December 28th, 1978. United Airlines Flight 173 took off from JFK International airport in New York heading to Portland, Oregon. Captain Malburn McBroom was a 52-year-old veteran of the Second World War, an exceptionally experienced pilot. Flying conditions were close to perfect. The flight was routine and uneventful until the moment at 17.10 when Captain McBroom pulled the lever to lower the landing gear for the final descent into Portland. Normally he would have heard an audible click as the landing gear locked into place. On this occasion, however, there was an altogether different sounding thud followed by a shudder felt throughout the aeroplane.
Captain McBroom was concerned the landing gear had failed to lower but he couldn’t be sure. He decided to circle above the airport while he considered his options. He lost track of time and while the minutes went by he still had no idea whether the landing gear was safely down. He thought furiously about how he could solve the problem, meanwhile, the engineer repeatedly alerted him to the alarmingly low level of fuel left in the aeroplane’s tanks.
The so-called ‘black box’ voice recorder would later reveal the extent to which Captain McBroom failed to hear the warnings of his Co-pilot and First Engineer about the dwindling fuel levels. He was too focused on the possibility that the landing gear had not lowered. Time was passing faster and faster for the Captain as his focus narrowed.
At 18.14, a full 64 minutes after his attempt to lower the landing gear, Flight 173 crashed into a wooded suburb killing eight passengers and two crew, including the Flight Engineer who had tried so hard to alert the Captain to the lack of fuel reserves. McBroom survived and his skill at averting a more significant crash was rightly praised; 179 passengers and crew also survived.
This incident proved to be a watershed moment for the aviation industry. Within minutes the air crash investigation team had begun to go over the evidence with a fine tooth-comb.
Ultimately, they found the Captain had become overly-focused on the wrong thing – the landing gear, and had failed to spot that a lack of fuel in the tanks would potentially be far more catastrophic than attempting to land without wheels. And so it proved.
The investigation team listened back to the voice recorder and found that the Flight Engineer had made numerous ‘hints’ to the pilot about the fuel level but could not quite bring himself to challenge his boss directly. For his reticence, he paid with his life.
The problem the investigators identified was not that McBroom had lost focus, he actually had too much focus – on the wrong problem. Task-focused behaviour is actually an effective way of applying one’s effort but when this focus comes at the expense of the ‘bigger picture’ it undermines performance. In this case McBroom hadn’t processed the information being given to him in increasingly desperate tones by his flight engineer colleague.
The story of United Airlines Flight 173 is told in more detail and with more drama in the book by Matthew Syed, ‘Black Box Thinking’*. I recently attended a conference where Syed spoke with brilliant alacrity about how the aviation industry has over the years learned to embrace failure. The case of Flight 173 is a case in point; the investigation made a recommendation that improved crew resource management should be implemented to confront the natural hierarchical blocks when challenging senior crew members. From failure, change emerged. The changes have saved lives.
Aviation is an incredibly safe industry. This is largely because investigators review air crashes (and near misses) in a climate of learning (from failure). Moreover, there is an avoidance of the so-called ‘blame game’; the primary purpose of air crash investigations is to find ways to ensure they can never happen again. And in the wider context there tends to be few public calls for sackings after an air crash, the mainstream media will report on the tragedy of lost lives rather than focusing on the ‘failure’ of the pilots, crew or even the guy back at the airport who filled the plane with fuel.
How does this compare with our child protection system in the UK? Just like aviation, child protection is a high-risk industry where failure can result in serious harm or even the death of a child. If a young person has been harmed by their carers a Serious Case Review is undertaken – although rarely is it done straight away so lessons can be learned quickly as they are in the aviation industry. Furthermore, the reviews tend to unearth the same mistakes being made in case after case with little evidence of learning from past failures.
And when it comes to the issue of blame one only has to look at the events following the death of Peter Connelly (Baby P) in 2008 when The Sun’s headline immediately following the criminal trial of Peter’s mother and step-father was “Blood on their Hands” – referring not to those who killed the 17-month old but the social workers and their managers. The Director, Sharon Shoesmith, was immediately relieved of her duties by the government minister Ed Balls; she contemplated suicide. The public outcry was deafening.
As Syed says in his book, the UK social work system would benefit from a complete change of culture directed at it becoming “a truly adaptive organisation with forward looking accountability” but this can only occur if children’s services adopt a just culture. A culture where learning happens every day and honest mistakes are not punished but are seen as an opportunity to learn, grow and improve. Whether the wider context of our national newspapers and our politicians would allow this is doubtful, but that is no reason not to try.
It is also worth remembering that the pilot of Flight 173 saved many lives despite his over-focus on the landing gear – his skill, courage and experience proving vital in otherwise appalling circumstances.
And social workers also save lives every day – this never gets reported – but the good work that they do is reflected by the fact that the homicide rate for children is falling while the numbers of children at risk of abuse and neglect has increased by 24% in the last five years**.
Learning from mistakes in any high-risk profession like children’s social work or aviation is critical to improvement and has a direct correlation with outcomes, whether it be passenger safety or a reduction of child deaths. But it needs a societal culture change as well as a change in the way local authority children’s services train, develop and support their social workers. A little bit of Black Box Thinking could go a long way.
If you are interested in this subject WillisPalmer is presenting a national conference at Kings College, London on May 18th. ‘Wisdom from failure: a kaleidoscope on child protection’ will include speakers from the legal profession, social workers, academics and survivors of abuse. The keynote speaker is Matthew Syed, author of the ground-breaking book ‘Black Box Thinking’. To book your ticket visit the WillisPalmer website.
*Black Box Thinking by Matthew Syed, Published by John Murray, 2015
** NSPCC, Every Child is Worth Fighting For, 2016