Sullenberger on the Fallacy of Pilot Error

I'm starting a crusade for a more judicious use of the term "pilot error" and I nominate as my campaign poster boy…Tada! -- Capt. Chesley Sullenberger.

The newest member of the formerly obscure community of aviation safety commentators has a new gig on CBS News.

From that platform he can say what many others who don’t have his good looks or American hero status have been saying, and he can make these points to the very people who have recently been given a somewhat mangled version of what happened on Air France Flight 447.

By that I mean that when Capt. Understatement said on television that the pilots of the Airbus 330 found themselves without essential flight information, in the dead of night out over the Atlantic en route from Rio de Janiero to Paris, they were “in a very difficult situation.” They could not work out the problem in the time they had, he said, which was more or less, three minutes.

This exceedingly moderate but important context put forward by the Airbus captain who handled the Hudson River landing of USAirways Flight 1549 in January 2009, is part of Sullenberger’s schtick and I’m delighted. He’s retired from USAirways, (and I hope, still enjoying "rock star sex") but he hasn’t lost his seven-mile high perspective.

As he wrote in his book, Highest Duty, fly-by-wire airplanes can be enormously helpful to the pilot, but contrary to the position taken by Airbus in William Langewiesche’s book, Fly by Wire, these airplanes cannot – correction – should not be “pilot proof”.

Sullenberger has been making this argument since Langewiesche's book, Fly by Wire came out last year. The book attributes much of the credit for the successful outcome of Flight 1549 to the technology behind the Airbus airplane. Langewiesche’s position launched these two knowledgeable and literate pilots into a public debate (channeled through me) in The New York Times.

On his CBS News appearance, Sullenberger told news anchor Harry Smith that the Air France disaster was a seminal event precisely because it raises anew the question of how man and machine work together in highly automated airplanes. “We have to wonder whether making airplanes more technologically advanced makes it more difficult for pilots to recover when things go awry," he said.

Harry was listening and so I hope, was his audience, the very same folks who have been exposed to the irresponsible headlines proclaiming Black Boxes Point to Pilot Error or the even more incredibly inaccurate AOL Travel story that said; "the black box from Air France Flight 447 showed that pilot error was to blame.
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What Sullenberger brings to the discourse is the plea to hold-your-horses, because what-the-hell-does-pilot error mean in a situation like this? The pilot isn’t alone in the conduct of a flight. The pilot is part of a system.

By saying this publicly, Sullenberger says what Key Dismukes, pilot, scientist, biophysicist, author and overall big thinker on the subject of human factors has been saying for years.

So I called Key the other night to get his take on all this “pilot error” news babble. (And also because I need little excuse to listen to Key talk about human performance. His performance is always brilliant.)

“The airplane, the designer, and the pilot are part of a complex system,” Key said. “Under certain circumstances things happen that leave the crew trying to figure out what’s going on.”

In the case of Air France 447, “all of a sudden everything starts going wrong; The surprise, its discombobulating. They can’t process it, it doesn’t map against what was happening four seconds ago.”

So in the quiet room in Paris where the parties investigating the crash listen to the cockpit voice recorder and compare what the pilots did with what was actually happening, the question is “Why did the pilot pull nose up when he should have done the reverse?” And if the investigators are conscientious - I’ve met a few of them and they seem to be -  they will not simply conclude there was something wrong with the decision-making abilities of these particular pilots - end-of-story. Or even that their training was deficient. They will look at the entire system of which these particular pilots were a part. Because pilot error isn’t a cause, it’s a clue. It suggests something is wrong with the larger picture.

Airplanes evolve. Over the past century of flight they have become more fuel efficient, more capacious, more robust and more complex, while the human remains essentially the same; fallible, prone to complacency on the negative side, flexible and able to improvise on the positive.

“Every day, somewhere in the air a cockpit crew averts disaster by routinely dealing with equipment malfunctions, weather uncertainties, or unscripted situations,” Key says, reminding me these are the not-to-be-ignored strengths of the human over the machine.

So that if an airplane evolves to a point that it relies on the plusses of the human and fails to take into account the minuses it is the system that has erred, not the pilot.

Don't believe it? Just ask Sully.