On May 31, 2009, Air France Flight 447 took off from Rio De Janeiro, en route to Paris. It was a clear summer evening as the plane lifted off the runway, preparing for the long flight across the Atlantic.
The 228 passengers included honeymooners, students, and the wife of one of the pilots – none of which anticipated that this flight would be their last.
As Charles Duhigg shares in Smarter Faster Better: The Secrets of Being Productive in Life and Business, it wasn’t until nearly two years later that the black box was recovered and the world finally discovered what happened during that fateful flight.
The Tragic Story of Air France Flight 447
Once the black box was recovered, the story of how Flight 447 ended up at the bottom of the ocean began to unfold.
Because the flight was 13 hours long (including prep time), there were three pilots on board – allowing each pilot to take a mandated break during the trip.
After reaching cruising altitude, the captain woke up the second co-pilot and went to the back to sleep.
Five minutes later, at 2:06 am, the acting pilot made an announcement that the passengers should expect turbulence ahead.
Then, the sound of hail can be heard on the cockpit windshield. Due to the cold and the sleet, ice began to accumulate in the outside pitot tubes which measure the airspeed. The autopilot sensed a false reading and automatically disengaged and an alarm rang through.
With autopilot off, the aircraft began to roll to the right. The junior pilot, who was at the stick, was surprised by this change. Unsure of what was going on, he overcompensated by veering too far to the left. For the next 30 seconds the plane pitched back and forth as the pilot attempted to gain control – simultaneously (and unknown to himself or the rest of the crew) increasing the pitch of the aircraft by 13%.
Suddenly the aircraft was climbing at a rate of 7,000 ft/minute – far faster than the typical rate of 2,000-3,000 ft/minute. Since the autopilot was disengaged, it was the responsibility of the pilots to control the aircraft and figure out the problem.
At this point though, the computer began spitting out instructions to correct the aircraft. However, these instructions from the computer differed from faulty readings provided by the iced-over instruments – causing greater confusion. As the co-pilot read off the instructions, the pilot flying the craft began to increase the tilt of the nose, thinking that they needed to pull up to recover.
The pilots became inundated with conflicting warnings, and neither pilot realized that the aircraft was exceeding its critical angle of attack, effectively stalling the plane. Even the stall sirens seemed to go unnoticed by the pilots as they each struggled to grasp the activities happening right in front of them.
Thirty seconds after the stall began, at 2:11:40, the captain re-entered the cockpit, asking “What the hell are you doing”?
The co-pilot responded, “I don’t know what’s happening”, and the pilot at the stick added “We’re losing control of the airplane!”.
Confused and unable to grasp what was going on, the pilots remained relatively silent for the next 40 seconds. While the aircraft continued falling at a rate of 10,000 feet per minute.
At the last moment you hear the pilots blurt out a few profanities, as they inevitably realize what’s happening.
Then, at 2:14:28, the recording stopped as the aircraft hit the ocean surface, presumably killing everyone on impact.
When Mechanical Malfunction Meets Human Cognitive Bias
As investigators and psychologists evaluated the outcome of Air France Flight 447, the conclusion is that the crash was the result of two factors: mechanical malfunction and cognitive bias.
First, there was a mechanical malfunction when the ice blocked the pitot tubes – making the aircraft speed reading inaccurate. While this is unfortunate, this error was only momentary, and all pilots know how to recover from this common occurrence.
The more substantial cause of the accident comes from cognitive bias among the pilots – particularly, cognitive tunneling. Along with a failure to create mental models.
Once the cockpit became overwhelmed with lights, sirens, and digital readouts, the pilots each focused on the activities right in front of them – failing to take a moment to step back and look at the big picture.
Like a pane of glass framing and subtly distorting our vision, mental models determine what we see.” -Peter Senge
Mental modeling is one’s thought process of how something works in the real world. It’s our evaluation of cause and effect – I do “x”, and “y” occurs. The more familiar we are with a subject or topic, and the more time we’ve spent developing scenarios in our minds, the better our mental models will be.
In this case, none of the pilots had been building mental models as the trip progressed. If they had stepped back and thought about the entire event as it unfolded, they would have recognized that they were falling at a rate of 10,000 feet a minute and just needed to point the nose down rather than up.
