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Saturday, April 15, 2017

United Airlines 3411: A Case Study in Linkages

The United Airlines fiasco will surely go down as a case study in how not to do things. It had all the elements of potential disaster, and the restriction on Chicago Aviation Authority officers (they were not Chicago police officers) not being permitted to carry guns may be the only thing that prevented a death that would have made the episode considerably worse. As with many disasters it’s rarely one factor that causes the event; it’s the piling on or linkage of several mistakes that when compounded inevitably lead to failure.

1. Passengers were fully seated, any overbooking had been taken care of at the gate, as it should be, and the plane was apparently close to push back and under control of the captain.
-The first problem arose when four United employees approached the agent and said they had to be in Louisville for a flight. (There is some uncertainty about what flight that was, but one report said it was to be the next afternoon.)
-The agent had several options at this point:
--Tell them to grab a different flight
--Bump four seated passengers to accommodate the employees
--Arrange for alternative transportation to Louisville by limo (that option seems to have occurred to no one) which was only 5 hrs by car and would have cost far less than the $3200 they were willing to pay bumped passengers. It would have certainly be exponentially less than the resulting firestorm.
--The agent chose to bump passengers.

2.The second problem arose when no one wanted to accept the voucher offer. (Note that vouchers suck. They come with all sorts of restrictions.
-Options open to the agent:
--Offer cash in increasing amounts (not sure if United/Republic policy offered this as an option)
--Offer cash instead of a voucher
--Force removal of four passengers
--Reported at first to be random, it was then said they used a sophisticated algorithm. How that formula made the choices has not been revealed and certainly was unknown to the passengers. Had it been, perhaps the outcome would have been different.
Three passengers reluctantly decided to leave rather than face forced removal which apparently was made as a threat. One passenger did not.

3.Problem three
-Someone (the agent?) called in security
-Questions remain.
--What were the officers (they were not Chicago police but Airport Security) told.
---Their reaction may well have been dictated by what they were told. Was this passenger a security risk? Was he unruly? Why was he being removed?

4.Problem four: Who was told what and who was in charge?
-An investigation needs to be made into just what they were told and their perception of who was in charge.
--Was the captain aware of the commotion in the cabin?
--Who was in charge of the officers?
--What were they told to do?

-All of these things had a bearing on the outcome.

5. Training
-The level of force was clearly excessive.
--How had the officers been trained to deal with the situation?
--How do you get a concussion, broken nose, and lose two front teeth by being dragged out of an airline seat?
I have a suspicion - item e is not supported by any evidence so it’s purely speculative -- that the following sequence occurred
Officers drag the man off the plane. He looks unconscious so may have hit his head (or been hit on the head)
Officers lose control of the man in the jetway or at the gate (!!!!!! how could that happen with three of them?)
Man runs back on the plane uttering incoherent statements (Kill me, I want to go home - let’s not forget he had escaped from Vietnam)
--The plane is emptied of passengers ostensibly to clean up the blood.
---The man is beaten to subdue him by the officers in the back of the plane. That’s when most of the injuries occurred.
---The man is taken off in a stretcher to the hospital.

6.Attitudinal Issues
-Post 9/11 passengers are treated as the “enemy” and as “potential terrorists” as soon as they enter the airport. Certainly TSA regards them as such and everyone in the airport is warned about strangers and unattended bags, etc., checked by bomb-sniffing dogs, searched, x-rayed, etc. This has infected the way crew view the passengers. They are considered as possible terrorists - --All of them. I think this is very important in causing the result on flight 3411.
-The United CEO had just replaced a CEO forced to resign because of his connection to the Bridgegate scandal. He wanted to be seen as supportive of the employees and not reflexively dismissive of their actions.

7. PR Missteps
-The United CEO made statements without being in possession of all (or one wonders, any) of the facts. The United PR department should be fired en masse for their bad advice.
-The second “apology” was horrible in its use of a new euphemism (re-accomodate) that simply inflamed a bad situation. Here again, waiting to collect all the information should be mandatory. Some thinking before speaking might also be useful.
-The final apology was a good one, but considering that the videos had gone viral in China where United wants to have a larger presence, seemed disingenuous and stemmed more from a fear of what the impact might be on their business in China, so its positive impact was lessened considerably.

8. Who was in charge?
-The episode gave the impression that no one was in charge.
--The pilot? Ultimately he needs to take some responsibility as he is presumably in charge of the plane. He had the authority to step in at any point and just say “stop” until things could be figured out.
--The gate agent? s/he presumably had authority to manipulate the amounts offered to passengers. Was s/he under pressure to keep the amounts as low as possible?
--The flight attendants? Couldn’t they have stopped the action at any point? Did they believe they had no authority to do so?
--Does United empower its employees to fix problems?
--The security officers? Did they assume they were in charge because they represented power and force? Again. What were they told about the ostensible threat and who told them? It seems not unreasonable their actions were governed to some extent by what they had been told and their perception of the event.


Note that at any point if someone had stepped in and said “stop let’s sit down and talk about this” or examined their options, the disaster would not have occurred. Clearly the passengers all felt cowed and the United employees unempowered. Each assumed someone else would make everything right. As in Charles Perrow’s excellent book, Normal Accidents*, breaking any one of the links in a coupled system will always prevent disaster. Someone has to break that link.

*https://www.goodreads.com/review/show/37704050?book_show_action=false&from_review_page=1


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