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◌  United 173 and the casual workplace

14 June 2009

What is distinctive about contemporary thinking in the developed world? What everyday attitudes have changed since, say, 1950?

One big difference is our relative disrespect for authority.

Where does this come from?

In general terms, I guess it’s part of macro stuff like peace, prosperity, and ease of communication. Popularly, it seems connected to postmodernism, LSD, and protest against the Vietnam War.

These are boring. Let’s look at something more specific – something where we can examine proximate causes.

When United flight 173 was coming into PDX on the evening of 28 December 1978, its landing gear didn’t lock properly. They circled for about an hour, preparing for a gear-less touchdown. When they were ready to land, according to the NTSB report,

At 1806:46, the first officer told the captain, We’re going to lose an engine…. The captain replied, Why? At 1806:49, the first officer again stated, We’re losing an engine. Again the captain asked, Why? The first officer responded, Fuel.

Seven minutes later, all the engines died. They declared a mayday and clipped trees until they broke up over a wooded backlot with some unused buildings at NE 159th and Burnside. Most of the crew and passengers survived.

Three things had gone wrong. First, the landing gear malfunctioned. The crew was dealing with this properly. Second, under the stress they apparently mixed up the multipliers on the fuel gauge – a relatively new type – and thought the reading was × 1000 instead of × 100. Third, and most interesting, when the fuel problem was clear to them, the rest of the crew didn’t check that it was clear to the captain. The NTSB wrote:

The Safety Board believes that this accident exemplifies a recurring problem—a breakdown in cockpit management and teamwork during a situation involving malfunctions of aircraft systems in flight. […]

Admittedly, the stature of a captain and his management style may exert subtle pressure on his crew to conform to his way of thinking. It may hinder interaction and adequate monitoring and force another crewmember to yield his right to express an opinion.

The first officer’s main responsibility is to monitor the captain. In particular, he provides feedback for the captain. If the captain infers from the first officer’s actions or inactions that his judgment is correct, the captain could receive reinforcement for an error or poor judgment. Although the first officer did, in fact, make several subtle comments questioning or discussing the aircraft’s fuel state, it was not until after the No. 4 engine flamed out that he expressed a direct view, Get this … on the ground. Before that time, the comments were not given in a positive or direct tone. […]

The Safety Board believes that, in training of all airline cockpit and cabin crewmembers, assertiveness training should be a part of the standard curricula, including the need for individual initiative and effective expression of concern.

The NTSB’s closing recommendation was that the FAA:

Issue an operations bulletin to all air carrier operations inspectors directing them to use their assigned operators to ensure that their flightcrews are indoctrinated in principles of flightdeck resource management, with particular emphasis on the merits of participative management for captains and assertiveness training for other cockpit crewmembers.

Things like this had been said before, in NTSB reports, in NASA, in the military, and among flight crews and psychologists. Clear thinking about human factors would have seeped into flight crew doctrine eventually. But the United 173 report, more than anything else, was what actually got crews trained not to worship the captain. And this quickly spread to reactor operations, operating theaters, and slowly even to non-critical management – this idea that, for bureaucratically acceptable reasons, the boss ought to be double-checked, kept up to date on trivia, and pestered as needed. Informality would have found a way, but Crew Resource Management brought it about brilliantly by putting it in the language of safety and efficiency.

(The report said the crash was in a wooded section of a populated area of suburban Portland. I was taking the MAX to the deep east of the city (i.e., beyond Laurelhurst Park) yesterday, and had time for a look around – the tracks are on Burnside out there. It’s a block of becourtyarded condos and McMansions now, with a few big firs.)

So sure, Abbie Hoffman and Andy Kaufman and whoever. But if you ask someone in a suit in charge of life-sustaining machinery why they aren’t a martinet, their answer is more likely to point back to United 173.