The “Hudson Miracle” and Safety Culture

The night before the “CFIT” descent into the Hudson River, I was, coincidentally, reading William Langewiesche’s collection on aviation, Inside the Sky. Reading the essay “On a Bombay Night,” about the Air India Flight 855 crash, this excerpt reminded me of just how staggeringly proficient and, yes, heroic, the flight crew’s response yesterday was, to something that had only been practiced on computer screens:

“The pilots knew something, but not what, and they were fully occupied with their confusion. Only the flight engineer clearly saw the errors being made. It was not a nightmare, though that possibility must have crossed his mind. After so many years during which these things had happened only to others, he was now the one actually going down, out of control, crashing. There was no reason for this, and it didn’t feel wild, but the instruments told an undeniable story. And yet he could do nothing but point.

“No, but go by this, Captain!”

Kukar [the captain] did not even answer him. It is impossible to know what denials he was engaged in. Pilots train in simulators to handle all sorts of failures, sometimes heaped on top of the other. But even the best of the simulators require a suspension of belief that never quite overcomes the understanding that they are pretend airplanes built for the purpose of experiencing failures and that no matter how poorly the pilots perform they will walk away unscathed. That, of course, is not true of failures inside the sky, where the first challenge is to suspend disbelief and where the urgency is real.”

The author goes on to conclude that the “underlying cause seems oddly enough to have been the very extent of Kukar’s flying experience… there comes a point in a pilot’s life when the sky feels like home.”

And yet for all the talk of miracles yesterday — for what great water landing success stories are there? — there was also something less sensational at work: Safety culture. Pilots are relentlessly trained in these contingencies, flight attendants are there not merely to be the object of contempt from ill-bred passengers (why can’t I go the bathroom as we’re landing?), the routine announcements may be done out of rote and may indeed seem superfluous, and it’s annoying when the plane is delayed three hours so an indicator light-bulb can be changed, but yesterday’s events showed the real and cumulative value all these things have.

“Safety culture” is the topic of the latest report from UC-Berkeley’s Traffic Safety Center; the newsletter itself is drawn from a longer report prepared by AAA’s Traffic Safety Foundation. As defined by one paper, safety culture, which emerged as a concept in the wake of the Chernobyl incident, “is the enduring value and priority placed on worker and public safety by everyone in every group at every level of an organization. It refers to the extent to which individuals and groups will commit to personal responsibility for safety, act to preserve, enhance and communicate safety concerns, strive to actively learn, adapt and modify (both individual and organizational) behavior based on lessons learned from mistakes, and be rewarded in a manner consistent with these values.”

The report goes on to call for a “traffic safety culture,” something which has yet to come to full fruition, particularly in the U.S. As Dinesh Mohan states, “‘Road traffic injuries are the only public health problem for which society and decision-makers still accept death and disability among young people on a large scale. This human sacrifice is seen as a justifiable externality of doing business: the only discussion revolves around the number of deaths and injuries that are acceptable.”

We tend to emphasize the random, “accidental” nature of car crashes, something that would be unacceptable in the commercial aviation industry (which hasn’t had a fatality in the last two years). Protocols are set, rules are followed, training is essential, and pilots are encouraged to avoid overconfidence and respond to input from other staff. In his forthcoming book Why We Make Mistakes, Joseph T. Hallinan quotes a study showing when pilots and doctors were asked the question, “even when fatigued, I perform effectively during critical times,” 70% of doctors said yes, compared to only 26% of pilots (I’d like to see this question asked to drivers). Hallinan notes the human body is more complicated than aviation; but still, culture matters.

Driver overconfidence is, I think, a key factor, in the ongoing safety problem: I can drive tired or impaired; I can drive faster than everyone else; the crash is not me but every other driver. Drivers (like many doctors, according to Hallinan’s book) tend to get annoyed when they get “feedback” or input on their performance from their passengers. Unfortunately, drivers aren’t given the kind of training pilots are; but then again, it’s not performance as much as attitude that counts on the road (which is, as much as anything, a place of social interaction).

There are, of course, a number of ways safety culture has penetrated into driving. As James Hedlund writes, “Infant and toddler safety seat use is now an integral part of the whole country’s safety culture. Hospital policies require newborns to ride home in a child safety seat. NHTSA’s 2006 survey reported that 98% of infants under the age of one and 89% of toddlers age one to three were riding in child safety seats. There’s no indifference here: parents understand that they must properly secure their infants and toddlers in a scientifically-designed seat on each trip.”

