Black Box Thinking

by Matthew Syed

  This was challenging, but by no means disastrous. Up at 8,000 feet, planes are typically traveling at around 240 knots. At touchdown, this has to be reduced to around 140 knots, otherwise the brakes would not be able to prevent the plane piling through the end of the runway. Speed is steadily reduced during the approach by taking off the thrust from the engine and using the flaps. This takes a certain number of “track miles” to complete.

  But the distance had now been shortened by twenty-five miles. The workload in the cabin had ramped up significantly. They had to retrieve new graphs from the loose-leaf file and create a new mental model of their approach. There was also a 10-knot tailwind, putting even more pressure on time. The smooth interaction of the crew was becoming strained.

  And then there was another unexpected problem. Outside Heathrow there are color-coded approach lights that appear like a Christmas tree on the ground, guiding the pilot visually toward the touchdown zone. ATC radioed to say that some of these lights were not functioning. This hardly mattered, given that there was no external visibility anyway. But protocol demanded that Leversha go through the checklist at the very moment he was reaching overload.

  Then yet another problem: they were cleared to land dangerously late. The thick fog meant that an unusual number of planes were circling above Heathrow, reducing the distance between aircraft coming into land. Air Traffic Control was under pressure. They were making the best of an increasingly fraught situation. It was later established that clearance for November Oscar was given later than regulations permitted. A hurried landing was being pushed to its absolute limits.

  But probably none of this would have mattered except for the last problem in a long chain of unforeseen events. Stewart, exhausted and under mounting pressure, unable to see anything but white fog outside his windows, focused his eyes on the instruments. The two radio beams at the far end of the runway were now sending out lateral and vertical guidance, crucial for November Oscar to calibrate its approach onto the correct path.

  But the autopilot didn’t seem to be capturing the lateral signal. It is almost certain that an Air France plane, still on the runway at Heathrow due to the squeezed distance between incoming aircraft, was deflecting the beam. Stewart, who had a low opinion of the Boeing 747 automatic functions, was straining his eyes at the localizer and glidescope, the internal instruments that should have been picking up the signals.

  The flight was now dropping through the London sky at 700 feet per minute. It was traveling at close to 200 mph. The tension in the cockpit was intense. But the autopilot was not locking on to the radio signal; instead it was “hemstitching.” As the journalist Stephan Wilkinson wrote in his report on the incident, the plane was “trundling back and forth through the localizer beam like a clumsy bloodhound not quite able to catch the scent.”

  The plane had now gone through the 1,000-foot legal minimum. Technically, Stewart was outside regulations. Nobody in the cockpit knew it, but the plane was deviating beyond the perimeter fence, and was rapidly converging with the long line of hotels that run alongside the Bath Road. According to protocol, Stewart should have been ordering a go-around.

  But he was exhausted. Fuel was critical. His first officer was still dazed with illness and, besides, was not qualified to assist. A go-around itself was not a risk-free option. Air traffic control had earlier indicated that the fog was lifting, causing Leversha to later argue that this entitled Stewart to wait a crucial few heartbeats to see if the plane broke out of the fog, allowing him to target the runway visually.

  Moments later, the plane was at 250 feet. The roof of the Penta Hotel was less than six seconds from impact. Stewart was straining his eyes through the cockpit window, frantically seeking out the white lights of the runway through the morning mist. The 255 passengers were oblivious to the looming catastrophe. Even Carol Leversha, reading a novel by Dean Koontz in the jump seat of the cockpit, hadn’t grasped the peril of the situation, or how close they were to disaster.

  At 125 feet aboveground Stewart finally ordered a go-around. Protocols dictate that he should have pulled up as rapidly as possible (insiders call this the “minimum height loss technique”), but he was a little slow. The plane dropped another fifty feet as the engines revved into life. Investigators would later establish that the undercarriage of the 200 ton jet, traveling at close to 200 mph through the London fog, came within five feet of the roof of the Penta Hotel.

  After the go-around the plane, as we now know, landed safely and smoothly. The passengers, as already noted, applauded. Luffingham noticed that Stewart’s hands were trembling. They were just a few minutes behind schedule. Stewart, who sincerely believed that he had done his best in the most trying conditions he had ever experienced as a pilot, breathed deeply and closed his eyes for a moment or two as if in prayer.

  Now, was Stewart to blame? Was he culpable? Or was he reacting to a series of difficulties that nobody could have anticipated in advance?

  In the summary version of the incident, Stewart seemed blameworthy. After all, he did fly the plane below the height required in the regulations. But when we explore the context with a little more tenacity, a new perspective emerges. We see the subtle factors lurking in the background. We get a sense of the high-pressure reality faced by Stewart as he confronted a series of unforeseen incidents. Suddenly he seems like a pilot doing his best in testing circumstances. He may not have acted perfectly, but he certainly doesn’t seem to have acted like a criminal either.

