Airblue Flight 202: A Human Factors Disaster

On July 28, 2010, Airblue Flight 202 departed Karachi for Islamabad with 152 people on board. The aircraft for this routine domestic flight was a modern, airworthy Airbus A321 and both pilots were fully qualified. Less than two hours later, it was flown into the Margalla Hills north of Islamabad with the loss of all lives on board.

The investigation found no mechanical breakdown of the aircraft, but rather, a human factors breakdown in the cockpit: a captain who spent the flight berating his first officer before flying an approach he improvised on the spot, and a first officer who saw what was going wrong but could not find a way to stop it. The report called it a classic failure of Crew Resource Management (CRM).

In this first episode of the Field Debrief podcast, I am joined by risk management expert Stuart Slay to discuss what happened on Flight 202, and what it means for those of us who take people into the field: guides, trip leaders, program directors, and outdoor educators.

Content note: all 152 people aboard Flight 202 lost their lives. We stay anchored to the official investigation findings and approach this as a system and culture failure, not personal villainy.

Prefer audio? Listen on Apple Podcasts.

Topics

• The experience gap in the cockpit: a captain near retirement with 25,000 hours, a younger, much less experienced first officer, and how that dynamic affects how teams work together.
• What an hour of berating did to the team, and the water the first officer was swimming in when the critical moments came.
• Hierarchy in the field: role clarity, single point accountability, and asserting your care as an organization, including a river near miss where a co-instructor knew it was a bad idea and did not say anything.
• Local rationality versus following what is written: the tension between trusting judgment in the moment and holding the line on protocols.
• "Let him say whatever he wants to say" - the captain's response to air traffic control, summit fever, and the competitor's flight that managed to land.
• The PACE escalation continuum (Probe, Alert, Challenge, Emergency), and how the avalanche industry trains people to narrate what they see and build a shared brain.
• Culture in aviation: power distance, who the controls are designed for, and why Outliers' analysis of national culture did not go deep enough.
• What to take into your next staff training: empowering people to grab the stick, making it as easy as possible for your co-guides to escalate, and, if you are the leader, "don't be a jerk."

Episode Chapters

• 00:00 Welcome and content note
• 03:04 Meet Stuart Slay
• 05:13 The flight, the crew, and the experience gap
• 09:52 An hour of berating: psychological safety in the cockpit
• 18:10 Hierarchy and role clarity in outdoor programs
• 26:32 The approach into Islamabad
• 34:05 "Let him say whatever he wants"
• 40:39 Seventy seconds from impact
• 55:19 PACE: probe, alert, challenge, escalate
• 1:03:31 Takeaways for leaders

Meet Stuart Slay

Stuart Slay is the founder of Slay Risk, a consulting and coaching practice that helps schools and outdoor programs see risk clearly and manage it together. He is the past chair of the Wilderness Risk Management Conference (WRMC), led National Risk and Safety at the Student Conservation Association, spent a decade building an outdoor education program in Korea, and has published original research on culture and risk management in outdoor programs. Before that he was a ski patroller, guide, and avalanche forecaster in California and the Andes, and a field instructor with Outward Bound. He is based in Taipei and works with programs throughout Asia and North America.

Resources and Further Reading

• The official CAA Pakistan investigation report (PDF): the primary source for this episode.
• My presentation slides from the episode (PDF): the case study visuals we reference throughout.
• Mentour Pilot's video on Airblue Flight 202: an excellent aviation-side breakdown of the accident from a professional airline pilot, and the video that first put this case study on our radar.
• Airblue Flight 202 on Wikipedia: a solid summary of the flight and investigation.

Why an Aviation Disaster Belongs on an Outdoor Leadership Podcast

Aviation is one of the most studied safety-critical fields in the world, and its accident investigations are public, detailed, and honest about human factors. Outdoor education, guiding, and expedition programs run in many of the same conditions: small teams, experience gradients, time pressure, weather, and decisions made far from supervision.

Flight 202 is a case study in what happens when the authority gradient gets too steep. Every outdoor program has a version of that dynamic somewhere.

Field Debrief is produced by Field Risk Systems™ LLC, the company behind Field Risk OS™, The Operating System for Expedition Programs.

Transcript

Lightly edited for clarity (filler words and false starts removed); wording otherwise as spoken. Timestamps match the published episode.

George Bull (00:00): Hi y'all, welcome to the very first episode of the Field Debrief Podcast. If you don't know me already, my name's George Bull. I've spent the last six or seven years in the outdoor industry doing a variety of things from running a summer camp trips program to coordinating expeditions in Antarctica and lots of other things that I'm excited to share as we release more and more episodes of this podcast. On this very first episode I'll be joined by Stuart Slay. Stuart's a colleague of mine and a friend of mine over these last few months. And he has some really insightful things to say on human factors risk management. Stu and I are gonna be breaking down an airline accident, actually. It's called Air Blue Flight 202. It was a flight from Karachi to Islamabad, Pakistan, back in July of 2010. And it's a really classic human factors accident. Two qualified pilots flew a perfectly functioning A320 into the side of a mountain in Islamabad, Pakistan, after sort of a breakdown of human factors and crew resource management in the cockpit. We'll be talking about things such as hierarchy in leadership, communication styles, and other risk management topics and how they relate to the outdoor industry. As I promise you will be able to tell, this is my very first time hosting a podcast. So things might seem a little bit scripted at times as I'm trying to get the details right on things like Stu's bio and some of the details of the crash, but I do promise it gets more conversational as we get farther into the video. And I thank you for bearing with me as I learn how to be a better podcast host. I've seen some awesome podcasts in our space that people do really well. And so it's not gonna be quite at that level yet, but I'm working hard to get there. And in the future on this podcast, you're gonna see things like videos I do myself breaking down personal experiences or talking about Field Risk OS, which is the platform I'm building for expedition programs. You'll see more traditional interview style episodes with very great people in our field. And then you'll also see some things like maybe a product breakdown or a tutorial video or something like that. This is sort of a companion or extension of my Field Debrief blog that I've been writing for a couple of months now. So thank you so much for being here. I'm really excited to get this going. One thing before we get started, this episode does involve significant loss of life. All passengers and crew on that flight did perish in the accident and so I wanted to make sure that that's clear before you decide to watch the rest of the video. Thanks for being here folks.

George Bull (03:04): I'm excited to be joined today by Stuart Slay. Welcome, Stuart.

