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The Checklist Manifesto: How to Get Things Right by Atul Gawande
Airbus A320, Atul Gawande, call centre, Captain Sullenberger Hudson, Checklist Manifesto, index card, John Snow's cholera map, megacity, RAND corporation, Tenerife airport disaster, US Airways Flight 1549, William Langewiesche
Maybe our idea of heroism needs updating. On January 14, 2009, WHO’s safe surgery checklist was made public. As it happened, the very next day, US Airways Flight 1549 took off from La Guardia Airport in New York City with 155 people on board, struck a large flock of Canadian geese over Manhattan, lost both engines, and famously crash-landed in the icy Hudson River. The fact that not a single life was lost led the press to christen the incident the “miracle on the Hudson.” A National Transportation Safety Board official said the flight “has to go down as the most successful ditching in aviation history.” Fifty-seven-year-old Captain Chesley B. “Sully” Sullenberger III, a former air force pilot with twenty thousand hours of flight experience, was hailed the world over. “Quiet Air Hero Is Captain America,” shouted the New York Post headline.
Zaslow, Highest Duty: My Search for What Really Matters (New York: William Morrow, 2009). 179 “Skiles managed to complete”: Testimony of Captain Terry Lutz, Experimental Test pilot, Engineering Flight Operations, Airbus, National Transportation Safety Board, “Public Hearing in the Matter of the Landing of US Air Flight 1549 in the Hudson River, Weehawken, New Jersey, January 15, 2009,” June 10, 2009. 180 “ ‘Flaps out?’ ”: D. P. Brazy, “Group Chairman’s Factual Report of Investigation: Cockpit Voice Recorder DCA09MA026,” National Transportation Safety Board, April 22, 2009. 180 “For, as journalist and pilot”: W. Langewiesche, “Anatomy of a Miracle,” Vanity Fair, June 2009. 181 “After the plane landed”: Testimony of Captain Chesley Sullenberger, A320 Captain, US Airways, National Transportation Safety Board, Public Hearing, June 9, 2009. ACKNOWLEDGMENTS Three kinds of people were pivotal to this book: the ones behind the writing, the ones behind the ideas, and the ones who made both possible. As the book involved background research in several fields beyond my expertise, the number of people I am indebted to is especially large.
But step one on the list is the most fascinating. It is simply: FLY THE AIRPLANE. Because pilots sometimes become so desperate trying to restart their engine, so crushed by the cognitive overload of thinking through what could have gone wrong, they forget this most basic task. FLY THE AIRPLANE. This isn’t rigidity. This is making sure everyone has their best shot at survival. About ninety seconds after takeoff, US Airways Flight 1549 was climbing up through three thousand feet when it crossed the path of the geese. The plane came upon the geese so suddenly Sullenberger’s immediate reaction was to duck. The sound of the birds hitting the windshield and the engines was loud enough to be heard on the cockpit voice recorder. As news reports later pointed out, planes have hit hundreds of thousands of birds without incident.
Future Perfect: The Case for Progress in a Networked Age by Steven Johnson
Airbus A320, airport security, algorithmic trading, banking crisis, barriers to entry, Bernie Sanders, call centre, Captain Sullenberger Hudson, Cass Sunstein, cognitive dissonance, credit crunch, crowdsourcing, dark matter, Dava Sobel, David Brooks, Donald Davies, future of journalism, hive mind, Howard Rheingold, HyperCard, Jane Jacobs, John Gruber, John Harrison: Longitude, Kevin Kelly, Kickstarter, lone genius, Mark Zuckerberg, mega-rich, meta analysis, meta-analysis, Naomi Klein, Nate Silver, Occupy movement, packet switching, peer-to-peer, Peter Thiel, planetary scale, pre–internet, RAND corporation, risk tolerance, shareholder value, Silicon Valley, Silicon Valley startup, social graph, Steve Jobs, Steven Pinker, Stewart Brand, The Death and Life of Great American Cities, Tim Cook: Apple, urban planning, US Airways Flight 1549, WikiLeaks, William Langewiesche, working poor, X Prize, your tax dollars at work
The question was, Who or what was responsible for that plane managing to lose two engines during takeoff and still keep its cargo secure? The mass media quickly offered up two primary explanations, both of which turned out to be typical interpretations of good news. First there was the hero narrative: Captain Chesley “Sully” Sullenberger, who had indeed brilliantly navigated his plane into the river with great poise under unthinkable pressure. And then there was the quasi-magical rhetoric that quickly became attached to the event, the Miracle on the Hudson. Those were the two options. That plane floating safely in the Hudson could be explained only by superheroes or miracles. There was no denying Sullenberger’s achievement that day, but the fact is, he was supported by a long history of decisions made by thousands of people over the preceding decades, all of which set up the conditions that made that perfect landing possible.