However, because they looked at each warning individually, rather than putting the pieces together, none of these pilots were able to put together an effective mental model of what was truly happening around them.
While Air France Flight 447’s flight crew failed to develop accurate mental models, on the other side of the world, Qantas flight 32 overcame a similar situation thanks to effective scenario development on part of the captain.
Qantas Flight 32 – A Disaster Averted Through Mental Modeling
Captain Richard Champion de Crespigny was notorious for drilling his crew on mental models he wanted them to take, even before arriving at the airport.
“Imagine there’s an engine fire” the captain would postulate, “what’s the first place you would look?” The pilots took turns sharing their thoughts on how to react to these situations.
This large, burly Australian captain shared his belief that the computer is only responsible for showing the pilots what’s going on, it’s their responsibility to interpret and act on that data.
Every commercial pilot must undergo regular performance reviews to ensure that they are qualified to safely fly. On this particular flight, it happened to be Captain Crespigny’s performance review – meaning that two other pilots, in addition to his crew, were going to be in the cockpit – evaluating his performance. If he failed to fly to the standards set by Qantas, he may find himself in early retirement.
One of these observers sat in the co-pilot seat and Crespigny called him out – saying that he wanted his crew to all sit together. “But then I won’t be able to see what you’re doing” the observer responded.
“That’s your problem.” said Crespigny – intent on keeping his environment how he needed it to effectively manage his mental models in case of an emergency.
It wasn’t until the observer volunteered to step in as second officer that Crespigny allowed him to keep his seat.
By allowing this change that ensured the safety of the craft, Crespigny reemphasized what he always told his team – that they are more than welcome to question his decision making, and he will take their responses seriously.
After everything was organized and the ground evaluation was completed, the aircraft took off.
It wasn’t long after being airborne, when the aircraft was at a mere 7,400 feet, that a loud burst was heard off one of the wings.
At first, Crespigny suspected it was just a wind gust going through the engine. However, after another loud crash and the sound of a million marbles being thrown up against the haul, he knew the situation had escalated. This was reaffirmed by the overload of errors the co-pilot reported popping up on the Flight Management Computer (FMC).
Inside the engine is a turbine (propeller, similar to a fan) that sucks air through the jet to move the plane. One of the engine’s turbines had detached from the drive shaft and shattered the engine – sending shards of shrapnel across the wing, making multiple holes, impacting the integrity of the wing.
Ten seconds after the incident, the captain radioed into what had happened and said they would touch base again within 5 minutes. At this point, the pilots began speaking calmly about the situation.
Twenty-one of the planes twenty-two systems were either damaged or completely inoperable – and no one knew if the airplane was still airworthy.
The co-pilots were working through all the errors that kept whizzing by on the computer system, too many to analyze. None of the pilots could determine what parts of the plane were damaged or how the plane might react if they made any control inputs.
However they had to make a decision, and the Captain, listening to the recommendations of his crew, decided to turn around and head back to Singapore. Unfortunately, this meant turning the plane which was risky because they didn’t know the extent of the damage.
So the captain radioed the control tower requesting permission to climb to 10,000 feet and turn around.
“No!” his copilots quickly responded. They went on to share that increasing the altitude could cause fuel to leak faster – they needed to keep the plane flat.
Just like the Air France pilots, Captain Crespigny had simulated hundreds of disasters and had thousands of hours of experience. However, he and his crew reacted quite differently to the influx in warnings and alarms.
They worked together as a team, delegated responsibilities and didn’t hold back the slightest bit of hesitation when responding to each other.
Based on their previous experiences working together and their countless simulations and drills around what to do in case of an emergency, the crew was able to maximize the safety of the aircraft – even without knowing the full extent of the damage.
For the next 20 minutes, the crew experienced countless reports, sirens, and flashing lights – similar to the Air France Flight 447. And while this crew was still unaware at times of where to focus, they maintained a clear mental model of what was occurring around them.
They knew the next problem would be determining whether the plane could even land. Planes have different takeoff and landing weights, and most planes are unable to land immediately without dumping or burning off fuel. After double checking the numbers, they realized they’d only have 328 ft of runway remaining; but only if they performed the landing perfectly.
