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).

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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

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(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.

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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

Ground causes accidents, claim pilots!

Newsflash - Pilots blame ground for accidents! A new federal study has revealed what was long suspected - the ground is responsible for most airline crashes. A working commission will release Guidelines in January for proposals to prohibit having ground in or near airports. "If it wasn't for the ground, we'd still be in the air!" commented First Officer Spock.

That last paragraph of invented news seems absurd, doesn't it?

But, every year, as my wife will confirm, around the time of the first snow, I will be bouncing off the walls at some newspaper headline stating "Ice causes accident" or "Ice causes 23 car pile-up on freeway, 8 dead."

To me, the claim "Ice caused the accident - I hit the brakes but couldn't stop in time!" is in the same category as pilots blaming the ground for accidents. Yes, there was ice present. No, the ice did not reach out, grab the 23 cars, and smash them into each other.

Actually, one of the first things they teach you in pilot training is that "Bad weather does not cause accidents. What causes accidents is the decision by the pilot to continue operations into conditions beyond their skill and ability to handle. "

The place to stop such accidents, then, is not at the point where the plane meets the ground, or the car smashes into a telephone pole -- but way back at the point where an incorrect decision was made to get on the road or in the air in the first place - given weather conditions.

The denial of blame and responsibility in the excuse "There was nothing I could do!" needs to be countered with - "Yes, there was, but it was earlier and further upstream. The outcome was sadly predictable."

I say all this leading up to another day's look at the Mortgage and Foreclosure crisis unfolding around us, particularly hard hitting in Michigan and Ohio.

I will grant that there were "predatory practices" at work in aggressively pushing very bad mortgages on people with zero chance of paying them and no idea what they were signing up for. That's bad in its own right, and should be outlawed.

Still, I and many others are struck by the attitude and mental model shown by some of the "victims." Talking to one homeowner who ran into trouble in the Cleveland Ohio area (Cuyahoga County), the New York Times today reported several comments, which I'll repeat here:

Can the Mortgage Crisis Swallow a Town?
by Nelson D. Schwartz
New York Times
September 2, 2007
Maple Heights, Ohio

TAMMI and Charles Eggleston never took out a risky mortgage, never borrowed more than they could afford and never missed a monthly payment on their neat, three-bedroom colonial in the Cleveland suburbs. But that hasn’t prevented them from getting caught in the undertow of the subprime mortgage mess now submerging this town.

Over the last 18 months, the Egglestons have watched one house after another on their street, Gardenview Drive, end up foreclosed and vacant...

It is a scene being repeated in cities and towns across America as loans that were made to borrowers with little or no credit history, many of whom could not even afford a down payment, fail in ever-growing numbers....

Indeed, what was once a problem confined mostly to economically struggling areas is quickly becoming a national phenomenon. ...At current rates so far this year, RealtyTrac expects foreclosure filings to hit two million in 2007, or roughly one per 62 American households — a rate approaching heights not seen since the Great Depression.

Analysts also say that the fallout from mortgages gone bad is spreading well beyond borrowers now in default. It has begun to engulf middle-class communities like Maple Heights, where nearly 10 percent of the houses — or 910 properties — have been seized by banks in the last two years...

“I don’t think we’ve hit bottom,” says Michael G. Ciaravino, the mayor of Maple Heights. “My fear is that foreclosure rates could go to double where they are today.”

IN terms of the subprime mortgage meltdown, Ohio has been among the hardest-hit states, according to the Mortgage Bankers Association....

For a mayor presiding over a town in crisis, Mr. Ciaravino doesn’t seem angry, but beneath an affable exterior is barely concealed frustration that the danger of subprime debt became a national issue only after Wall Street began to wake up to the threat this summer. “We’ve been warning of problems for years,” he says. “I’m just a small-town mayor. Where was the foresight?”

“There’s plenty of blame to go around,” warns Mr. Ciaravino...

It is also clear that the Sweets bear some responsibility for their predicament. “I do blame myself a little bit,” Mrs. Sweet acknowledges. “I feel dumb.” She explains that she was focused on the monthly payment when she borrowed from Countrywide, not the interest rate or taxes due. “Once we got the loan documents at the closing, I just came home and stuck them in a drawer.”

So, when her monthly payment requirement doubled, "There was nothing she could do." Hmmm.

Maybe, one thing she might have done was not put her foot into the bear-trap in the first place. There's little doubt that it was a trap, and it was mis-represented, and she was taken advantage of , and the bait looked very inviting, and the trap part wasn't obvious.

But, then again, that is how traps for the unwary are always designed, isn't it? Find some kind of attractive bait, cover up the steel jaws with dead leaves or something, and put it right in the path where people will come upon it frequently until they "give in" and decide to reach for the cheese in the mousetrap.

This was some kind of surprise, that there are financial traps for the unwary out there? Or that "Fools and their money are soon parted" ? From here, that looks about as unexpected as discovering that ice on a road is slippery.