This is how progress happens: some problem or unmet need is identified, imaginative new solutions are proposed, and eventually society decides to implement one (or more) of those solutions. The circulation of ideas and decisions in that cycle is ultimately as important as the physical matter that is transformed in implementing the solutions themselves. Yes, it was crucial to the passengers on US Airways flight 1549 that the plane’s engines had been forged via the staggering physical energy and immense financial expense of a jet engine production cycle. But it was just as important that someone, somewhere, had decided that it would be a good idea to make sure those engines could survive bird impacts. The information that made that decision possible, and the social architecture that allowed its wisdom to spread—all these were every bit as important to the safe landing on the Hudson as the physical act of building the engines.
The 311 hive mind is deft not just at detecting reliable patterns but also at providing insights when the normal patterns have been disrupted. Clusters of calls about food-borne illness or sanitary problems from the same restaurant now trigger a rapid response from the city’s health department. And during emergencies, callers help provide real-time insight into what’s really happening. After US Airways flight 1549 crash-landed on the Hudson, a few callers dialed 311 asking what they should do with hand luggage they’d retrieved from the river. The city had extensive plans for its response to an urban plane crash, but dealing with floating luggage was not one of them. Within minutes they had established a procedure for New Yorkers who wanted to turn in debris they’d recovered from the river. This is the beauty of 311.
The Eureka Factor by John Kounios
active measures, Albert Einstein, call centre, Captain Sullenberger Hudson, deliberate practice, en.wikipedia.org, Everything should be made as simple as possible, Flynn Effect, functional fixedness, Google Hangouts, impulse control, invention of the telephone, invention of the telescope, Isaac Newton, Louis Pasteur, meta analysis, meta-analysis, Necker cube, pattern recognition, Silicon Valley, Skype, Steve Jobs, theory of mind, US Airways Flight 1549, Wall-E, William of Occam
Force an expert chess player to play rapidly and his performance will deteriorate little. Experts don’t need much time because they don’t ordinarily need to compute many possibilities. They immediately know what will work and what won’t. The quick wits of experts can even save lives. On January 15, 2009, US Airways flight 1549 took off from New York’s LaGuardia Airport bound for Charlotte, North Carolina. While ascending, the plane struck a flock of birds. Captain Chesley (“Sully”) Sullenberger smelled burning—birds had been sucked into the engines. Then the engines went dead. Within thirty seconds, Captain Sullenberger concluded that the engines couldn’t be restarted. The plane’s altitude was three thousand feet and decreasing rapidly. He communicated the situation to the air traffic control tower and looked for a place to land.
A recent article discusses more recent perspectives and misquotations of de Groot’s work: M. Bilalic, P. McLeod, and F. Gobet, “Expert and ‘Novice’ Problem Solving Strategies in Chess: Sixty Years of Citing de Groot (1946),” Thinking and Reasoning 14 (2008): 395–408. Regarding Bent Larsen’s approach to playing chess, see query.nytimes.com/gst/fullpage.html?res=9403E0DD1638F931A2575AC0A9669D8B63. Quick Think 1 The information about, and quotes from, Captain Chesley Sullenberger are derived from www.airspacemag.com/flight-today/Sullys-Tale.html/; www.cbsnews.com/news/flight-1549-a-routine-takeoff-turns-ugly/; and Wikipedia, s.v. “Chesley Sullenberger,” last modified June 26, 2014, en.wikipedia.org/wiki/Sullenberger. CHAPTER 4: ALL OF A SUDDEN … * * * 1 The idea that creativity does not differ from “ordinary” thought is discussed in R. W. Weisberg, Creativity: Understanding Innovation in Problem Solving, Science, Invention, and the Arts (Hoboken, N.J.: John Wiley and Sons, 2006). 2 The anagram study by R.