Despite the math, the crew was nervous as they brought the aircraft down – aware of what was at stake. From overshooting the runway to losing another system or even an engine – there were many challenges involved in having a successful landing.
Although they touched down at 35 knots faster than normal – blowing out three of the landing gears – the plane slowed to a crawl nearing the end of the runway.
Once on the ground, the drama wasn’t over. The brake pads were extremely hot from the landing, Engine 1 wouldn’t shut off, and oil from the damaged plane was spilling across the runway.
The crew debated sending the passengers out in a rapid evacuation, but the emergency slides can be dangerous themselves and are better avoided when possible. Meanwhile, the gasoline, damaged engine, and potential for a spark to light it all up made it clear that the passengers were safest if they remained on board. The flight crew stood by with the doors open and inflatable slides ready to disembark if needed. Fortunately, everything calmed down and the entire 440 passengers and 29 crew members were able to disembark from a single set of stairs.
Every single person walked away uninjured.
The Power of Mental Modeling
By comparing the two flight crews we can see a stark difference in each team’s ability to act based on how developed their mental models were ahead of time.
The Air France Flight 447 team was overloaded with conflicting information and the confusion of the pilots by their inability to exchange information and analyze the situation correctly.
After this incident, the FAA recommended to commercial pilots is to not let automation fade their proficiency for actually flying the plane. Inevitably, it’s an issue that will continue to grow as automation becomes more complex and takes over more responsibilities in the cockpit.
Meanwhile, the crew of Qantas Flight 32 would continuously role play through scenarios, developing ways to respond when difficult situations arose. Additionally, the crew not only worked as a team, but the copilots were comfortable questioning the captain’s orders in an effort to create the most accurate picture of what was going on based on the data they had at the time.
By running through various scenarios ahead of time, the crew of Flight 32 was far more prepared to handle an emergency like this one.
How to Incorporate Mental Modeling into Your Life and Business
Most of the decisions you make on a daily basis won’t have a sudden life-or-death outcome for hundreds of people. However, the success of your life and business is largely dependent on your ability to make the right decisions at the right time.
By working through scenarios ahead of time, rather than waiting for disaster to strike, you can ensure the success of your goals for the long haul.
As a species, it’s far too easy for us to get lazy and put all of our eggs in one basket. For example, many businesses failed after Google made the Panda update – reducing traffic to their websites by 95%+. Meanwhile, many other small businesses lost out after investing a substantial amount of time into growing their Facebook following, only to be stuck paying Facebook in order to be seen by their followers. In each of these situations, people became too comfortable with something that worked and stopped learning.
What would happen if you had a flat tire on the way to work today or if your home was broken into while you were out? How would you make a living if you lost your job tomorrow due to automation or outsourcing?
Mental models, developed by brainstorming scenarios like those above, prepare you for challenges when they inevitably arrive. By regularly practicing mental modeling, you can remain aware of the big picture in the moment, rather than responding to each little issue on its own.
Go back to your business and personal vision statements every 3 months to evaluate how you’re measuring up
To improve my mental models, I created a mindmap for all my personal and professional goals. Then I mapped out the steps I know I need to take to get there, and brainstormed all the issues that might come up at every level along the way – planning how I might respond to each.
Apart from having thought out what problems might occur, as discussed in what captain hindsight can teach you, having such a map will give you greater peace of mind. Should any difficult situations come up, you’ve already considered several “what-if scenarios.” Even if what comes up isn’t in your manual, simply being in that head space will give you an edge in how to respond.
So ask yourself, are your activities guiding you towards the final destination you wish to reach, or are you being efficient at the expense of being effective? Mental models allow you to stay alert and mentally prepared for what might be just around the corner, ensuring you’ll be more effective at handling whatever lemons life throws your way.
In a very real sense, you are the captain of your business, life and legacy.
Just as the two captains above illustrated, how you plan and prepare for the road ahead determines the success and survival of your entire flight. So have an effective flight plan and review it every quarter.
We can never know what’s going to happen, but spending a little time today thinking about what might – will improve your odds of having a successful outcome.
There are no revisions for this post.