The Human Factor

A perfectly good airplane had crashed. Seventy-three people were dead. But what caused the crash was not what you might think.

In Malcom Gladwell’s best-selling book, Outliers, he recounts the events surrounding the crash of Colombian airliner Avianca flight 052 in January of 1990. Although the story itself has nothing to do with police work, there are, I think, some uncanny parallels that shed light on the human factors that can determine whether or not a chaotic event ends in success or abject disaster.

Snowball Effect

After a full investigation into the crash, the findings were shocking. There were no glaring errors. No single epic failure. No coup de grâce. There was, however, a series of unfortunate events influenced by little, easily ignored variables that culminated in tragedy. The cause of the crash: “fuel exhaustion.” The plane had simply run out of gas.¹

Gladwell lays out some of the findings found in a typical crash. Not that any crash is typical, much like no traffic top is routine, but when tragedy strikes there are common denominators. What investigators found is that no single factor was detrimental. And as you’ll see there is an aggregation of variables that create a snowball effect leading to a series of errors that ends in disaster.

Common Denominators

As you read the following list of variables found in a typical plane crash think of them in terms of police work:

Bad weather – not terrible, but bad enough that the pilot is more stressed than usual.
Behind schedule – the pilots feel rushed or are hurrying
Awake for 12 or more hours – the pilot is tired and not thinking sharply
Unfamiliar copilot – the two pilots have not worked together before and are not comfortable with each other.²

Here’s where you should see some parallels. Answer yes or no:

• Have you worked in bad weather or in other circumstances that aren’t terrible, but that cause more stress than usual? The added stress induces mental fatigue.

• Have you felt rushed to get to a call or to clear a call? The pressure causes emotional fatigue.

• Have you been on shift after being awake for more than 12 hours? The long hours result in physical fatigue.

• Have you gone to calls with people you have never worked with or don’t often work with? The interpersonal conflicts cause relational fatigue.

Unlucky Number Seven

If you’ve been on the job for any amount of time you probably answered Yes, all the time! to each one of those questions. Now, here’s where it gets dicey. We’ve got four types of fatigue stacked on top of each other before the errors start. Investigations into a typical plane crash show that the crash itself wasn’t a result of one error. Or two errors. Or even five errors. The crash was a result of seven consecutive human errors. Seven. It is the combination of those errors that resulted in disaster.²

You might argue that there’s no way you’d make seven errors in a row. You’re too well-trained for that. I would agree, and so would the pilots. But interestingly the errors that led to the crashes were not ones of skill or knowledge. In other words, the errors had nothing to do with talent or ability. The errors that were made had to do with errors of teamwork and communication.²

Ouch.

Missing Things

If we’re honest, communication and teamwork are things we all struggle with — especially under stress and when we’re tired.

Gladwell quotes Suren Ratwatte, a veteran pilot involved in research that analyzes how human beings interact with complex systems like nuclear power plants and airplanes.³ Ratwatte said of the pilot in the Avianca crash, “He was maxed out. He had no resources left to do anything else. That’s what happens when you’re tired. Your decision-making skills erode. You start missing things — things that you would pick up on any other day.”⁴

Within the data from the black box recovered at the crash site of Avianca flight 052 we get insight into how the four variables manifested themselves in the errors that followed. All of these may be familiar to you.

Auditory Exclusion

On nine occasions the pilot asked for directions to be repeated, saying, “Tell me things louder,” and, “I’m not hearing them.” It seems clear that he was suffering from auditory exclusion, not listening or unable to process what he was hearing.⁴

Verbal Stagnation

There were long stretches of silence in the cockpit. Nothing but the sounds of rustling and engine noise could be heard on the recordings. The pilots weren’t talking to each other. It was as if they went into a form of vapor lock.

Confusion

When they did talk, the pilots didn’t communicate clearly, directly, or matter-of-factly. Implied meanings were lost on each other resulting in misinterpretation and confusion.

Passive Behavior

One pilot knows something important, but doesn’t say anything. One pilot does something wrong and the other pilot doesn’t catch it, address it, or correct it. They either didn’t have the energy to address it or missed it altogether.

In your city or town, you may ride solo but you are constantly working together with other officers or dispatchers. You’ve heard communication break down over the radio or you’ve seen someone go catatonic in a stressful situation. Stress can cause us to not see, hear, communicate, or be proactive. It’s up to the other to catch us when we fall, to address the problem, or to correct it. We must be able to rely on each other to pick up the slack.

Catastrophe

In the end, it seems, the plane only ran out of fuel because the pilots had run out first. They were physically, mentally, emotionally, and relationally exhausted which resulted in a cascade of errors that ended in catastrophe.

And that’s the human factor. We get tired, we get stressed, our decision-making skills erode, and we miss things that we normally wouldn’t miss on any other day. And that’s where the errors start stacking up — which begs the question: how many officers killed in the line of duty were under more stress than usual that day, felt pressed for time, had been awake for more than 12 hours, or were working with people they weren’t that familiar with? How did those factors effect the outcome?

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• Are you monitoring your fatigue level?
• Do you you know your own limits?
• How are your communication skills under stress?
• What can you do to guard against the four common denominators?

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¹Malcolm Gladwell, Outliers: The Story of Success (New York: Little, Brown, and Company, 2008), 186.

²Gladwell, Outliers, 184.

³Gladwell, Outliers, 187.

⁴Gladwell, Outliers, 188.