When to Rob a Bank: ...And 131 More Warped Suggestions and Well-Intended Rants by Steven D. Levitt, Stephen J. Dubner
Affordable Care Act / Obamacare, Airbus A320, airport security, augmented reality, barriers to entry, Bernie Madoff, Black Swan, Broken windows theory, Captain Sullenberger Hudson, creative destruction, Daniel Kahneman / Amos Tversky, deliberate practice, feminist movement, food miles, George Akerlof, information asymmetry, invisible hand, loss aversion, mental accounting, Netflix Prize, obamacare, oil shale / tar sands, Pareto efficiency, peak oil, pre–internet, price anchoring, price discrimination, principal–agent problem, profit maximization, Richard Thaler, security theater, Ted Kaczynski, the built environment, The Chicago School, the High Line, Thorstein Veblen, transaction costs, US Airways Flight 1549
Maybe I will write more about that tomorrow™. What Captain Sullenberger Meant to Say (But Was Too Polite to Do So) (BY “CAPTAIN STEVE”) Captain Steve is a seasoned international pilot for a major U.S. carrier and a friend of Freakonomics. (Given the sensitivity of what he writes, he prefers anonymity.) This post was published on June 24, 2009, six months after the “The Miracle on the Hudson,” in which Captain Chesley Sullenberger safely landed an Airbus A320-200 in the Hudson River. Both the plane’s engines had failed, due to a bird strike, shortly after takeoff from LaGuardia Airport in New York. After reading some of the excerpts of Captain Sullenberger’s various speeches, especially those of a few weeks ago with the National Transportation Safety Board, I would like to add my editorial. Captain Sullenberger has been a class act all the way.
Captain Sullenberger has been a class act all the way. He’s not been petty, pious, or egotistical. He is, however, like most of the captains I know and, more broadly, most of the pilots I know. Why? He doesn’t need to be otherwise. When someone has accomplished what he and the scores of men and women like him have accomplished, why do we need to boast? He implies that what he did while serving as the “skipper” of US Airways flight 1549 was simply his job. He is being as honest and accurate as he can be: “Please, no fanfare, no applause, just doing my job.” But what he has also alluded to in some of his speeches is that it has taken years, even decades, to prepare himself for that one single “lifetime event” of guiding his jet into the safe, smooth landing on the Hudson River. What he is not saying is this: We, the airline pilots, are facing a losing battle in the PR department.
., 38–39 stock markets, capitalization of, 67 strangers, fear of, 130–33 street gangs, 229–36, 246–47, 248–49 street handouts, 328–37 Stubbs, Bob, 46 subjectivity, 170 Sullenberger, Chesley “Sully,” 82–83 SuperFreakonomics (Levitt & Dubner), 54, 101, 105, 119, 121, 261 supply and demand, 78–80, 110, 112, 115, 128, 341–44 Swift, Jonathan, 258–59 Taleb, Nassim Nicholas, 329, 334–37 tax code, 159–60 taxes: on athletes’ incomes, 72–74 cheating on, 158–60 on sex, 256–59 war on, 11–14 Taylor, Brian, 253 Taylor, Sean, 241 teachers, cheating by, 103–4, 160–61 Tejada, Miguel, 149 tenure, 16–19 Terrible Towel, 215 terrorism, 5–11, 108–9, 252 Thaler, Richard, 68, 308–9 Think Like a Freak (Levitt & Dubner), 26, 27 350.org, 178–84 ticketless travel, 141 Tierney, John, 114–16 Tinker, David, 40 tipping, and flight attendants, 19–20 Tomlin, Mike, 218 tooth decay, 275–76 Tour de France, 151–52 Travolta, John, 306 Tropicana, 174–75 TSA, 5–6, 11, 108–9, 251–53 Tversky, Amos, 206 TV viewing habits, 322–24 Twitter contest, 94–96 umbrellas, dangers of, 108–9 United States, six-word motto for, 96–99 Unlawful Internet Gambling Enforcement Act (UIGEA), 129–30 US Airways flight 1549, 82–83 Veblen, Thorstein, 184 veganism, 179–84 Velde, François, 62 Venkatesh, Sudhir, 229–36, 246–47 Vermeil, Dick, 207–8 Virgin Mobile, 63–64 voting mechanisms, 29–31 wages: and markets, 24, 25 of politicians, 32–36 and quality of applicants, 34 walking drunk, 101 Wayne (middle name), 38–40 Weber, Christopher L., 171, 172 Weller, Mark, 62–63 Werner, James, 40 Wertheim, Jon, 209–12 Weyl, Glen, 30–31 White, Byron “Whizzer,” 214 Williams, Tom, 148–49 Wilson, A.N., 282 Winfrey, Oprah, 51 Wire, The, 229–33 Witt, Robert, 225–26 Wolf, Cyril, 51–53 Wolfers, Justin, 344–47 women: feminist movement, 346–47 and happiness, 344–47 work: incentives in, 339–40 leisure vs., 168 World Preservation Foundation, 179–82, 192–95 World Series of Poker, 187–88, 192–95 Worthy, Paige, 44–45 Zelinsky, Aaron, 152–53 About the Authors STEVEN D.
