Outliers, The Story of Success
CAVIEDES: What did he say
KLOTZ: The guy is angry.
Angry! Klotz's feelings are hurt! His plane is moments from disaster. But he cannot escape the dynamic dictated to him by his culture in which subordinates must respect the dictates of their superiors. In his mind, he has tried and failed to communicate his plight, and his only conclusion is that he must have somehow offended his superiors in the control tower.
In the aftermath of the Kennedy crash, the management of Avianca airlines held a postmortem. Avianca had just had four accidents in quick successionBarranquilla, Cucuta, Madrid, and New Yorkand all four cases, the airline concluded, “had to do with airplanes in perfect flight condition, aircrew without physical limitations and considered of average or above-average flight ability, and still the accidents happened.” (italics mine)
In the company's Madrid crash, the report went on, the copilot tried to warn the captain about how dangerous the situation was:
The copilot was right. But they died because... when the copilot asked questions, his implied suggestions were very weak. The captain's reply was to ignore him totally. Per haps the copilot did not want to appear rebellious, questioning the judgment of the captain, or he did not want to play the fool because he knew that the pilot had a great deal of experience flying in that area. The copilot should have advocated for his own opinions in a stronger way...
Our ability to succeed at what we do is powerfully bound up with where we re from, and being a good pilot and coming from a high-power distance culture is a difficult mix. Colombia by no means has the highest PDI, by the way. Helmreich and a colleague, Ashleigh Merritt, once measured the P D I of pilots from around the world. Number one was Brazil. Number two was South Korea.“”
The National Transportation Safety Board, the US agency responsible for investigating plane crashes, is headquartered in a squat, seventies-era office building on the banks * Here are the topfivepilot PDIs by country. If you compare this list to the ranking of plane crashes by country, they match up very closely.
1. Brazil 2. South Korea 3. Morocco 4.Mexico 5. Philippines Thefivelowest pilot PDIs by country are:
15. United States 16. Ireland 17. South Africa 18. Australia 19. New Zealand of the Potomac River in Washington, DC. Off the agency's long hallways are laboratories filled with airplane wreckage: a mangled piece of an engine turbine, a problematic piece of a helicopter rotor. On a shelf in one of the laboratories is the cockpit voice and data recorderthe so-called black boxfrom the devastating Valujet crash in Florida in 1996, in which n o people were killed. The recorder is encased in a shoe box-size housing made out of thick hardened steel, and on one end of the box is a jagged hole, as if someoneor, rather, somethinghad driven a stake into it with tremendous force. Some of the NTSB investigators are engineers, who reconstruct crashes from the material evidence. Others are pilots. A surprising number of them, however, are psychologists, whose job it is to listen to the cockpit recorder and reconstruct what was said and done by the flight crew in the final minutes before a crash. One of the NTSB's leading black-box specialists is a gangly fiftyish PhD psychologist named Malcolm Brenner, and Brenner was one of the investigators into the Korean Air crash in Guam.
“Normally that approach into Guam is not difficult,” Brenner began. Guam airport has what is called a glide scope, which is like a giant beam of light stretching up into the sky from the airport, and the pilot simply follows the beam all the way down to the runway. But on this particular night, the glide scope was down. “It was out of service,” Brenner said. “It had been sent to another island to be repaired. So there was a notice to airmen that the glide scope was not operating.”
In the grand scheme of things, this should not have been a big problem. In the month the glide scope had been under repair, there had been about fifteen hundred safe landings at Guam airport. It was just a small thingan inconvenience, reallythat made the task of landing a plane just a little bit more difficult.
“The second complication was the weather,” Brenner continued. “Normally in the South Pacific, you've got these brief weather situations. But they go by quickly. You don't have storms. It's a tropical paradise. But that night, there were some little cells, and it just happens that that evening, they were going to be flying into one of those little cells, a few miles from the airport. So the captain has to decide, W hat exactly is my procedure for landingWell, they were cleared for what's called a VOR/DME approach. It's complicated. It's a pain in the ass. It takes a lot of coordination to set it up. You have to come down in steps. But then, as it happens, from miles out, the captain seesthelightsofGuam.Soherelaxes.And hesays,'We're doing a visual approach.' ”
The VOR is a beacon that sends out a signal that allows pilots to calculate their altitude as they approach an airport. It's what pilots relied on before the invention of the glide scope. The captain's strategy was to use the V O R to get the plane close and then, once he could see the lights of the runway, to land the plane visually. It seemed to make sense. Pilots do visual landings all the time. But every time a pilot chooses a plan, he is supposed to prepare a backup in case things go awry. A nd this captain didn't.
“They should have been coordinating. He should have been briefing for the [DME]step-downs,” Brenner went on. “But he doesn't talk about that. The storm cells are all around them, and what the captain seems to be doing is assuming that at some point he's going to break out of the clouds and see the airport, and if he doesn't see it by five hundred sixty feet, he'll just go around. Now, that would work, except for one more thing. The V O R on which he's basing this strategy is not at the airport. It's two-point-five miles away on Nimitz Hill. There's a number of airports in the world where this is true. Sometimes you can follow the V O R down and it takes you straight to the airport. Here if you follow the V O R down, it takes you straight to Nimitz Hill.”
The pilot knew about the VOR. It was clearly stated in the airport's navigational charts. He'd flown into Guam eight times before, and in fact, he had specifically mentioned it in the briefing he gave before takeoff. But then again, it was one in the morning, and he'd been up since six a.m. the previous day.
“We believe that fatigue was involved,” Brenner went on. “It's a back-of-the-clock flight. You fly in and arrive at one in the morning, Korean time. Then you spend a few hours on the ground, and you fly back as the sun is coming up. The captain has flown it a month before. In that case, he slept on the first-class seat. Now he's flying in and says he's really tired.”
So there they are, three classic preconditions of a plane crash, the same three that set the stage for Avianca 052: a minor technical malfunction; bad weather; and a tired pilot. By itself, none of these would be sufficient for an accident. But all three in combination require the combined efforts of everyone in the cockpit. And that's where Korean Air 801 ran into trouble.
Here is the flight recorder transcript of the final thirty minutes of K A L flight 801: It begins with the captain complaining of exhaustion.
0120:01. CAPTAIN: If this round-trip is more than a nine-hour trip, we might get a little something. With eight hours, we get nothing. Eight hours do not help us at all.... They make us work to maximum, up to maximum. Probably this way... hotel expenses will be saved for cabin crews, and maximize the flight hours. Anyway, they make us... work to maximum.
There is the sound of a man shifting in his seat. A minute passes.
0121:13. CAPTAIN: Eh... really... sleepy, [unintelligible words]