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Like everyone else, I wish that the suicidal Germanwings pilot had been stopped from boarding the plane. I even think it makes sense for Europe to copy our “two people in the cockpit at all times” rule. Nonetheless, I love this essay by Stacey Gordon on her blog Xray nrazbykdyf
Vision about the impossibility of predicting and preventing every tragedy.
SHOULDACOULDAWOULDA, by Stacey Gordon
After every tragedy that involves numerous casualties has been analyzed from every conceivable angle; after it has been Monday morning quarterbacked to death by the 24 hours news cycle, a mantra is born. It is always the same question, over and over again. Whether it’s a school shooting or the crash of an airliner, the chant has become: How can we keep this exact circumstance from happening again?
The truth is; it is only possible in retrospect….
The litigious society we live in now sees negligence at every turn, demanding that somehow, someone should have seen it coming. Every tragedy is boiled down to a mere lack of vigilance, the implication being, if somehow we could “increase” our vigilance enough, fate would be assuaged and safety assured.
Risk management is an oxymoron.
This is dangerous and superstitious thinking. The scary truth is, we can’t foresee or prevent every calamity, no matter how cautious, no matter how many rules, regulations and government security organizations we create. Our anger and our pain drive us to demand that some “one” or some “thing” be held accountable. We demand action for the future, because in our arrogance we presume that it will tip the scales in our favor.
In the end, no amount of dancing for lawyers will prevent heartbreak and catastrophe.
We could never fully account for the unintended consequences of every precaution we implement….
Terrorists busting down your cockpit doors?
Make the doors stronger, unbreakable from the outside.
So unbreakable, that a suicidal co-pilot may now effectively lock a pilot out of the cockpit.
Read the rest here. Stacey is not advocating complacency when it comes to safety. In fact, she sent me a little follow-up to her post that is so great, I have to reprint it, too:
There are certain dangers or threats that we should mitigate because 1) They happen with a certain frequency and 2) The mitigation does not appreciably diminish our quality of life. (seatbelts, helmets etc…)Sadly, many are ignoring these qualifications and are demanding that every awful event result in some law, plan, or procedure that will protect us from “the next time.” We cannot live this way and truly be a free people. We are vulnerable… Let’s just accept that vulnerability and live free. I do not have children but I am a fan of Free Range Kids because I‘m a big believer in freedom and personal choice. Whether or not Lenore intended to become a political activist, I see her on the cutting edge of the battle between freedom on the one hand the loss of our rights in the name of unattainable, perfect security.
Political activist or not, I agree: The demand for perfect safety steamrolls over everything else in life. Watch out when folks play the “safety card.” Consider what we might lose in its pursuit. – L
22 Comments
To quote a character from one of my favorite sci-fi t.v. shows:
Life is chaos. Chaos is life. Control is an illusion.
· Trance Gemini, “Andromeda”
This is so true. It’s been driving me crazy that the news heads are all trying to come up with a specific remedy to prevent this from happening again; considering that there have been millions of airplane trips and it’s only happened once, it really isn’t a good use of anybody’s resources to try to prevent it. The two-people rule is probably prudent, but it still seems that the homicidal/suicidal pilot could have overpowered someone if he’d wanted to, especially with the element of surprise in his favor.
This reminds me of a local pilot who was arrested shortly after 9/11. They were hassling him at security over some tweezers or scissors or something in his carryon that could be used as a “weapon.” They were making him late for the flight and in frustration, he pointed out that he was the pilot. If he wanted to crash the plane, he didn’t need to smuggle tweezers onboard, he could just crash the plane. They considered that a “threat” and arrested him.
The two person rule is a simple and sensible precaution, but not foolproof, and this is not the first time that a pilot has (or has been suspected of) crashing a plane deliberately.
For example:
* http://en.wikipedia.org/wiki/LAM_Mozambique_Airlines_Flight_470
* http://en.wikipedia.org/wiki/Royal_Air_Maroc_Flight_630
* http://en.wikipedia.org/wiki/Japan_Airlines_Flight_350
In the Japan Airlines incident, there were two other people in the cockpit, but they could not stop the pilot crashing the plane.
More seriously, I suspect we might seen a backlash against people with depression “just in case”. Most people with clinical depression are not suicidal, and almost none are mass murderers.
Ms. Gordon’s SHOULDACOULDAWOULDA essay reminds adults of two human behaviors that children have recognized for a long time. They are well known in children’s rhymes.
The reasoning behind demands to anticipate catastrophic risks from causes that usually have negligible consequences, such as licensing a pilot who once sought psychiatric counseling:
For want of a nail, the shoe was lost,
For want of a shoe, the horse was lost,
For want of a horse, the rider was lost,
For want of a rider, the message was lost,
For want of a message, the battle was lost,
For want of a battle, the war was lost,
For want of a war, the kingdom was lost,
The reasoning behind “remedies” designed to protect pilots from intrusions into the cockpit, which require a chain of further remedies to allow a pilot to enter the cockpit taken over by a dangerous person:
There was an old woman who swallowed a fly,
I don’t know why she swallowed a fly,
Perhaps she’ll die.