Airbus A320, Alfred Russel Wallace, Arthur Eddington, Atul Gawande, Black Swan, British Empire, call centre, Captain Sullenberger Hudson, Checklist Manifesto, cognitive bias, cognitive dissonance, conceptual framework, corporate governance, creative destruction, credit crunch, crew resource management, deliberate practice, double helix, epigenetics, fear of failure, fundamental attribution error, Henri Poincaré, hindsight bias, Isaac Newton, iterative process, James Dyson, James Hargreaves, James Watt: steam engine, Joseph Schumpeter, Lean Startup, mandatory minimum, meta analysis, meta-analysis, minimum viable product, publication bias, quantitative easing, randomized controlled trial, selection bias, Silicon Valley, six sigma, spinning jenny, Steve Jobs, the scientific method, Thomas Kuhn: the structure of scientific revolutions, too big to fail, Toyota Production System, US Airways Flight 1549, Wall-E, Yom Kippur War
One hopes that this remarkable and gentle man also took comfort from the fact that his analytical insights played a crucial role in defeating the evil ideology that murdered his loved ones. He was a black box thinker par excellence. Chapter 3 The Paradox of Success I At 3:25 p.m. on January 15, 2009, US Airways Flight 1549 was given clearance to take off from runway 4 of New York’s LaGuardia Airport. It was a clear afternoon and up in the cockpit Captain Chesley Sullenberger and First Officer Jeffrey Skiles ran through the checklists. They were looking forward to the trip. What neither of them realized is that they were about to embark on one of the most celebrated commercial flights of modern times.1 Less than two minutes after takeoff, a flock of Canada geese suddenly loomed into view to the right of the plane.
Leigh, 268 Thomson, Donald, 115 3M, 144 Time, 39, 53 time, perception of, 28–29, 30, 59 Tour de France, 171–73 Toyota Production System (TPS), 48–49, 51, 290 Toy Story (film), 207 Toy Story 2 (film), 207, 208–9 training, 30–31, 47–48 trial by jury, 118, 119 Tyson, Neil deGrasse, 111–12, 113, 114, 117 Uncontrolled (Manzi), 187 Unilever, 125–26, 128, 137, 147 unindicted co-ejaculator theory, 81 United Airlines, 21–25 United Airlines 173, 20, 27–31, 39, 40, 84 United Kingdom criminal justice system reforms and, 117 health care and, 10, 18, 54–55 math proficiency in, 271 United States of America DNA testing and, 84 economics and, 94–97, 98 entrepreneurship culture and, 270–71 health care and, 9–10, 17, 32, 49–54, 55–56, 106 math proficiency in, 271 US Airways Flight 1549, 38, 39–40 U.S. Army, 19, 261–63 Vanier, Andre, 138–40 variation, 286 Vesalius, Andreas, 279 Veterans Affairs Medical Center, 16 Virginia Mason Health System, 48, 49–52, 53, 290 Vowles, James, 180–81, 182, 183, 184 Vries, Hugo de, 201 Wald, Abraham, 33–37 Wald, Martin, 33, 34 Wallace, Alfred Russel, 201 Wall Street Journal, 95 war, 278 Ward, Maria, 236 Watt, James, 132 weapons of mass destruction (WMD), 73–74, 74, 91–92, 93, 94 West Point, 261–63 When Prophecy Fails (Festiger), 71n, 72 White Man’s Burden, The (Easterly), 174 Why Smart Executives Fail: And What You Can Learn from Their Mistakes (Finkelstein), 100 Wiggins, Bradley, 172 Wilkinson, Stephan, 242, 245, 248–49 Will and Vision (Tellis and Golder), 205 Wilson, Kevin, 35 Wimbledon High School, 267–68, 269 wind-up radio, 195 Wolff, Toto, 182 World Health Organization, 11 World War II, 33–37 Wright brothers, 199 wrongful convictions, 63–71, 77–85, 114–17 Borchard’s compilation of, 67 Bromgard case, 77–79, 116 cognitive dissonance and, 79–83 DNA evidence and, 68–71, 77, 79–83, 84, 120 drive-bys and, 114 exonerations through DNA testing, 69–70 eyewitness identification and, 114–15 false confessions and, 116 finality doctrines and, 84 hair analysis and, 116 justice system’s initial refusal to learn from, 67–68 as learning opportunity, 65 lineups and, 115–16 memory and, 114 prosecutorial responses to exonerating DNA evidence, 78–83 reform and, 115–17 Rivera case, 63–65, 70–71, 82–83, 116, 119–21 Supreme Court policy of reviewing cases involving procedural errors only, 84–8 Xenophanes, 278 Zappos, 143 *All names of medical staff have been changed to protect anonymity.
