Professionalism/China Airlines Flight 611

On May 25th 2002, China Airlines Flight 611 (CAL611, Cl611, or Dynasty 611) disintegrated in midair just 20 minutes after takeoff upon reaching the cruising altitude of 35,000 feet over the Taiwan Strait, killing all 209 passengers and 19 crew members on board. Failure to act in a professional manner at both organizational and individual levels might be the root cause of this tragic incident.

Background

Investigation

The investigators used ballistic trajectory analysis to determine which section of the airplane was the first to break off. Columbia STS 107 flight accident investigation team also used this analysis to reveal that the Flight Day 2 (FD2) object became loose during liftoff. The analysis revealed that the breakup initiated from the aft fuselage or the tail section and narrowed the investigation.
The investigator focused on the item number 640 which was located precisely where the analysis told them the breakup had started. Unlike other pieces that showed sign of overload fracture, this piece showed sign of fatigue fracture. In other words, the piece number 640 had separated from the body of the airplane gradually overtime, not ripped apart violently and suddenly in midair like any other pieces.
This piece also had a doubler plate, which was the equivalence of a patch on a punctured tire. It suggested that this section of the airplane had been repaired before.

Tailstrike

Figure 1: An example of a tailstrike during landing

When the plane was 6 months old (February 7th, 1980), the tail of the airplane struck the runway while landing at Kai Tak Airport, Hong Kong. This incident is usually referred to as a tailstrike. Maintenance records stated that preliminary inspection found the serious abrasion damage on fuselage tail portion bottom skin. The maintenance crews scheduled a temporary repair replacement with a permanent repair within four months.
Maintenance records stated that the permanent repair was accomplished in accordance with the Boeing Structural Repair Manual (SRM) and China Airlines engineering recommendations on May 25th, 1980.
The record was as follows:

Aft Belly Skin Scratch (25, May'80)
1. Peel area cut out + trimmed.
2. Patched with doubler.
3. Accomplished aft belly skin repair I.A.W. CAL ENGR reccomendations + Boeing SRM 53-30-03 Fig.1.

Item number 640 told the investigators a different story. Maintenance records clearly stated that the tail section was removed before the installation of the doubler plate. However, the damaged skin was not removed but instead sanded down. The plate was also 10% less than the recommended size, which was 125 inches long and 23 inches wide. Note that this recommended plate size was meant for a temporary repair. Moreover, the investigators could not obtain any other engineering process records for this permanent repair, i.e. work cards; inspector signoffs; detailed description of the process. The scratch was well hidden underneath the doubler plate from 1980 onward.
Overtime, cabin pressurization applied stress to the damaged area. The stress was far beyond the fatigue stress design values, and thus initiated a fatigue crack. The crack continued to grow undetected with every flight cycle. On May 25th, 2002, the crack reached its critical length and transferred the load to an undamaged area, which eventually became overloaded. Consequently, the plane broke off in midair.

Mysterious stains

Figure 2: Dark-brown stain at bottom of aft fuselage section

China Airlines came close to preventing this incident. When China Airlines performed the repair assessment program (RAP) on the accident aircraft on November 02, 2001, the inspectors took pictures of all the repaired doublers. Two of those pictures were from the aft lower lobe fuselage. They showed a mysterious dark-brown stains around the doubler plate. The investigator revealed that the dark-brown stains was nicotine stains.
Around 1995, China Airlines started to ban smoking on board. Cabin pressurization forced the smoke out through the cracks. Overtime, the smoke left the nicotine stains outside of the plane. These stains were an indication of a possible hidden cracks beneath the doubler plate, which means that the cracks had been there long before 1995. Still, China Airlines was not treating the tailstrike accident as a major repair.

Connections to Professionalism

Structure of Business Organization

During the permanent repair conducted after the temporary repair, China Airlines decided to minimize the cost by disregarding the instructions suggested by the SRM. Consequently, the poor repair led to the accident in 2002. Besides the financial loss, China Airlines also lost the trusts from both the investors and customers. The company shares plummeted by 25%. Its reputation was slaughtered as it became the “least safety airline.” After the accident, Delta Airlines also withdrew its previously proposed partnership.
As business organizations maximize their profitability while being obligated to exercise their expertise and judgment that meet their clients’ best interests, they face one important dilemma. Because their clients trust that the business organizations operating professionally, business organizations have freedom to set the balance between profit and ethic responsibility. It is vital that every companies be prudent and focus on the long run benefits. In this China Airlines Flight 611 case, the company chose to cut the cost to gain short run profit, but lost much more in the long term.

Sense of responsibility

Another possible cause of China Airlines Flight 611 accident was that China Airlines entrusted the repair to the maintenance team, but the team did not carry on the job properly. The fact that a trailstrike accident rarely caused significant damage suggested that the maintenance team might be affected by the normalization of deviance. In the permanent repair, the damaged areas were not removed and the doubler plate used was smaller than the recommended size.
Moreover, there was the diffusion of responsibility involved. Even though, the inspectors discovered the nicotine stains (Figure 2), they did not take any actions as they might have felt that it was not their responsibility and the others would deal with that. All in all, it is evident that the maintenance team did not work meticulously. If they had, they would not have fallen into the status quo trap. They would be alarmed about the nicotine stains, immediately sought the cause of the stain, and eventually discovered the cracks underneath the plate. When the maintenance team conducted the permanent repair, they should have kept in mind that it was their responsibility to ensure the safety of the customers.