Stuart Slay (03:09): Hey, thanks for having me today.

George Bull (03:12): Stuart is the founder of Slay Risk, a consulting and coaching practice that helps schools and outdoor programs see risk clearly and manage it together. Stu is the past chair of the WRMC and has published original research on culture, risk management, and outdoor programs. He spent a decade in Korea building an outdoor education program, then led National Risk and Safety at the Student Conservation Association, the oldest and largest provider of conservation service programs in the U.S. Before that, he was a ski patroller, guide, and avalanche forecaster in California and the Andes, and a field instructor with Outward Bound and numerous other outdoor schools and organizations. Today he's based in Taipei, where he works with programs throughout Asia and North America.

George Bull (03:56): Before we get into it, let's talk a little bit about what this podcast today is and isn't.

Stuart Slay (04:03): Yeah, so George and I were talking as colleagues and as friends, and we've both in various ways have studied aviation. And a lot of people study aviation in terms of safety and safety science. It's just a big, well-resourced field. And there's a lot that we can learn in outdoor education and outdoor programs from this larger field. And so we were having this conversation about various accidents that we've read about and studied and just kind of the takeaways. And so we thought that we would just have the similar conversation and share it with others who might be interested. But we do just want to say upfront that we're not pilots. We're not aviation experts. I don't know, never put me in a cockpit because that won't go well. But man, I sure know how to read. I can read a lot of papers and so sort of talk some of the language. But don't get confused about us being pilots and aviation experts. We're here to really draw the learnings from those papers and those studies and those accident investigations. And it's those findings that we're looking at and really looking at what does that mean for us? How is that helpful to us as practitioners and program directors and instructors and so on?

George Bull (05:13): Yeah, 100%. The information in this episode is coming directly from the Pakistani Aviation Authority resources and their accident report. There'll be more resources about the accident if you really want to dig into the technical pieces and things on my website, fieldriskos.com/field-debrief for that info. And then we will be approaching this from the lens of outdoor leadership and outdoor safety. All right, let's get into Air Blue Flight two two. This was a routine domestic flight from Karachi to Islamabad on July twenty-eighth, two thousand and ten. The flight was carrying one hundred and forty-six passengers and six crew, and unfortunately, all the lives on board the flight were lost. At the time of takeoff from Karachi, they were aware in the cockpit that the weather was very poor in Islamabad and they were gonna have to do a non-standard approach. And we'll talk about that in a little while. Some background information that we can start out here with. The aircraft they were flying was a modern Airbus A321. It was manufactured in Germany and the aircraft was fairly new, about 10 years old, fully airworthy, and the pre-flight checks had been completed. When we're looking at the captain and first officer here, what do you see, Stu, that stands out to you? I know we have some things highlighted.

Stuart Slay (06:45): Yeah, something that stuck out to me was their difference in experience. One guy was nearing retirement age. He's in his 60s. He has something like 25 or 26,000 flight hours, which sounds like a really big number and just a ton of experience. This is something he's been doing his whole career. And the first officer, he's in his mid 30s. So sort of mid career guy and he's got like 1800 flight hours, so still sort of building his rap sheet and his experience. And so right out of the gate, just looking at this aspect alone, these two really important positions, there's a pretty big differential in their experience level. And that comes up throughout the case study, and it's a big point on the case study. But this is also totally normal. It's normal to work with someone experienced and someone who's still building their experience. And that's pretty similar to what we do in our space with field instructors or guides in the field.

George Bull (07:46): Yeah, absolutely. How would you approach this scenario if say you were a much more experienced person in this situation, or not necessarily in the cockpit of an airplane, but working with a less experienced person in your field, whether or not it was in an office environment or a field environment?

Stuart Slay (08:04): Yeah, as I get older, I'm more and more in that case, but I'm certainly not 60, so still have room to

Stuart Slay (08:12): grow and get some more miles underneath me. But I really enjoy working with newer field instructors, for example, or newer program directors as it is the case more and more these days for me. And everyone's on their own journey, and so everybody has a foundation somewhere in there. Certainly pilots, I think it's pretty clear what that foundation is because they have to go to flight school and have to have certain credentials and this sort of thing. In our space, if I'm working with Americans, I mean, that's my cultural background and where I come from in terms of outdoor ed, I can sort of understand pretty quickly what somebody is coming in with. And I want to find out what they're working on. Where do they want to improve? What do they want to learn? And what's the right container and the space that I can make for them to do that? And that's what helps me to grow as I get more experienced is trial and error and testing and doing some of those things in terms of providing that space for somebody. But I think most listeners to this podcast will recognize that there's an element of psychological safety and a bit of a security blanket that it's your job to provide and that's what's going to make you work together because ultimately while there is an experience gap in there or a differential in there you're working together as a team to do a job, which is to keep other people safe, in this case land the plane. For us it could be to climb the mountain and learn about ourselves and other people, but that's what the ultimate job is, and the training and the learning and that sort of stuff, it is secondary to those safety critical functions.

George Bull (09:52): And I think this plays really well into the next part of this case study as well, which we get into very shortly after takeoff. The flight took off at seven forty one in the morning from Karachi International Airport. And pretty much immediately after takeoff, within about 10 minutes, they had gotten up towards cruise. They were still ascending from the airport. The flight crew actually offered the pilot some tea and croissants. And so the flight crew was sipping on tea and having croissants. And the captain in that moment started what's been described as berating the first officer. And these are some quotes here from the official incident investigation. During the initial climb, the captain tested the knowledge of the first officer and used harsh words and a snobbish tone. This was not a training flight by any means. This was just a normal operational flight, and so that first officer wouldn't have been expecting to be quizzed essentially on their deep operational knowledge during that routine flight. They lasted for about an hour intermittently from immediately 10 minutes after they took off until right before they started their approach procedure into Islamabad. And after the intermittent, humiliating sessions, the first officer remained quiet, became underconfident, submissive, and as we'll see, doesn't really challenge the captain in the future. In some times where it may have been or would have been appropriate for the first officer to probably more strictly challenge rather than sort of probe and we'll talk about what that looks like in a bit as well. Something that we were talking about a couple of days ago, Stu, with this is I think in our industry it's pretty rare to see outright berating of someone that you're working with.

