Mentally Pulling Out of Queues

Think about a scenario where you are turning out of a side road onto a busy main road in your car. You have a passenger with you and you are both heading to work. You are trying to make the turn across one lane of traffic, but there is no break in the constant stream of cars. No one is kind enough to stop and permit you to turn. Directly behind you, a queue of cars has built up, and both you and your passenger are anxious to get to the office on time. The motorists queuing behind are becoming increasingly frustrated. One has already tooted their horn. Two minutes later, you are tempted to take a risk and make the turn in front of an oncoming car that is travelling a little too fast for the conditions.

I’m not suggesting that a viable option would be to pull out of the traffic queue altogether. In the case of Air Florida Flight 90, leaving the queue to return to the gate was absolutely necessary to prevent disaster. To avoid increasing the risk of a road traffic accident, however, it is necessary to ‘mentally pull out of the queue’. Mindful of the pressure, the best course of action is to calm your nerves in order to respond rather than react to the situation. This is precisely where mindfulness training is indispensable. Being aware of our reactions to stressful situations, whether they manifest themselves in bodily sensations, or the kinds of thoughts we have, is the key to choosing the safest course of action.

A Tolerance of Danger

The flight crew were aware before takeoff that the tops of the wings were covered in snow or slush. They apparently did not believe this would significantly affect the takeoff, or the ability of the aircraft to climb. Neither did they want to forego the takeoff opportunity for another round of deicing, and further delay the flight unnecessarily. They could see that other aircraft were taking off successfully without incident. All the flight training material on winter operations stressed the importance of ‘clean’ wings for takeoff. At that time, however, a form of collective mindlessness existed amongst pilots at a professional level. They tended to believe that snow or ice on the wings did not pose a significant risk. The flight crew were certainly not alone in their beliefs, as highlighted by the NTSB:

.. .the Safety Board believes that this crew’s decision to take off with snow adhering to

the aircraft is not an isolated incident, but is a too frequent occurrence.6

This under-appreciation of the risks involved was probably reinforced by pilots’ common experience of icing during cruise flight, which was normally encountered without difficulty. Flight manual statements also suggested that aircraft could cope perfectly with icing, once cruise altitude had been reached. This is a good example of how ill-informed assumptions can create the conditions for a kind of mindlessness prevailing at all levels, from the individual level through to the organisational and beyond. A tolerance of danger thrives where the safety risks are misunderstood or under-appreciated, and in the absence of scientific research.

Winter Operations

The NTSB concluded that the flight crew had shown insufficient concern for the winter hazards they faced.7 An important question to ask is why? After upgrading to his role flying B-737 aircraft, the captain had only flown eight takeoffs or landings in similar freezing or near-freezing conditions. The first officer had only flown two takeoffs or landings in such conditions after joining Air Florida. Both young and in their 30s, the risk of their combined inexperience in such conditions could have been mitigated with more robust training. The Air Florida training regimen covered cold weather operating procedures in the classroom, but there was a notable omission. It did not include detailed discussions of the possible effects on instrument readings if the engine anti-ice system was off. Knowledge gained in this area may have made the captain more receptive to the possibility of faulty thrust readings. He w'ould then have possessed the mental tools to make a more effective diagnosis of the situation he faced on the runway.

Neither did the formal training provide sufficient opportunities to demonstrate cold weather operations under the guidance of an instructor. It is one thing to be shown presentations, films and slides, and be given lectures in the classroom, but quite another to practise with the benefit of expert feedback from an instructor. Knowledge of cold weather operations was far more difficult to operationalise, retain and commit to memory under these conditions. In the case of Air Florida, important operational knowledge for dealing w'ith winter hazards never made it out of the classroom.

The Training Dilemma

This brings to the fore an ever-present training dilemma: how do we effectively train operational staff to respond appropriately to a scenario they wall encounter infrequently? When the scenario finally arises in real life, the knowledge of how best to tackle it may have long faded from memory. And that is if the knowledge required to respond has been committed to memory in the first place. It is a bit like driving a car on an icy road and finding yourself in a skid. You may not encounter these road conditions often, yet you need to be prepared for them when they happen. Your immediate response upon detecting a skid will determine whether the car stays on the road or ends up communing with the roadside shrubbery. Skid control is not something routinely taught by most driving instructors either. Ideally, you would want to give drivers live instruction in this under safe conditions, away from real traffic. This form of training then needs to be refreshed at regular intervals.