As a mechanic, when you are doing work on an airplane, you are not thinking about the people who might be flying on that fuselage twenty years from now but their safety depends on you doing the repair properly.

– John Delisi, National Transportation Safety Board (NTSB) Investigator

Integrity

In a business organization, managers’ responsibility is to ensure the company profitability. The technicians, on the other hand, are specialized in technical knowledge, and thus have the duty to carry on the technical tasks properly. They have to identify the potential risks and notify the managers. In the China Airlines Flight 611 case, the maintenance team just followed the order from the managers, conducted the poor permanent repair, and logged the record incorrectly. They also failed as professionals by not dissuading the company from cutting the repair cost. If they held on to their ethics, they would have refused the unethical cost cutting and prevented the accident. Therefore it is important for individual to value integrity and understand when to challenge authority.

Mindfulness

Figure 3: Group Mindfulness Meditation Practice

Traps in judgment

Flawed repair during the maintenance and failure during subsequent routine inspections may be attributed to the following traps working in isolation/concert:

Table 1: Hidden Traps in Judgment

Maintenance

Maintenance technicians might have judged that it was unnecessary to remove the damaged skin having not done so for other tailstrikes due to a combination of status-quo, sunk-cost, and framing traps:

• Status-quo & Sunk-cost traps: Technicians are inclined to perpetuate past mistakes of not properly repairing due to unwillingness to admit them.
• Framing trap: The question of repair might have been framed in the following way: is the repair necessary if there is a 90% of a tailstrike being inconsequential? If the question was framed differently (is the repair necessary if without it, there is a 10% of disintegration in midair), the repair might have been carried out more carefully.

Inspection

Inspectors missed the damage mostly because it was covered up and difficult to spot. Arguably, if they had been more thorough in their inspections, they might have spotted the poor maintenance. This slight negligence might be due to confirming-evidence trap, and two of the estimating & forecasting traps:

• Confirming-evidence trap: Inspectors found that a tailstrike repair was performed awhile ago, and any evidence during inspection is used to confirm their preconceived notions that the tail was fine.
• Over confidence trap: Inspectors underestimated the range of potential outcomes as a result of there being other inspections (i.e. diffusion of responsibility)
• Recallability trap: The likelihood of tailstrike causing significant danger is understated prior to crash (due to disproportionate attention in the media). Inspectors pay much more attention to other less probable causes of failure.

The best protection against all psychological traps is awareness. Forewarned is forearmed. Even if you can't eradicate the distortions ingrained into the way your mind works, you can build tests and disciplines into your decision-making process that can uncover errors in thinking before they become errors in judgment.

– John S. Hammond, Ralph L. Kenny, Howard Raiffa, The Hidden Traps in Decision Making

Awareness and Mindfulness are two sides of the same coin; a mindful state of mind results in greater awareness, which can eradicate the distortions ingrained into the way our minds work (see Evidence from Neuroscience) through self-knowledge (know thyself).

Mindfulness to overcome barriers to self-knowledge

A two-component model of Mindfulness is proposed to overcome these barriers.

Improving attention

Mindfulness begins by focusing attention on breadth, other sensations, thoughts, and feelings. Through practice, strong concentration to maintain awareness is developed. Research showed that this sustained attention/vigilance is related to increased attention span, higher memory capacity, reduced stress. Together, these lead to greater awareness of any bias in judgment.

Eliminating ego

The second component involves nonevaluative observation about experience. Of the 7 essentials of mindfulness, 5 are directly related to the elimination of ego:

• non-judging
• non-striving
• acceptance
• letting go
• beginner's mind

Loss of ego leads to lowered reactivity and defensiveness to self-threatening information (even when facing death). Self-verification and self-enhancement motives are reduced, and traps that rely on ego--status-quo, sunk-cost, and over confidence--are overcome.

Mindfulness in the world

Several mainstream companies realize the many benefits of mindfulness (its effectiveness in overcoming traps in judgment is just one among many), and the following have implemented mindfulness programs: Google ( Search Inside Yourself Leadership Institute), Apple, McKinsey & Company, Deutsche Bank, and General Mills . Influence of Mindfulness has also expanded to schools, universities, and other sectors. For instance, University of Virginia launched the Contemplative Science Center in 2012 with the following goal:

...to explore contemplative practices ... as well as to help develop new applications and learning programs for their integration into varied sectors of our society.

– Contemplative Sciences Center

Conclusion

Failure to act in a professional manner at both organizational and individual levels is the root cause of a catastrophe. An organization that focuses on profitability is usually faced with the issues of safety. Such organization frequently considers economic motivations over safety, which might result in the company growth in the short run. This type of an organizational culture might interfere with employees' professionalism, shaping a "two plus two equals five" environment, and thus violate their professional integrity and ethics. However, the fault does not lie wholly with an organization. Individuals have rights and choices to object and remain adamant in their judgements, despite the risk of losing their jobs. Traps in decision making also contribute to the failure. Practicing mindfulness can eradicate the distortions ingrained into the way our minds work through self-knowledge and thereby improve our awareness of these traps. Hence, the risk of a catastrophe can be reduced by conducting ourselves in a professional manner.

Future extension

1. Evidence from neuroscience
   1. Magnetic Resonance Imaging MRI),Electroencephalography (EEG), and Magnetoencephalography (MEG) allow us to measure brain activity and analyze mindfulness.
2. Studies of long term mindfulness
3. Applying lessons to similar/different cases