Aviation

Under Pressure, The Narrowing Cognitive Map: Lessons from the Tragedy of Singapore Airlines Flight 6

July 10, 2023 By Nagesh Belludi Leave a Comment

Picture this: You’re parking your car when, suddenly, you catch sight of the bus you desperately need to catch pulling into the station. Acting on instinct, you swiftly navigate your car into a vacant spot, deftly gather your bags, and launch yourself towards the bus stop, driven by an unwavering determination to evade a tedious fifteen-minute wait for the next one. In the whirlwind of your frantic sprint, you absentmindedly and hastily tuck your cherished cell phone into your back pocket, oblivious that it slips out during the adrenaline-fueled pursuit of catching the bus. It’s only after another five minutes that you become aware of your cell phone’s absence, and the weight of its loss gradually descends upon you.

Isn’t it fascinating how our minds tend to close off under time pressure? This fascinating cognitive phenomenon is known as the “narrowing of the cognitive map.” It’s as if our attention becomes laser-focused, but unfortunately, that can lead us to make unfortunate errors in judgment.

When we find ourselves in the clutches of tunnel vision, our thinking becomes constrained, and we unknowingly fall into the trap of limited perspective. Not only do we become so fixated on a specific course of action that we overlook crucial details in our environment, but we also become oblivious to the subtle signals whispering, “Something’s amiss.”

Inattentional blindness, indeed. It’s a common problem in high-stress situations, and it can have serious consequences, as in the following case study of the Singapore Airlines Flight 6 crash.

Speed Stress Causes Serious Breakdowns in the Reliability of Judgment

Flight 6’s tragic case accident occurred on October 31, 2000, at Taipei’s Chiang Kai-shek International Airport. Various factors contributed to the crash, including severe weather conditions, limited visibility, inadequate airport markings, and insufficient actions taken by both the pilots and air traffic controllers.

During a scheduled stop in Taipei on its journey from Singapore to Los Angeles, Flight 6’s flight crew became aware of an approaching storm. They realized that if they delayed the takeoff, they would have to wait for the storm to pass, resulting in a lengthy 12-hour delay. This interruption would have entailed making overnight arrangements for the passengers, disrupting the crew’s schedule, and potentially impacting future flight schedules involving the aircraft and company personnel. Consequently, the crew made the decision to expedite the departure and take off before the typhoon made landfall on the island.

The Rushed Pilots Missed Clues That They Were Taking Off on a Closed Runway

Under immense time pressure, the flight crew became singularly focused on expediting their takeoff in rainy and windy conditions before the weather conditions deteriorated further. Despite being instructed to taxi to Runway 05 Left, they deviated from the assigned route and instead positioned themselves on Runway 05 Right, which was closed for takeoff due to ongoing pavement repairs.

Complicating matters, a section of Runway 05 Right was still being used as a taxiway during the construction period. The signage at the entrance of the runway did not adequately indicate the presence of a stop sign and construction equipment along the converted taxiway.

Moreover, the local air traffic controller failed to provide progressive taxi or ground movement instructions, which would have been appropriate considering the low visibility during the taxi. However, due to the crew’s heightened sense of urgency, they neglected to request step-by-step instructions for their taxi route.

Misleading Airport Markings Contributed to Pilots’ Mistaken Belief of Correct Runway Selection

In the midst of low visibility and feeling rushed, the pilots neglected crucial resources that could have guided them to the correct runway, such as runway and taxiway charts, signage, markings, and cockpit instruments. This lapse in judgment resulted in a loss of situational awareness, leading them to initiate takeoff from a runway closed for construction.

The Harsh Reality of Rushing: Examining the Aftermath of Singapore Airlines Flight 6's Closed Runway Mishap Approximately 3,300 feet down the runway, around 11:17 PM that night, the Boeing 747 collided with concrete barriers and construction equipment, resulting in the aircraft breaking apart and bursting into flames.

Tragically, 83 out of the 179 people on board lost their lives.

The crew’s loss of awareness was further compounded by the airport’s negligence in terms of maintenance and safety precautions. By failing to place mandatory construction warnings at the entrance of Runway 05 Right, they disregarded the potential risk of aircraft mistakenly attempting to take off from a partially closed runway.