In short, it is important not to analyse human error in an isolated context. The errors made by Flight 90’s flight crew took place downstream of a limited organisational training regimen, which failed to instil some of the basics for winter operations. It can be deduced that organisational mindfulness plays an equal role to individual mindfulness in the prevention of accidents.

M4: Applying Mindful Safety to Air Florida Flight 90

The case study of Flight 90 shows how the analysis of complex accidents must be approached from a multi-level perspective. We can achieve a much greater understanding of accident causation by looking at the contribution each level makes to the big picture, empathically recreating the events to gain more insight. There are many lessons that can be learned from Flight 90, and these can usefully be applied in other domains where safety is of paramount importance.

Individual

  • • We must always be alert to the dangers of mindlessness, as it can cause huge problems when it is allowed to develop in safety critical situations. A clear example is provided by the case of Flight 90 and the tragic loss of life.
  • • Pilot training in mindfulness can prevent the loss of awareness being played out in tragic circumstances.
  • • Checklists provide an opportunity for mindlessness, if they are carried out routinely through force of habit.
  • • In the absence of evidence and research, we can be prone to fill the void with assumptions, which may appear logical. Though they may be extrapolated from other more familiar situations, they can be deadly if they are applied inappropriately in safety critical situations.

Relational

  • • We may think we are communicating effectively, but communication is more than just an exchange of words or information.
  • • The captain of Flight 90 heard the words spoken by his first officer, but he did not respond appropriately.
  • • To avoid narrowing our range of options, we need to cultivate our ability to respond rather than react to what another person says.

• Our professional or social status can be a hindrance in communications. If we act to defend it, we may find ourselves unable to listen. In safety critical situations, this may threaten life.

Organisational

  • • If two organisations fail to communicate effectively over contractual arrangements and their practicalities, it can cause confusion and create significant safety risks.
  • • Clear instruction manuals to help carry out maintenance activities are essential, especially where aircraft with unique characteristics are concerned.
  • • Pilot training for winter operations could have been improved at Air Florida. Insufficient attention was given to operationalising knowledge gained in the classroom.
  • • A training dilemma is posed wherever operational staff have to meet the challenge of a situation that arises infrequently. Their skills need to be maintained for such situations.
  • • A professional tolerance of danger can thrive where safety risks are under- appreciated or misunderstood. Awareness raising activities can help counter the attitudes that drive unsafe behaviours.

Societal

  • • Being aware of societal pressures is also a key component of mindfulness. Societal values, attitudes and patterns of behaviour can be hugely influential in our thinking.
  • • ‘Last place aversion’ is a good example of how our behaviour can be determined by collectively held views in wider society. We can take riskier decisions to avoid being last, as borne out by the research.
  • • Dropping out of the queue for takeoff was improbable for Flight 90, but staying increased the risk of an accident massively.
  • • We can experience the same kind of pressure in road traffic queues.
  • • Societal pressures need to be resisted to reduce safety risks in certain situations. Being able to ‘mentally pull out’ of a queue and resist these pressures can save lives.

Notes

  • 1. National Safety Transportation Board (1982). Aircraft Accident Report. Air Florida, Inc. Boeing 737-222, N62AF. Collision with 14th Street Bridge, Near Washington National Airport, Washington, D.C. January 13,1982, p. 7 of transcript. Available from http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR82- 08.pdf (Accessed02.08.2018).
  • 2. Ibid., p. 56.
  • 3. Ibid., p. 68.
  • 4. Ibid., p. 69.
  • 5. Kuziemko, I., Buell, R.W., Reich, T. & Norton, M.I. (2011). “Last Place Aversion”: evidence and redistributive implications. NBER Working Paper No. 17234, July 2011.
  • 6. National Safety Transportation Board (1982). Aircraft Accident Report. Air Florida, Inc. Boeing 737-222, N62AF. Collision with 14th Street Bridge, Near Washington National Airport, Washington, D.C. January 13, 1982, p. 62. Available from http:// libraryonline. erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR82-08.pdf (Accessed 02.08.2018).
  • 7. Ibid., p. 66.

Self-Care

 
Source
< Prev   CONTENTS   Source   Next >