blue, called "two two." 

But, on this day, when they got to it, the short section of the taxiway marked with the "X" in the photograph was barricaded with orange barricades and flashing lights, which was not expected.  The pilots would each have normally had a copy of the airport diagram, showing the taxiway layout before the recent construction. 

Possibly not fully vigilant, probably with the runway chart memorized as a mental rule ("When you get to the end of the taxi way turn left, that's your runway")   when they came to the new "end of the taxiway" produced by the barricades,  the plane took the only left turn.  They  turned onto the short runway ("two six"), in the picture in red, and proceeded to accelerate for take off in an almost Westerly direction.

Commercial-aircraft runways, such as the longer runway 22, typically have center-line lighting and edge-lighting. On Sunday morning,  the center-line lighting was reported to be out of service for runway 22 in the notices the crew would normally have read carefully as part of their pre-flight preparation.  The shorter runway, 26,  was listed as closed until further notice.

The synchronized transcript and reconstructed aircraft positions will probably be released in another week or so.  The final NTSB investigative report will probably take at least a year.  The first lawsuit has already been filed.

Even lacking final information,  for educational purposes we can look at the available information and learn a great deal about what kinds of things lead to such accidents in general, and what might be done to prevent them.

Where the factors contributing to or leading to the "accident" are social or system in nature,  the lessons are immediately portable as well to all other high-risk environments, including hospitals, nuclear power control rooms, military operations, etc.

The purpose of this paper is not to assess legal "blame", but to consider what we can learn immediately that we can put into place, regardless who did what when in this particular case.


Student Activity

It will really help your learning if you pause before reading any further in the case, and  actually write down your initial impression of the answer to the following 6 questions.

            1)  Why did the crew not taxi all the way to the correct runway?

2)  If the taxiways were confusing or different from what the crew showed on the
airport diagrams they had used when they prepared
their preflight,  and the tower had a ground-controller on duty,
why didn't the crew ask the tower for assistance or a visual confirmation that they were on the correct runway?   (Both would normally be provided if requested.  Controllers often get requests like that.)

            3)  Do you think the pilots noticed that the runway they picked had no lights?

 4)  Once lined up for takeoff, why did neither pilot notice that they were pointed
west instead of southwest?

5)  Once rolling, why  did neither pilot notice crossing the lit, correct runway
 as they crossed over it, which still would have given them time to
abort the take-off safely?
           
            7)  If you were in charge of everything, what changes would you make
                        so that this kind of thing didn't happen again?

            8)  Much of this information was obtained from the on-line web-site Wikipedia.
                        Can you trust that?


Preliminary Investigation - Known Facts

The flight in question, Flight 5191,  was operated by Comair, a service provider to Delta. Both Comair and Delta are in bankruptcy proceedings.  

The crash took place on take-off from Kentucky's Blue Grass airport in Lexington,  with the airport identified "KLEX".

A good introduction, with latest news, photographs of the plane and a runway and taxiway diagram is provided on Wikipedia's page on the crash, located at http://en.wikipedia.org/wiki/Comair_Flight_5191 .  

           [ Advanced student activity:   Go visit that web-site and look around. ]


The information known about this case may have changed substantially by the time you read this case.

Quoting from Wikipedia (as of September 7, 2006):
Analysis of the cockpit voice recorder indicated the aircraft was cleared to take off from Runway 22, a 7,003-foot (2,135 meter) long strip used by most airline traffic at Lexington.[4] Instead, after confirming "Runway two-two," Captain Jeffrey Clay taxied onto Runway 26, an unlit secondary runway 3,500 ft (1,067 m) in length[5] without stopping the aircraft,[6] a common occurrence during light traffic periods, and turned the controls over to First Officer James Polehinke for takeoff.[7] The air traffic controller in the tower was not required to maintain visual contact with the aircraft; in fact, he was performing administrative duties at the time and did not see the aircraft taxi to the runway.[7]
Based upon an estimated takeoff weight of 49,087 pounds (22,265 kg)[8], the manufacturer calculated a distance of 3,744 ft (1141 m) and a speed of 138 knots (159 mph or 256 km/h) would have been needed for rotation, with more needed for lift-off.[9] The flight data recorder gave no indication either pilot tried to abort the takeoff as the aircraft accelerated to 137 knots (158 mph or 254 km/h), Clay called for rotation,[6] and the aircraft sped off the end of the runway. It then crashed through the airport boundary fence, became momentarily airborne after running up a berm, and then collided with trees, separating the fuselage and cockpit from the tail. The aircraft impacted the ground about 1000 feet (305 m) from the end of the runway,[8] killing most victims instantly,[10] and was destroyed by the resulting fire.
 The discussion in the press, on TV, and on the web generally alternated between blaming the pilots for the "accident",  and blaming the person in the tower, who was covering both ground traffic control and air traffic control.

[ Advanced student activity:  For typical press comments, see appendix or visit this web site: _________]


Regardless, there was generally stunned amazement and the question on everyone's mind was "How on earth could this happen?"

Treating that question seriously, instead of rhetorically,  is the whole point of this case.

