The meta lesson for everyone from AF447
A four-step pattern you can apply to your own life situations too.
In a three-person group or team, there are seven sets of loops running at once; each individual has his own problems and perceptions in life (x3), then between each of the individuals as pairs there is a first layer of shared interactions (x3) and then there is the whole team level of shared meaning (x1), what they all understand together.
Almost all of the way down in the darkness, none of the pilots on AF447 worked out what was really going on. Possibly in the last 40 seconds or so, the Dubois-Robert pair realised what the problem was, after Bonin announced he had been pulling the stick back most of the time. By the time Bonin made his announcement, however, the plane was below 9,000 feet, so physics, aerodynamics and spacetime were against them.
But Bonin himself was still wondering about it as the plane smashed into the ocean surface, his very last words being: “But what’s happening?”. So they never reached complete, shared awareness of the situation as a whole crew.
The physics and aerodynamics, though, the knowledge the three undertrained but professional pilots needed to access in order to solve for the new problem situation, were theoretically available to them from the very first instant, as soon as the ice crystals hit, and the plane was screaming “Stall!” at them the whole way down. As pilots, they knew what a stall was, they just couldn’t see it in front of them.
So the first error was mental and emotional, conceptual. Bonin, the most junior of the three, panicked immediately. Robert, the most experienced guy on the crew on the A330 model and the South American route, was completely overwhelmed in under 50 seconds. And when Captain Dubois made it back into the cockpit after a few minutes of sleep, in the dark and the buffeting, already two minutes into the crisis, he had no idea what was going on or how they had gotten into that mess so quickly. Nobody asserted a clear piloting vision or authority. They reacted like human beings who realised they were falling out of the sky in the dark and were about to die, not like master pilots confident they could get their passengers out of that flying mess.
“I am a master pilot” vs. “I am a panicking human being about to die horribly”.
The second error was then a non-realistic appreciation of the situation. The aircraft was screaming stall, the altitude indicator was winding down fast. The other two did not know, could not see in the dark, and were not being told by the aircraft systems and cockpit design what Bonin was doing with his stick. They were thinking about overspeed, or reading out the ECAM text messages, or just confused and increasingly panicked. None of them said “stall”, “buffett”, “emergency” or “mayday” all the way down. None of them made a distress call, so while they must have felt awful, the rational realisation and verbalisation of “emergency” did not materialise.
So the second thing you need to do is to correctly identify, to become aware of, the actual real situation in front of you. That gets you to “I am a master pilot in a stall situation” vs. “I am panicking human being about to die horribly and have no clue what is really happening here”.
Their third error, which stemmed from the first and the second, was therefore not being able to access the actual specific rational knowledge needed to solve for that situation: the stall. They didn’t even come to the conclusion they were in a stall, so they couldn’t then realise that they needed the anti-stall procedure to get out of it. But you could imagine a hypothetical case in which a crew is able to realise they are in a stall but for one reason or another cannot access the right knowledge to solve for it. Maybe the panic makes them forget whatever training they have received, or they can’t find the right checklist, or they remember a wrong stall procedure.
So the third thing you need to do is access the specific knowledge required to solve for the actual, real situation in front of you. That moves us along to “I am a master pilot in a stall situation, so I know I must push the nose down so that my aircraft returns to its flight envelope” vs. “I am panicking human being about to die horribly and have no clue what is really happening here, so have even less of a clue about what the solution might be”.
The final fourth error was then not following or executing that right, rational action for that actual situation they had to solve for. They couldn’t do that right thing because they didn’t know what the right thing was because they didn’t even really know what the problem was because it was all suddently very confusing and contrary to all their prior training and experience in the dark and the buffeting at 2 a.m.
So the fourth thing you need is to then do the actual right, rational action for the situation you are solving for. That gets you all the way to “I am a master pilot in a stall situation, so I know I must push the nose down so that my aircraft returns to its flight envelope, so now I am going to execute that decisively” vs. “I am panicking human being about to die horribly and have no clue what is really happening here, so have even less of a clue about what the solution might be, and I am just making random inputs on the controls every few seconds”.
Once you understand the meta pattern, you can apply it to all sorts of life situations.
→ Read the full case study here
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I really appreciate how you pull apart the taffy to see the sugar crystals. 🙏