activist fund / activist shareholder / activist investor, Affordable Care Act / Obamacare, AI winter, Airbnb, Atul Gawande, Captain Sullenberger Hudson, Checklist Manifesto, Chuck Templeton: OpenTable, Clayton Christensen, collapse of Lehman Brothers, computer age, creative destruction, crowdsourcing, deskilling, en.wikipedia.org, Erik Brynjolfsson, everywhere but in the productivity statistics, Firefox, Frank Levy and Richard Murnane: The New Division of Labor, Google Glasses, Ignaz Semmelweis: hand washing, Internet of things, job satisfaction, Joseph Schumpeter, knowledge worker, lifelogging, medical malpractice, medical residency, Menlo Park, minimum viable product, natural language processing, Network effects, Nicholas Carr, obamacare, pattern recognition, peer-to-peer, personalized medicine, pets.com, Productivity paradox, Ralph Nader, RAND corporation, Second Machine Age, self-driving car, Silicon Valley, Silicon Valley startup, six sigma, Skype, Snapchat, software as a service, Steve Jobs, Steven Levy, the payments system, The Wisdom of Crowds, Thomas Bayes, Toyota Production System, Uber for X, US Airways Flight 1549, Watson beat the top human players on Jeopardy!, Yogi Berra
—Marc Benioff, Chairman and CEO, Salesforce “Noted physician-author Bob Wachter takes the reader on a fascinating journey of discovery through medicine’s nascent digital world. He shows us that it’s not just the technology but how we manage it that will determine whether the computerization of medicine will be for good or for ill. And he reminds us that the promise of technology in healthcare will be realized only if it augments, but does not replace, the human touch.” —Captain Chesley “Sully” Sullenberger speaker; consultant; author of Highest Duty and Making a Difference; pilot of US Airways 1549, the “Miracle on the Hudson” “With vivid stories and sharp analysis, Wachter exposes the good, the bad, and the ugly of electronic health records and all things electronic in the complex settings of hospitals, physician offices, and pharmacies. Everyone will learn from Wachter’s intelligent assessment and become a believer that, despite today’s glitches and frustrations, the future computer age will make medicine much better for us all.”
In the face of such cacophony, Drew asked the nurse what kind of alarm would cause her to snap to attention. She thought for a moment and then said, “If the alarms went silent. That would be scary.” Medicine, of course, is not the only industry in which professionals need to perform their tasks in a swirling, often confusing, high-stakes environment, nor the only one that has to grapple with the matter of computerized alerts. I spoke to Captain Chesley “Sully” Sullenberger, the famed “Miracle on the Hudson” pilot, about how aviation handles the matter of alerts. “The warnings in cockpits now are prioritized so you don’t get alarm fatigue,” he told me. “We work very hard to avoid false positives because false positives are one of the worst things you could do to any warning system. It just makes people tune them out.” He encouraged me to visit Boeing to see how its cockpit engineers manage the feat of alerting pilots at the right time, in the right way, while avoiding alert fatigue.