Here's some additional information:

*  WEATHER: The weather conditions at the time of the accident were reported to be "light rain" with "haze". 

* TIME: The crash occurred at about 6:05 AM  Eastern Daylight Time.  According to airport information,  that would have been about 3 minutes after "civil twilight" which means the sky was still dark, but there was just enough light to make out the outlines of buildings, etc. on the horizon, if the weather had been clear, if your eyes were dark adapted.

* VISIBILITY:  In short, it was a dark and rainy night. 
                            No factors are known that would make it hard for the                                                           pilots to see out their windows.

*  PLANE HEADLIGHTS:    no reported problems with those
                             We don't know from what we have how well the lights
     illuminate area to the side of the aircraft.



* CONSTRUCTION

1)  There was known construction underway at the airport, with some work being done on taxiways and runways, although no workers were present at 6 AM this Sunday. The runways were being repaved, which is apparently done every 7  years.

Presumably because of the construction,  power was off to many items normally on, including the center-line lights for the long runway,  the approach lights for that runway,  the instrument approach "glide-slope" as well as the radio-compass for that runway.  All of the lights were off entirely for the short runway.    Apparently many of the taxiway lights were out at the terminal end of the runways. 

Apparently, the normally lit signs indicating what taxiway or runway the pilots were approaching while taxiing were not lit as well.


* THE RUNWAYS

2)  The intended runway, suitable for commercial traffic, known by its true compass heading, was "22", at about a direction of 220 degrees clockwise from true north,  which heading Southwest, away from whatever sunrise there was.

3) Runway 22 is listed as a 7500 foot runway, 150 feet wide, asphalt.[2]  It normally has special instrument markings on it, including edge lines,  two blocks of stripes at the each end,  runway numbers,  large markings every 500 feet for the first 3000 feet at each end,
center-line lights, and very elaborate approach lighting just off at the 26 end.

4)  Runway 26, the shorter runway, pointed 40 degrees to the left of runway 26, It is listed as a 75 foot wide concrete runway in poor condition. It has no instrument markings, it normally has numbers at each on the pavement, it has no approach lights. 

8)  It's not clear, but it's possible the runway numbers "26" on the short runway itself had been similarly paved over with asphalt.

RECENT CHANGES IN RUNWAY LIGHTING


THE TAXIWAYS

5)  In addition, due to a significant number of non-commercial pilots entering the wrong runway (known as "runway incursions")  at many airports, an extensive national set of signage is normally required.  This includes a large lit sign indicating what runway this is,  lit signs indicating which taxiway this is,  and pavement markings (basically double yellow lines) indicating where traffic should come to a complete stop before crossing, unless cleared or pre-cleared by the ground controller in the tower.  (see appendix.)

6)  However, due to the construction at the airport,  it appears that none of the taxiway lights had power, nor did the normally lit sign identifying the runway, if it was even still in place and not moved. 

7)  The taxiway markings indicating the place to stop had apparently been paved over with asphalt,  and not yet repainted.



 12)  If you examine the taxiway pattern,  you can see that a mental rule of thumb they might use,  to get to the correct runway in the first place, in the absence of any signs,  is "Stay to the right,  taxi until the taxiway ends, and that's the correct runway."[3]


RECENT CHANGES IN TAXIWAYS

13)  It appears, from a posting by a flight instructor at the airport, that the taxiway to
runway 22 had been blocked or barricaded just far of runway 26 sometime on Friday.   He commented with anger and frustration that there had not been notification that such a barricade was going to be done. 

There was no NOTAM I could find of this change in the taxiway, described in press releases as "a minor change in taxi patterns".[4]

14)  It turns out, from carefully looking at the Google imagery, that the wrong runway actually is also what a normal person would call 150 feet wide.   It just happens to have the center 75 feet marked with edge-lines, and 37.5 foot wide "shoulders" on each side.

Also, it appears that the runway had been repaved with asphalt, at least at that end.


THE CREW


EARLIER EVENTS
           * Last time the crew saw the airport.



15)  It was reported that the crew had started the day, at 5:15 AM, by boarding the wrong plane,  and preparing it for takeoff, which was detected by the ground crew only when they started the auxiliary power unit (starter motor) before firing up the main engines.  The ground crew quickly set them straight, and they moved, probably on the same ramp, to a different plane.


THE COCKPIT and STEERING on the ground.

16)  Now, we also have another structural factor.  The plane (see Wikipedia) was equipped so that only the left-hand seat person in the cockpit could steer the nose-wheel when taxiing.   This means the captain (pilot in command) was doing the taxiing from the left seat.

Meanwhile,  more-so if  they were now late,  there are  high odds that the co-pilot in the right seat[5] was very busy, head down, eyes in the cockpit,  running through his
pre-flight check-lists.   



