CarolinaFireJournal - Robert Boyd

Train to failure to improve decision making

Robert Boyd
01/11/2011 -

On a clear, cold afternoon in January of 2009, U.S. Airways Flight 1549 was wheels up on its way to Charlotte from New York City with 155 souls onboard. Less than six minutes after clearing the LaGuardia runway, Flight 1549 is slowly sinking into the frigid waters of the Hudson River with all 155 persons onboard scrambling to evacuate the A320 aircraft. As The Economists Journal noted in its Sept. 9, 2006 edition, “...in the history of aviation the number of wide-bodied aircraft that have made successful landings on water is zero.”

As improbable as it is for all souls to survive an emergency landing on water, this event on January 15 was more severe because both of Flight 1549’s jet engines suffered complete power loss less than three minutes after take-off. The events that transpired in the fleeting seconds following the loss of engine power, as the plane plummeted back toward earth, were not only miraculous, but provide a myriad of lessons on the importance of building the intuitive mind to improve decision-making. When humans are thrust into chaotic circumstances where uncertainty reigns, it is the intuitive or unconscious mind that takes over decision-making processes. Whether one’s intuitive decisions prove to be good or bad depends on preparation and experiences over one’s life-time.

Just over two minutes into flight, at 15:27:36 that afternoon, and roughly 3,200 feet above the earth, Flight 1549 suffered a double bird strike. Geese were ingested into both engines, causing a complete loss of thrust. Immediately following the bird strike, Captain Chesley B. Sullenberger took control of the airplane from his co-pilot, Jeffrey Skiles, and notified the tower of the in-flight emergency. Meanwhile, Skiles grabbed the check list manual that pilots use to help guide them through a matrix of trouble shooting exercises to restart the engines and prevent an inevitable catastrophic crash. A minute after the bird strike, Sullenberger calmly radioed the control tower for a second time to notify them that Flight 1549 was likely going to end up in the Hudson. Roughly 45 seconds later, at 15:29:28, he confirmed that Flight 1549 could not make an airport and would be ditching into the Hudson River.

At the time of this incident, Captain Sullenberger had been flying airplanes for almost 40 years; however, the successful conclusion to this event is less about the number of years he had been flying and more about the exhaustive number of experiences he had accumulated and sought out during this period of time. After graduating from the Air Force Academy in 1973, Sullenberger joined the Air Force where he became a fighter pilot. This led to a long and distinguished career as a commercial airline pilot, where he made a myriad of academic and technical contributions to the industry that would ultimately culminate in the successful ditching of Flight 1549 into the Hudson River on that cold January afternoon. In particular, Sullenberger participated in numerous airline crash investigations during his career, studying their causes and seeking out solutions to prevent such events.

Sullenberger, inspired to some extent by these crash investigations, became involved in developing and then teaching other pilots Crew Resource Management (CRM) techniques, which likely has prevented many airliner crashes over the past two decades. CRM teaches flight crews to function as teams through open communication and trust, breaking the barriers of seniority and rank that often impede good decisions under conditions of uncertainty in the cockpit.

In addition to his many contributions to the industry, Sullenberger was also a glider pilot and possessed a keen sense of wind currents, hydraulics, and descent angles needed to sustain flight without engine thrust.

Without thrust on that chilly afternoon, Sullenberger worked to maintain control of Flight 1549 over New York City while fighting the unyielding grip of gravity that was pulling the airplane toward the earth at three times its normal descent rate. At roughly 15:30 hours, not long after passing less than 900 feet above the George Washington Bridge, Sullenberger asked Skiles if he had any more ideas to get the engines fired. Skiles replied that he did not. Having exhausted their options, the Hudson became the inevitable termination point of the flight.

According to the NTSB, from take-off to touch down in the Hudson, Flight 1549 spent exactly five minutes and eight seconds airborne. The pilots had less than four of those minutes to orient themselves to the problem, make a decision, and then take action to avoid catastrophe. Many have termed the outcome to this event “lucky,” but luck is when you win the lottery or call coin tosses correctly, not when you successfully ditch a 73 ton airliner into a river less than five minutes after take-off with 100 percent of the souls onboard surviving. It was certainly unlucky that both engines were disabled by birds, but the events that followed were driven by well-honed intuitive capabilities developed through exhaustive preparation and experiences, which allowed Sullenberger to rely on his unconscious mind to, intuitively, make rational decisions under intense pressure.

Intuition is in many ways simply “...how we translate our experiences into action.” Clearly, Sullenberger relied on all of his experiences to make sound decisions to overcome a set of unique circumstances that neither he nor any other pilot had ever encountered.

