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Emmanuel Ojeifo: Malcolm Gladwell and the lesson from plane crashes
by Emmanuel Ojeifo
“To know that the past can illuminate the contours of the present is to be better equipped to make intelligent decisions about difficult public issues.”
– John Tosh
Plane crashes rarely happen in real life the same way they happen in the movies. Some engine part does not just explode in a fiery bang. The rudder doesn’t suddenly snap under the force of take-off. The captain doesn’t gasp, “Dear God,” as he’s thrown back against his seat. The typical commercial jetliner is about as dependable as a toaster. However, when plane crashes happen in real life, the consequences are always dire. They usually bring in their train a harvest of blood and death.
In his telling account of some of humanity’s most disastrous plane crashes, Malcolm Gladwell, one of America’s most gifted journalists, in his fascinating book, Outliers (2010), locates the place of complex human behaviour in the incidents of plane crashes. Listening to “black box” cockpit recorder, examining the flight records, looking at the weather and the terrain and the airport conditions, Gladwell tells us that the complexity of plane crashes turns on a very simple fact, namely: “Plane crashes are much more likely to be the result of an accumulation of minor difficulties and seemingly trivial malfunctions.”
According to him, “in a typical crash, for example, the weather is poor – not terrible, necessarily, but bad enough that the pilot feels a little bit more stressed than usual. In an overwhelming number of crashes, the plane is behind schedule, so the pilots are hurrying. In 52 per cent of crashes, the pilot at the time of the accident has been awake for 12 hours or more, meaning that he is tired and not thinking sharply. And 44 per cent of the time the two pilots have never flown together before, so they’re not comfortable with each other. Then the error starts – and it’s not just one error. The typical accident involves seven consecutive human errors. One of the pilots does something wrong that by itself is not a problem. Then one of them makes another error on top of that, which combined with the first error does not amount to catastrophe. But then they make a third error on top of that, and then another and another and another and another, and it is the combination of all these errors that leads to disaster.
“These seven errors, furthermore, are rarely problems of knowledge or flying skill. It’s not that the pilot has to negotiate some critical technical manoeuvre and fails. The kinds of errors that cause plane crashes are invariably errors of teamwork and communication. One pilot knows something important and somehow doesn’t tell the other pilot. One pilot does something wrong, and the other pilot doesn’t catch the error. A tricky situation needs to be resolved through a complex series of steps – and somehow the pilots fail to coordinate or miss one of them.”
Pilots, aviation experts, airplane manufacturers and safety engineers know that the whole flight-deck design is intended to be operated by two people, and that operation works best when you have one person checking the other, or both people willing to participate. In the words of Earl Weener, who was for many years chief engineer for safety at Boeing, “Airplanes are very unforgiving if you don’t do things right. And for a long time it’s been clear that if you have two people operating the airplane cooperatively, you will have a safer operation than if you have a single pilot flying the plane and another person who is simply there to take over if the pilot is incapacitated.”
The above analysis is not the report of what caused the crash on Thursday, October 2, of an airplane belonging to Associated Airlines en route Lagos to Akure, which killed 15 of the 20 people on board. The Accident Investigation Bureau (AIB) in collaboration with the Brazil-based manufacturer of the Embraer 120 aircraft is currently carrying out investigations into the probable causes of the air crash, and we graciously await the outcome of their investigations. However, we must admit that the near frequent occurrences of plane crash have cast a dark shadow on the image of our country as a place where death and bloodshed have become the cheapest commodity.
Just a few months ago, we observed the one-year memorial of the Dana Air Crash, also in Lagos, which systematically liquidated the lives of over 160 Nigerians. In my article, “Dana Crash: Why Memory Matters” published in The Guardian newspaper of Friday, May 31, 2013 and in Thisday newspaper of Tuesday, June 4, 2013 I commented on the need for us as a people and as a nation to learn from experience. Among other things, I said: “I believe that when tragedies happen, they should force upon us the burden of critical thinking. We must ask ourselves how we got where we are today. How did our collective will allow so many to die such a senseless and callous kind of death?”
I then went further to draw the lesson from the Dana Crash: “We can make something out of our tragedies if we make our tragedies count. Put differently, it is our collective duty to channel our anger and rage each time something goes wrong into actions that will not only save our lives when the time comes but that will be a monument to the lives lost. With every tragedy comes the opportunity to build a monument – a monument of good governance, inspired citizenry and bold actions. Tragedy is an opportunity to do better, to create better systems and conditions that ensure that such tragedy does not happen again. To do this we must find out what happened, punish those who let it happen and reform the system in question in order to prevent another breakdown.”
I believe that if the relevant agencies of the aviation sector had learnt the painful but significant lessons accruing from the Dana tragedy, they would not have allowed another air crash to happen. This recent tragedy is another opportunity to do things rightly. If our leaders truly desire to restore sanity to the aviation industry, they must sincerely move beyond the sanctimonious pronouncements and the usual pledge that “every possible effort will be made to boost the nation’s aviation safety” which seem to be the official mantra whenever air tragedies happen will never help us.
Government must be seen to do something to stop the frequency at which precious human lives are being decimated on our nation’s airspace. We need a good government that can build a policy marked by an extraordinary combination of sober realism and visionary idealism with respect to the need to protect and safeguard human life. This is something more than just a theory; it has to be a doctrine that can be translated into practical politics. I believe that if we do this, we might be able to make the Associated Airlines tragedy a positive dawn for the emergence of a new Nigeria.
– This Best Outside Opinion was written by Emmanuel Ojeifo, a Catholic priest in Abuja