MANAGING SAFETY PERFORMANCE NEWS

Factoring In The Human

“I still cannot believe you have not yet taken into account the human factor”
 
 ~Sully
 

Earlier this month, on final approach into New York’s LaGuardia Airport, looking down on all those buildings and crowded streets below, I couldn’t help but think: if not on a runway, where the heck could you set down a commercial aircraft in New York City?

US Airways 1549. Aka, Sully.

On January 15, 2009 Captain Chesley Sullenberger had no choice but to come up with an answer to that question. On takeoff from LaGuardia, the Airbus 320 he was piloting flew into a flock of geese, resulting in an immediate and total loss of power. Gliding at 3,000 feet, he had to first determine where to land, and then figure out how to successfully land there. 

An assignment like that could keep a team of experts busy for a week – in a conference room. Buckled in the cockpit of a gliding commercial aircraft, Captain Sullenberger had 208 seconds to decide and execute, with 155 lives hanging in the balance.

That he successfully accomplished; it was “the miracle on the Hudson.”

It’s no exaggeration. The combination of what is known in the industry as a dead stick landing and a water ditch was nothing short of miraculous.  But if not for the equally amazing emergency response by the good citizens of the New York metropolitan area – in twenty-four minutes! – that successful landing would have counted for nothing. It didn’t take long before that Airbus was sitting on the bottom of the Hudson, covered over by icy cold water. 

A few years ago, I met one of the passengers on that flight, who worked for a good client. I had to ask, “Were you scared?”

“No. Didn’t have time. It all happened so fast.”

208 seconds is that fast.

Sully: The Movie

As amazing as the miracle on the Hudson was, it’s hard to imagine it making much of a movie. For openers, it’s way too short. More to the point, everyone knows how the story ends. What’s the drama in that? 

I watched the movie, hanging on the edge my seat. I watched it again last night, still hanging on the edge of my seat. If you haven’t seen it, you need to. It’s not like I’ve given away the ending. The recreation of the event makes it clear just what a miracle it was, but a movie needs more than just visuals to make it a compelling watch. In Sully, the director figured out the flight wasn’t the story: the investigation was.

It was a stroke of genius; credit Clint Eastwood for that.

If I didn’t know differently, I’d strongly suspect that Mr. Eastwood grew up like me: working in operations, getting dragged into more than a few of those post-event shootouts. Otherwise known as the Root Cause Investigation. The very thought of them still sends cold chills down my spine.

I don’t use that term shootout lightly. Back in the day, we had a Division President who started out life as a PhD, working in R&D. if ever there was ever a leader who’d want to see good science practiced when something went wrong, you would surely think it would be someone like that.

Wrong! 

After an incident, all he’d want to know was, “Who’d you shoot?’  Give him a name, and he’d go away happy. 

If you’ve seen something like that yourself, don’t go chalking it up to a lack of intelligence or education. Or something wrong in the water where he grew up: the guy was from the same small town as me. Some people are like that, and some of them sit in positions of authority. 

That does not make them an authority on a subject like human performance.

Art Imitates Life

In commercial aviation, the task of finding out what went wrong falls to the National Transportation Safety Board; they do this for a living. In the movie, the Director made them the adversary: asking all those embarrassing questions, running simulations that showed that the aircraft didn’t have to be ditched in the Hudson, and suggesting the flight data indicated one of those two engines was running just fine. 

In other words, there might have not been a darn thing Capt. Sullenberger did wrong flying into those birds, but deciding to put that aircraft down on the Hudson River? That’s the stuff of “pilot error.”

Dramatic tension: the stuff of good theatre. 

The movie made you think the NTSB had its mind made up, the investigators intent on proving their case, leaving the Captain to be hung out to dry. Or to prove them wrong – in a hearing room that looked like the floor of the US Senate, with the investigation panel sitting high above, like the Justices of the Supreme Court. All that was missing was their robes.

Powerful stuff. I’m sure the real-life version of the investigation looked nothing like that. More likely, all this took place in a conference room, with one of those faux-mahogany conference room tables lined with notebook computers, half-empty coffee mugs, yellow notepads, and a cell phone strewn here and there. A few empty chairs, because some members were taking phone calls down the hall.  You get the picture: that’s exactly what a real-life investigation looks like.

What’s the tension in that.

If you’ve been there, done that, you know the answer: it’s huge! Reputations, careers, even employment can hang in the balance. 

That’s where in Sully, Eastwood hit a nerve!

Can We Get Serious Now?

The climax in the movie begins when Sully faces the Board, who appear to have made up their minds that landing on the Hudson was a clear case of pilot error, and asks, “Can we get serious now?” If you are a student of the investigation process – not to mention managing hazard and risk – there’s a lot in Sully’s comment to ruminate on. 

For example, the problem started with an aircraft striking birds. Big birds. Is that a known hazard in the industry? Of course it is. Are commercial aircraft engines designed to ingest a flock of Canadian geese and keep on ticking? No. Do airplanes still take off? 

Known hazard. Acceptable risk. Preventable accident?

I’m sure you know this, but back in your shop, you face questions like these all the time. They just involve things – actually, hazards – other than aircraft and birds. Said another way, in every human activity, there is risk that cannot be reduced to zero. 

What then is an “acceptable risk”?

Then there is the matter of human performance. Pilot error is just another term for human error. Nothing new there: human behavior is found at the root of most problems. It’s either an Act of God, or an act by us humans.  

Sooner or later just about every investigation is going to wind up facing human behavior in one form or another, and judging that behavior: acceptable, or unacceptable? 

In Sully, that – not the landing – was the moment of high drama. And the point where Sully asks the Board, “Can we get serious now?” It’s such a great line.

The NTSB had run all of its simulations allowing no time for the flight crew to process information, evaluate choices and decide how to execute something that no pilot had ever been trained to do.  “You’ve taken all of the humanity out of the cockpit. You are looking for human error: then make it human” Sully says.

Give the good captain thirty-five seconds to size up the situation, collect the cockpit data, weigh the alternatives, and make a decision – thirty-five seconds to do all that! – every simulated landing on terra firma failed catastrophically.

Proving Sully right.

The Investigation Process

In the movie, it took a dramatic speech by the Captain to make the investigation team do something that they should never have needed to be told to do: properly weigh all the evidence. I’d like to think in real life, it happened the other way around: “Captain, taking into consideration all of the variables you had to factor in to arrive at your decision, what you did in seconds was an amazing feat in human performance.”

Because it was.

Over five decades, I’ve witnessed the investigation process up close and personal: conducted investigations and been investigated. Studied it, taught it, written about it. I’ve seen the extremes: “Something went wrong, somebody must have done something wrong, so who do we hold accountable?” And the other, “People are human; stuff happens, it’s nobody’s fault.”

As to how to evaluate human error in real life, the best advice on the matter comes from of all people, a screenwriter: the person who wrote the line in Sully an actor delivered so eloquently: “You are looking for human error: then make it human.”

In other words, apply a simple standard: given the situation, what should I reasonably expect someone to have done?

Yes, that is easier said than done. But absolutely worth doing – because it’s the right thing to do.

It really is that simple.

Paul Balmert
June 2019

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