Quick Links
Statistics
Total entries in this blog:
Total entries in this category:
Published On: Jan 19, 2009 02:43 PM
Total entries in this category:
Published On: Jan 19, 2009 02:43 PM
My thoughts on the Garuda Airlines GA 200 incident at Yogyakarta, Indonesia, March 7, 2007
The following blog entry is a rare one
for me, as I usually don't comment on airline fatalities. But this incident,
involving Australians, has seen me interviewed in the media. So this blog entry
is to assist existing, past and prospective patients, and interested readers and
members of the media understand better what's happening.
This past week saw a tragic loss of life in an
airline incident in the Indonesian island of Java, at the international airport
that services Yogyakarta (pronounced
"Jog-jakarta").
Shown below is a map of Indonesia, with the area of central Java highlighted in bright green. This area is about 500 miles to the north-west of Australia, about an hour's flight away.
Shown below is a map of Indonesia, with the area of central Java highlighted in bright green. This area is about 500 miles to the north-west of Australia, about an hour's flight away.
Let's magnify the location to show the city of Yogyakarta, where the incident took place.
You can use GoogleEarth to locate the district's airport, known as Adisucipto International Airport. Wikipedia will tell you more about it, and is keeping a current article open on this incident.
The runway runs East-West (in aerial view, an
aircraft landing from the left would be coming in from the West to the East. You
can see the terminal area three-quarters down and above the runway. Despite an
extensive search on the 'net, I haven't been able to establish if the aircraft
landed from the West or from the East, and the photo isn't clear enough to show
the rice field in which the plane, upon over-running the runway, came to a
halt.
In this blog entry I want to discuss some details of
the incident as far as is known at the time of writing, knowing also that the
cause of the incident has yet to be officially proclaimed, and a number of
survivors are still in critical condition, some undergoing life-preserving
surgery. I wish them and their families the very best in what will be a long
period of recovery. New ways of thinking about what constitutes "normal" will
likely occur.
To those who lost loved ones, family and friends, please accept my sincerest condolences. It is one thing to lose people to premature death, it's another to lose them in such horrendous circumstances.
The purpose of this blog entry is not to minimise what has happened, but to try to provide a psychologist's viewpoint which may bring some understanding to what has happened and what will likely happen. I am hopeful current and past patients will use the information I'm going to provide in an effort to "hold their own" when it comes to their management of their flying behaviours, and not see themselves "slide back."
To prospective patients (of any psychologist or airline's fear of flying program), I hope the information here will help to balance some of the more sensationalistic reports you are likely to see and read before this incident is laid to rest. And my final hope is that media who are seeking some commentary and unique perspectives may learn something as well.
First, let me state that having worked with fearful flyers, both within and independent of an airline setting, I've exposed myself to many of the the more well-known commercial aircraft incidents, ones which frequently are portrayed on television and often come up for discussion in consultations. In addition, my training with airlines such United Airlines and Continental Airlines has contributed to my knowledge of the passenger and crew welfare aftermath, and my studies in Knowledge Management focussed on what happens on the flight deck and larger airline systems wihich can help explain why rare incidents such as the one at Yogyakarta do in fact occur.
Let's start here: While we await more definitive explanations of what happened at Yogyakarta, experience has some lessons to teach:
1. Many theories of what caused the incident will be bandied about within the media. As time goes on, some of the theories will be eliminated and others will emerge as strong candidates. But one thing will become abundantly clear. No one cause of this incident will be found. Airline incidents of this nature rarely occur because of one fateful error or malfunction. If you read my blog entry on "Safety and Swiss Cheese", you will see how events within a system of "check, cross-check and re-check" rarely occur alone, but have a multiplicative set of linked causations. Multiple defensive structures must fail almost simultaneously for the inherent safety in commercial aviation to be overwhelmed.
2. As rare as these incidents are, those that came previously have been studied and their lessons learnt will be applied in quickly understanding what happened at Yogyarkata. Nevertheless, certain media reports from those most of us have come to trust implicitly such as commercial pilots, have already leapt to conclusions based on the same information you are I are reading in newspapers and hearing on the TV or radio news. These have concluded the fault lies at the feet of the pilots.
3. Others have condemned the Indonesian airline safety culture as being too lax, especially after recent incidents such as where a very heavy landing saw a similar aircraft break its back from a heavy landing at Indonesia's second largest city, Surubaya in February 2007. See the pictures below.
To those who lost loved ones, family and friends, please accept my sincerest condolences. It is one thing to lose people to premature death, it's another to lose them in such horrendous circumstances.