., “Mortality and Morbidity in Patients Receiving Encainide, Flecainide, or Placebo: The Cardiac Arrhythmia Suppression Trial,” New England Journal of Medicine 324:781–788 (1991). 146 “Based on what I can extract from the data” Interview of Shahram Ebadollahi by the author, August 18, 2014. 146 “Missing a real event is much more costly” Quoted in L. Kowalczyk, “Patient Alarms Often Unheard.” 147 I spoke to Captain Chesley “Sully” Sullenberger Interview of Sullenberger by the author, May 12, 2014. 147 So I spent a day in Seattle with several of the Boeing engineers Interviews of Bob Myers, Alan Jacobsen, and Mark Nikolic by the author, June 4, 2014. 150 and a 2010 Australian study confirmed that it is J. I. Westbrook, A. Woods, M. I. Rob, et al., “Association of Interruptions with an Increased Risk and Severity of Medication Administration Errors,” Archives of Internal Medicine 170:683–690 (2010). 151 Studies of air traffic controllers S.
The Glass Cage: Automation and Us by Nicholas Carr
Airbnb, Airbus A320, Andy Kessler, Atul Gawande, autonomous vehicles, Bernard Ziegler, business process, call centre, Captain Sullenberger Hudson, Checklist Manifesto, cloud computing, computerized trading, David Brooks, deliberate practice, deskilling, digital map, Douglas Engelbart, drone strike, Elon Musk, Erik Brynjolfsson, Flash crash, Frank Gehry, Frank Levy and Richard Murnane: The New Division of Labor, Frederick Winslow Taylor, future of work, global supply chain, Google Glasses, Google Hangouts, High speed trading, indoor plumbing, industrial robot, Internet of things, Jacquard loom, Jacquard loom, James Watt: steam engine, job automation, John Maynard Keynes: Economic Possibilities for our Grandchildren, John Maynard Keynes: technological unemployment, Kevin Kelly, knowledge worker, Lyft, Marc Andreessen, Mark Zuckerberg, means of production, natural language processing, new economy, Nicholas Carr, Norbert Wiener, Oculus Rift, pattern recognition, Peter Thiel, place-making, Plutocrats, plutocrats, profit motive, Ralph Waldo Emerson, RAND corporation, randomized controlled trial, Ray Kurzweil, recommendation engine, robot derives from the Czech word robota Czech, meaning slave, Second Machine Age, self-driving car, Silicon Valley, Silicon Valley ideology, software is eating the world, Stephen Hawking, Steve Jobs, TaskRabbit, technoutopianism, The Wealth of Nations by Adam Smith, turn-by-turn navigation, US Airways Flight 1549, Watson beat the top human players on Jeopardy!, William Langewiesche
Sooner or later, even the most advanced technology will break down, misfire, or, in the case of a computerized system, encounter a cluster of circumstances that its designers and programmers never anticipated and that leave its algorithms baffled. In early 2009, just a few weeks before the Continental Connection crash in Buffalo, a US Airways Airbus A320 lost all engine power after hitting a flock of Canada geese on takeoff from LaGuardia Airport in New York. Acting quickly and coolly, Captain Chesley Sullenberger and his first officer, Jeffrey Skiles, managed, in three harrowing minutes, to ditch the crippled jet safely in the Hudson River. All passengers and crew were evacuated. If the pilots hadn’t been there to “babysit” the A320, a craft with state-of-the-art automation, the jet would have crashed and everyone on board would almost certainly have perished. For a passenger jet to have all its engines fail is rare.
Gillespie, “We Flew the Atlantic ‘No Hands,’ ” Popular Science, December 1947. 9.Anonymous, “Automatic Control,” Flight, October 9, 1947. 10.For a thorough account of NASA’s work, see Lane E. Wallace, Airborne Trailblazer: Two Decades with NASA Langley’s 737 Flying Laboratory (Washington, D.C.: NASA History Office, 1994). 11.William Langewiesche, Fly by Wire: The Geese, the Glide, the “Miracle” on the Hudson (New York: Farrar, Straus & Giroux, 2009), 103. 12.Antoine de Saint-Exupéry, Wind, Sand and Stars (New York: Reynal & Hitchcock, 1939), 20. 13.Don Harris, Human Performance on the Flight Deck (Surrey, U.K.: Ashgate, 2011), 221. 14.“How Does Automation Affect Airline Safety?,” Flight Safety Foundation, July 3, 2012, flightsafety.org/node/4249. 15.Hemant Bhana, “Trust but Verify,” AeroSafety World, June 2010. 16.Quoted in Nick A.
