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Friday, March 4, 2011

The Vacuum Salesman and the Black Box




I still remember as a newly married husband the vacuum salesman.  He asked my wife if her carpet was clean, "of course" she exclaimed.  He asked if she would indulge him and go over it one more time with her current vacuum. Afterwards, he put a new filter in the model he was selling and vacuumed the same section of rug.  It picked up a substantial amount of additional dirt.  He definitely got our attention.  What choice did we have?  Buy his machine or live with dirty carpet.

Dr. David Warren was born in 1925 in the remote Northern Territories of Australia.  To receive a better education he attended 12 years of boarding school in Sydney.  His father’s last gift to him before an untimely death in a plane crash in 1934 was a crystal radio set.  David hope to pursue radio telephony and electronics, however, the war efforts were inconsistent with “radio hams” and he turned to his other hobby chemistry.  Chemistry took his career path into the fuels industry, but he is more famous for his contributions in electronics.

David was involved in the accident investigations related to the mysterious crash of the world’s first jet-powered aircraft, the Comet, in 1953.  He theorized that the cause of the accident would be obtained much easier if they knew what statements, if any, about the aircraft’s malfunctions the crew might have made in their last moments. He proposed a device to record cockpit conversation.   Aviation had little interest for such a device at the time, however, David built a prototype based on a miniature wire recorder he had purchased.  Voice and sound could be recorded on this pocket-sized device.  He built two prototypes, one for voice and one for recording aircraft parameters such as speed, altitude, heading, etc.

There was little acceptance of the devices in Australia, however, a British company bought the manufacturing rights and began to produce cockpit voice recorders and flight data recorders. Dr. Warren recalled how his device got the name "Black Box". “It was called a black box because in the records of my meeting in London when it was first demonstrated and they were so keen, one of the people in the discussion afterwards said, "This is a wonderful black box."   And a black box was a gadget box.  You didn't have to understand it but it did wonderful things.”

Ironically, the first government to make the flight and voice recorders mandatory was Australia after the investigation of a Fokker F27 crash in Queensland was unable to reach a definite conclusion in the probable cause of the accident.

The United States FAA, with support from the pilots’ union, made the flight data recorders mandatory in 1964. In contrast to the flight data recorders, FDRs. there was universal opposition among pilots to the cockpit voice recorders, CVRs, This was not surprising since most of the conversation in the cockpit during low workload could be highly personal and unrelated to the flight itself.

Even though their use was common throughout the airline industry, CVRs were not mandated in the U. S. until 1978.   Rightly suspicious, the Air Line Pilots Association had finally relented to the use of CVRs, but with clear stipulations. Only 30 minutes of recording could be kept.  There had to be a means to erase the recording after every flight.  Finally, and most importantly the information was only to be used for accident investigation.  The proverbial camel's nose was inside the tent.

Today, the NTSB, with some misguided congressional support, is now strongly advocating the routine auditing of CVRs to evaluate and manage the engagement and "professionalism" of airline crews.  This would be a galactic mistake as well as being totally unnecessary.  There is currently in use a program, FOQA,  that monitors crew and  airplane performance through optical digital recorders that continually captures thousands of aircraft parameters. With  the common goal of improving safety recognized by both the pilot's union and company management this information is de-identified and used only for safety assurance not individual corrective action by the company.  There are some non-US carriers that use this type of data punitively, but they have experienced some unintended negative consequences.  FOQA data has been used effectively to address trends that indicate corrective action is needed by the pilot group as a whole. When there are individual events of concern, the union is has been successful addressing them without identifying the pilot(s) to the company. When presented with the data, the pilot(s) self corrects.


Dr. Warren passed away in July 2010.  He lived long  enough to see his invention realize it’s potential as an essential investigative tool.  However, he also watched as his device was used for purposes that he never intended.  After accident investigation the CVR is now used primarily by journalists and attorneys to support their agendas. Aviation safety is a distant third when it comes to the non-investigative use of those recordings.  Prosecution, editorial criticism, civil litigation, liability management and punitive action have become the more common fate of CVR recordings.

When I use CVR transcripts in aviation safety classes, they are profoundly effective.   I emphasize that those involved always started their flight with the intention of success.  We must value that concept in order to understand that "we are them!".  Often those involved lost their lives in the accident being studied.  If we are to respect our colleagues’ experience we must learn from, not sanctimoniously criticize it.  The FAA and airline managements must value learning WHY pilots do what they do over everything else if creating safe operations is truly their goal.  Cesar Milan, The Dog Whisperer, is able to rehabilitate even the most recalcitrant dog, not through intimidation and coercion, but through understanding who they are and what their natural tendencies are. Anyone who says humans are much more highly evolved has never tried to lose weight or keep a New Year's resolution.

Although there was no CVR transcript involved in the Minneapolis over flight incident, the FAA's emergency revocation of the crews' certificates is just another example of putting training and safety behind other agendas.  After the incident the Captain lamented that he just couldn't believe they were distracted for so long.  Wouldn't it be nice if the rest of the industry could learn from that crew not just what happened, but WHY?  Not from people who weren't merely speculating.  Unfortunately, I seriously doubt and would be very surprised if this crew ever talks publicly about the incident. Are we so naive that we think this was the first and last crew to get themselves that disengaged?  If there was ANY reason to believe that they planned to do this I would strongly favor criminal prosecution, but that is not the case.  They specifically did not "plan" for this to happen.  So what was different about this crew?  I would like to know so I could avoid the same fate.  We will explain it away by saying they were distracted or not paying attention.  So we will teach and attend workshops where we will all agree that we shouldn't become that disengaged as though the Minneapolis crew hadn't been taught the same thing.  Didn't they know they were supposed to pay attention? The answer is obviously yes, but I ask again, WHY did they let themselves get so distracted? Never underestimate the power of a personal testimony from someone who has "been there".

I will never forget the dirt that new vacuum got off our rug.  I could be wrong, but I don't think we would have bought the vacuum or remembered the sales pitch from so many years ago if the salesman had scolded or demeaned us for having a dirty carpet.

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