17) But, this flight leg was going to be flown by the co-pilot. [6]


THE TOWER (Ground controller)

18)  Now, let's look at the ground control.  The tower, which FAA regulations and agreement said should have two people, only had one. [7]

19)  And,  as is typical if there is little traffic, the tower had simply cleared flight 5191 to take off  whenever they got to the runway and were ready  That clearance may have even been given while the plane was still far from the runway, possibly as soon as they called from the gate and announced that they were ready to taxi to runway 22 for departure.  [8]

20) But, let's say he had decided to stay with the flight a few more seconds. (The crash occurred 33 seconds after he turned away, for reference.)


THE AIRPORT LAYOUT


If you look closely at the airport diagram, you see that there are two structural features that leap out, in hindsight.
a)  The two runways come together at the end, instead of near the middle (a V shape, not an X shape).   This makes the necessary positions for takeoff easy to get wrong. In fact, see wikipedia,  in 1993 a similar commercial jet took the wrong runway, but tragedy was averted by two routes.  The pilots delayed takeoff because they were checking weather radar, and that's when they noticed the discrepancy in direction, and, simultaneously, the tower spotted the problem, and cancelled their clearance to take off.

b)  The tower is located so that the two take-off positions are almost exactly in the same line of sight,  which is directly across a parking lot that probably has bright lighting.
One could imagine a tower located on the airport proper, not off to the side, or, even, located between the two runways.  From that vantage point,  this accident setup would have been instantly obviously, if the controller was looking.   But, it might be less safe because of other reasons.  

In any case, a different runway layout might have averted this accident, and a different tower location might have averted it.

INFO:  now, a brief update on what instruments are in the cockpit.  Modern aircraft use some combination of gyroscopic compass (known affectionately as a "DG" for directional Gyro") and a GPS, global positioning system.   The GPS is poor at giving direction unless one is motion.    There is also a very low-tech, old-style magnetic compass in every cockpit, by regulation, in case all the fancy new stuff goes haywire.

The magnetic compass bounces around a lot when in motion, or taxiing, or turning, or tipping when in flight, or when accelerating or slowing down.  The DG is much more stable, rock-solid except for a slow drift (over 10's of minutes), and has only one problem, which is relevant here:   it has no absolute zero reference point.    Every-time the plane is restarted, the electric gyro spins up and the DG settles in to pointing some random direction, very stably.    

Typically, a pilot taxis to the edge of the runway, stops,  and, if at right angles to the runway,  "sets the DG", ie, twists the dial to make it know which way is North. Or, if the taxiway comes in at an angle, as it often does and as it does for the bad runway, runway 26,  the pilot will "taxi into position and hold", ie, line up with the centerline exactly,
then reach over and "set the DG" to the runway heading.

The DG has no idea what the right heading is. So, if the pilot had believed he was on runway 26, he would have lined up on the centerline,  then "set the DG" to read "26".
After that, he could count on the DG being correct for at least 10 minutes, and then it would only be a few degrees off.

21) But,  it is also likely, if they were late, or under pressure from management to arrive on time regardless of trouble,  they might have done a rolling setup - ie, turned onto the runway while accelerating, and just set the DG as they line up with the centerline, now moving about 20 mph.

22) one could cross-check the magnetic compass as well, but that only works if it has a chance to settle down.  Due to the pressure for high-speed operation it may never settle down.  This is from airliners.net (and I agree):

TTailSteve From United States, joined May 2006, 41 posts, RR: 0
Reply 50, posted Tue Aug 29 2006 14:01:06 UTC+2 and read 10499 times:

Quoting VS239 (Reply 41):
I appreciate checking the compass would not show the difference between, for example 24L and 24R, at whichever airport has something like these but it would tell the difference between 220 degrees and 260.

If they made a rolling takeoff, that is advanced the throttles as they turned onto the runway, the compass would be useless to check. A compass is not accurate when accelerating or decelerating. It will indicate a turn and slightly wrong heading. A compass can only be used in stable flight. Of course, there are other instruments that are not affected by acceleration or deceleration that can be used to check the heading of the aircraft. However I just wanted to point out that a compass is not accurate in these conditions. This question is asked in many variations in every private pilot check ride and written test.


22) But, in this case, the "hand-off" of control probably occurred in an accelerating turn.   Reading the general aviation bulletin boards, other people recount how this often happens and what it's like when the wrong runway has been selected:

Skaggs From United States, joined Dec 2003, 129 posts, RR: 1
Reply 160, posted Wed Aug 30 2006 19:25:44 UTC+2 and read 1500 times:
I just talked to my Dad (Retired DL 777 Capt) about this. He told me he damn near took off on a taxiway in a DC-9 years back. The Capt. taxied it while my Dad was head down tuning radios or whatever, it was my Dad's leg and the Capt advanced the throttles and told my Dad 'you got it'.....They were doing 20 kts or so and my dad noticed green lights on the centerline and shut it down. He said he didn't immediately know what was wrong but he knew something was off.

I bet something similar happened here.


23)  So, the magnetic compass was effectively disabled by the decision not to pause and let it settle down and cross check it.  That was, in turn, brought on by being a little late, and the mental frame that this was surely the right runway. 

It appears there never was any doubt that this was the right runway, so vigilance was never triggered.  There was no "time out", as now used in operating rooms in hospitals, to ask if there was any way that this could be the wrong patient / wrong runway.