Again, I'm not saying she wasn't taken advantage of. The same article has a few words from a banker, Marc A. Stefanski, the chief executive of Cleveland's Third Federal Savings and Loan, worth quoting:

“The model has shifted,” says Mr. Stefanski. “It became very lucrative. But it was totally irresponsible for the sake of greed.” Not that Mr. Stefanski didn’t notice the profits to be had. “Absolutely, we were tempted,” he acknowledges. “We arm-wrestled and talked, but we decided not to change the model. We felt it wasn’t the right thing to do.”

Mr. Stefanski is no social worker. He lives in an affluent suburb of Cleveland and earned nearly $2 million last year. But he does not hide his feelings about just what went wrong in places like Maple Heights. “The whole system was based on raping the public,” he says, matter-of-factly. “Not everyone should own a home — just those who can afford it.”

Third Federal has a branch in Maple Heights, Mr. Stefanski says, and in the past, “we owned Maple Heights.” But in recent years, he says, “The predators just jumped on it.”

But what I am saying is that Mrs. Sweet mentioned above was an adult, surrounded by millions of other adults, libraries, the Internet, places of worship, bars, supermarkets, or other places where this kind of thing could be discussed. Oh yes, then there are also schools and continuing education courses. And TV specials. And weblogs.

And, Mrs. Sweet is not alone. Quoting that article again,

At current rates so far this year, RealtyTrac expects foreclosure filings to hit two million in 2007, or roughly one per 62 American households — a rate approaching heights not seen since the Great Depression.

So, this is to me the most surprising and curious part of this whole situation. In this day and age, how can it be that two million households, probably more like 4 million people, could be so naive that they would make a $100,000 or more purchase, probably the largest amount they had ever dealt with in their entire lives, with so little caution or so little getting good advice?

And, this is not just on the poor end of the spectrum. There were also people buying million dollar homes that couldn't afford them by any rational scenario -- people that already owned $400,000 homes, lived in good neighborhoods with good schools and libraries, and probably had high-speed internet to their home and wireless connections to their four laptop computers.

So, while poverty can surely diminish available resources or make them more expensive, it's not an adequate explanation for this. We know predators are out there and greedy - that's nothing new to this century or this country.

But, why did all that social wisdom, and all those resources in the books and internet, have so little beneficial effect?

There is an obsession in education with math and science and problem solving, but it seems those don't help much without this lesson:

"When you are thinking about doing something new, first seek out the tribal elders and talk to them and get their advice."

In turn, when I consider why people don't do that, one thing that keeps coming up is the wide-spread social attitude that we are not responsible for the bad results of our own actions, or expected to have or use any foresight or planning or judgment.

In other words, "Ice causes accidents."

We need to dig deeper into how this total collapse of responsibility has worked its way into being so commonplace. I have a suspicion that the term "freedom" has been confused with "anarchy", and that what people think they can obtain is "freedom from consequences of their own choices and actions."

Rich people seem to think that their wealth, or their attorneys and doctors and pills can provide freedom from consequences. Poor people can blame bad schools, or poverty, or fate for being trained repeatedly that any sort of self-control is either impossible or pointless.

That concept of "freedom" is more like the freedom of a jellyfish or slug from the "constraints" of having bones that are not flexible.

The truth is that you are free to run a lot faster with bones than without them. And, without bones, you are free to be a free lunch to whatever predator comes by next.

We get to pick what kind of freedom we prefer.

Pick wisely.


also see my post from last December: Honey, We're losing the house.
Quotes from that:

[Consultation] is also an intervention point, a leverage point, a place were we can fix something. We could take some of those same people who figure out how to sell us cars and pills, and put them to work selling us on the simple idea that it's ok to ask for help, and it's ok to not know everything, and it's ok to need each other to get by.

I think that would be a better investment than many others we're currently doing trying to clean up the messes that avoidable bad decisions have created.

There are some initiatives underway. One example is the Baha'i faith's emphasis on the process of local "consultation" among regular people trying to figure out how to make hard decisions in an increasingly complex world. In my mind we need a lot more energy put into such initiatives by many more groups, more collaboration, more social networking.

In it's own way, that attention will produce an "emergent" solution to many problems that formal analysis and huge government programs would never address.

Put another way - on a personal, corporate, and national level, it's a really bad idea to toss overboard things like integrity, honesty, self-discipline, and respect for wise people (some of which may be old people or even dead people..) It's a bad idea to be so taken with "face" and "pride" that one can't consult with others on big decisions. That's a bad road to go down. The consequences will always come back to haunt you.

Oh, and one last thing. Today's Washington Post's article on the mortgage crisis has this advice.

And beware of mortgage rescue scams.

"The worst thing people can do is bury their heads in the sand," said Jean Constantine-Davis, a senior attorney for AARP Foundation Litigation, a legal advocacy group in the District. "The second-worst thing is dealing with people that are making promises that will make matters worse."

Yep, now the people who show up with a deal too good to be true to rescue those who fell for the first trap can be actually setting a second trap. Now is a time to be very very careful.

Related Post: Mental Fog causes 100 car pileup

(photo by crowbert )