What are Human Factors?
You have probably heard of human factors including hypoxia, ozone sickness, carbon monoxide, smoking, hyperventilation, decompression sickness, vision (depth perception, night vision, DERP) hypothermia, sensory illusions, spacial disorientation, physical fitness, stress, attitude etc.
All of the above have a great impact on how the pilot will perform, react, communicate, feel...
By complete fluke, I have recently stumbled upon a 'factor' I didn't expect to make the list.
I'm currently reading a book entitled Outliers: The Story of Success (If you have heard of The Tipping Point or Blink, this book is by the same author) . One of the chapters is entitled: "The Ethnic Theory of Plane Crashes". I know it sound a little dramatic, but Malcolm, the author, embarks on a second-by-second reenactment of one of the most horrific plane crashes in recent history.
The reader is introduced to a word-for-word transcript from the black box of communications between the pilot, first officer, flight engineer and ATC. When you first read how the action unfolds, you can't necessarily pinpoint anything that is wrong with the decisions of the pilots or ATC (or at least I couldn't).
Mind you the weather was not cooperating, the pilot was tired but this is not unusual after a 12+ hr flight.
Some facts about the pilot and the flight:
- Captain of the plane was 42 years of age, fit, healthy, prepared for the trip
- 8900 hours of flight time (3200 in jumbo jets)
- Plane: Korean Air Boeing 747 (KAL 801)
- Flight to Guam from Kimpo (over 7000km trip)
- VOR/DME approach (glide slope equipment was out of service that night)
- Pilot flew there 8 times that route in the past
- Haven't slept for over 12 hrs
Last few minutes of the flight:
1:20:01Captain: ...with 8 hrs we get nothing...they make us work to max...
1:21:13 Captain: Eh, I'm really sleepy
1:21:13 First Officer: Of course
1:29:xx Flight engineer: Is it Guam?
1:29:xx Flight engineer: It's Guam!
1:29:xx Captain: Good!
1:29:xx Flight engineer: Captain, the weather radar has helped us a lot.
1:29:xx First Officer to ATC: Clear of Charlie Bravo (cumulonimbus clouds), request vectors for runway six left
1:30:xx ATC: Korean 801, Roger...cleared ILS runway six left approach, light slope unusable
1:30:xx Captain: Let's make a visual approach
1:41:48 Captain: Wiper on
1:41:59 First Office asks : Not in sight?
1:42:00 GPWS: Five hundred feet
1:42:02 Flight engineer: Eh?
1:42:19 First officer: Let's make a missed approach
1:42:20 Flight Engineer: Not in sight?
1:42:22 First Officer: Not in sight
1:42:23 Flight Engineer: Go around
1:42:24 Captain: Go around
1:42:24 Ground Proximity Warning System (GPWS): One hundred
1:42:24 GPWS: Fifty
1:42:25 GPWS: Fourty
1:42:25 GPWS: Thirty
1:42:25 GPWS: Twenty
1:42:26 Sound of initial impact
1:42:28 Sound of tone
1:42:30 Sound of tone
End of Recording
Did you pick up anything strange, peculiar? Can you spot the issue?
Here are some stats from late 90s...when this accident occurred:
Loss rate in US - 0.27 per million departures (meaning one lost plane in 4 million flights)
Loss Rate in Korea - 4.79 per million departures - 17 times higher (at one point this stat was so bad that Canadian officials considered revoking overflight and landing privileges in Canadian airspace)
Why was the loss rate 17 times higher in Korea?
You may argue that US pilots are better qualified and trained than Korean pilots, that may be true but is that the main reason?...Upon a closer look, they did spot some interesting trends...not just with Korean Air accidents...
- They found that in 52% of 'losses' the pilot has been awake for more than 12 hrs
- 44% of the time, the two pilots (captain-first officer) have never flown together
- Crashes are more likely to occur when the Captain is the PIC (pilot in command)
Can you believe the last point? Seems contrary to popular belief.
Why would the last point be true? Does it have to do with the fact that older pilots are worse than their younger stallion counterparts?
Far from it.
One of the issues has to do with something the author labels as Mitigated Speech, or the tendency of the speaker to downplay the meaning of what is being said, including when we are polite, ashamed, embarrassed, intimidated by authority etc.
The truth is the first officer is less likely to 'speak up' when an issue arises to the Captain due to this phenomenon. You don't want to tell your boss he/she is doing something wrong...hence undermining their authority.
Planes are generally safer when the less experienced pilot (first officer) is flying because the captain is perfectly content to tell the first officer they are doing something wrong!
Crazy but true. So, let's go back to the situation described above? Why did the Korean airline suffer many more losses? Can you spot the issue in the transcript?
When you look closely, you will find the tone and approach of the first officer and the flight engineer is very passive and in some cases they fail to speak up at all. They basically let the captain make the mistakes...They are just not assertive enough when the time requires them to be. By the way, the investigation ruled that the Pilot made some critical procedural errors including not following standard non precision VOR/DME approach. Here is the official accident report. The crew failed to point out the issues when they had the chance to the Captain.
Malcolm goes further to explain this issue by introducing, Geert Hofstede and Hofstede's Dimensions (Power Distance Index (PDI), Individualism, Uncertainty Avoidance, Masculinity) that help us understand cultural differences and their tendencies.
Check out this site for a global map of scores such as world map of power distance scores.
According to the book, Korea like many Asian countries has a very high PDI, meaning there is an overwhelming tendency for subordinates (flight officer and engineer) to acknowledge the power of others simply based on where they are situated in a formal, hierarchical position. In this culture it is expected to speak only when spoken to, follow orders rather than offer suggestions, don't speak up when speaking with people of higher standing than your own etc.
This provides us with a hint to why Korean first officer and the engineer didn't speak up...they probably felt it was not their place to do so!
How would most Canadian pilots react? Let's assume the answer lies with Canada's PDI score:
Power Distance (lower score means we have much less issue with authority, we consider each other equals)
UK - 35
Canada - 39 (we are generally not afraid to speak up even with our superiours! and hence we would be more likely to say something when in dire straits)
US - 40
India - 77
Venezuela - 81
Check out Individualism (high in Canada), Uncertainty Avoidance (low in Canada), Masculinity (balanced in Canada).
Next time you fly with someone, remember; count mainly on yourself, not your co-pilot, ATC. Always retain the responsibility but most importantly work as a team! If you are wondering...Korean Air has discovered the root of the issue and now is one of the safest airlines in the world! One solution was to enforce English in their crew communications that alleviated some of the formality of the Korean language hence reducing the issue of Mitigated Speech. Many other airlines have also invested in training their first officers and other crew to reinforce the importance of communicating with the Captain especially in times of luring danger.
Make sure to take the above into consideration when flying. Remember, safety first!
P.S. Outliers: The Story of Success is not an aviation book. It really is a deconstruction of the notion of 'success'. Certainly intriguing, and I would recommend to those with an inquiring mind.
Here is a link to the author's quick intro: http://www.amazon.ca/gp/mpd/permalink/m3K73VOL0U85ZQ
On a brighter note. Have a look at Seinfeld's take on some of the issues surrounding cultural dimensions including personal space....http://www.youtube.com/watch?v=j41tJdqZX7E