25)  Also, in general, the crew would have engaged their flight-director (autopilot deluxe), and set in the instrument landing system frequency, which would be a further cross check.   But, due to the construction, according to the NOTAM,  that was also not powered and not available.

Fact: Also, planes have no odometers.  You can't measure distance driven along the ground.

27) Also, GPS devices exist that can figure out automatically which runway you are on, how many feet are left, and that warn you out-loud if there is not enough runway left to complete your takeoff.  However,  the versions of these that would be suitable for cars are not considered safe for commercial aviation.  (Some private pilots take along their own unauthorized GPS anyway.)   And the commercial versions, much safer because they are fully validated,  cost $18,000.  

The airline, in bankruptcy, had elected not to add these devices to the fleet, saving $18,000 per aircraft. 




INITIAL ANALYSIS

So,  there were none of the normal markings or signs available to the pilot, due to the construction, and the end of the correct runway had to be located and confirmed some other way.   

Given subsequent events, it's very likely that the pilot and co-pilot knew "the lights were out at this end".



(Note, the total of the lawsuits will easily exceed $18,000.)

28) And, if you stand way, way back,  someone had decided that it "was an acceptable risk" to continue flight operations at the airport during construction, as opposed to just
closing it entirely until the work was done.

29) And Comair had decided it was acceptable risk to continue commercial operations, including night operations, during construction.

And, of course, many someones had decided that planes could safely operate taking off in the dark in the haze / fog, with sufficient training and instruments. That activity, once unheard of, was now considered "routine" and the risks "acceptable."

 Finally, let's look at the take-off roll itself.  The last chance to detect that something was seriously wrong and "question the frame", challenge the mental-model with these pesky "small" contradictory pieces of evidence that keep annoyingly popping up.
( here we should cross-reference Karl Weick's work).

What's the pilot (left hand seat) doing?  He would be staring intently inside the cockpit at the airspeed indicator,  waiting for it to reach the speed (called "V1") at which the control yoke could be pulled back, which would pull the nose up after a few seconds,  and the plane changed from driving to flying.     This is a trained dance - the number 2 stares at the gauge, until he can announce "V1".  Then he looks up.    For this flight, "V1" occured about 100 feet before the end of the runway they were on, at which point they were going something like 135 miles per hour or so.  The yoke had been eased back (actually, it wants to go back, so one just stops pushing it forward so much., but the plane had not yet gotten the message and started to climb, when they ran out of runway..

How about the copilot?  Well, he is staring down the runway intently, looking for deer, trucks, or anything else unexpected to pop out of the haze.  He has absolute tunnel vision, focused as he has been trained, concentrating as he should on his single critical task, getting down that runway safely and transitioning to flight.

(example of basketball game and woman with umbrella - trained blindness due to trained focus.)

Still, probably with peripheral vision they notice when they cross over the actual runway 26. Eyes stay fixated on tasks, but brain is trying to figure out what that was that just happened. Why did lights appear and then disappear off to the side. Can't look now.

The, runway 26 is behind them and the rest of runway 22 is entirely dark.  They can continue to takeoff just fine, because they have headlights,   but this doesn't fit their mental model.  Only the start of this runway was supposed to be unlit.

At about this point, according to the NTSB,  one voice in the cockpit comments, probably in surprise given that they're very busy,  that there aren't any runway lights.

Now, the only way that statement makes sense is if they expected only half the runway to be lit, as runway 26 was when they arrived 2 days earlier.

They are probably still processing it, 8 seconds later, when the end of the runway flashes by.   Frame-challenging data tends to produce several seconds of dazed paralysis while all the mental gyro's tumble and, metaphorically, one looks for the new, correct interpretation of the data at hand.  Several seconds uses up all their remaining runway.

So, at this point,  we can point fingers at about 30 different people and groups,  handoffs on the ground, handoffs in the cockpit,  teamwork on the ground, at the tower, in the cockpit where multiple people tried to coordinate to do one function that would have worked just fine if one person alone had done it.

Possible anger and rage, embodied in blind adherence to procedures or blind but mandated breaking of procedures, effectively removed the tower from being helpful, even 20 years later.

Multiple people could have had "It's not my job - itis" and furthermore, proven that they were correct and not legally liable.

Social distal decisions,  involving profit-making and work-speedup and more speedup, lurk in many places here, each one pushing the environment towards more danger.

[ if you really want to add a new note, along the lines of TV's CIS, it turns out that a State Senator was supposed to be on that flight,   because he was going to come and speak to the US-Islamic friendship association (I have the cite somewhere.).   So,  maybe someone wanted this flight to crash, someone who hated Islam and Islam's friends.   That may be distracting.]
==================
Tower had cleared them:  What do we get from that?