The purpose of this blog entry is not to minimise what has happened, but to try to provide a psychologist's viewpoint which may bring some understanding to what has happened and what will likely happen. I am hopeful current and past patients will use the information I'm going to provide in an effort to "hold their own" when it comes to their management of their flying behaviours, and not see themselves "slide back."
To prospective patients (of any psychologist or airline's fear of flying program), I hope the information here will help to balance some of the more sensationalistic reports you are likely to see and read before this incident is laid to rest. And my final hope is that media who are seeking some commentary and unique perspectives may learn something as well.
First, let me state that having worked with fearful flyers, both within and independent of an airline setting, I've exposed myself to many of the the more well-known commercial aircraft incidents, ones which frequently are portrayed on television and often come up for discussion in consultations. In addition, my training with airlines such United Airlines and Continental Airlines has contributed to my knowledge of the passenger and crew welfare aftermath, and my studies in Knowledge Management focussed on what happens on the flight deck and larger airline systems wihich can help explain why rare incidents such as the one at Yogyakarta do in fact occur.
Let's start here: While we await more definitive explanations of what happened at Yogyakarta, experience has some lessons to teach:
1. Many theories of what caused the incident will be bandied about within the media. As time goes on, some of the theories will be eliminated and others will emerge as strong candidates. But one thing will become abundantly clear. No one cause of this incident will be found. Airline incidents of this nature rarely occur because of one fateful error or malfunction. If you read my blog entry on "Safety and Swiss Cheese", you will see how events within a system of "check, cross-check and re-check" rarely occur alone, but have a multiplicative set of linked causations. Multiple defensive structures must fail almost simultaneously for the inherent safety in commercial aviation to be overwhelmed.
2. As rare as these incidents are, those that came previously have been studied and their lessons learnt will be applied in quickly understanding what happened at Yogyarkata. Nevertheless, certain media reports from those most of us have come to trust implicitly such as commercial pilots, have already leapt to conclusions based on the same information you are I are reading in newspapers and hearing on the TV or radio news. These have concluded the fault lies at the feet of the pilots.
3. Others have condemned the Indonesian airline safety culture as being too lax, especially after recent incidents such as where a very heavy landing saw a similar aircraft break its back from a heavy landing at Indonesia's second largest city, Surubaya in February 2007. See the pictures below.
Adam Air lost another 737 on New Year's day 2007, and other reported incidents suggest that this airline's safety culture leaves much to be desired. I would have little problem telling my clients to avoid this airline and find alternative means to travel within Indonesia.
4. Australia's Foreign Minister, who was in Indonesia as part of a conference on international terrorism together with the country's Attorney-General, has questioned Indonesia air safety culture, and his concerns are rightly placed, as far as I can tell. Nonetheless, the matter of wind shear has also been implicated in the Yogyakarta incident, and reports since the incident suggest the same aircraft had experienced landing gear issues the day or two before. Other reports, stating that the aircraft's approach speed was much higher than expected, as judged by passengers and observers, might be due to pilot error, wind shear, or faulty mechanicals, such as the trailing edge flaps not being successfully deployed.
These devices, and the ones at the leading edge, extend the wing length from front to back, as well as increase the wing's curvature, allowing the wing to create greater lift at lower speeds. This enables a slower landing (and take-off where flaps are extended to a lesser degree), but also cause greater drag, noise, and "roughness" due to the smooth structure of the wing changing. Engines normally have abundant power to handle the extra drag at slower speeds, and of course the flaps are retracted in sequence after takeoff, as the aircraft accelerates to cruise speed. On the approach, they are extended in sequence according to speed. You can see them on the damaged 737 above right at their fully extended setting, where you can see the triple-slotted panels that make up the flaps. Extending or retracting the aircraft's undercarriage also affects speed, handling, buffeting, noise, and drag, and occurs according to a planned schedule.
What will need to be known with the current incident is whether the pilots had full control over the flaps, whether any failure for them to simultaneously fully extend (on both wings) occurred and the pilots were notified of it by the usual system checks, and if there was a failure, how is it that the pilots continued their approach if they knew their aircraft was unsafely configured.
5. In addition to expecting more information, both accurate and plausible as well as inaccurate and sensationalistic, we can expect more human interest stories to emerge. Those Australians who were killed and injured have become well-known to the Australian public following rather unprecedented media coverage. Some have cynically suggested that had no Australians been on board this would have been just another third-world loss of non-Western life. The incident received very brief coverage in the American press, and what it got was no doubt due to initial thought of terrorism given the number of Australians on board who were in the service of their country.