But in so many other ways — speed, alcohol, mobile phones, etc. etc. — we toss safety culture out the window (even while the infant is strapped in). Just imagine the outcome yesterday if the pilot was fatigued, impaired, talking on the phone to his buddy in Reno, or just simply felt some rule or performance protocol didn’t apply to him. Yesterday may have been a miracle, but the outcome also represented the perfect alignment of a safety culture firing on all cylinders.

This entry was posted on Friday, January 16th, 2009 at 10:27 am and is filed under Etc., Traffic safety, Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.

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Traffic Tom Vanderbilt

How We Drive is the companion blog to Tom Vanderbilt’s New York Times bestselling book, Traffic: Why We Drive the Way We Do (and What It Says About Us), published by Alfred A. Knopf in the U.S. and Canada, Penguin in the U.K, and in languages other than English by a number of other fine publishers worldwide.

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Upcoming Talks

April 9, 2008.
California Office of Traffic Safety Summit
San Francisco, CA.

May 19, 2009
University of Minnesota Center for Transportation Studies
Bloomington, MN

June 23, 2009
Driving Assessment 2009
Big Sky, Montana

June 26, 2009
PRI World Congress
Rotterdam, The Netherlands

June 27, 2009
Day of Architecture
Utrecht, The Netherlands

July 13, 2009
Association of Transportation Safety Information Professionals (ATSIP)
Phoenix, AZ.

August 12-14
Texas Department of Transportation “Save a Life Summit”
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September 2, 2009
Governors Highway Safety Association Annual Meeting
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September 11, 2009
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October 8
Honda R&D Americas
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October 10-11
INFORMS Roundtable
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October 21, 2009
California State University-San Bernardino, Leonard Transportation Center
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November 5
Southern New England Planning Association Planning Conference
Uncasville, Connecticut

January 6
Texas Transportation Forum
Austin, TX

January 19
Yale University
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Monday, February 22
Yale University School of Architecture
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Friday, March 19
University of Delaware
Delaware Center for Transportation

April 5-7
University of Utah
Salt Lake City
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April 19
International Bridge, Tunnel and Turnpike Association (Organization Management Workshop)
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Monday, April 26
Edmonton Traffic Safety Conference
Edmonton, Canada

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Canadian Association of Road Safety Professionals
Niagara Falls, Ontario

Wednesday, July 6
Fondo de Prevención Vial
Bogotá, Colombia

Tuesday, August 31
Royal Automobile Club
Perth, Australia

Wednesday, September 1
Australasian Road Safety Conference
Canberra, Australia

Wednesday, September 22

Wisconsin Department of Transportation’s
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Statewide Conference
Wisconsin Dells, WI

Wednesday, October 20
Rutgers University
Center for Advanced Infrastructure and Transportation
Piscataway, NJ

Tuesday, March 8, 2011
Ontario Injury Prevention Resource Centre
Injury Prevention Forum

Monday, May 2
Idaho Public Driver Education Conference
Boise, Idaho

Tuesday, June 2, 2011
California Association of Cities
Costa Mesa, California

Sunday, August 21, 2011
American Association of Motor Vehicle Administrators
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Wednesday, October 26, 2011
Attitudes: Iniciativa Social de Audi
Madrid, Spain

April 16, 2012
Institute for Sensible Transport Seminar
Gardens Theatre, QUT
Brisbane, Australia

April 17, 2012
Institute for Sensible Transport Seminar
Centennial Plaza, Sydney
Sydney, Australia

April 19, 2012
Institute for Sensible Transport Seminar
Melbourne Town Hall
Melbourne, Australia

January 30, 2013
University of Minnesota City Engineers Association Meeting
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January 31, 2013
Metropolis and Mobile Life
School of Architecture, University of Toronto

February 22, 2013
ISL Engineering
Edmonton, Canada

March 1, 2013
Australian Road Summit
Melbourne, Australia

May 8, 2013
New York State Association of
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Rochester, NY

August 18, 2013 “Ingenuity” Conference
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September 26, 2013
TransComm 2013
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of State Highway and Transportation
Officials’ Subcommittee on Transportation
Grand Rapids MI



January 2009

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