24)  And, the controller had cleared them.  Tacitly, this means the controller had no doubt that they'd find the correct runway.  Of course, the controller knew the correct runway had all the edge-lights on, and he would never mistake it for a runway with no lights on.  He tacitly assumed the crew knew this.  \

From the tower's vantage point, probably above the ground-haze (which tends to form very close to the ground just at dawn),  both runways were probably clearly in view,  and he could clearly see runway 22 in the distance, all lit up.  In fact, it was the only runway lit up.  From his cat-seat,  there was no ambiguity, and no risk to trigger vigilance. From the plane's point of view,  runway 22 was probably just a blur in the haze.
I believe at least one major military disaster was caused when the commander, atop a hill, with all forces clearly in view, neglected to inform his men, down in one valley, that the enemy was coming up the other valley.  There was a failure to see the scene from the other party's viewpoint.


==================
SIDEBAR

This fact is rich with information and possibilities. Here's a few, all with different meanings.

a) The crew could have been operating at low capacity and couldn't even find the right plane that was clearly marked. 
b)  The pilot couldn't find the right plane, and they not only switched planes, but decided it was the copilot's leg to fly.

c)  The pilot and copilot went to the plane they "always" use, but the airport staff for COMAIR had changed things around and not notified the crew.

Possibly, there had been a meeting on this, and a memo, but the crew, on extended leave, missed it.  This would make it a "handoff error", as the ground staff for COMAIR thought that "everyone knew" about the changes. 

In fact, maybe there was a whole packet of information that got dropped in handoff here, including information about what was going to be lit when.    Maybe, due to staff cutbacks by Comair, in bankruptcy,  the person who normally would have handled that had been laid off. Maybe the person who normally handled that was feeling put-upon and didn't feel like passing on the information.

(Is this possible? Well, consider this:  at the end of June,  my wife and I flew Northwest to Baltimore.  This was in the middle of a possible strike by airline staff, including ticket agents, etc.    After we had checked in, along with many other people, the airline cancelled the flight, as, we were told by other flight attendants, they had done frequently lately if there weren't enough passengers to make it profitable.  Our choices were to wait 12 hours for the next flight,
or to take a flight to DC in an hour and somehow get from there to Baltimore.  We elected to go to DC,  and arranged to have our luggage forwarded.

Upon arrival in DC, our luggage was nowhere to be found.  About 50 other passengers also had no luggage.  The claim-filing room was packed.

The next day, our luggage still was not located by the Northwest.  On a hunch, we went out to the Baltimore airport, and, sure enough, there was our luggage and what looked like 50 other persons' luggage.  My wife's bag was very easy to find, because it had distinctive polka-dots.

We asked the person at the lost-luggage desk what was up. She gave us an earful about how busy she was, and the fact that they kept doing this to her, but expecting her to stay at the desk and answer the phones, and,  they were talking about cancelling her pension after all these years and, frankly, she had not had time in the last 26 hours to check those bags in yet.

We asked if she didn't have some sort of portable wireless scanner, such as the one Hertz used to check our car in, in under 38 seconds. (we counted.) She laughed uproariously and said, no, no one gave them the tools they needed to do their job.

So, as far as she was concerned, "they" could just come check the bags in themselves. This was not in her job description.)
In any case, the pilots got on the wrong plane initially.

What that also means, is that their carefully planned schedule was now wrecked. They had just lost 10 to 15 minutes checking out the wrong plane.  And, they had to hurriedly pack their belongings back into their flight bags, possibly in haste and in the wrong order, and get over to the other plane.

And, we don't know what else that means. Maybe, the ground crew was laughing at this, or laughing at them, or asked them point blank if they'd been drinking, or otherwise set a bad tone to the morning, raising adrenaline, and possibly making it less likely that the pilot would "ask for help" in locating the runway 30 minutes later.

This of course, plays into the US male-gender training that it is unacceptable to ever ask for directions when lost while driving.  This is a culturally trained norm, for some reason, and some males would reportedly spend hours on the wrong road or get shot before they'd stop and ask for help.   That does not help build a culture of open trust and a safe environment.

====================================
All of the above may explain why flight crews have moved on to "Threat and Error Management", where they assume that it is not possible to perfect procedures with enough control,  so instead they seek to get people out of blind-adherence mode and back to eyes-open mode, with common sense engaged, on top of fully-trained procedural knowledge.  In other words, people are trained to spot "small" things wrong and amplify them instead of suppress them, as the possible single warning that the whole model and frame is wrong.

The military (Army at least) is adopting that, judging  from the Center for Army Leadership's The U.S. Army Leadership Field Manual, McGraw Hill, 2004.

Missing cites can be found by using the Blogger (google) search window at the top
of my weblog  Systems Thinking in Public Health  (http://cscwteam.blogspot.com/).
Crash articles can be found with  keywords "5191", "crash" or "KLEX".










Supplemental materials for The Case of Comair Flight 5191
===========================================


M.C. Escher "waterfall", illustrating a "system" where everything checks out perfectly in any local area (except for "insignificant errors"), but there is still a global (system) problem that needs to be detected.




(image above from
used without permission)

larger size view





Many details, but in particular look at the "interactive runway map", which
is a Google map view, and zoom down to examine the taxiway section
and actual runway widths and markings (prior to construction).