Stuart Slay (11:58): Yeah, this is a good one. The accident investigation, the official one, really centers on this point. And that's the big takeaway right from that accident investigation, which is about psychological safety and so on. And so, soon after takeoff, this guy just really starts drilling his colleague and his coworker. Sure, he's younger than him. For sure, he has a little bit less experience, but he just starts drilling him and sort of testing him. We'll see later on in the case study, right, about how that affects various decisions and so on. But yeah, certainly in the outdoor education space, I've heard stories. I haven't experienced it. I think if you were interviewing a woman, you might probably draw some of those stories out more easily than with me, for example. But as you know, our field is so interesting because it's on the edge of education. Education is all about psychological safety and has a lot of good approaches in that way. And we're on the edge of recreation, where it's a little bit more performance based, a little more type A driven space. And so these things can sort of bleed. So for me, I would have more stories about ski patrolling and where there is time pressure, you're under the pressure to perform and sort of very physical and things like this. Certainly guiding stories can, I think it's somewhat rare, I would say, in the guiding space, but as you sort of get more on that recreational side of our spectrum, I think these things can bleed and happen. But to me, if I'm sort of putting myself as a fly in the cockpit in this case, well, what is this guy doing? Why is he doing this? And what is the point of this? And it's obviously some sort of weird power thing that he has, maybe

Stuart Slay (13:53): at a bad day or I mean, who knows, or is this normal for him? Not really sure. But what strikes me is this sort of gatekeeping that he's doing with his power, with his power distance that he's creating among his colleague, and sort of gatekeeping of like, you got to pass my test, are you worthy in my eyes and this sort of thing. And this is something that I've definitely experienced even in the outdoor education space. And I remember for example I did a review and I was working with somebody, sort of reporting back to somebody who was much much older than me and much more experienced than me. Decades and decades and decades. Yeah that's three, at least three maybe more actually. Four decades older than me. And the first question, we didn't really talk that much about the review and what I saw, was much more about, like I need to give this gentleman my rap sheet about my technical experience. And am I a boater first or am I a climber first? And what have I done and this sort of thing. And just that always sort of sits with me. And I think some of that stuff is becoming more outdated, especially in the safety space and everything that we do in our field, but that just really, really stuck with me for a long time. And I answered his questions, but I'm just sort of like, why do I need to pass your test about my technical abilities when this wasn't even in technical review? It wasn't like an activity review. So again, I think this stuff exists in its own way, this sort of gatekeeping in our field. I think that this gatekeeping stuff does exist in our field and is prevalent. And certainly your own demographics and characteristics and life experiences, people have different stories, but on some degree, if me as a white guy is sitting here and is telling some of these stories, I mean, imagine for so many other people in our field who are moving around and rising and learning.

George Bull (15:53): Yeah. And I can think of a time in my experience where I was at a deep field camp in Antarctica and that's an environment where there's so many interpersonal dynamics that are occurring. It's, I guess, similar to being on a NOLS course or an Outward Bound course, like an extended period, right? I can think of times for sure from not explicitly the outdoor leadership when it was a safety critical situation and I was really put down a little bit after asking a question. And it's not necessarily an outdoor leadership context, but it is for sure a work context. And so I do think the higher stress scenarios, and reflecting on that, I think my superior actually in that moment was not very confident. And so I think that could be what we're seeing a little bit of here as we'll see is that the captain actually gets really confused later on and maybe is coping by projecting a ton of confidence.

Stuart Slay (16:56): I think about this sort of characteristic, right? I think I would be less surprised if it came from somebody younger and who was, let's say, a newer captain,

Stuart Slay (17:08): When I was a newer program director, some colleagues gave me feedback, some field instructors gave me feedback. They're like, Hey, the way that you are responding to one specific instructor is really off putting, and you're sort of shutting him down. And I didn't even realize it. I was like, oh my gosh, that's terrible. I didn't even realize I was doing that. And why am I even subconsciously doing that?

Stuart Slay (17:29): And so that was a point of awareness and growth for me that my colleagues felt safe enough to come and tell me that, which I was really appreciative. And I'm sure hopefully I did change and make a difference for that other instructor and hopefully they were appreciative too. But that's not necessarily what is happening in this case. The guy is significantly older and more experienced. Which is a really interesting thing and it's sort of harder for me to wrap my head around that, maybe because I'm not of that age and that experience level yet to really identify with that, other than being in a much more milder way on the other side of it as a younger person.

George Bull (18:10): Okay, something I want to get into a little bit here before we get into the approach and the accident itself is sort of the context more broadly of that captain first officer relationship. I know in the outdoor industry, that's also a pretty common setup, a lead instructor, assistant instructor, or lead guide, assistant guide, but I've seen organizations also that kind of don't do that. And I think we both have strong feelings on this topic. How do you feel about that concrete hierarchy or on-paper hierarchy in outdoor leadership contexts?

Stuart Slay (18:53): I am a big fan of the hierarchy. When it comes to two people or three people working in the field, in this really close relationship with safety critical responsibilities, I'm a fan of the hierarchy. I'm a fan of role clarity. And I've worked in many places and I have many clients that don't think the way that I think about this, which is okay, you can always disagree with me. Plenty of people do and there are plenty of people with good points. So that's all good. This is one that I feel really strongly about and it comes from the safety science stuff. And it comes from like parenting, it comes from psychology. And I'll tell you what those things are. But in terms of that hierarchy, even if you have the same experience level, then it's not so much about hierarchy as it is about role clarity. And so it's a really common default, right? So when you make staffing decisions to go, well, this person has more qualifications, this person has more experience, they are now in charge. And sometimes that's not necessarily the right way to do it either. Like you gotta consider burnout, you gotta consider sometimes personality or knowledge of the area, whatever it is, experience with the program. So that's not necessarily a good rule, like a blanket default too. But having that hierarchy, the other way to say is having that role clarity, goes a long way. Right. And so we love flat hierarchies. We love flat power dynamics in our field. We're all about egalitarian and stuff like this. And that's really important in a lot of ways for what we do. But this is one area where I don't believe it's as important. And so for example, everyone is responsible for safety, including the participants, including the parents, including the program directors, including both instructors and our guides. Everyone's responsible for safety but we really like single point accountability. And so when it comes down to making the safety critical decision, when it comes down to stepping into a role and fulfilling that role or performing when it matters most, we want that point to be really clear. And so we want to reduce the ambiguity out of that. Now, accountability can be delegated. You can have different accountabilities for different parts of the role and the function that needs to happen. For example, you have an incident commander. Yeah, they're accountable to that incident, delegating various strands of that to the field incident commander. The CEO is delegating some of that various strands. The CEO might make the ultimate decision. The CEO is always the most accountable or the single point of accountability. They might be delegating some of that to the incident commander, for example. So that's the safety science of it. We want really clear actions and decisions. We don't want to delay those with ambiguity. On the psychology side, in parenting, it's about role clarity as about asserting your care as an organization for these people doing those jobs. We want to reduce that ambiguity. We want to reduce the friction that it takes to figure it out, either in the moment or sometimes even beforehand. Because we know there's all these other social dynamics and peer pressures and blah, blah, blah that can slow that down and make it harder. And I've seen this as a program director with two co-instructors working in the field, and there's a longer story about a near miss on a river and they made some really bad decisions. The river was rising and they put kids on the water anyway. In fact they had them swim in the river and one co-instructor knew this was a bad idea but he didn't say anything. He perceived the decision to be a little bit more flat than it should have been. Well in hindsight and the review and what I learned from that is that my role as a director I should have had clear roles between them and their jobs and I should have had clear policies about what we do and therefore what we don't do on the river and in those circumstances. So the point is that when we have those clear structures, those clear policies, those clear roles, then we reduce the ambiguity and that is we're asserting our care for those people and our participants by doing that.