The air traffic controllers also neglected to verify the aircraft’s position before granting takeoff clearances, despite the aircraft having turned onto Runway 05 Right. The airport lacked the necessary Airport Surface Detection Equipment, which could have been crucial in detecting and mitigating risks, especially given the heavy precipitation that could have hampered radar presentation at the time. In their defense, the pilots had assumed that the air traffic controllers could visually observe the aircraft, and the fact that takeoff clearance was issued just as the aircraft turned onto the taxiway gave them the impression that everything was in order.

Anxiety Leads to Attentional Tunneling and Narrowed Field of Focus

The tragedy of Singapore Airlines Flight 6 serves as a poignant case study highlighting the dangers of tunnel vision and its ability to hinder our perspective and decision-making.

Often, seemingly minor errors, when combined with time constraints and cognitive biases, can intertwine and escalate, leading to catastrophic outcomes. Even in a highly advanced cockpit and a complex system with numerous safeguards, a chain of minor errors can transform it into a deadly trap.

The human brain is naturally inclined to seek confirmation and convince itself that it completely understands the situation at hand. When faced with contradictory information, we tend to ignore it and focus solely on our preconceived notions. Furthermore, anxiety further impairs our ability to perceive the entire situation, leaving us prone to impulsive actions rather than rational responses.

It is vital to be aware of the perils of tunnel vision. It can close our eyes to the broader context and limit our capacity to consider peripheral information. This narrowed perception can have severe consequences, emphasizing the importance of maintaining a broader perspective in decision-making.

Availability Heuristic: Our Preference for the Familiar

May 27, 2023 By Nagesh Belludi Leave a Comment

The availability heuristic is a cognitive bias that can lead people to rely on readily available information or emotionally charged and inherently interesting examples when making decisions or judgments. Essentially, individuals tend to overestimate the probability of events that are easy to recall or that they’ve personally experienced, while underestimating the likelihood of less memorable or less frequent events.

In other words, the ease of retrieval of a misleading cue may make people rely on evidence not because it is dependable but because it is memorable or striking and thus psychologically available to them. They may do so even if the evidence is not logically acceptable or does not logically support their decision.

Doctors often depend on recalling their past dramatic cases and mistakenly apply them to the current situation. People may overestimate the crime rate in their community based on news coverage, even though crime rates may be relatively low. People may dismiss the reality of climate change if they’ve recently experienced a cold winter or heard of a cold snap in a particular region, even though global warming is a long-term trend. Individuals are more likely to purchase insurance after experiencing a natural disaster than before it occurs. In each of these scenarios, the vivid and emotional evidence feels more persuasive rather than it being the most accurate or reliable information.

The availability heuristic can also shape people’s perceptions of air travel safety and lead them to believe that flying is more dangerous than it really is. Airplane accidents are often sensationalized and highly publicized by the media, making them more memorable and more prominent in people’s minds. This can cause individuals to perceive the risk of flying much higher than it actually is, leading them to avoid air travel even though it is statistically one of the safest forms of transportation. In reality, many less vivid and less memorable (i.e., psychologically unavailable) things are much more dangerous than air travel, such as falling down stairs, drowning, choking, and accidental poisoning.

Avoid falling prey to the availability heuristic and making serious misjudgments about the risks associated with different situations. Acknowledge that personal experiences and recent events may not accurately reflect the overall reality of the situation.

“Fly the Aircraft First”

December 29, 2022 By Nagesh Belludi Leave a Comment

Today is the 50th anniversary of the Flight 401 disaster. I’ve previously cited how the crew of the ill-fated Eastern Airlines Lockheed L-1011 got so single-mindedly preoccupied with tackling a nose landing gear indicator light malfunction that they didn’t pay attention to the fact that their airliner was descending gradually into the Florida Everglades.

In summary, the pilots were too distracted to fly the aircraft. Human factors, specifically cognitive impairments, can precipitate distractions away from vital tasks.

The incident led to a breakthrough called Crew Resource Management (CRM.) This “human nature innovation” actively orients pilots to prioritize tasks in order of operational safety. The adage “Aviate, Navigate, and Communicate (A-N-C)” reinforces the ‘fly the aircraft first’behaviors until they’re internalized and become routine.