Gross and Ellen Yi-Luen Do, “Ambiguous Intentions: A Paper-like Interface for Creative Design,” in Proceedings of the ACM Symposium on User Interface Software and Technology (New York: ACM, 1996), 183–192. 29.Julie Dorsey et al., “The Mental Canvas: A Tool for Conceptual Architectural Design and Analysis,” in Proceedings of the Pacific Conference on Computer Graphics and Applications (2007), 201–210. 30.William Langewiesche, Fly by Wire: The Geese, the Glide, the “Miracle” on the Hudson (New York: Farrar, Straus & Giroux, 2009), 102. 31.Lee, “Human Factors and Ergonomics.” 32.CBS News, “Faulty Data Misled Pilots in ’09 Air France Crash,” July 5, 2012, cbsnews.com/8301-505263_162-57466644/faulty-data-misled-pilots-in-09-air-france-crash/. 33.Langewiesche, Fly by Wire, 109. 34.Federal Aviation Administration, “NextGen Air Traffic Control/Technical Operations Human Factors (Controller Efficiency & Air Ground Integration) Research and Development Plan,” version one, April 2011. 35.Nathaniel Popper, “Bank Gains by Putting Brakes on Traders,” New York Times, June 26, 2013. 36.Thomas P.
QI: The Second Book of General Ignorance by Lloyd, John, Mitchinson, John
Ada Lovelace, British Empire, Buckminster Fuller, Captain Sullenberger Hudson, clean water, double helix, Etonian, George Santayana, ghettoisation, Isaac Newton, Lao Tzu, Louis Pasteur, Mikhail Gorbachev, Murano, Venice glass, out of africa, the built environment, trade route, transatlantic slave trade, transatlantic slave trade, traveling salesman, US Airways Flight 1549
Then there’s the weather, and sea conditions, either of which could wreck the plane, no matter how calmly the pilot behaves. Despite such unnerving obstacles, there have been at least half a dozen successful emergency landings by airliners on water, including one off the coast of Sicily in 2005. The most recent and spectacular example occurred in January 2009 when an Airbus A380, US Airways Flight 1549, ditched in the Hudson River in New York. Shortly after take off, the plane hit a flock of geese and Captain Chesley ‘Sully’ Sullenberger III had to make a forced landing on the water. He did this perfectly, saving the lives of all 155 people on board. Airline statisticians like to say that you are ten times more likely to be hit by a comet than to die in a plane crash. This is because, once every million years or so, an extraterrestrial body collides with Earth.
Our Robots, Ourselves: Robotics and the Myths of Autonomy by David A. Mindell
Air France Flight 447, autonomous vehicles, Captain Sullenberger Hudson, Chris Urmson, digital map, drone strike, en.wikipedia.org, Erik Brynjolfsson, fudge factor, index card, John Markoff, Mars Rover, ride hailing / ride sharing, Ronald Reagan, self-driving car, Silicon Valley, telepresence, telerobotics, trade route, US Airways Flight 1549, William Langewiesche, zero-sum game
Finally, de Crespigny recalled the actions of Flight Controller Gene Kranz during the Apollo 13 emergency: don’t focus on your failures, figure out what’s working, and work with that for a safe return. De Crespigny marshaled his remaining resources, focused his attention, and the crew landed flight QF32 safely back in Singapore with no injuries. Every time lives are lost due to human error, we can think of other times when they have been saved by human judgment and skill. QF32, and the “miraculous” 2009 US Airways landing on the Hudson River at the hands of Captain Chesley Sullenberger, seem to show that experienced, skilled, calculating humans are critical safety features of these systems on which our lives depend, the last line of defense when the machines fail. Air France 447 and others undermine those hopes. In the summer of 2013, pilots of Asiana Airlines flight 214 failed to successfully land their modern Boeing 777 in San Francisco on a perfectly clear day; the crash landing killed three and injured scores.