Since the incident, the local mainstream media have told us the life stories of those Australians, and we hopefully await news of the success of the recovery of those in intense care as I write.
6. Expect more unusual stories to emerge: Those who couldn't get on the flight and gave up their seat for someone who perished, someone who had a premonition and refused to fly, someone for whom this is not their first incident and they appear blessed with good luck (or bad depending on your perspective), and news of the pilots themselves. We'll hear of heroic acts (when either adrenaline or training or both kick in) and perhaps less than heroic acts from those we might expect better from.
7. Expect to hear more of the Swiss Cheese theory and how this incident will turn out to be what seems to be a conspiracy of low-probability events coming together when the usual safety defenses were breached. "Usual" is relative, and what will be exposed is whether "usual" in Indonesian terms matches "usual" in Australian or American or British aviation terms.
8. Against common sense, there will be fewer self-referrals for fear of flying treatment. Psychological assessment and treatment for fear of flying usually includes any patient's concerns about airline safety, but frankly, this is not where the action lies for most patients. Most accept how safe commercial aviation is compared to other forms of mass transport, and interventions lie in other than areas of safety for most people. However, for some patients where safety is the most pressing concern, these incidents confirm for them that their fears are real and necessary, and not at all irrational or out of the norm. Thus, the see themselves as not needing to be "treated", and they go about finding the best ways to construct their lives around not flying. Many people do this, and never seek treatment, and come to terms with travelling by much higher risk activities such as bus or train or car.
7. Incidents such as this do permit or even force us to pause and review our risk management strategies. Whether we like it or not, risk is all about us, and life cannot occur with any. At the moment, governments and concerned populations are reviewing the risks of continuing their activities while changes to world climate are being assessed as potentially life-threatening.
There are a number of people who write extensively about how we humans assess risk, and how we get it wrong. Sometimes, and often with adolescents, they underestimate risk; with older people, especially those of a conservative nature, risk is overassessed, and often conservative politicians play on these excessive fears, excessive because they don't match any replicable data gathering.
Much of our capacity to estimate risk is determined biologically, Here is one person's thoughts about how the brain is involved, using software as a metaphor:
"The brain is a beautifully engineered get-out-of-the-way machine that constantly scans the environment for things out of whose way it should right now get. That’s what brains did for several hundred million years—and then, just a few million years ago, the mammalian brain learned a new trick: to predict the timing and location of dangers before they actually happened.
Our ability to duck that which is not yet coming is one of the brain’s most stunning innovations, and we wouldn’t have dental floss or 401(k) plans without it. But this innovation is in the early stages of development. The application that allows us to respond to visible baseballs is ancient and reliable, but the add-on utility that allows us to respond to threats that loom in an unseen future is still in beta testing." (Daniel Gilbert, “If only gay sex caused global warming,” Los Angeles Times, July 2, 2006.)
Notice the table below, reproduced from a draft report by computer security expert Bruce Schneier, entitled "The Psychology of Security", which you can download here. (I"m already handing it out to select patients.)
Gathered from numerous pieces of research, this
table attempts to summarise some of the ways we fallible human beings assess
risk without really being aware of how we do
it.
With aviation, many people report having a moment of doubt about the flight they are about to take, and then just as quickly dismiss it with a very rapid internal calculation that says the chances of something happening on their flight are extremely low, and haven't changed just because a thought of their mortality popped into their head unbidden. I occasionally have Lotto numbers pop into my head, but so far, I'm not driving around in a Ferrari as a result of taking a bet with them. (Mind you I did win a few thousand dollars a few years ago when I used the frequently occurring mystery numbers in the TV series LOST - which ironically started with an aircraft crash - to play Lotto)
8. That means that just because you have a thought doesn't make it true, but does require you to review it for veracity and utility. The brain has several mechanisms to cause it to go into "flight and fight" mode - the one that produces those uncomfortable sensations associated with anxiety - before you have a chance to think things through. If you're already perceiving strong physical sensations when confronted with a typical scary scenario, your brain is already into high anxiety mode, and trying to think yourself out of it is unlikely to be successful on its own.
You need to send the "calm" centres of the brain a very direct message that says "I'm safe, I'm just perceiving uncomfortable sensations due to (turbulence, thoughts, sights, sounds, unexplained events, etc.). Then you can follow it up with your cognitions once you start your self-calming activities. This is not the same as feeling relaxed but a very direct means to alter your breathing rate and heart rate variability. I will write more about the latter in another blog entry because I am achieving very good success with some new biofeedback equipment which serves to train patients with getting more heart rate variability.