George Bull (23:08): That makes a lot of sense. I had a similar experience actually at an organization that I worked for as a program manager. And before I had stepped into a leadership role, we didn't have clear lead and not lead, essentially, on the trip, and all the communication was like it's a shared responsibility, safety's a shared responsibility. And I think that organization was not in any means lackluster on training. I thought out of organizations that I've worked with, it's really good, but that was always a touchy point because it's a little bit awkward, maybe, in the beginning, to have to, as a program manager, decide who is the lead. Especially when you're working with maybe 19 to 21 year olds who maybe have either big egos, there's a lot of big egos in outdoor leadership, and just that conversation can be a little bit more difficult to have. But for the exact reasons that you were saying, I implemented that, the lead trip leader designation. And essentially the way I communicated it was we need to have someone's name on this piece of paper. And in a safety critical moment, there needs to be lower friction for someone to step up and make a decision. I think we both agree that someone needs to be accountable for those decisions that are made in the field. If that leader is about to make a decision that is the wrong decision, or that the co-guide or assistant guide feels really strongly is the wrong decision, what is the role of that assistant in that case, in your eyes?

Stuart Slay (24:54): This goes back to everyone has responsibility. Yeah, the lead instructor might be accountable to those decisions. And if they're making the wrong decision, then the assistant or the secondary person has a responsibility to intervene in some way. I don't mean take over. I don't mean whatever time down and do whatever they want. But they have a responsibility to raise the questions and to say something, slow it down in some way, pause in some way, go deeper into a conversation in some way. In the case of the river accident or a near miss that I was telling you about, this sort of happened, and what the assistant instructor did, he was really good boater, and he volunteered to set safety. And he actually is the one that saved the whole incident, started picking up kids out of the river and was really good. He's just a really strong boater and was able to do that. Thank God. But that was his way of interjecting and okay, what can I do with what I'm working with to make this better? Ideally, you can slow it down even more and not even make that bad decision. But it's a hard thing to do. And there's a lot of literature out there about speaking up and about safety voice, and it's good to do a little mini audit of your organization and your staff about safety voice and the ability to speak up and how safe it feels to speak up.

George Bull (26:32): Talking about the approach and accident sequence here, a little bit under an hour into the flight, the crew began their descent and approach into Islamabad. And before we get into the continuation of the human factor side, I do want to cover a few aviation terms and things, just so that our viewers can follow along a little bit more easily. But you can see on the left-hand side of this slide here that approach path. And that blue dotted line is what you would expect to see for what's called a circling approach. A circling approach, and you can see they're coming in and then they're gonna turn, make that right turn, and then circle around back to the airport to land on that one-two side of the runway. That type of approach is used at this airport when visibility is really poor. Today the visibility was really poor. Post-flight analysis has said that it probably was too poor to even try this circling approach. But a key piece of the circling approach is that you have to keep the airport in sight for the entirety of the approach. And so they're using their instruments, they're doing that instrument approach up until they get to that point where they're breaking off right from the approach. So essentially they're doing the published instrument approach to runway 3-0. And then they're breaking off, but keeping visual contact with the airport for that whole loop there back into the runway one-two side. Something that I want to call attention to as well is which side of the aircraft does the captain sit on?

Stuart Slay (28:16): He sits on the left side.

George Bull (28:17): He sits on the left side. And so when you're doing this type of approach, from the right side of the plane, the first officer probably can't see the airport regardless, because it's down and to the left. And so the only person in the cockpit who would even be able to see the airport is the captain. And that's also gonna play a role in the future, during this incident, because we'll see the first officer asking the captain, can you see the airport? And the captain kind of like, yeah, okay. But it's just that power dynamics even higher than it would be otherwise here, because not only is it asymmetric experience, but it's also asymmetric information. So getting into the approach sequence here, the minimum safe altitude around this airport is 2,500 feet. That's the minimum altitude you're allowed to descend to, and as long as you stay kind of close to the airport and above 2,500 feet, you shouldn't hit anything. That's kind of the idea behind that minimum safe altitude. During the descent, the captain selects 2,300 feet. In that moment, the first officer actually corrects him and says, hey, the minimum safe altitude is 2,500 feet. And so we should correct it back up to 2,500 feet. What do you feel like this is showing in the cockpit at this point, that dynamic of the captain selecting an altitude lower than the minimum safe altitude?

Stuart Slay (29:46): Yeah, there's so much interesting stuff going on with this captain. He gets in the cockpit and he starts drilling his colleague and his co-worker. And then he has a flight plan. The company says, this is how you're supposed to land at this airport. It's a tricky airport to land at. And there's all these protocols in place, is exactly how you do it. This is what works, much every time. Air traffic control, they give direction on that type of stuff as well. And time again, decision after decision, it's clear that the pilot was on his own plan. He was doing his own thing. So he goes a different way. He goes right instead of left, for example. He goes low instead of high, for example. And he's just on his own path, making his own decisions.