…
There was an old woman who swallowed a cow,
I don’t know how she swallowed a cow!
She swallowed the cow to catch the goat,
She swallowed the goat to catch the dog,
She swallowed the dog to catch the cat,
She swallowed the cat to catch the bird,
She swallowed the bird to catch the spider,
That wriggled and jiggled and tickled inside her,
She swallowed the spider to catch the fly,
I don’t know why she swallowed the fly,
Perhaps she’ll die.
There was an old woman who swallowed a horse,
She’s dead—of course!
When mired in the morass of endless demands to anticipate disaster from every insignificant possible cause, and the imposition of remedies to prevent every possible disaster, adults would be wise to include in their “reasoning” that the primary initial goal was to drain the swamp.
I use this argument towards my mother (who was a very free range parent to me but acts nuts about my kids) a lot whenever she gets nuts and over paranoid. That I could drop dead of a brain aneurysm right now and nothing anyone could do about it. A drunk driver could run head on into my car anytime we leave the house and nothing I can do about it. A tree could fall on the kids and crush them anytime they go play outside and nothing we can do about it. Sometime, you have to accept it is in God’s hands and when its your time, its your time. Does not mean not to be reasonably careful or cautious or smart. But it also means use common sense about it because at the end of the day if God or the universe wants you gone, you are gone one way or another.
Personally I think far too large a part of the population think that being born gives them the right to never die. They cannot accept that no matter what you are doing it is roll of the dice.
Control is an illusion. Have always seen life like an old time butcher shop. When you are born you take a number, and when that number is called, it is over. Doesn’t matter what you are doing, sleeping, skydiving, commercial flight or eating a snack. Your number is called, it is called.
James Fallows at the Atlantic has been very good on this topic. Specifically in this post: http://www.theatlantic.com/international/archive/2015/03/germanwings-crash-murder-suicide-pilot/388778/
“Precisely because you have to allow override measures in case of emergency, you necessarily will leave a system vulnerable to abuse by someone in a position of trust. Something similar is true of the use of autopilots and automated flight-management systems. Because you have to give pilots the ability to override automated controls that go wrong, you necessarily leave the system vulnerable to someone intent on harm. This is an insoluble dilemma.”
Those who are interested in this topic will want to read all he’s written on it. http://www.theatlantic.com/james-fallows/
Hmmm …
*) Mozambique Airlines Flight 470
*) Royal Air Maroc Flight 630
*) Japan Airlines Flight 350
*) Germanwings Flight 9525
It is pretty clear to me that we need to stop number flights
such that they are multiple of 5 if we want to stop suicidal
pilots.
We must do something. Renumbering flights is something. Therefore we must renumber the flights …
“I even think it makes sense for Europe to copy our “two people in the cockpit at all times” rule.”
After copying your “unbreakable door to cockpit must always be locked” policy?
Sorry. Sigh.
To me it shows that every safety measure has side effects, too.
“1) They happen with a certain frequency and 2) The mitigation does not appreciably diminish our quality of life. (seatbelts, helmets etc…)”
And 3: that this ‘mitigation’ has actually been proven to be effective and does more good than harm. (There’s the infamous example of Australia’s mandatory bike helmet law, which dimished cycling altogether.)
@Mark Roulo: LOL 🙂
Okay let me get this straight, two people in the cockpit at all times, to prevent such intentional crashes.
So this means that a pilot or whoever, that has already commited to killing everyone on board, is going to not kill the second person in the cockpit? Makes sense to me. Wow I feel so much better.
30,000+ people killed by cars every year.
And we will spend millions of dollars and thousands of hours of time trying to prevent this one particular accident from happening again.
It’s not logical.
Like an OCD sufferer that can’t stop seeing germs, our society has evolved (dissolved?) into one that is trying to take precautions against every possible thing that can go wrong. However this leads to blindness.
The invisible Gorilla is a perfect example of this. There was a case study were people were given a difficult task. (like trying to anticipate every possible outcome) However they were so absorbed in it that 50% of the people tested failed to see it when a person in gorilla suit walk through the activity!
The more we overload our brain, the less we can see.
http://www.theinvisiblegorilla.com/videos.html
A few weeks ago, my mother had a stroke while visiting another state. On her return home a couple days later, I got permission to go through security to meet her at the plane because she was afraid to navigate the mess that is Atlanta airport on her own. So with our little special pass (remarkably easy to get, by the way), we get to security and I am randomly stopped for a special, upgraded security check. I had to go through the special x-ray machine, get felt up by the TSA agent, get my purse hand searched, get my hands tested for explosives, etc. At some point, I looked at the TSA people and said “wouldn’t it be a better use of your time to search people who are … oh I don’t know … actually getting on a plane!!
It is all security theater because the truth is we know that we can’t stop random acts of craziness, but we want to believe that we can if we just put enough security measures in place.
