Part I: “The Human Factor” – Air France Flight 447
Over the past few weeks, I’ve been discussing the following article with Dr. Adam M. Grant, my professor for MGMT238: Organizational Behavior (OB). It’s an analysis of the 2009 crash of Air France Flight 447, and is truly a captivating piece of journalism. By reconstructing the plane’s last few hours (based on cockpit voice recorder data), the article discusses the failings of an organizational behavior system in helping to prevent this disaster.
The topic of OB as it pertains to aviation/aerospace is beyond fascinating to me – and it’s something we touched on briefly in class a few weeks ago when discussing the 1986 Challenger space shuttle disaster. Here are my preliminary thoughts on the topic.
The concept of Crew Resource Management (CRM) became widespread across airlines in the 1990s. The idea was to encourage junior pilots to speak up when they felt that their senior captain was making a wrong decision. At the same time, massive technological advances meant that these junior pilots were not receiving the same quantity or quality of flight experience as their seniors (many of whom had flown for their countries’ air forces or had otherwise received intensive “fly-by-stick” experience when this was the norm). This automation in modern aircraft was designed with two fundamental expectations: a) that CRM is practiced by all pilots present in the cockpit, and b) that in the event of a technical failure, “pilot knows best.” As a result, you have planes that require pilots to communicate very effectively and fly the plane completely manually in an emergency. In the case of Air France 447, neither of the junior pilots were truly comfortable with the aircraft – indeed, the article notes that each pilot only had 4 hours per year of actual hands-on-stick flying time – but they assumed that the built-in autonomy would take care of them. This was combined with an unusual deference of the junior pilots to the senior captain, and a complete breakdown of effective communication. The CRM model failed, and the results were catastrophic.
I notice an interesting pattern between the events described in this article and a more recent crash: Asiana Airlines Flight 214 in 2013. The planes involved in flights 447 and 214 – an Airbus A330 and a Boeing 777 respectively – were both introduced in the early 1990s. Both aircraft were products of the same technological expectations described above, and both crashes involved some failure of the pilots to communicate effectively and respond adequately to the plane’s autopilot. Furthermore, the article mentions how the breakdown in CRM may be caused by cultural norms, and for this reason I wonder if the deference to one’s elders rooted in Asian culture may have in some way played a role in the Asiana tragedy.
This is Part I in a series of blog posts on “The Failure of Crew Resource Management.” Click here to read Part II.