(used without permission)









WLEX-TV
Despite the wet weather, plans to reopen the main runway at Lexington's Blue Grass Airport went smoothly Sunday. Just after 6 p.m., the first jet touched down without a hitch.
Over the weekend the airport had been completely shut down to commercial and private jets, as some 350 workers managed to repave the seven-thousand foot runway in just two days. The work, marks the end of a $35 million runway safety project that began back in 2003.
The runway is typically shut down and repaved only once every 12 years. So when airport officials saw Sunday's bad weather bearing down they kept a close eye on the sky. "The weather is obviously very crucial for us in order to get this project done and we were lucky. By the time it started raining we had most of the runway already repaved. So the large portion of the project had already been completed before the bad weather hit." Said airport spokesperson Amy Caudil.
As early as Sunday afternoon there were signs that the airport was returning to normal. As passengers began to check-in again, work crews made some final checks on the runway.
Airport officials also say they certainly lost money with no air traffic for two days, however they're not saying exactly how much.
Travelers who need to check on their flight times can call the Lexington Blue Grass Airport at; 425-3114.



WLEX-TV
(AP) -- Workers at Lexington's Blue Grass Airport have put up large 'X' warning signs at both ends of runway 26 to let pilots know the runway is closed.
Airport spokesman Brian Ellestad says the signs were put up Tuesday morning as a precaution. The runway has been closed since Sunday, when Comair Flight 5191 crashed just past the end of the runway shortly after takeoff. 49 people died in the crash. Only one person survived.
...


FAA official airport diagram



Wikipedia Entry on Blue-Grass Airport  (with links to many views,
including TerraServer zoom-able satellite imagery)


(via that site, link to AirNav.com, which has sunrise and sunset times
and link to NOTAMS )

https://pilotweb.nas.faa.gov/geo/geoQuery.html  (as of 9/8/06 at 4:35 AM EDT):


EX BLUE GRASS
6/8333 - FI/T LEXINGTON/BLUEGRASS, LEXINGTON, KY. TAKE-OFF MINIMUMS AND (OBSTACLE) DEPARTURE PROCEDURES. TAKE-OFF MINIMUMS: RWY 8 NA. WIE UNTIL UFN
6/8332 - FI/T LEXINGTON/BLUEGRASS, LEXINGTON, KY. RNAV (GPS) RWY 8, ORIG... RNAV (GPS) RWY 26, ORIG... LNAV MDA NA. CIRCLING TO RWY 8/26 NA. WIE UNTIL UFN
6/8331 - FI/T LEXINGTON/BLUEGRASS, LEXINGTON, KY. VOR OR GPS-A, AMDT 8A... ILS RWY 22, AMDT 19... RNAV (GPS) RWY 22, ORIG... ILS RWY 4, AMDT 16... RNAV (GPS) RWY 4, ORIG... CIRCLING TO RWY 8/26 NA. WIE UNTIL UFN
6/6992 - FI/T BLUE GRASS, LEXINGTON, KY. ILS RWY 4 AMDT 16 ... AIRPORT ELEVATION 979. TERMINAL ROUTE FROM HYK VORTAC TO BLAYD LOM (IAF) MINIMUM ALTITUDE 2600. TERMINAL ROUTE FROM SAAPP/HYK 15.3 DME TO BLAYD LOM MINIMUM ALTITUDE 2200. MINIMUM ALTITUDE AT BLAYD LOM (FAF) 2200. GLIDE SLOPE 3.00 DEGREES. GS ALT AT OM 2045. DISREGARD ALL REFERENCES TO MIDDLE MARKER. DISTANCE FAF TO MAP 3.25 NM. DISTANCE FAF TO THLD 3.25 NM. TIME/DIST TABLE: 60=3:15 90=2:10 120=1:38 150=1:18 180=1.05. MISSED APPROACH: CLIMB TO 2000, THEN CLIMBING RIGHT TURN TO 3100 DIRECT HYK VORTAC AND HOLD, CONTINUE CLIMB IN HOLD TO 3100. S-ILS 4: VISIBILITY RVR 4000 ALL CATS. S-LOC 4: VISIBILITY RVR 4000 ALL CATS. CIRCLING: HAA 441 CAT A, HAA 461 CAT B/C, HAA 561 CAT D. INOPERATIVE TABLE DOES NOT APPLY TO S-ILS. FOR INOPERATIVE MALSR INCREASE S-LOC ALL CATS, VISIBILITY TO RVR 5000. VISIBILITY REDUCTION BY HELICOPTERS NA. DISREGARD NOTE: ADF OR DME REQUIRED. WIE UNTIL UFN
4/1897 - FI/T BLUE GRASS, LEXINGTON, KY. VOR OR GPS-A AMDT 8A .... CIRCLING MINIMUMS: MDA 1580/HAA 601 ALL CATS. VIS CAT C 1 3/4. ALTITUDE AT HYK 5.00 DME 1580. TEMPORARY FAS CONTROLLING OBSTACLE 1240 MSL/205 AGL TOWER AT 380007.65N-0843132.58W WIE UNTIL UFN
10/041 - CLEGG ONE ARRIVAL... LOUISVILLE TRANSITION (IIU.CLEGG1) PROCEDURE NOT AUTHORIZED. 27 OCT 09:01 UNTIL UFN
08/037 - TOWER 1138 (280 AGL) 16 SW LGTS OTS (ASR 1229868) WIE UNTIL 14 SEP 01:22
08/035 - 8/26 CLSD WIE UNTIL UFN
08/024 - 4/22 ASDA 7003 TORA 7003 TODA 7003 LDA 6603 20 AUG 22:00 UNTIL UFN
08/023 - 22 ILS GP OTS 18 AUG 13:30 UNTIL UFN
08/007 - 4/22 RCLL OTS WIE UNTIL UFN
08/005 - 4 ALS OTS WIE UNTIL UFN
07/013 - 4 TDZ LGT OTS WIE UNTIL UFN
01/030 - 4 MALSR CMSN 31 JAN 15:45 UNTIL UFN