  I have spoken to dozens of pilots, investigators, and regulators about the November Oscar incident and, although perspectives vary, there is a broad consensus that it was a mistake to pin the blame on Stewart. It was wrong of British Airways to censure him and for the lawyers at the CAA to put him on trial. Why? Because if pilots anticipate being blamed unfairly, they will not make the reports on their own mistakes and near misses, thus suppressing the precious information that has driven aviation’s remarkable safety record. This is why blame should never be apportioned for reasons of corporate or political expediency, but only ever after a proper investigation by experts with a ground-level understanding of the complexity in which professionals operate.

  The jury did their best to make up their minds on the facts, but it is not easy while sitting in a staid courtroom to make a judgment about split-second decisions made in the cockpit of a 200-ton jumbo jet flying through thick fog at nearly 200 mph.

  But if the Oscar November incident shows anything, it is just how easy it is to engage in the blame game. A tragedy very nearly happened, therefore someone had to be punished. Aviation is generally an industry with an empowering attitude toward error, and is rightly considered a leader when it comes to having a just culture. It rarely engages in blame and uses mistakes to drive learning. This is worth reemphasizing because the case of William Glen Stewart should not obscure the lessons we learned from aviation in Part 1 of the book.

  But what the Oscar November incident reveals is that even a pioneering industry like aviation is not completely immune from the blame tendency. And perhaps it exposes, more than anything, just how far we need to travel to eradicate the blame instinct once and for all.

  • • •

  On a cold winter morning, I visited Brian Leversha, the flight engineer, and his wife Carol. Leversha had left British Airways in the aftermath of the event out of sadness for the way he and his fellow crew members had been treated. The couple have lived for the last three decades in a rural retreat, forty miles from London.

  Leversha has had more than twenty years to reflect on the most infamous near-miss event in British aviation history. He spent much of our time together talking about his friend William Glen Stewart, the pilot who had been criminalized. “Such a lovely guy, so decent and thoughtful,” Leversha said. “He was old-school in his manners and his sense of duty.”

  In his sentencing the trial judge had given Stewart a choice between a £2,000 fine or 45
days in prison: he took the former. “The leniency of the sentence reflected the fact that the judge didn’t think the case should ever have been brought to trial,” Leversha said. “But Glen was deeply hurt by the affair. He was humiliated by the trial and the conviction. He was such a gracious man. Just three days after the incident, he wrote to me and the co-pilot taking full responsibility.”

  Leversha passed me a cardboard box, ten inches thick with papers, notes, and reports relating to the incident. Over the next few weeks, I delved into the paperwork, which included internal British Airways reports, correspondence with the legal teams, and technical data relating to the incident. About three-quarters of the way down, I found the letter that Stewart wrote to Leversha. It revealed the sense of honor of the man who had faced prosecutors at Isleworth Crown Court, standing in a dock usually reserved for murderers, thieves, and con men. It read:

  Dear Brian,

  I would like to state that during the recent trip . . . you carried out your duties in the manner I have come to expect from experienced flight engineers, but which I also know is far beyond what is written in official manuals. Your help makes my job easier . . . Regarding the go-around incident my opinion is that you behaved and called every standard and non-standard action as written in all manuals, plus the welcome extras. Well done, I could not have asked for better.

  Leversha said:

  If he made a mistake, it was in not fully cooperating with the airline investigation, but then he sensed that they were out to get him from the start. He was a family man, loved by his wife, Samantha, and their children. And, you know, he just loved flying. He got into it as a boy, watching the Tiger Moths up at RAF Leuchars, just over the bay from St. Andrews Golf Club. That place must have meant so much to him. It was where his love of flying was born.

  Stewart’s final journey took place on December 1, 1992, three years and nine days after B747-136 caused the fire sprinklers to activate in the corridors of the Penta Hotel. It is retold with telling sparseness by the journalist Stephan Wilkinson:

  He left his small house in Wokingham without a word to his wife. He drove some nine hours to a beach ten miles from his birth place in Scotland, near RAF Leuchars.

  Stewart attached a hose to the exhaust pipe, led it into the car through a nearly closed window, and in moments had asphyxiated himself. He did not leave a letter or any explanation for his action.

  Part VI

  CREATING A GROWTH CULTURE

  Chapter 13

  The Beckham Effect

  I

  David Beckham is one of England’s finest modern soccer players. He holds the record number of caps for an outfield player with the England team with 115 appearances. He captained England for six years and fifty-nine games, and scored goals in three World Cups.

  As a club player he won the Premier League title six times, the FA Cup twice, and the UEFA Champions League once with Manchester United. He also won La Liga with Real Madrid, the Major League Soccer Cup twice with LA Galaxy, and made contributions to A. C. Milan during two loan spells.

  Beckham’s forte was as a free-kick taker and crosser. For a time he was arguably the finest dead-ball specialist in the world. Perhaps his most famous strike was two and a half minutes into stoppage time in England’s crucial game against Greece in 2001, a match his team had to at least draw to guarantee qualification for the 2002 World Cup. They were trailing 2–1 at the time.

  A foul had been committed ten yards outside the Greece box. Beckham placed the ball down on the turf and then stepped back to size up the challenge. He took his run-up, and, with an effortlessness that remains mesmerizing on YouTube more than ten years later, bent the ball around a four-man wall and into the top corner of the goal more than thirty yards away, the trajectory describing a parabola of pure artistry. It was virtually the last kick of the game.

