Archive for January 16th, 2009

Survivors Of Gas Station Explosion Mourn Tragic Loss Of Gasoline

Much more funny at $4 a gallon, but still…

Transport for London has already riffed on “inattentional blindness,” without giving props to Daniel Simon — but hey, it’s for the public good, right? But I hadn’t yet seen this take on “change blindness.”

I won’t give it away but I did very poorly.

Photo by MS SDB/Flickr

The night before the “CFIT” descent into the Hudson River, I was, coincidentally, reading William Langewiesche’s collection on aviation, Inside the Sky. Reading the essay “On a Bombay Night,” about the Air India Flight 855 crash, this excerpt reminded me of just how staggeringly proficient and, yes, heroic, the flight crew’s response yesterday was, to something that had only been practiced on computer screens:

“The pilots knew something, but not what, and they were fully occupied with their confusion. Only the flight engineer clearly saw the errors being made. It was not a nightmare, though that possibility must have crossed his mind. After so many years during which these things had happened only to others, he was now the one actually going down, out of control, crashing. There was no reason for this, and it didn’t feel wild, but the instruments told an undeniable story. And yet he could do nothing but point.

Kukar [the captain] did not even answer him. It is impossible to know what denials he was engaged in. Pilots train in simulators to handle all sorts of failures, sometimes heaped on top of the other. But even the best of the simulators require a suspension of belief that never quite overcomes the understanding that they are pretend airplanes built for the purpose of experiencing failures and that no matter how poorly the pilots perform they will walk away unscathed. That, of course, is not true of failures inside the sky, where the first challenge is to suspend disbelief and where the urgency is real.”

The author goes on to conclude that the “underlying cause seems oddly enough to have been the very extent of Kukar’s flying experience… there comes a point in a pilot’s life when the sky feels like home.”

And yet for all the talk of miracles yesterday — for what great water landing success stories are there? — there was also something less sensational at work: Safety culture. Pilots are relentlessly trained in these contingencies, flight attendants are there not merely to be the object of contempt from ill-bred passengers (why can’t I go the bathroom as we’re landing?), the routine announcements may be done out of rote and may indeed seem superfluous, and it’s annoying when the plane is delayed three hours so an indicator light-bulb can be changed, but yesterday’s events showed the real and cumulative value all these things have.

“Safety culture” is the topic of the latest report from UC-Berkeley’s Traffic Safety Center; the newsletter itself is drawn from a longer report prepared by AAA’s Traffic Safety Foundation. As defined by one paper, safety culture, which emerged as a concept in the wake of the Chernobyl incident, “is the enduring value and priority placed on worker and public safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety, act to preserve, enhance and communicate safety concerns, strive to actively learn, adapt and modify (both individual and organizational) behavior based on lessons learned from mistakes, and be rewarded in a manner consistent with these values.”

The report goes on to call for a “traffic safety culture,” something which has yet to come to full fruition, particularly in the U.S. As Dinesh Mohan states, “‘Road traffic injuries are the only public health problem for which society and decision-makers still accept death and disability among young people on a large scale. This human sacrifice is seen as a justifiable externality of doing business: the only discussion revolves around the number of deaths and injuries that are acceptable.”

We tend to emphasize the random, “accidental” nature of car crashes, something that would be unacceptable in the commercial aviation industry (which hasn’t had a fatality in the last two years). Protocols are set, rules are followed, training is essential, and pilots are encouraged to avoid overconfidence and respond to input from other staff. In his forthcoming book Why We Make Mistakes, Joseph T. Hallinan quotes a study showing when pilots and doctors were asked the question, “even when fatigued, I perform effectively during critical times,” 70% of doctors said yes, compared to only 26% of pilots (I’d like to see this question asked to drivers). Hallinan notes the human body is more complicated than aviation; but still, culture matters.

Driver overconfidence is, I think, a key factor, in the ongoing safety problem: I can drive tired or impaired; I can drive faster than everyone else; the crash is not me but every other driver. Drivers (like many doctors, according to Hallinan’s book) tend to get annoyed when they get “feedback” or input on their performance from their passengers. Unfortunately, drivers aren’t given the kind of training pilots are; but then again, it’s not performance as much as attitude that counts on the road (which is, as much as anything, a place of social interaction).

There are, of course, a number of ways safety culture has penetrated into driving. As James Hedlund writes, “Infant and toddler safety seat use is now an integral part of the whole country’s safety culture. Hospital policies require newborns to ride home in a child safety seat. NHTSA’s 2006 survey reported that 98% of infants under the age of one and 89% of toddlers age one to three were riding in child safety seats. There’s no indifference here: parents understand that they must properly secure their infants and toddlers in a scientifically-designed seat on each trip.”

But in so many other ways — speed, alcohol, mobile phones, etc. etc. — we toss safety culture out the window (even while the infant is strapped in). Just imagine the outcome yesterday if the pilot was fatigued, impaired, talking on the phone to his buddy in Reno, or just simply felt some rule or performance protocol didn’t apply to him. Yesterday may have been a miracle, but the outcome also represented the perfect alignment of a safety culture firing on all cylinders.

Photo by Alf Gillman/Flickr

That’s apparently a road warning sign in Lagos, Nigeria, from an interesting post on traffic, and other things.

We were a slave to our first real traffic jam today. It wasn’t so much that it took us three hours to get somewhere. It was more that there was a T intersection in a major road that was packed with cars, and our taxi driver was trying to make a left, across traffic, while everyone else seemed to be attempting a left in all 360 degrees. There was a small divider that was meant to guide people coming and going along where the base of the T met the top, one side to keep people coming, one side for those going. That’s what became the circle of traffic snarl. And there we sat for probably a half hour, millimetering our way into the smallest crevices between cars, as motorcycles squeezed through in all directions, street hawkers offered prepaid cellphone cards, candies, wallets, DVDs, whatever as they weaved their way between every car. Drivers began yelling at other drivers. Everyone looked kind of mad about the whole thing. As our car finally pointed in the direction of the turn, that was when I noticed that someone in an SUV had decided to drive against traffic along the wrong side of the base of T, which made it almost impossible, somehow, for anyone to pass a car in any direction. The pieces had all fit perfectly together, and no one could move. Had I not been paying attention in the moments up to this, and just had this single moment to draw information from, it would have been impossible for me to actually gauge which direction any car should have been going, based on a traffic pattern. This was what total chaos actually looks like. And just when it couldn’t get any more intense, police officers appeared from the other side of cars in front of us, yelling, waving big machine guns in the air, angry at the snarled traffic. One in particular was shouting “these drivers, look how they drive!” There was a moment when I had to remind myself that a lot of yelling goes on in places like Nigeria that doesn’t necessarily mean anything worse is around the corner. Like the two men yelling viciously at each other next to the car earlier that day, as we waited our way through another jam on the highway—you could just tell that, no matter how much they yelled, there weren’t going to be punches. In America, this would have looked like punches were coming. So, as the police were yelling and waving their guns, I had to take a deep breath and convince myself this was just like that earlier shouting match. No worries, right? Right?