George Bull (30:31): Yeah, it is really interesting. You can see also on the screen here that PBD 10 and PBD11, those were the captain's waypoints that he asked the first officer to punch in before starting the descent, and the first officer did without questioning. Those waypoints there are not the published approach. You can see that that blue line, which is much closer to the airport, is the published approach. And so those waypoints that the captain asked the first officer to punch in or essentially his made-up approach to the airport. And you can see especially here, PBD 11 takes them really close to those mountains that are outside of that safety zone of the airport where it would be safe to even be at 2,500 feet.

Stuart Slay (31:19): He plots his own course. Oh my gosh, what can we take away of this in terms of Outdoor Ed? Have a protected itinerary, you sort of know more or less where you're supposed to be. And instead of going north to your pickup, you just go south because why not? You've never been there, it's a cool place. Let's just take him there. So there's just so many interesting things in terms of this. And obviously there's a lot going on with this captain. But if we sort of generalize and we can take away what's relevant for us, what really sticks out for me in terms of safety science is this concept of local rationality versus following the procedure, following what's written, following what you're supposed to do or what's prescribed for you to do. And I bring this up because it's a tension. As our field, we learn more from aviation and safety science and so on. We learn more about systems thinking. That's what they're calling safety three. There's a lot of stuff you can listen to out there about safety one and safety two. Well, systems thinking is that safety three. Scientists sort of coined that term in 2020 or 2021. And we used to really say, well, you got to do one or the other. Systems thinking came around and really took hold in the 20 teens and we said, oh my gosh, this is the way to do it. But as time goes on, we're going, actually, we got to do all of them. We got to do all three. And that's the sort of art to the science. So sort of art of risk management is when am I doing which ones? And this is a tension that I felt as a program director or as a risk management director to when I feel consulting and what I do now. And it's a question that I get a lot. And the basis of it is local rationality. Okay. I'm supposed to prioritize and really lean on what makes sense at the time and at the place and their good judgment. But also sometimes their judgment is not good, like in this case. We do have these written things for a reason. We do want people to follow these things. So help me navigate that, that's the question that I get, that's the tension that I felt. Lawyers and executives would tell me all the time, no, no, your job is to make sure that people follow. That's the sort of cop part of the job, this sort of compliance officer part of the job. And I would always sort of push back and say, they're going to have really good judgment and we should be learning from that judgment. And that's also true. So there's elements of both of these that are true. So in this case, we would say that this pilot, I'm putting in air quotes here, local rationality, was not good. He did not have good judgment. He should have been following the protocols and there were many protocols that he broke. And it's really clear in the accident investigation, he even admits to doing that.

George Bull (34:05): And you can see here from that red course on the map, the actual course that the flight took, that they didn't even fly the plan that the captain had plan for. So he made his own plan and then didn't even stick with that plan. They were late making that right turn. And as we look at the voice recorder and the ATC recordings here, during that moment, as they're making that right turn to decide to continue with this circling approach, just a little while earlier, a China Southern Airlines flight had diverted to another airport. And a Pakistani International Airlines flight, after three attempts and over 30 minutes of trying to land, did end up being able to land at the airport. And the captain at this point calls up the control tower to confirm that that PIA flight who's their competitor was able to land, and the control tower confirms, yes, that flight did end up landing here. When I read that I thought of Summit Fever. Like if you were a guide in that scenario and other guides are taking their clients up to the top of a mountain, and you have safety reservations, but hey, if everyone else, if other clients are going up this mountain with their guides, how does that make me look if I don't do that?

Stuart Slay (35:31): What it sort of draws for me is goals. And this question of local rationality, do we really trust their judgment and are they going to tell us and do what's best versus are they going to follow the written protocols and expectations as they are. And in terms of navigating that as a program administrator and as a safety leader. Goals can be a helpful way. And so what is the ultimate goal? And are we on the same page about the goal? Is the goal to reach the summit? Is the goal to, I don't know, I'm not a pilot, I'm not sure what the guy's goals were obviously. I'm sure he wanted to land the plane and not die that day. But it was his goal to plot his own course in bad weather and adverse weather and because he's a skilled pilot, or something like this. So in terms of safety science, always going back to the goals of the system. So are those goals clear?

George Bull (36:30): So continuing on after the initial right turn here on this red track, we can see that they extend out far beyond that blue dotted line, which is where they would expect to be. They're having trouble seeing in the cockpit. The first officer is asking the captain at this point, hey, can you still see the airport? Because from the first officer's perspective on the right, he's like, this weather is awful, I don't think you can see the airport, essentially, is sort of the way that it seemed like he was meaning that question, but what he really said was, can you still see the airport? And the captain dismissively said, airport okay yes, not really engaging with that line of discussion. And at that point also the air traffic control calls, because they can't see the plane anymore, and suggests that the plane flies a missed approach or does the published kind of diversion movement to maybe try again or go to another airport, to get them to safety. And I don't know if you noticed from the incident report what the captain's response to that was.

Stuart Slay (37:52): I think he said something on the flight recorder like, they can say whatever they want. Or something

Stuart Slay (37:59): like this, right?

George Bull (38:00): Let him say whatever he wants to say. Yeah. How does that sit with you?

Stuart Slay (38:12): Can't tell you how many times in the field I've heard something similar to this. Whether it's a radio thing or direction you get on the radio or written policy or we're supposed to do this, but you know what, I just really feel like doing this other thing. I really feel like jumping off that higher rock right now. Something like this. What this really reminds me of, Jeff Jackson has a bunch of really good papers about safety culture in our field. And in one of those papers somewhere, he talks about how our field is unique in terms of other safety critical fields. Because our staff on wilderness expeditions are completely unsupervised, which is not normal. Think about nuclear power or transportation or healthcare. Supervision is right there in the room.

Stuart Slay (39:07): Aviation is interesting one. And I don't really know, this is a question for an aviation expert, they would say it's unsupervised because they're pretty much always in contact, right? With air traffic control and this type of thing. And that was certainly the case here, but there's an element of that crew is unsupervised and they should be doing what they're trained to do. And working within the parameters that it's given, just like in our field. But it's much more possible to deviate when your boss isn't standing over your shoulder or in the room with you, as in this case. So that's always an interesting thing that comes up. Again, I'm going to lean on Jeff Jackson here, another thing I've always taken away from his work is he'll say, safety culture, this is the best definition of safety culture that I've ever heard, which is it's about the way that we do work here. And so this pilot, if you look at this pilot's history, previously, he aged out. You have to retire or leave when you're 60, as previous company. He ages out and he comes, so it's his first year, I think, at this new company. And what we don't know is the safety culture or some of the cultural traits of either of these organizations. And so the report sort of talks about it as a personality thing, and this guy's pretty much a jerk, and that's what his behavior shows. But we don't know why he's a jerk. We don't know if it's sort of in the water that he was coming from or in the water that he's in now for this new organization.