For translations in general, see


For translation in specific (from the writer's weblog,
Systems Thinking in Public Health,
posting " Comair 5191 as a "handoff" problem,



Translations: (http://www.geocities.com/cfidarren/r-notams.htm )
8/26 is the short runway. CLSD = closed
WIE = from right now ("with immediate effect")
UFN = until further notice.

4/22 is the long runway.
ILS = instrument landing service
RCLL = runway center line lighting
TDZ = touchdown zone
LGT = lighting

08/035 - 8/26 CLSD WIE UNTIL UFN
08/023 - 22 ILS GP OTS 18 AUG 13:30 UNTIL UFN
08/007 - 4/22 RCLL OTS WIE UNTIL UFN
08/005 - 4 ALS OTS WIE UNTIL UFN
07/013 - 4 TDZ LGT OTS WIE UNTIL UFN

So, in English:
runway 8/86 - the short one, the one you don't want, is closed.
the instrument landing system for the your runway
approached from the northeast is out.
Your runway centerline lights are out
Your runway approach lights from southwest are out

Now, what is NOT stated here are things like:
There is a lot of construction.
Ground traffic patterns have been rearranged.
Carrier gate assignments have been rearranged.

And most of all, there is no graphic, no map, no
picture showing, at a glance, what lights are lit
and what lights are out.

And, there is no notice that the RUNWAY IDENTIFIER signs
for ground taxi purposes are NOT LIT.

Much of that information is implicit, tacit, or something that might
come from a voice briefing.



Miscellaneous Commentary
from the writer's weblog,
Systems Thinking in Public Health,

 



1)  Threat and Error Management (TEM) and the BMJ series relating this to hospital safety



Univ of Texas Threat and Error Management (TEM)-- Airlines now use TEM and there's some cross-over into hospital settings. BMJpaper, BMJ slideshow , aircraft pilot comments from KLEX discussion follow.

From BMJ
Error results from physiological and psychological limitations of humans.2 Causes of error include fatigue, workload, and fear as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making.3 In both aviation and medicine, teamwork is required, and team error can be defined as action or inaction leading to deviation from team or organisational intentions. Aviation increasingly uses error management strategies to improve safety. Error management is based on understanding the nature and extent of error, changing the conditions that induce error, determining behaviours that prevent or mitigate error, and training personnel in their use.4 Though recognising that operating theatres are not cockpits, I describe approaches that may help improve patient safety.

From Airliners.net - Civil Aviation discussion BBS of Kentucky plane crash (Comair flight 5191) due to mistaken runway on takeoff:
The perfect vehicle for this is a new concept, new in the last 3 years, called "Threat and Error Management." Prior to TEM training focused on never making mistakes in the cockpit.

While in a utopian world this would be great, it is just not possible. There is too much going on in a modern (or old) jet transport. Mistakes happen. TEM acknowledges this by saying mistakes and threats are going to happen. It tries to change the way we think in the cockpit by taking more of a big picture outlook on what is going on, slowing down what we do, and communicating concerns to find threats and errors before they cause a violation, incident, or accident. Robert Sumwalt, Vice Chairman of the NTSB, has been a huge supporter of TEM and has been promoting it for years at various carriers and industry working groups across the country. Many airlines have recently included it into their recurrent training programs. TEM is still evolving and I think is the perfect vehicle for teaching confirmation bias avoidance.

727forever



2) Six sigma is dead! Long live six sigma!

http://cscwteam.blogspot.com/2006/09/six-sigma-is-dead-long-live-six-sigma_06.html


3)  Zen thought for reframing this whole issue of context sensitivity
They said, "You have a blue guitar,
You do not play things as they are."

The man replied, "Things as they are
Are changed upon the blue guitar."

from Wallace Stevens, The Man with the Blue Guitar

 



Recommended further study:

4) Failure is perhaps our most taboo subject

 

( A brief tribute to U of Michigan's John Gall, MD, and

his must-read marvelous book

Systemantics - How things Fail )

http://cscwteam.blogspot.com/2006/09/failure-is-perhaps-our-most-taboo.html
"At the very least it is hoped that this little book may serve as a warning to those who read it, thus helping to counter the headlong rush into Systemism that characterizes our age...

