Disc 323 Decision Behavior Assignment # 1 Group # 8 Zarnab Malik Abdul Moiz Moeez Abid Seenam Zia Abbas Anjum Husnain Muzaffar 1. Highlight the key heuristics and biases that clouded the judgment of the pilots in the case and led to the disaster. Overconfidence bias: The fact that they kept on chatting while they were being briefed about the approach to be taken , nor did they prepare the aircraft from descend also indicating a lack of following instructions consciously. The crew had assumed a handover to the next frequency and essentially muted the air traffic control - “It should be mentioned here that we almost never switch to a new frequency in the air unless we are clearly handed over by the previous air traffic controller (ATC), so the fact that they did this anyway is just another indication of severe complacency” - This clearly shows overplacement as the captain thought the ATC was not as experienced as him and therefore just a distraction. He did not value their opinion because he thought of himself as better, placing himself over the ATC. (Over Placement) The approach controller noticed that the plane was twice as high as it should be and he contacted the pilot asking them if they were comfortable to descend to which the answer came “Affirm” this shows over precision , he was dismissive of any fact that suggested he was wrong. The pilot felt that even though he was flying twice as high as he should be yet he felt the situation was under his control and that he will be able to control it. Also when the copilot asked to report to the ground about the severity of the situation he was confident in himself saying “ No , this could be because of the hold” still having an illusion of control ,(23:26) (25:50 - 26:06 ) Captain’s file shows that this approach was nothing new to him - high speed, high path, high rate of descent, long flares, and GPWS warnings. (overconfidence, illusion of control) (27:03- 27:20)) Operator: “Sir orbit is available if you want” captain “ Say it is okay” . The captain seemed to have an illusion of control, where he wasn’t ready to take instructions or advice. Group think also plays an important role here .Even though the copilot did feel suspicious of the situation they were in he still stood back in pointing it out and followed what the captain had said. (28:00) “He will be surprised that we have done this” referring to the controller. Here comes in the optimistic bias. The pilot was sure enough that they will land safely and that nothing will go wrong. (28:34-) “Pakistan 8303 disregard turn left heading 180” was also responded with “ sir we are comfortable now and we are 3000 out for 3500 established ILS 25L← illusion of control. After all the warnings that were going on the pilots still disregarded the warnings and called them off ←- overconfidence (35:21) split had now occurred in the cockpit as the First officer now was suggesting an orbit . Captain “ NO , No leave it “ and also pressed the priority button taking full control. This shows over placement. The captain viewed himself better than the first officer and hence thought it suitable to take full control. (41:59) - When the plane hit the runway about 14 seconds after the first touchdown, the first officer shouted, “Take off, sir!” In the confusion, the captain followed this advice. Given that it was peak COVID and they were fasting, the stress led him to make an emotional choice instead of a logical one, showing the Affect Heuristic, where feelings take over thinking. (49:31) The first officer saying “ Please increase the speed” Captain responding “ How would i increase the speed” Showing complete chaos and distress . His situational awareness was rendered by the fact that he was in stressful conditions and was unable to respond even though he was capable of controlling the situation. (49:51) “Confirm you are carrying out a belly landing” “negative sir” “is the gear extended” “No” The captain immediately lowered the gear. This was a system 1 thinking where the captain made a quick and irrational decision without evaluating the effect that it would have on the speed of the plane. 8:00) - When the narrator talked about the white left turn arrow, SABEN appeared twice on the monitor, and Hold was getting highlighted in white color. The narrator said that 'Both the things were not noticed by the crew. This is a clear indication of change blindness, i.e. they didn't notice this change on the monitor screen. (CHANGE BLINDNESS) (23:00 - 26:00) - When asked to report the level passing, the captain said “Out of 75 for 3,000.”, even though the altitude was actually 7,700 ft, to make the situation seem safer than it was. Even when they were about 10 nautical miles away, the controller mentioned that the altitude was too high but the captain again said “No problem sir”. Downplaying the concerns of the air traffic control and only acting on the information that confirmed his beliefs shows the confirmation bias at play. (CONFIRMATION TRAP) Sunk cost fallacy: The captain might have been unwilling to change his approach till the last minute because he had already invested his time and effort into his approach. Group-think when both of them thought it was okay to follow orders of captain. Bandwagon effect What could have been done to avoid the disaster? Avoidance from the base: ● Not only was the crew at fault, the Pakistan International Airlines Airline was also guilty. Firstly, it should not even have hired the captain as a pilot due to his failure in psychological assessments. Secondly, even if they did hire him due to him applying his file before the airline stopped second opinion, they should have fired him after observing his behavior which was reported in the captain’s file. By doing so, the captain would not have gotten the chance to operate the plane; none of this would have happened. Belly-landing: ● In Karachi Airport, when the plane was belly landing, the captain should have rationally evaluated the situation (compared on ground and off ground situation in terms of fuel consumption) and not taken off on impulse as the first officer instructed, they might have survived. Second landing: ● If the crew did not extend the gear when preparing for a second landing, the plane which was already slowed down, would not have been further slowed and the chances of survival would have been higher. Other Runaways: ● When the Karachi controller informed them that the other runaways were available for landing, they should have heed upon their words. Use of System 2 Thinking and Ignoring Cognitive Biases- The average flight activity decreased worldwide during the pandemic. The airline should have run refresher courses on common cognitive biases in this period of inactivity for the flight crew, as the Captain had already been employing his overconfidence bias in previous flights. The awareness of such biases would have led to the deployment of System 2 thinking, where the crew could have avoided slippery slope fallacies due to their rash decisions. Crew Communication- The communication between the Captain and First Officer could have been effective if they had planned everything together and had a supportive environment to encourage voicing issues or contradictions. This promotes transparency and continuous improvement in communication practices. There should have been thorough pre-flight briefings to discuss potential risks, clarify roles for the flight, and discuss the practices both pilots are comfortable with, including their flying procedure. The Sterile Cockpit Rule states that communication and activities on the flight deck should be limited to those essential to the safe operation of the flight during all flight operations at or below 10,000 ft AGL, including ground operations of the aircraft, and all other critical phases of flight as declared by PIC. During the event flight, the crew did not follow the Sterile Cockpit Rule and discussed various topics unrelated to aircraft operations (Avherald). The Captain and First Officer should have been aware of their roles to avoid disaster; however, many other SOPs were neglected, which were not given priority either. Following the SOPS- Strict adherence to standard operating procedures (SOPs) should have been maintained throughout the flight. Proper execution of approach and landing procedures is critical for ensuring the safety of flight operations. This could have prevented the gear deployment problem, which led to engine loss. The cockpit crew should have been vigilant in checking the code red signals constantly appearing on the screen to retract their bad decisions; however, they were trapped in planning fallacy, believing they could do it. Some go-around policies are always intact for such situations, and pilots must constantly measure the parameters during the approach. There were many deviations throughout the flight, which should've prompted immediate consideration for a go-around. Emphasis should have been placed on the fact that performing a go-around is safe and standard procedure, not an indication of failure. During any approach, pilots should have taken Air Traffic Control (ATC) in confidence and clearly stated their intentions to them rather than trying to do the opposite of what ATC had suggested. PIA should have taken necessary measures for compliance with SOPs by the flight crew, effective implementation of the Flight Data Analysis Program, and its integration into the Safety Management System. Aviation safety can be significantly enhanced by emphasizing strict adherence to SOPs, particularly during the approach and landing phases.