9. If your flight is imminent and you are not travelling in Indonesia or with an Indonesian airline, your risks of being involved have only changed to make it even less risky because your airline's safety culture is likely to have reviewed its systems, and those who will control your flight will be even more vigilant and risk-aversive. Otherwise, best to keep away from unreliable media reports which are only second-guessing official findings which will ultimately assemble the discoverable facts into a meaningful array. That will take some time while the flight recorder equipment is being analysed in Canberra. This included the Cockpit voice recorder (CVR - shown in orange, below) which records the last 30 minutes flight deck audio of the flight (reports have it the pilots spoke with air traffic control (ATC) in Indonesian, and this was likely the language used on the flight deck. This will need careful translation, not just for the expressions used, but to detect emotional status also.) The other equipment will be the flight data recorder (FDR), which keeps a computer record of the flight parameters, such as control surfaces, speeds, engine performance, altitude and attitude (the angle of the aircraft) and other important measures like wind direction and speed, as assessed by the onboard computers. This data is matched with what the pilots and air traffic control said (as compared to what they did), and a picture begins to emerge about which hypotheses can be constructed and then compared with actual damage sustained.
With aviation, many people report having a moment of doubt about the flight they are about to take, and then just as quickly dismiss it with a very rapid internal calculation that says the chances of something happening on their flight are extremely low, and haven't changed just because a thought of their mortality popped into their head unbidden. I occasionally have Lotto numbers pop into my head, but so far, I'm not driving around in a Ferrari as a result of taking a bet with them. (Mind you I did win a few thousand dollars a few years ago when I used the frequently occurring mystery numbers in the TV series LOST - which ironically started with an aircraft crash - to play Lotto)
8. That means that just because you have a thought doesn't make it true, but does require you to review it for veracity and utility. The brain has several mechanisms to cause it to go into "flight and fight" mode - the one that produces those uncomfortable sensations associated with anxiety - before you have a chance to think things through. If you're already perceiving strong physical sensations when confronted with a typical scary scenario, your brain is already into high anxiety mode, and trying to think yourself out of it is unlikely to be successful on its own.
You need to send the "calm" centres of the brain a very direct message that says "I'm safe, I'm just perceiving uncomfortable sensations due to (turbulence, thoughts, sights, sounds, unexplained events, etc.). Then you can follow it up with your cognitions once you start your self-calming activities. This is not the same as feeling relaxed but a very direct means to alter your breathing rate and heart rate variability. I will write more about the latter in another blog entry because I am achieving very good success with some new biofeedback equipment which serves to train patients with getting more heart rate variability.
9. If your flight is imminent and you are not travelling in Indonesia or with an Indonesian airline, your risks of being involved have only changed to make it even less risky because your airline's safety culture is likely to have reviewed its systems, and those who will control your flight will be even more vigilant and risk-aversive. Otherwise, best to keep away from unreliable media reports which are only second-guessing official findings which will ultimately assemble the discoverable facts into a meaningful array. That will take some time while the flight recorder equipment is being analysed in Canberra. This included the Cockpit voice recorder (CVR - shown in orange, below) which records the last 30 minutes flight deck audio of the flight (reports have it the pilots spoke with air traffic control (ATC) in Indonesian, and this was likely the language used on the flight deck. This will need careful translation, not just for the expressions used, but to detect emotional status also.) The other equipment will be the flight data recorder (FDR), which keeps a computer record of the flight parameters, such as control surfaces, speeds, engine performance, altitude and attitude (the angle of the aircraft) and other important measures like wind direction and speed, as assessed by the onboard computers. This data is matched with what the pilots and air traffic control said (as compared to what they did), and a picture begins to emerge about which hypotheses can be constructed and then compared with actual damage sustained.
Today, the Australian Transport Safety Bureau, charged with deciphering the recorded data, published a media release stating that some data was successfully downloaded from the recorders, but that for the CVR was unsuccessful, and the unit would have to be taken to the US to its manufacturer, Honeywell, to recovery data.
10. Bookmark this link and come back every few days as I add some more thoughts, as new findings become available. If you've found what I've written so far to be of value, more of the same will follow.
11. To existing clients: Now is a good time to check, and recheck what you have learnt and practised so far, and bring in any questions you want answered. I'll do my best to give it to you straight, as per usual.
Posted: Sunday - March 11, 2007 at 05:55 PM |