SYSTEMISM n. 1. The state of mindless belief in Systems; the belief that Systems can be made to function to achieve desired goals. 2. The state of being immersed in Systems; the state of being a Systems-person."

(John Gall, "Systemantics - How Systems Really Work and How they Fail.)
Gall, continues
Systems-functions are not the result of human intransigence. We take it as given that people are generally doing the very best they know how. Our point, repeatedly stressed in this text, is that Systems operate according to Laws of Nature, and that Laws of Nature are not suspended to accommodate our human shortcomings. There is no alternative but to learning How Systems Work... Whoever does not study the Laws of Systemantics and learn them that way is destined to learn them the hard way...

S. Freud, in his great work on the Psychopathology of Everyday Life, directed attention to the lapses, failures, and mishaps resulting from forces operating within the individual. We, on the other hand, are intestesed in those lapses, failures, and mishaps that are attributable to the (mal)functioning of the Systems surrounding the individual, wihtin which the individual is immersed, and with which he or she must interact and attempt to cope in everyday life.

Specifically, we are interested, not in the process of forgetting to mail a letter, but in the Post Office Box that is too full to accept the letter.

=================================================
FAA website on "runway incursions"

RECOMMENDED:
FAA Flash presentation and learning tool on Runway Incursions (in general)

=================================================
Passenger list (still partial) and tributes to those killed in flight #5191, in the hope that we learn something from all this and make their deaths at least mean something for the rest of us.
http://www.bluegrassreport.com/bluegrass_politics/2006/08/tribute_open_th.html


====================================================
(someone else posted this, cite not instantly available. It shows what might have been in the NOTAM, but wasn't)

FlightAware's airport
information page for Houston Hobby (KHOU)
. The remark reads:
"DUE TO COMPLEX RY CONFIGURATION;
WHEN TAXIING TO THRS 12L & 12R AND 17
CHECK COMPASS HEADING BEFORE DEPARTING."

No similar information is available for Lexington airport.










































































































[1] You can view the airport photo at much larger size at http://en.wikipedia.org/wiki/Image:KLEX_USGS_Comair_Paths.jpg

[2]  A more detailed aerial photo of the ends of the runways is in the supplemental material at the end of htis case.
[3] That's the kind of rule one can give one's own internal "autopilot" in order to move attention to other tasks.   Pilots are trained to heavily on autopilots to manage tasks so they can attend to other issues.

[4] However,  if the taxiway really was blocked just at the far edge of runway 22, then unthinking application of the mental autopilot rule "go until you can't go any further, and that's the runway" would have resulted in the pilot ending up selecting runway 26 and lining up on the center-line in preparation for take-off.

Both pilots were familiar with the airport (as it used to be) and, in this case, that familiarity and comfort level with an internal rule of thumb might have contributed to the accident by reducing vigilance.

So, at this point,  there are a number of factors all adding up to mislead the pilots, remove all their familiar landmarks, mentally frame them with the wrong frame, in which they "knew" there were no edge-lights on the runway they desired, and getting them headed towards lining up on the wrong runway.



[5] Incidentally, the senior crew member always sits in the left-hand seat in the cockpit. It's a strong tradition and would never be violated, ever.   In fact, if you watch off-duty pilots riding in the passenger section, they always sit on the left hand side. That's the side that's associated with prestige, power,  and the locus of control.  
[6] So, the tasks of taxiing into position, getting set to roll, and taking off had been divided among two team members, which now required seamless coordination instead of all being in one person's head.

This was forced by the design of  the nose-wheel steering of the aircraft, combined with the absolute norm-busting inconceivable restriction against the co-pilot simply sitting in the left-hand seat for the flight so that less coordination would be required during this handoff operation.

[7] This is a residual of the air traffic controller strike that Ronald Reagan solved by firing people, which is still rippling through the system.  Also, due to the desire of the FAA to save money and treat controllers as powerless (? not a neutral point of view?),   the fact that the lone controller had only had 2 hours of sleep in the last 24 hours was not in violation of regulations.


[8] Here we have additional behaviors of teams that are induced, structurally, by the desire to fly more aircraft through airports than they were designed for.  (In fact, John Gall mentions and I can believe it but haven't checked, that at one point the controllers had a job-action by slowing down traffic and clogging the system by actually following the regulations, instead of cheating as their supervisors had forced them to do normally.)

In any case, having cleared the flight (the 3rd one of that morning), and seen it was near the right location,  the tower controller turned away to do paperwork.   (Possibly, he was filling out some mandatory statistical report required to help make the airways safer.)

He certainly could have "stayed with" flight 5191 another 15 seconds, but didn't. That's a whole study in itself.   One can imagine controllers trying to be helpful, and being told that they are stepping outside their job description, which is slowing down production, and not letting the pilots learn how to take responsibility for the pilots' jobs.  One can imagine a memo going out, a clear directive, that controllers are, under no circumstances, to delay, but, having given a clearance, must move on to their next task within their own job description.  The controller might have thought "I could, but it's not my job, and every time I do that I get punished."


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