You may ask, what does Flight 1549 have to do with fighting fires? Well, it is impossible for firefighters, even those who have been around for decades, to have firsthand experience with all situations or problem scenarios they may confront. Like Sullenberger, we frequently encounter critical situations where time is of the essence and information is scarce. Whether we want it to or not, when confronted with chaotic, uncertain, and time-sensitive decisions, the unconscious brain, or intuition, takes over.

For those who are not prepared, their intuition will ultimately lead to bad decisions that will produce undesirable outcomes. Good decisions when chaos and uncertainty reign are a product of intuitive capabilities developed through deliberate practice and experiences that lead to expert knowledge. The human mind is much more sensitive to failure than to success. When you fail or witness someone else fail, it sears a much stronger mark in your mind than when you succeed.

This does not mean that we do not learn from success, but the impact of failure is an exponentially stronger influence on developing intuitive capabilities. Whether you read about, witness, or experience failure, it sears a more powerful marker on the unconscious mind. It is likely, for example, that Sullenberger’s intuitive decisions were informed by the many accident investigations he conducted, where he witnessed the mistakes or flawed decisions of others. Sullenberger commented after the landing that as the plane approached the Hudson he was trying to ditch close to boats and/or ferries to expedite a rescue. His accident investigations taught him that delayed rescue impedes survival.

As Albert Einstein once said, “The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift.” This is certainly true within the emergency service community, where we have strayed from building intuition. Informing the unconscious brain of emergency service personnel through training is a challenge, but it is critical to the success and safety of those who work within this dynamic and often unforgiving environment.

Studying failure and capitalizing on one’s own failures is the basis of developing intuition to guide better decision-making. YouTube videos, after action reports, and reading about first hand experiences are just a few of the ways to study failure. Critically assessing your own actions and the actions of those around you after each incident is another way to build intuition.

We constantly make mistakes, some more costly than others. Learning from those mistakes and other experiences is the basis of intuitive capabilities. For example, think back to a recent structure fire you responded to. Did you identify the type of building construction, perform a walk around, and search for other hazards — smoke/fire conditions, power lines, dead weight on the roof, etc. — before making entry? Deliberate practice of the decisions that are most important and difficult to your job improves judgment (i.e. Offensive or Defensive attack?). Just thinking about such questions or reviewing them with others helps the unconscious brain to make such information intuitive or second nature, rather than something that you have to think about when arriving at working incidents where time is of the essence.

Intuition is not a panacea if one does not carefully prepare the unconscious mind, so that even under the most stressful of circumstances you can effectively slow things down and make good decisions. As Charles Darwin stated, “Ignorance more frequently begets confidence than does knowledge.” It takes work to know what you don’t know and make decisions under conditions of uncertainty.

Sullenberger had never ditched an airliner into the water, and the FAA hardly focuses training programs on such scenarios because they are so improbable. Even the trouble shooting guidebook for the airliner proved problematic during the descent, as these documents assume the plane is at its normal cruising altitude, which in the case of Flight 1549 was to be at least 15,000 feet. This may explain why Skiles and Sullenberger did not flip the switch that seals the plane in the event of a water landing to help keep it buoyant to facilitate evacuation. The pilots simply did not have the time to make it to this point on the checklist before touching down in the Hudson. This did not matter, as a hole was ripped in the belly of the plane when it contacted the water. Despite all of this, the crash landing was executed to perfection.

It is neither necessary nor possible to train for every potential scenario. Intuition is based on pattern recognition, which can be simulated and learned through a myriad of techniques. Studying failure and participating in training evolutions that cause failure is critical to this process. Simply going through drills and repeating the same scenarios is not sufficient to develop expertise in the intuitive mind. Instead, it is necessary to search for failure and in some cases induce failure. Although such training may not be comfortable, it is this discomfort that sears vivid images in the unconscious brain that can be the catalyst for good decision-making at the most critical times. Often it is difficult to explain a decision that is based on intuition, because the human mind is “better at visual recognition than verbal description.” Good decision-making is a balance of deliberate and instinctive thinking all of which is informed by preparation and experiences.

Carr Boyd is a Captain with the Charlotte Fire Department and serves as an Adjunct Faculty member at the University of North Carolina at Charlotte. He is a nationally registered paramedic, and holds a Ph.D. in Public Policy.
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Issue 26.4 | Spring 2012

Keeping First Responders Safe
Ideas to improve safety on the job, leadership, serving our community and keeping the desire to serve others...
 

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