Miscellaneous
Social Immune Systems The Hidden Psychology of High-Stakes Organizational Decisions The hidden psychology of high stakes organizational decisions Some of the very best critical thinking research in the world has been done with flight crews and medical teams. There is an almost endless number of fascinating cases to explore. There's one, though, that I've become more obsessed with than others. It happened on Thursday, January 25th, 1990. At 9:34 pm, after a long flight and multiple holding patterns, Avianca flight 52 was given clearance to land on runway 22L at JFK. Wind shear was terrible that night and visibility was limited. The crew found themselves descending quickly and only 200 feet off the ground more than a mile from the airport. If you listen to the cockpit voice recorder, you hear the captain abruptly ask the first officer where the runway is, and the first officer answers “I don’t see it." The ground proximity warning system gave them voice alerts to pull up, and they executed a missed approach. Their go-around ended in disaster when they crashed 20 miles northeast of the airport in Cove Neck, killing 73 of the 158 people on board. The crumpled fuselage looked a lot like a crushed soda can and came to rest only 20 feet from the back of John and Katy McEnroe's house, the parents of tennis legend John McEnroe. What's so frustrating about the Avianca accident is it seems that the warning signs should have shone like neon beacons. The fact is though, they didn't, they only became visible in hindsight. I recognize these symptoms better now and after you hear the rest of the story, I bet you will too. I speak for expert audiences that make high-stakes decisions as a routine part of their jobs. One day I showed an audience crash scene photos from three different perspectives of flight 52’s crash site and asked them to tell me what clues they saw as to the cause of the accident. The air in the room thickened. There was a fear to share ideas that might be less than perfect. But, after a little nudging, some thoughts started to leak out. The first person to speak pointed out that the weather had been bad. Someone else said the plane was close to a house, while another observed that the cockpit wasn't even visible in the pictures. If you take a second to think about these statements, you realize they are safe and superficial. People are only acknowledging what everyone else can plainly see. The hesitancy to share their personal thoughts created a veil over evidence hidden in plain sight. I worked a little more to try to remove the threat, and finally, someone sees it and says, “Why isn't there a fire?” This response is so different because it's not just an observation of what's obvious, it's also a personal insight. This doesn’t come out until someone feels safe enough to risk being curious, instead of wanting to avoid criticism. The audience on this day was full of forensic experts, but not in aviation; they were financial auditors. People ask why I would have auditors or analysts examine things outside of their specialty. First of all; I've found the benefits of cross-disciplinary training to be remarkable. The reason someone in aviation may say “get your head out of the cockpit,” is why all specialists should step outside the rigid structures of their industry. It helps them see counterintuitive patterns and discover new problem-solving strategies. When I speak for aviation experts, I start with anything except aviation before we look at how the concepts apply to their specialty. The second reason is that understanding why flight 52 ended in a disaster has very little to do with the technical aspects of aviation. The problem with silence The case of Avianca flight 52 deserves a more detailed review. It started out in Bogotá, Columbia and was headed up the east coast of the United States when air traffic control directed them to take a holding pat...