A Cautionary Tale

Dec. 23, 2008

Came across the following story online the other day. Now Vanity Fair is not the sort of magazine one looks to for stories about engineering of any kind, much less ones about the problems inherent in some of the most sophisticated HMI technology around, but there you are. Amid the dishy stories about celebrities, Eurotrash, assorted other rich and powerful folks misbehaving, and the ads for clothing, jewelry and cars I could never have afforded even when we had a boom economy, a story like this one pops up.

Came across the following story online the other day. Now Vanity Fair is not the sort of magazine one looks to for stories about engineering of any kind, much less ones about the problems inherent in some of the most sophisticated HMI technology around, but there you are. Amid the dishy stories about celebrities, Eurotrash, assorted other rich and powerful folks misbehaving, and the ads for clothing, jewelry and cars I could never have afforded even when we had a boom economy, a story like this one pops up.

"The Devil at 37,000 Feet" is the story of an aircraft collision over the Amazon in 2006. Here's the teaser quote at the opening.

"There were so many opportunities for the accident not to happen—the collision between a Legacy 600 private jet and a Boeing 737 carrying 154 people. But on September 29, 2006, high above the Amazon, a long, thin thread of acts and omissions brought the two airplanes together. From the vantage point of the pilots, the Brazilian air-traffic controllers, and the Caiapó Indians, whose rain forest became a charnel house, the author reconstructs a fatal intersection between high-performance technology and human fallibility."

The author, William Langewiesche writes the way I write only in my dreams. The story is a riveting one, and I suggest you don't start to read it unless you're prepared to go to the end in the same sitting. But the real reason I'm calling attention to it is the haunting parallel to control room operations, where the best, most sophisticated, automated systems may be leading our operators into some of the same traps the caught the pilots of these planes.

Yes, human error did play a role in this accident, but what keeps bugging me is the role that the best technology--designed with the best of intentions--played in causing the pilots to become confused and miss important signals and to trust their readings over their instincts.

Just something to think about. And, it's a heck of a good read.