Tuesday, July 23, 2013

The Code in Aviation

An email from a frequent reader/listener, and really smart person, provoked by the recent Roberts-Munger podcast on "The Code" in sports

What follows is a LONG post, with a lot of links and videos.  But it is remarkable (remember, I didn't write it; I'm just reproducing it, redacted a bit).  Save it for sometime when you have 20 minutes to really think about it.  Fascinating.  And quite a commentary on how air travel is much less planned, and much more of a spontaneous order, than many people think.  I am most grateful to the anonymous person who sent the email; great stuff.

[Your] show made me think about aviation. It's a profession THICK with your conception of how law, legislation, equipment, and code interplay. There is much I could say about this. Thought you might be interested in just a little bit since there are connections to both your podcast topic and (possibly) the Asiana accident that's in the headlines these days. The evolution of aviation provides an example where
1) "The code" proved faulty
2) Intervention was required to change it, and
3) Change was successfully adopted/embraced with measurably better results.

Much more after the jump...

The very short story: It became obvious during the period of the 1970's that something human-factor related in aviation had to change. Airplanes had become MUCH more reliable, but we still had unacceptable accident rates. Solution: http://en.wikipedia.org/wiki/Crew_resource_management Stripped of all of the buzzwords and window dressing, what this effort amounted to was  de-tyrannizing the cockpit. We figured out that traditional boss-subordinate relationships were inappropriate for the complex task of flying airplanes. The "captain as king" model of management was crashing airplanes and killing people.

This is well summarized by a famous captain in that wikipedia link:  

"Captain Al Haynes, pilot of United Airlines Flight 232, credits Crew Resource Management as being one of the factors that saved his own life, and many others, in the Sioux City, Iowa, crash of July 1989. ...the preparation that paid off for the crew was something ... called Cockpit Resource Management....Up until 1980, we kind of worked on the concept that the captain was THE authority on the aircraft. What he said, goes. And we lost a few airplanes because of that. Sometimes the captain isn't as smart as we thought he was. And we would listen to him, and do what he said, and we wouldn't know what he's talking about. And we had 103 years of flying experience there in the cockpit, trying to get that airplane on the ground, not one minute of which we had actually practiced, any one of us. So why would I know more about getting that airplane on the ground under those conditions than the other three. So if I hadn't used CRM, if we had not let everybody put their input in, it's a cinch we wouldn't have made it."
A real-world example of a breakdown in teamwork under the "old code." The difference between a duck and co-pilot?


The implementation of CRM was successful and the reform effort had a massive impact. The culture (code) has changed. There is a mountain of literature on this. In the podcast you mention being interested in how groups of people accomplish the creation of value through exchange in non-market settings. I thought the evolution of cockpit teamwork to be an illustrative example. It involves a "fatal conceit" problem where the effective exchange of information was inhibited by lopsided bargaining power between the captain and the rest of the crew. This problem was fixed by decentralizing decision-making authority. This is starting to sound like the theme of good economics.

Asiana Flight 214 thoughts: [NOTE: These comments are uncareful/biased/not quite fair/improperly speculative for the purposes of keeping it short and topically consistent (bar talk vs. "expert" opinion), so don't take them too seriously; just speculation. Just suggesting an area to pay attention to as the investigation unfolds that you might find interesting.]

Accidents like that involving modern airplanes flown by well-trained aircrews typically do not happen unless SEVERAL things have gone wrong. The overlapping checks and balances in equipment/procedures/protocol can contain pilot error and even a mildly incompetent pilot. Suspect that we may find out that a VERY incompetent pilot was at the controls of that airplane. Suspect further that cultural factors may be cited to explain why the other 3 pilots were not assertive enough to demand that approach be abandoned before things got really ugly. It is somewhat known in the aviation community that Korean cockpit teamwork has not quite caught up with the modern "code." A popular account of this has even appeared in one of Malcolm Gladwell's books .

A little more from an American simulator instructor who trained Asiana pilots.....
"The Koreans are very very bright and smart so I was puzzled by their inability to fly an airplane well. They would show up on Day 1 of training (an hour before the scheduled briefing time, in a 3-piece suit, and shined shoes) with the entire contents of the FCOM and Flight Manual totally memorized. But, putting that information to actual use was many times impossible. Crosswind landings are also an unsolvable puzzle for most of them. I never did figure it out completely, but I think I did uncover a few clues.

Here is my best guess. First off, their educational system emphasizes ROTE memorization from the first day of school as little kids. As you know, that is the lowest form of learning and they act like robots. They are also taught to NEVER challenge authority and in spite of the flight training heavily emphasizing CRM/CLR, it still exists either on the surface or very subtly. You just can’t change 3000 years of culture... "
 What I find most interesting about the accident: The public's/media's irrational fixation on it. I'm an airline pilot and I find it amazing that we don't manage to wipe out an airplane everyday considering the tremendous volume of air traffic operating in the U.S. everyday (tens of thousands of flights)

Isn't it amazing that we are able to do this so successfully with fallible human beings operating complex equipment in complex, volatile environments? It's a modern marvel. No one seems interested in that story nor do they seem interested in concerning themselves more in areas where they are at much more risk to human error: Medical errors kill enough people to fill four jumbo jets a week. (BTW, there there is a lot of literature available about efforts to apply aviation protocols to medicine). 

Just felt like sharing a few thoughts after listening to the podcast and mentioning that aviation offers a goldmine of material that I find consistent with your topic.


chrisA said...

Does the data suggest that Korean aircraft have a higher accident rate than other areas? I mean the Asiana flight was just one case, and it is not like there have never been any crashes in the US before. There is definitely a bit of the old stereotype of Asians in this post.

G Wolf said...

just FYI - your link to flight UA 232 is broken.

Gordon said...

The topics covered here were discussed in a 1997 series from TLC called "Survival in the Sky." I found the 1st episode online which covers how the cultural attitude of deferring to the captain led to the Canary Islands tragedy. And it covers how automation has in some cases hindered efforts to improve safety.


Peter McIlhon said...

As someone who lived in Korea for over two years, yes. I can attest to their terrible driving skills. Although, Korea Air is the best airline I've ever flown on. So go figure.

sfw said...

When will Angus call this right wing racist Dorp? He sees it everywhere and I have no doubt that what is written is true. It must be called for what it is. Truth can't be used an excuse for racism.