The top priority—always—is to aviate. That means fly the airplane by using the flight controls and flight instruments to direct the airplane’s attitude, airspeed, and altitude. Rounding out those top priorities are figuring out where you are and where you’re going (Navigate,) and, as appropriate, talking to ATC or someone outside the airplane (Communicate.) However, it doesn’t matter if we’re navigating and communicating perfectly if we lose control of the aircraft and crash. A-N-C seems simple to follow, but it’s easy to forget when you get busy or distracted in the cockpit.

Idea for Impact: “Fly the aircraft first.” Know when to set aside the seemingly important things to accomplish the more vital ones.

Innovation’s Valley of Death

December 20, 2022 By Nagesh Belludi Leave a Comment

The discovery and development of an invention are usually easier relative to the creativity and resources required to make it a commercial success. Indeed, many entrepreneurs and intrapreneurs struggle to commercialize their idea meaningfully—establish the idea’s marketability to prospective backers, engage potential customers, and price and promote their product or service for a favorable return on investment. Consider this case study of the Bombardier CSeries jets—fated for misfortune for many years only to morph into the successful Airbus A220 series:

As a country, we habitually underinvest in R&D. And, when domestic champions like Bombardier do emerge, they often prove unable to turn their great ideas into commercially successful, globally dominant businesses.

In a knowledge economy, a country’s future prosperity is increasingly tied to its ability to generate and capitalize on innovative new ideas.

“The paradox is that while there is innovation going on in Canada, we do not observe the same level of commercialization and ownership of those innovations [as in other countries]. In many cases, inventions developed in Canada are then commercialized by foreign companies that keep much of that benefit.”

Idea for Impact: Don’t let your idea fizzle because they can’t take your sizzle to market. Focus not just on overcoming internal barriers but also on how to commercialize your innovation. Hire outside capabilities if necessary.

Books in Brief: ‘Flying Blind’ and the Crisis at Boeing

September 24, 2022 By Nagesh Belludi Leave a Comment

Bloomberg investigative journalist Peter Robison’s thoroughly researched Flying Blind: The 737 MAX Tragedy and the Fall of Boeing (2022) offers noteworthy lessons about corporate responsibility and leadership problem-solving.

In a nutshell, starting in the late 1990s, Boeing shifted from a company run by engineers who emphasized product integrity to one run by MBA-types who prized shareholder value over long-term product planning. Inspired by General Electric’s Jack Welch, the company embraced cost-cutting, outsourcing, financial engineering, union-busting, and co-opting regulators. These miscalculated strategies culminated in the 737 MAX disasters and disgraceful corporate responses.

Recommendation: Read Peter Robison’s Flying Blind, but be wary of the author’s broad-brush political biases, which, I found, sidetracked from the storyline. The internal organizational tensions that led to corporate deception and the fateful consequences of federal regulators’ consigning design approvals to Boeing are particularly interesting.

Key Takeaway: Negligent engineering to minimize costs and adhere to a delivery schedule is a symptom of ethical blight.

Dear Customer, Speak Early and Have it Your Way!

September 12, 2022 By Nagesh Belludi Leave a Comment

At the heart of every successful product is the ability to address a real need or circumstance of struggle—a “job to be done”—in consumers’ lives. Identification of this “job” happens early in the innovation process, as it forms the core insight around innovation development and execution.

Feedback-Influenced Design is a Key Point of Differentiation

Long before its current mess, Boeing was once the pioneer in aspects of product development. No example illustrates Boeing’s inventive stills than the groundbreaking Boeing 777 program, particularly in its use of iterative, paperless computer-aided design, assembly process-planning, and agile product development. Not only that, the Boeing 777 program offers the most high-profile examples of companies tapping consumers as never before to help them create new products.

Knowing very well that the secret to long-term success starts very early in the innovation process, director of engineering Alan Mulally led a “working together” initiative to organize product development around customer input. (Mulally left Boeing after not being named CEO in 2006 and engineered a dramatic turnaround at Ford Motor Co.)

