Groups and Wisdom I

January 14, 2007
Posted by Jay Livingston

On Friday, The Washington Post published an article about a plane crash that occurred twenty-five years ago. The plane hadn’t been properly de-iced, and it barely lifted off the ground before crashing into a bridge.

The moral of the story, though, is not about ice but about group structure and culture, especially as these shape lines of communication. The Post calls it “a textbook example of what can go wrong when pilots do not communicate and listen properly.” As the plane was moving down the runway, the co-pilot looked at the instrument panel and said, “God, look at that thing, That doesn't seem right, does it?” He repeated his reservation, but the pilot ignored him.

At the time, the accepted way of doing things, the cockpit culture, was an authoritarian one with the captain at the top. This culture made it more likely that the captain would not hear information coming up from others and less likely that those below would speak up loudly enough to make sure they were heard.

The pilot and co-pilot in the doomed plane were “residue of an era when fighter jocks from World War II and Korea flew for the airlines. In that gung-ho environment, captains were always right. They did not need advice, and co-pilots and other crew members often were afraid to assert themselves.”

The crash led to an industry-wide attempt to change cockpit culture. Now the pilot has a checklist of conditions and readings that he and the others must review, and he has to listen closely to what others report about these items. Hospitals have tried to put a similar system in operating rooms, and in both of these places, the last checklist item is, “If anyone sees any red flags, something they are uncomfortable with, bring it to my attention.”

There’s a more general sociological truth here, one that decades of case studies and small-group experiments have shown. Authoritarian systems are very efficient for doing routine tasks in unchanging environments. But when the situation changes, centralized authoritarian structures are accidents waiting to happen. They are inflexible, mostly because the top people are reluctant to change their ways and ideas, especially if these ideas seem to have been working. Often, people lower in the system have helpful ideas for dealing with the new circumstances, but the people at the top don’t pay attention or dismiss the ideas as unworkable. By contrast, democratic systems, with information flowing freely in all directions, are much better at adapting to change.

The Post mentions only cockpits and operating rooms. But the timing of the story is interesting. The story didn’t describe pilots and surgeons as “staying the course” despite negative information, but the Post ran it only a day or two after President Bush announced his intention to put even more effort and troops into his Iraq policy, essentially ignoring information and recommendations from a variety of other voices including members of the Iraq Study Group, the military, and Congressional Republicans, and an overwhelming majority of the US population.

(Hat tip to Mark Kleiman at The Reality Based Community for catching this story.)