George Bull (40:39): Yeah, that's a great point. I think something too that I think about is, I'm sure you've done research on this throughout your career, but in the nineteen eighties, those air accidents that led to the creation of CRM or crew resource management in aviation. And this is 30 years after that. That's something I'm thinking about as I'm reading this is, this type of behavior, it's well known and trained in the industry that this is not a way to maintain a good relationship in the cockpit. Continuing on, at this point, we're about 70 seconds from impact and things start happening really fast. We're here on the slide in this final line towards impact. And the first audible warning says, terrain ahead. And pilots are trained to, when you hear a proximity warning, it's called a ground proximity warning system, it's not supposed to be like a conversation even at that point. It's basically you full throttle and pull up. And that's what they're trained to do essentially, you hear terrain ahead, you hear pull up terrain, which are both warnings that are played throughout the cockpit, and you're not really supposed to think about it. You're supposed to full throttle and pull up on the stick. It's the first of 21 audible terrain warnings from the aircraft in the next 70 seconds. And the first officer said, sir, the higher ground is reached. There's terrain ahead. Turn left. They see that terrain on their radar, and he's saying, do something, to the captain. At this point there's a lot of confusion in the cockpit, and we'll get on to the confusion piece in just a second here. But how does that moment relate to you in the outdoor industry, where there's a warning coming from the aircraft, and the first officer in this case sees fully clearly there's a problem here. In a training environment, it's likely that this pilot was trained in this scenario to probably just take the stick and execute that maneuver. There's many reasons why that may not have happened, and that's something that I wanted your input on here, in that moment when the first officer is recognizing this is a really serious emergency and is telling the captain that.

Stuart Slay (43:24): Yeah, this is the final critical moments and there's all these things that have sort of stacked up and happened that lead to this. And so if you were to zoom in from the outside, you get a red flag warning like this, you're trained to do something, you're trained to do some maneuver, go left, go right, go up, whatever it is, quickly intervene, yet it doesn't happen. So just looking at that in isolation, you might go, man, that guy really messed up. He should have done something. He should have known better. He didn't follow his training. But this is a red flag warning. Think about panic and your amygdala, right? It's like swollen. Look at some of Debiango's work and Claire Dalot's work about working under pressure and not really high stress like that. And this is what's happening. And so you sort of freeze, right? That's also a normal response. But also let's dig into why he froze or why it got so chaotic in those last final seconds. You have all the stimulus, all this input and just look at the water that again, the first officer was swimming in. Just minutes ago, he was being berated and drilled about his experience. He's been belittled. He's been humiliated in front of this pilot that he's probably just met and is now sitting next to. And there's been a series of decisions and things where I think at one point he sort of does speak up and he gets shut down. And then the report talks about, he doesn't really ever speak up again. And actually what I thought was really interesting out of the investigation is they said, well, he should have, he obviously felt comfortable to speak up. He did it once. I'm like, well, not really. He did it once and he got shut down and he didn't do it again. And so, for us to really understand, and this has a little bit to do with local rationality again, of putting ourselves in that situation. What is it like to be that first officer? Was it really safe to speak up? And it was really prime to follow his training and to grab the sticks and do something. So it's a really interesting point. The other point that this brings up to me is, how I started to look into this stuff was through culture. In grad school, I looked at culture and national culture. And my question was, how does national culture influence or impact risk management for outdoor programs? And so there's a bunch of really good studies from the nineties and the early two thousands that dove into this stuff. So there's some cultural traits about hierarchy and relationships. So in some cultures, it's normal to have a bigger power distance. In other cultures, like Western, like in the US, it's normal to have flatter distances. Also these aircraft, aviation is Western in concept and in design. And so these aircraft are designed with that flat hierarchy in mind. And so there's a really good study from the early 2000s, or I think it was published in 2000, where they looked at the physical layout of the cockpit and does it make sense for all cultures. And so in the West, we would say, yeah, we should put critical controls in the middle between the two pilots. So they both feel comfortable to reach over and grab it and do something. They both feel comfortable to speak up. And that's sort of their obligation to speak up, we were talking about before. And this paper really said, well, maybe that's not true for all cultural environments. And so if we want the co-pilot to be more likely to speak up or to do something or to intervene in a safety critical moment, then actually we should put the critical controls facing away from each other. And they would be more likely and better set up and feel safer to reach over and quickly intervene that way. So I always thought that was kind of an interesting way to think about it. Think about the way that the world is designed and what we expect people to do and how we design work in physical environments to do the job. And does it really make the most sense considering the water that we swim in?

George Bull (47:24): In this case specifically, and we didn't really get too into this, the systems thinking and things, but there is a moment here right at the end where the captain thinks that he's on an autopilot mode where twisting a knob in the middle of the cockpit is turning the aircraft. And so as the first officer is saying, turn left, turn left, the captain's turning the autopilot knob to the left, but he's actually not in the right autopilot mode for that to be doing anything. And what they needed to do in that moment was pull a button, pull out on the little knob that's right between them. And as you're saying, the first officer here clearly recognizes that they're not turning left. And that's why he's repeatedly like, turn left, pull up. And the captain thinks he's doing something, but isn't. And I'm sure in that moment, 21 different warnings going off and extremely chaotic, but yeah, like you said, that button in this case happened to be in the middle right between them and it's a button that the captain's already working with at that moment.