Concept Testing at Every Stage of Development

In the late 1980s, just as the 777 program was being launched, Mulally made a consequential decision to involve its major potential customers in the development of the aircraft specifications. Mulally made up a “gang of eight” comprising All Nippon Airways, American Airlines, British Airways, Cathay Pacific, Delta Air Lines, Japan Airlines, Qantas, and United Airlines. At the group’s first meeting in January 1990, Mulally’s team distributed a 23-page questionnaire asking what each customer wanted in the design. Within two months, Boeing and the airlines decided on a basic design configuration.

The “working together” initiative was a radical departure from the bureaucratic project organization. Internally, Boeing had become bureaucratic and department-focused. Specialists in various departments would design their parts. Then, it was up to the manufacturing team (the system integrators) to figure out how to make it all come together. It was a “throw-it-over-the-wall” environment where the disconnect was a persistent problem.

Having customer input implied that development was centered on customer needs. This would also tear down the walls between departments—designers, suppliers, and assemblers usually separated by organizations or development phases would now be engaged collaboratively and talking and collaborating in real-time.

In an industry where manufacturers classically designed aircraft with only token customer input. Rather than presenting the market with what Boeing perceived as their idea of what was required, customers had direct input. Over the decades, the Boeing 777 became one of the world’s most successful commercial aircraft and continues to be the workhorse of many a customer fleet.

Idea for Impact: Create Something People Want

Whether selling products or services, fast food, or experiential travel, the most innovative companies organize their offerings around customers’ needs. From the very beginning, they tap consumers as never before to help them create new products, and they’re embedding customer knowledge into the business. Early and frequent feedback is one way to cope with the pressure for shorter product cycles and to be prudent about not investing time and resources in unpromising ideas. It also augurs well for the experiences-over-possessions shift in consumer values.

The Loss Aversion Mental Model: A Case Study on Why People Think Spirit is a Horrible Airline

August 11, 2022 By Nagesh Belludi 1 Comment

When Spirit Airlines pivoted to competing on price in the late 2000s, it quickly gained a reputation not only for operational inefficiencies but also for its in-your-face, take-it-or-leave attitude towards customer service.

Where other airlines charged by-the-package fares for the flight experience, Spirit pared back service and introduced an a la carte pricing model. Charging for the “ancillaries”—i.e., everything optional, including water—allowed Spirit to keep ticket prices down and appeal to price-sensitive travelers willing to sacrifice the usual amenities for a lower ticket price.

In the ensuing years, the unconventionality of this business model did not go down well with customers. Much of the flying public’s frustration with Spirit had to do with Loss Aversion. That’s the notion that the emotional disappointment of a loss is more extreme than the joy of a comparable gain. If finding a cheaper fare on Spirit felt delightful, giving up some—or all—of the savings to purchase ancillaries and surrender the savings felt utterly miserable.

Passengers felt ripped off by these seemingly hidden fees, especially when the true cost of flying Spirit ended up greater than what the initial ticket price led them to believe.

Spirit became quickly convinced that there was a perception problem—its customers didn’t fully understand how its fares work. Particularly, first-time customers blindly presumed that Spirit Airlines works the same way as other airlines. In reality, there were no hidden or excessive fees, and passengers could only pay for what they need or want. In 2014, the airline introduced its “Spirit 101” campaign to educate customers and alter their perceptions. With time and the increased adaptation of the “Basic Fare” model and curtailed customer service by every other airline, passengers’ expectations have since been right-sized. Spirit Airlines has come a long way, and its customer service has improved vastly.

Further studies on loss aversion have shown that a cascade of successive fees is worse than the cumulative: i.e., three ancillary fees that add up to, say, $70, feel a lot worse than a single $70 fee. Appropriately, Spirit offers a “Bundle it Combo” package.

Nothing Unites Like a Common Enemy

December 14, 2021 By Nagesh Belludi Leave a Comment

On a recent Airlines Confidential podcast, former CEO of Airbus-America Barry Eccleston discussed how Airbus has grown over the years to dethrone Boeing as the world’s largest commercial aircraft maker.

