New Tools for Incident Investigation

In the field of human relations nothing is so important as safety, for safety applies with equal force to the individual, to the family, to the employer, to the country. Safety in its widest sense, concerns the happiness, contentment and freedom of everyone.

- Bill Jeffers

The M4 approach can be applied very effectively to accidents, in order to explain rather than judge how events unfolded and led to catastrophic consequences. In contrast to the approach taken in most accident investigations, the emphasis is on empathically reconstructing events for all those who played a role at the time. In reality, the reconstruction of complex environments after the event is fraught with difficulty, but this doesn’t prevent us from learning lessons.

This chapter presents a working case study of Air Florida Flight 90, w'here you will see the analytical side of the M4 approach in action. Despite the obvious tendency to blame human error for the accident, many other factors were responsible. By analysing things from each level in turn, we can obtain a more balanced perspective and address the systemic failings too. This is an approach we will be taking throughout the book.

Case Study: Air Florida Flight 90

This case study of Air Florida Flight 90 applies M4 thinking to a major disaster. There is evidence of mindlessness occurring at all levels here. In an effort to identify issues and circumstances that we may all face in the workplace, we are interested in understanding what happened at a deeper, experiential level. Blame must always be jettisoned if we are to learn from the ‘errors’ of the past. With the benefit of hindsight, it is far too easy to label human actions as errors, and far too easy to ignore the full situational context. If the highly trained professionals often held responsible for so many accidents could turn back time and make a different set of decisions, they surely would. Taking a more holistic approach, we must also free our thinking from the analytic reduction of New'tonian cause and effect.

Flying Mindlessly

When things go w'rong for pilots, the consequences can cause loss of life on a horrific scale. The importance of being mindful at all levels is illustrated well by the example of Air Florida Flight 90. Picture a very wintry day at Washington National Airport.

It is 13 January 1982, and the temperature is 4°C. When Air Florida Flight 90 finally accelerates down the runway for takeoff, just before 4 pm, heavy snow is falling. There has been a 49-minute wait in a taxi line with many other aircraft. In the cockpit are the 34-year-old captain, Larry Wheaton, and the 31-year-old first officer, Roger Petit.

Just 90 seconds later, the Boeing 737, in an extreme nose up pitch attitude, falls out of the sky and crashes into the 14th Street Bridge over the Potomac River. Before plunging through the ice into the water, the aircraft strikes seven vehicles on the bridge, killing four motorists. In total, the aircraft was carrying 74 passengers and five crew members. Tragically, just four passengers and one flight attendant survived after being rescued from the freezing river. What went wrong?

The subsequent investigation by the National Safety Transportation Board (NSTB) pointed, amongst other things, to the flight crew’s pre-takeoff control checks in the cockpit.1 The first officer dutifully called out each control on the list. The captain and first officer were meant to ensure that the switches were in the correct positions. This is the conversation as it happened:

First officer: Pilot heat?

Captain: On.

First officer: Engine anti-ice?

Captain: Off

Remember that it was freezing outside. Though they ran through the checklist together, the engine anti-ice switch was never moved into the ‘on’ position. The flight crew were acting mindlessly. The captain and first officer were just going through their routine checklist, just as they had always done. This time, however, they were not flying in the weather they were accustomed to. It was icy and the conditions were treacherous. It is not difficult to empathise with the flight crew under these circumstances. These pre-takeoff control checks are similar to the safety demonstrations given by flight attendants. As passengers, we may often find these tiresome. The consequence of this is that we may ‘tune out’ and ignore important safety information. Blindly following routines can make us behave like automatons. Our eyes glaze over and our attention falls away.

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