Speak Up and Keep Us All Alive

Capt. W. Patrick Gordon, M.Sc.
​November 1999

“November Oscar” was part of the callsign of a Boeing 747, and this month marks the ten-year anniversary of the “November Oscar incident.” This incident became a landmark case in aviation history because of the fact that, due to a series of judgment calls, an airline captain involved in an incident, not an accident, was judged a criminal, lost his job with a  major international airline and, shortly thereafter, committed suicide.

What a waste! A 53-year-old 747 captain with 15,000 hours of flying time watched his career, and then his life, crumble because of “the snowball effect.” This term aptly describes the increasing severity that evolves as the first small problem is encountered that, if handled improperly, can escalate into a larger problem, much like a small snowball rolling down a hill can eventually create an avalanche, destroying all in its path.

We’ve all been told that there are two sides to every story, and the telling of the November Oscar incident certainly has more sides than can adequately be addressed in an article of this scope. However, a brief description of the incident is necessary.  (For more complete description of one side of this incident, suggested reading would include the February 1994 issue of Pilot magazine, “The November Oscar incident” by Stephan Wilkinson.)

November Oscar’s problems began during a layover on the Island of Mauritius. The crew had dinner together and several of them fell ill from food poisoning. Those sick included the copilot and the flight engineer. What followed over the remainder of this trip were a complex series of errant judgment calls by both the captain and the company for which he worked. The end result is that this captain made a Cat II approach with a sick and unqualified copilot and a less than desirable autopilot. His missed approach was executed slow enough, low enough and far enough off the runway centerline that it set off automobile alarms in the parking of a major hotel at the airport.

After safely landing, November Oscar’s captain avoided the chief pilot, went home and seemed to enter into a state of denial. There is no question that the captain erred in numerous judgment calls, but one can also read into them a possible mindset that can develop with a professional pilot who has become ensnared in the get-the-job-done syndrome.

Wilkinson in his referenced article above succinctly states a significant problem facing the professional pilot. “In fact here is the core of the professional pilot’s constant conflict. Into one ear, the company lectures, ‘Never break regulations. Never take a chance. Never ignore written procedures. Never compromise safety.’ Yet into the other it whispers, ‘Don’t cost us time. Don’t waste our money. Get your passengers to their destination rather than finding reasons why you can’t.’”

Piloting an aircraft involves the performance of many complex tasks with almost no margin for error. The successful performance of these crucial tasks depends on a competent knowledge of facts and procedures, sufficient skill and proper decision-making. Errors in in decision-making, made as early as during the preflight, or even the day before the flight, can lead to additional errors in the later phases of flight. The November Oscar incident is a classic example of this.

The basic understanding of the aeronautical decision-making process, from a cognitive perspective, is still very limited. Until now, the development of decision interventions has been primarily personality based. This means that errors in decision-making will continue, and escalate, unless someone involved speaks up and says, “Enough, this doesn’t make sense. Let’s stop this.”

Responsibility for speaking up does not rest solely in the cockpit. Decision intervention comments should, of course, be made by pilots. However, they should also be made by engineers, schedulers, operations, administration and especially management. Those involved in the decision-making process should hear those who might be saying something incredibly important, but not strongly or convincingly enough. That is where the term “personality based” arises. Kinder, gentler personalities might not adequately communicate to stronger, more goal-oriented personalities.

A situation akin to personality-based differences might exist in a cross-cultural environment that puts people from high-power distance cultures into a work situation with people from low-power distance cultures. (High-power distance cultures put a great deal of emphasis on respecting their elders, seniors and superior. As a result, high-power distance cultures tend to accept decisions and not question their veracity. Low-power cultures see everyone on a more or less equal playing field and are more likely to question and debate issues with their elders, senior and superiors.)

Lest we make the mistake of thinking this cross-cultural situation exists only between expatriate flight crews in the Middle East, take a moment to visualize the flight and cabin crew of many airlines in Europe and the U.S. Both of these areas have become enormous melting pots of varying cultures over the years. Even though individuals might have been “Born in the USA,” they probably grew up in widely varying cultural environments in their homes. These individual backgrounds surely contribute to cultural personality-based differences.

Based on the very nature of the occupation, there is little likelihood that one can expect an error-free career in aviation. To expect this would be to expect infallibility, which is just not possible in the real world.
If pilots are honest with themselves, they would probably admit that there is no such thig as an absolutely error-free flight. The errors might be minuscule and include only a missed ATC call or a missed position report. Unless the snowball effect develops, these are survivable errors.

Other, more serious errors could involve landing at the wrong airport, after all Nawabshah does sound a lot like Nouakchott, but one is in Pakistan and the other is in Mauritania, and we’ve all heard about pilots accidentally taking the boss to Dulles instead of Dallas. Miscalculating fuel and landing below minimum fuel levels still occurs. Landing in surface winds beyond the capacity of either the pilot or the airplane is also not unheard of, and hydroplaning is a very real and continuing threat.

The Majority of aircraft accidents today do not happen because of aircraft system errors, or lack of knowledge of aircraft systems on the part of pilots. They occur because of judgment calls which could have been short-circuited by an interruption in the decision-making process by just about anyone involved who could have made themselves heard. Speak up and keep us all alive.