Airbus began in the late 1960s as a consortium of pan-European companies connected by a shared crusade to counter American industrial prowess. Once aviation’s leaders in innovation, these European underdogs had been surpassed by Boeing, McDonnell Douglas, and Lockheed in the ’50s and ’60s.

Once Airbus got started and was standing on its own feet, the concept of ‘Beat Boeing’ became the Airbus mantra. Indeed, it brought together the French, the Germans, the Brits, and the Spanish. If you think about it, Europe had been trying previously to do joint venture programs successfully for quite a while, but most of them didn’t happen. But this one did. And, I believe, it happened, not solely, but in large part, because everybody rallied around a flag, and the flag was called Beat Boeing. Do you remember, in the old days, the Avis slogan was “We are number two, and we try harder?” That kind of like, was where we were at in Airbus. We knew we were number two; we knew we could become number one, and we tried harder.

Idea for Impact: Nothing unites a team like a common enemy. The adversary doesn’t have to be a person, a team, or a competitor. It can be a being-the-underdog mindset or an against-the-the-odds challenge. It can even be a system that has resisted change.

How to See Opportunities Your Competition Doesn’t

November 19, 2021 By Nagesh Belludi Leave a Comment

Harvard strategy professor Youngme Moon’s Different: Escaping the Competitive Herd (2010) describes how many companies pursue the same opportunities that every other company is chasing and thus miss the same opportunities that everyone else is missing.

In category after category, companies have gotten so locked into a particular cadence of competition that they appear to have lost sight of their mandate—which is to create meaningful grooves of separation from one another. Consequently, the harder they compete, the less differentiated they become … Products are no longer competing against each other; they are collapsing into each other in the minds of anyone who consumes them.

Moon argues that the companies and brands that see a different game win big. Such innovators don’t just try to outcompete their rivals at the margin. Instead, they redefine the competitive landscape by embracing unique ideas in a world crammed with me-too thinking.

European airline Ryanair unleashed a new wave of relentless cost- and price-leadership by charging customers extra for everything beyond a seat itself. If you want to check a bag, you pay extra. If you want an airport agent to check you in and print your boarding pass, you pay extra. If you want food and drink, you pay extra. Later on, Spirit Airlines took the price-obsession further by charging for carry-on bags too. After a rough rollout and customer defiance, paying for carry-on bags has become the new normal.

Idea for Impact: Being different is what makes all the difference. If you do things the same way everyone else in your field does things, why would you expect to do any better? What are you doing to raise your game—not just to stay in place, but to get ahead?

Many Hard Leadership Lessons in the Boeing 737 MAX Debacle

August 24, 2021 By Nagesh Belludi Leave a Comment

The U.S. House committee’s report on Boeing’s 737 MAX disaster makes interesting reading on contemporary leadership, particularly the pressures of rapid product development.

The rush to market and a culture of contributory negligence and concealment conspired to ensure that a not-yet-airworthy plane carried passengers into service, resulting in two fatal accidents and a long grounding.

Boeing’s design and development of the 737 MAX was marred by technical design failures, a lack of transparency with both regulators and customers, and efforts to downplay or disregard concerns about the operation of the aircraft.

Of particular importance are the “management failures,” “inherent conflicts of interest,” and “grossly insufficient oversight” at both Boeing and its regulator, the Federal Aviation Administration (FAA.) Boeing failed to offset the design limitations and cost- and schedule-pressures in favor of attention to customer safety. Leadership was fixated on fending off the runaway success of the Airbus A320neo program.

The company relied on too many technical assumptions—and they couldn’t make themselves the space and time to be reasonable about any of this. Boeing’s “culture of concealment” and an “unwillingness to share technical details” are the report’s most damning indictment. Employees spoke but went unheard; indeed, their voices were suppressed.

Aviation

Speed Stress Causes Serious Breakdowns in the Reliability of Judgment

The Rushed Pilots Missed Clues That They Were Taking Off on a Closed Runway

Misleading Airport Markings Contributed to Pilots’ Mistaken Belief of Correct Runway Selection

Anxiety Leads to Attentional Tunneling and Narrowed Field of Focus

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Feedback-Influenced Design is a Key Point of Differentiation

Concept Testing at Every Stage of Development

Idea for Impact: Create Something People Want

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