Stuart Slay (48:30): Going back to the culture stuff, there's a bunch of papers and research about automation and aviation, but in other places too, but especially in aviation. So in grad school, I really looked at one specific case study involving Asian flight from Korea and it goes and it lands in San Francisco. Well, it doesn't land very well and tragedy ensues. And also I like that case study because I was flying that route a lot at the time and so I remember that one being in the news and being like, oh my gosh, maybe I'll fly to a different airport or a different airline this week. But it has to do with the autothrottle. And again, the pilots thought the autothrottle was engaged when it wasn't or something like this. But the papers, in terms of culture and looking at it that way and again, culture is embedded in the things that we build and design. So aviation, and in that case, it was a Boeing aircraft, 100 % designed in the US and built in the US. And so all those cultural traits embedded in that design. Well, there's a preference for manual control over automation versus what all these psychologists and sociologists find is that in the East, there's a preference for automation over manual control. And so it can be confusing for pilots who now have to code switch. And they have to, what are they naturally reliant and thinking about and doing? And it's more friction, right? When you have to work with a different system, the same is true for our field. And this is one that I don't think we talk about very much. Because what I always like about aviation in terms of outdoor education and what we do is that there's so many similarities. And look at crew resource management that you brought up before. We've learned a lot of that stuff and applied it from aviation. Look at staffing and pilots in the way that that works and how they work together and how they're supervised. Look at our field in terms of concept and design and what we do, what we're learning about ourselves and others, our relationship with nature, therefore our protocols, our concepts around good leadership and what we teach and practice. Nearly all of that stuff is heavily, heavily weighted in a Western paradigm of thinking. But what we do is we work in an international sector. We're moving around and mastering all the time. You and I and so many other people, we work abroad and we take all these assumptions, all these things. We take those protocols, take those plans and we apply them in other environments with people with different cultural backgrounds in our own. But we don't necessarily think about how confusing and how much friction there is for those other

Stuart Slay (51:16): people to really work within that system. So anyway, I always find that really interesting. I don't know. No aviation expert that I know has looked into this case study from a cultural perspective. But there's a lot of similarities from some of the other stuff. And I think there's good stuff for us in that way.

George Bull (51:38): Yeah. And for our listeners, if you're interested in another study, I think from another Pakistani airline actually, that does have some more cultural investigations, about ten years later there was a PIA flight eight three zero three. And some information came out during that investigation that we're not gonna get too deep into on this episode, but that did have to do with Pakistani training habits and some cultural things there too. And so if you're interested in looking into that as a listener, that would be where we'd point you a little bit.

Stuart Slay (52:16): If you choose to go down that path and read that stuff, which I think that you should, there's one thing that I'm always reminded of and I remind myself of as you go down the culture path. Which is that when it comes to risk management and safety and culture and how national culture plays a part, it's not about diagnosing the person. And culture has never intended to be a lens to diagnose the person because we're all individuals. We all have our own individual traits. Like this pilot, for example, sounds like he was just a jerk. Like there's nothing in Pakistani culture that would say, you're a jerk. You know, that's how you work with each other. And so we look at culture as a lens to understand larger trends and patterns. We look at culture to understand what is the context and the social context that people work in and work with each other in and the social context they relate to themselves in. So it's helpful in that way. It's almost like astrology or like looking at the stars. Or you might look at a collection of stars and go, that's a collection of stars. We might look a little deeper and go, I can see if we drew lines here, this is the shape of a bear or the shape of a dragon. And that's how I view culture. We can look at it and it can start to tell stories and just sort of help us make sense of things and be a guiding light, not necessarily a diagnosis. I'm gonna keep going just for a minute, because I'm really passionate about this topic.

Stuart Slay (53:44): There's a really popular book out there that's been around for a while by Malcolm Gladwell called Outliers. And in it, he talks about aviation, just like we are. He talks about Korean culture. And what he says is that Korean culture is so much more dangerous when it comes to aviation for all these cultural reasons, all the things we already talked about, power distance and hierarchy and so on. And that's where his analysis sort of ends. And that's always sat with me in a really funny way, certainly after living for a decade in Korea or working for a decade in Korea and this sort of thing. But it's always sort of sat with me in a funny way, part of what I went to pursue in graduate school. And my big takeaway from that is that his analysis didn't go deep enough because he didn't consider all the cultural traits that are embedded in the design of the waters that they swim in when it comes to putting on their captain's hat and jumping in the seat, like the cockpit layout or emergency protocols. Let's go back to who's supposed to do what in an emergency. Well, if you buy Boeing's training curriculum, the protocols are built around function and what you do. And so whoever's closest to the fire alarm should pull the fire alarm. But that's ambiguity when you apply that in a cultural environment where the roles are much more clear typically. So we can't just look at culture in isolation and the culture of the people involved. You have to look at the culture of the system as it's designed.

George Bull (55:19): Yeah, that's a great point. So as we get into the final seconds of this flight, essentially they do eventually get the autopilot sorted out. Still, up until just seconds before impact, neither pilot actually touched the flight controls. The autopilot by that point was not operating the way that they thought it was, and it actually turned them closer to the mountain because they had turned that knob so far in trying to get it to turn left that the heading was actually to the right. And in the last moments the captain did do a little bit of an input on the stick, but it was not sufficient, and they ended up impacting the terrain and tragically every life on board was lost. Something that those final moments remind me of a bit, and I think this is really relevant to the outdoor industry as well, is this escalation continuum, and the acronym for it is PACE, P-A-C-E. It was developed by an airline pilot and researcher, Robert Besco, but is now trained throughout aviation and healthcare and other safety critical fields. But it's something that I've seen in my own life as well and I imagine you have too Stu, but essentially it's probe, alert, challenge, and escalate or emergency. And what this could look like is the continuum that a more junior person typically will engage with a superior when they see that something is wrong. And we see it mapped really well to this incident, it just doesn't go all the way to the end there, but initially, a subordinate might probe. So in this example, it was like, hey, can you still see the runway? Because they're supposed to still be able to see the runway. And so the first officer's saying, can you still see the runway? You're not telling him to do anything, you're not really challenging, but you're saying, can you still see the runway? And I can see this, I know I've done it myself as a field guide. So after the probe, the next step in the process would be to alert. And so that's to actually state out loud what the issue might be. So in this case, it's 70 seconds before impact, that first officer said, hey, there's terrain ahead. You're not necessarily taking control, you're not even stating a specific thing for that person to do, but you're just noting it. You're saying, hey, there's terrain ahead. I'm thinking of something like a river crossing in the outdoor industry, where maybe initially you'd see a river that's too high or too fast, and you might ask your lead instructor, hey, what are our river crossing guidelines again? Or what's the fastest current that we're supposed to cross, river at walking pace? You know what I mean? Something like that, where you're not actually saying,

George Bull (58:36): hey, I feel unsafe.