  In all, Beckham scored from an astonishing 65 free kicks during his career: 29 for Manchester United, 14 for Real Madrid, 12 for LA Galaxy, 7 for England’s national team, 2 for Preston North End, and 1 for A. C. Milan. When you factor in his contributions from open play, his defensive stamina, and his capacity to create scoring opportunities for his teammates, it is some track record.

  It is intriguing, then, to rewind to Beckham’s youth to see how he built up this mastery. As a six-year-old he would spend afternoons practicing keep-me-ups in his tiny back garden in East London. This is the way that most youngsters develop ball control: trying to keep the ball in the air by kicking, kneeing and heading. It is one of the most popular training techniques in the game.

  At first little David was pretty average. He could do five or six before the ball would elude his control and land on the ground. But he stuck at it. He spent afternoon after afternoon, slipping up again and again, but with each mistake learning how to finesse the ball, sustain his concentration, and get his body back into position to keep the sequence going.

  Sandra, his mother, who would watch him through the kitchen window as she cooked dinner, told me: “I was amazed at how devoted he was. He would start when he got back from school and then continue until his dad got back from work. Then they would go down to the park to practice some more. He was such an amazing kid when it came to his appetite for hard work.”

  Slowly, Beckham improved. After six months, he could get up to 50 keep-me-ups. Six months after that he was up to 200. By the time he got to the age of nine, he had reached a new record: 2,003. In total the sequence took around fifteen minutes and his legs ached at the end of it.

  For an outsider looking in this sequence would have seemed miraculous. It would have unfolded like a chain of logic. Two thousand and three touches of the ball without it even touching the ground! It would have seemed like a revelation of genius.

  But to Sandra, who had watched for three years through the kitchen window, it looked very different. She had seen the countless failures that had driven progress. She had witnessed all the frustrations and disappointments. And she had seen how young David had learned from every one.

  Only after getting to 2,003 did Beckham conclude that he had mastered the art of keep-me-ups, so he focused his attention on something new. You guessed it: free kicks. He spent afternoon after afternoon with Ted, his father, aiming at the wire meshing over the window of a shed at the local park.

  His dad would often stand in between Beckham and the target, forcing him to bend the ball around him. Over time the ball was taken farther and farther back, encouraging Beckham to deliver with greater power and velocity. Just like his keep-me-ups, he improved with every attempt.

  “After a couple of years, people would stop and stare,” Ted told me. “He must have taken more than 50,000 free kicks at that park. He had an incredible appetite.”

  • • •

  In the spring of 2014, I went to Paris to interview Beckham. He was in his final year at Paris Saint-Germain and living in the Hôtel Le Bristol, near the Champs-Élysées. “When people talk about my free kicks they focus on the goals,” he said. “But when I think about free kicks I think about all those failures. It took tons of misses before I got it right.”

  Beckham, relaxing in a beige beanie, ripped jeans, and a white T-shirt, sustained this work ethic throughout his career. As England captain he was well known for staying behind after practice to work on his free kicks. The day before my visit he had remained an extra two hours at the Paris Saint-Germain training ground to work on his technique and accuracy.

  He was still working out how to improve, learning from his mistakes, into the twilight of his career. “You have to keep pushing yourself, if you want to improve . . . Without that journey I would never have succeeded.”

  It is striking how often successful people have a counterintuitive perspective on failure. They strive to succeed, like everyone else, but they are intimately aware of how indispensable failure is to the overall process. And they embrace, rather than shy away from, this par
t of the journey.

  Michael Jordan, the basketball great, is a case in point. In a famous Nike commercial, he said: “I’ve missed more than nine thousand shots. I’ve lost almost three hundred games. Twenty-six times I’ve been trusted to take the game-winning shot and missed.”

  For many the ad was perplexing. Why boast about your mistakes? But to Jordan it made perfect sense. “Mental toughness and heart are a lot stronger than some of the physical advantages you might have,” he said. “I’ve always said that and I’ve always believed that.”

  James Dyson embodies this perspective, too. He was once called “an evangelist for failure.” “The most important quality I look for in people coming to Dyson is the willingness to try, fail and learn. I love that spirit, all too rare in the world today,” he says.

  In the previous section we looked at how blame can undermine openness and learning, and how to address it. But in Part 2, we noted that there is a different and altogether more subtle barrier to meaningful evolution: the internal fear of failure. This is the threat to ego; the damage to our self-esteem; the fact that many of us can’t admit our mistakes even to ourselves—and often give up as soon as we hit difficulties.

  In this section we are going to look at how to overcome both tendencies, which undermine learning in so many ways. We will examine why some people and organizations are able to look failure squarely in the face; how they learn from mistakes rather than spinning them; how they avoid the instinct to blame. We will also look at how they sustain their motivation through multiple setbacks and challenges rather than fizzling out.

  In short: If learning from failure is vital to success, how do we overcome both the internal as well as the external barriers that prevent this from happening?