This is not the first time that I have heard risk management getting blamed. I’ve had to work with risk management protocols and I have to say that the general public doesn’t understand risk management at all.
Before 9/11 I could chain events from one tiny thing to a catastrophic outcome with the most paranoid among us. And back then people called me paranoid for it. Now people respond to that stuff with “better safe than sorry.” But that is when it got through to me that you could do everything “right” and still die. Getting to work on time is ‘right’ being late that day saved lives. At the time we thought it was ‘right’ to just hand the plane over to hijackers. That day it killed. I concluded to enjoy life even if what sounded enjoyable was something I knew to have some dangers. I went skiing and didn’t crash into a tree. I went white water rafting, and even though I got caught in a current I couldn’t fight, someone helped me and I didn’t drown.
Then I learned about risk management. One of the fundamentals is that your mission and context are important. That there is such a thing as an acceptable level of risk. If you can break the chain of ‘and then’ before reaching catastrophe your risk is under control. If the risk is catastrophic but really rare, the risk can be assumed… that means you say “yes there is a risk, but the steps to mitigate that risk are not reasonable, so it is just going to be out there this is why we have life/property/etc insurance.” Most memorable of all the risks, the ones you pray never come up, are the ones where no matter what you do chances are someone will die. And you accept those risks anyhow because you honestly believe that this world would be worse off if everyone facing these risks packed up and went home.
The other thing people fail to understand is that risk management works best for machines. Machines behave predictably, humans do not. You can only do so much with Human Systems Integration to minimize the risk, but you can’t never fully eliminate the risk of humans overriding a system. Nor can you eliminate the risk of an evil person (especially in a position of trust) bent on harm. Both types have come up in my life to terrible effect. I suppose I could try curling up and hiding from the world. But that wouldn’t be living, what is more it would make the world a more brutal place to live. Twice when I was in need of help I encountered people hiding from the world. I’d rather take on the risk and complete the mission to live a life worth living.
“Random acts of craziness” is why I just shook my head when some clamoured for armed teachers and security people at schools after the Sandy Hook tragedy.
Really? MORE guns in a school? Who knows if Terry the security guard will go off the deep end one day because he found his wife in bed with his best friend? Who knows if Patty the 2nd grade teacher is going to accidentally leave her loaded weapon in a place where the kids can find it and one of them shoots their classmate?
The idea of arming laypeople, or even professionals, in a school, in order to prevent harm being done with firearms in a school seems beyond illogical to me.
But this is the kind of thinking that leads us to disaster. Start with values, and examine the strategies carefully to see if they actually support those values. The value is safety? Well, maybe less guns then, not more. The value is safety? Well, random acts are just that: random, so let us all get on the airplane the normal way like we used to, and meet our loved ones at the gate.
Before reinforced cockpit doors and x-ray screening were introduced, plane hijacks by passengers were a recurrent fact. The 1970s and 1980s had a list of such events, which at one point were happening as almost a monthly occurrence.
Since 9/11, hijack of civilian planes was virtually eliminated.
So I’d say isolating the cockpit with a reinforced door is a sane measure, even at the increased risk a pilot might lock him/herself alone on cockpit and down the plane.
I’m not sure when airports began x-ray screening but I can’t recall ever flying without going through security and I’ve been flying since the late 70s. In fact, every 9/11 hijacker went through x-ray screening. The weapons they chose were allowed on planes at the time.
Which just proves the point – you can’t stop crazy. Someone hellbent on destruction is going to find a way to commit that destruction. They will simply come up with a way you never thought of to get around whatever bells and whistles you install. Luckily extremely few are hellbent on destruction.
LMAO!
Had friends over last night for drinks. We are thinking of going to Belize, and were talking about it. My buddies wife asked us all worried, “Aren’t you afraid to fly after that suicidal pilot?”
I asked her, “Why would we be afraid, that pilot is already dead?”
I agree with a lot of whats here. There is simply no such thing as a risk free anything in life. Part of life and parenting is finding the balance between surrender (accepting what we can’t control) and placing appropriate boundries for our (and or children’s) physical and psychological safety. Thanks for sharing
We determine what’s an acceptable level of risk every time we drive on a two-lane road. Are you *sure* that oncoming driver isn’t about to go crazy and head-on you?? But in reality it doesn’t happen often enough to justify shutting down the roads, so the default is “trust the oncoming driver”. We make some high-traffic roads into divided highways to mitigate obvious risks like “tried to pass against traffic”, and we keep driving on the remaining roads without losing our minds to paranoia about those oncoming drivers … against whom the only sure defense is to stay home.
This should be an object lesson about far-rarer risks.
This is what Dick Cheney always preached. More and more money spent on an impossible idea – that you could seal every border – inspect every package and container, know every, well, everything really.
Anyone with any smarts at all can usually think of a gaping hole in most security. Why? Because you can’t use the past to predict the future 100%.
Shit happens.