Stuart Slay (58:37): Yeah, totally. The avalanche industry does a really good job of training people this way. And so in this case with aviation and so on, we just expect that people will sort of do this. And it sounds like researchers have identified this is the kind of normal pattern. And I remember from all the avalanche training and how people work together and how guides work together, you're just walking around commenting on things that you see. It's like when my nephew was like two years old. And I would just walk, even less than that. And he was on my chest, in the little carrier, and walk around the park, I'd be like, oh, look, that's green. And my mom, who has a PhD in education, she's like, this is what you should do with a child at stage. Out colors, point out things that you can see and just sort of narrate the world around you. That's what it reminds me of. And so the avalanche industry has done such a good job of training people to go, you're just commenting on stuff that you see. You're building a shared brain. And it's like priming for these next levels of PACE, of like, do you see this wind crust? Looks like the sun on this aspect is doing this, or do you see those roller balls over there? You could apply this to anything. Do you see that boulder upstream? Do you see how it looks like on that rock, the water has dropped a little bit overnight. Just observations, and you're building that shared brain. Same thing socially. Oh, did you see so and so in the group? They made that funny comment, or they're a little bit different today. I don't know, I don't know what's going on, I can't quite figure it out. What do you notice about that? And just sort of building that shared brain.

George Bull (1:00:13): Yeah, exactly. And I feel like we do this, this is now something that's been recognized as how people act and also as being trained as a way to act. But I feel like, like you're saying, we do this innately almost, at least in a Western culture.

Stuart Slay (1:00:31): I was told once that because I'm American, I love to share my opinion. And then I was like,

Stuart Slay (1:00:39): my gosh, is that true? And everyone at the table was like, yes, Americans love to tell me what they think. I was like, my gosh, I'm so sorry. And it's true. We're just sort of primed. And also with small talk, we're sort of primed in the U.S. I always find this interesting. My wife and I talk about this when we come back from Asia, we come back to the US and we're like, man, people are so chatty. It's so true. We just love to make small talk and talk about the weather. But this is where, especially in those different cultural contexts and environments, you do have to train people to do this. The avalanche industry, I think they have it right in this. I think there's a lot we can learn from this. Again, the waters that you swim in. I'm putting on my work hat today. I'm putting on my guide hat. And so I'm going to comment about the weather and things that I see. And this is the normal part of what it means to go to work every day with somebody.

George Bull (1:01:30): Yeah, absolutely. The third step here then would be challenge. And as we saw with this incident, in the last minute of the crash, the first officer was saying, Sir, turn left, sir, pull up repeatedly. And so he did make it to the third step of PACE, which is the challenge to the captain's authority, like, hey, I'm telling you what to do now. You need to do this. And unfortunately in this case, that last step, that escalation or emergency step, which is where you're supposed to just say what you're doing and do it, is that last step in PACE which is like, I'm taking controls, I'm pulling up, and then you would do it. And in this case, that first officer didn't make it to that fourth step.

Stuart Slay (1:02:20): It's sort of like in that example I gave earlier, the river story, I was a program director and everybody got swept downstream.

Stuart Slay (1:02:27): And that instructor was like, okay, well, I'm going to set safety. And that was his decision. He sort of announced it and he went and he did it. And again, thank God that he did. And he was such a good builder and they really pick everybody up. I could see how that could apply even further upstream, whereas in this plane crash, it was too late to get to that sea.

George Bull (1:02:49): Yeah. And maybe something I think about when I think of this crash is that first hour of berating the first officer and that breakdown in the power dynamic could have had an impact on the first officer's ability to actually get to that escalation step in the moment.

George Bull (1:03:12): If you had one thing from this case study that you wanted, whether you're a first-year assistant trip leader at a summer camp or the executive director of a national organization or international school, what would be something that could be a takeaway from this?

Stuart Slay (1:03:31): There's so many good leadership examples and lessons from this. And then in my space, I spent a lot of time in the systems thinking world, and looking at organizational stuff and the context that organizations make decisions and so on. And there's some of those takeaways for sure, especially when it comes to culture and some of these other things. But the leadership space and the psychological safety, the context, again, the waters that people swim in and what they show up to work in, there's so many good takeaways from that. I think if I was to deliver a staff training tomorrow, I could easily incorporate this. Presenting this as a case study very briefly, this plane crashed because the pilots, one belittled the other, and that investigation said, actually, yeah, he shouldn't have belittled him, but also the copilot should have spoken up. He should have done more. And he had a responsibility to do something. And so here's the question, staff, was that his fault? Did he contribute to this accident? And I would be curious what they would say. But you could draw learnings out of that in terms of the escalation continuum like you talked about. But you could draw it out in terms of leadership and asserting your care and that sort of thing. And you could draw it out in terms of speaking up and having responsibility. And so yes, you do have a responsibility to intervene when it's safety critical. If you are that leader, don't be a jerk. I think most people listening will probably go, well, yeah, why would I be a jerk as a leader? And so organizationally, what is the waters that people are swimming in when they go to practice their leadership and to work with each other? And how are you as an organization asserting your care over things like role clarity, over things like policies and procedures and training, and the tools to navigate that conflict when it does come up, like PACE, for example? And so how are you setting people up to work with each other? What's your takeaway for leadership? What would you want, if you were to go train staff, what would be the takeaway from this case study for you?

George Bull (1:05:42): I think a big takeaway, especially with working with younger staff or newer trip leaders, is empowering people to grab the stick, to make sure that they know. There's a difference maybe between accountability and responsibility sometimes. But even if your name isn't on the briefing form as the lead trip leader, you do need to grab that stick. If you see something, as we saw from this accident, it's vital that you do something. And I think, from the flip side, of course you're also training the leaders, and the goal could be make it as easy as possible for your co-guides to escalate when they need to, maintain that good relationship.

Stuart Slay (1:06:38): Yeah, nice. Good takeaways for everybody.

George Bull (1:06:40): All right, well, a huge thank you to Stuart Slay for joining us here on our first Field Debrief podcast. Stu, if people want to find you or your work, where can they look?

Stuart Slay (1:06:53): You can check out my website, it's probably the easiest thing that you can do. I'm on LinkedIn as well, but my website is SlayRisk.com.

George Bull (1:07:00): Awesome. Thanks again, Stu. This was fun.

Stuart Slay (1:07:03): Yeah, that was fun, George. Thanks.