Fly by Wire: The Geese, the Glide, the Miracle on the Hudson by William Langewiesche
The Escape New York, January 15, 2009 It was a wintry Thursday afternoon, and the city had turned inward on itself against the cold. On Manhattan’s west side, a few people who happened to be looking toward the Hudson River caught a glimpse of an airline accident that initially brought back memories of another case, eight years earlier, of airplanes crashing into the heart of New York. This time it was US Airways Flight 1549, an Airbus A320 that ran into a flock of geese, lost thrust from both engines, and glided without power to a safe landing in the Hudson’s frigid waters. The Department of Homeland Security flashed its badges, but only as bureaucracies do. There were no foreign terrorists here. The geese were innocent birds. The captain was the very definition of a good citizen, a man named Chesley Sullenberger whose life until now had been so uneventful that many of his peers at US Airways had overlooked his presence.
There were perhaps forty of them there, and possibly many more. They were expending minimal effort at staying aloft, finessing the vortices swirling from one another’s wings and maneuvering to keep their companions in sight. In theory these are the purposes of goose formations. And nature is marvelous, of course. But about six miles north of LaGuardia, and at about the same time that Wajda switched US Airways Flight 1549 to New York Departure Control, the geese flew into the departure corridor from Runway 4. Immediately after takeoff, Flight 1549 swept past the city’s enormous prison complex on Rikers Island, off to the left. Climbing through 500 feet, Skiles rolled the Airbus into a 20-degree left bank, to begin the required turn from northeast to the north. Sullenberger checked in with Departure Control, saying, “Cactus 1549, 700, climbing [to] 5,000.”
He has been termed one of the leading writers of The New New Journalism, a group of writers who have secured a place at the centre of contemporary American literature, as Tom Wolfe and The New Journalism did in the sixties. ALSO BY WILLIAM LANGEWIESCHE Cutting for Sign Sahara Unveiled Aloft American Ground The Outlaw Sea The Atomic Bazaar FLY BY WIRE The Geese, The Glide, The ‘Miracle’ on the Hudson WILLIAM LANGEWIESCHE PENGUIN BOOKS PENGUIN BOOKS Published by the Penguin Group Penguin Books Ltd, 80 Strand, London WC2R 0RL, England Penguin Group (USA) Inc., 375 Hudson Street, New York, New York 10014, USA Penguin Group (Canada), 90 Eglinton Avenue East, Suite 700, Toronto, Ontario, Canada M4P 2Y3 (a division of Pearson Penguin Canada Inc.) Penguin Ireland, 25 St Stephen’s Green, Dublin 2, Ireland (a division of Penguin Books Ltd) Penguin Group (Australia), 250 Camberwell Road, Camberwell, Victoria 3124, Australia (a division of Pearson Australia Group Pty Ltd) Penguin Books India Pvt Ltd, 11 Community Centre, Panchsheel Park, New Delhi – 110 017, India Penguin Group (NZ), 67 Apollo Drive, Rosedale, North Shore 0632, New Zealand (a division of Pearson New Zealand Ltd) Penguin Books (South Africa) (Pty) Ltd, 24 Sturdee Avenue, Rosebank, Johannesburg 2196, South Africa Penguin Books Ltd, Registered Offices: 80 Strand, London WC2R 0RL, England www.penguin.com First published in the United States by Farrar, Straus and Giroux 2009 Published in Penguin Books 2010 Copyright © William Langwiesche, 2009 All rights reserved The moral right of the author has been asserted Portions of this book were previously published in Vanity Fair Except in the United States of America, this book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, re-sold, hired out, or otherwise circulated without the publisher’s prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent purchaser ISBN: 978-1-84-614308-3 This is the second book I dedicate to Cullen Murphy, my editor and friend.
Against All Enemies by Tom Clancy, Peter Telep
It all depended on whether or not they thought they had enough power to keep the plane level. If they attempted to turn without sufficient power, they’d very quickly lose altitude. Pilots of single-engine aircraft were instructed to never, ever, attempt to return to the runway, because they would lose too much altitude to effect the turnaround. Case in point: On January 15, 2009, Captain Chesley Sullenberger was in command of US Airways Flight 1549 en route from La Guardia to Charlotte. He had lifted off and flown through a flock of birds, resulting in the loss of both engines. He knew he’d lose precious altitude if he started a turnaround with no engines producing power, and determined that his best course of action was to ditch in the river. His actions had saved the lives of the crew and every passenger on board.
Airbus A320, airline deregulation, airport security, Atul Gawande, call centre, Captain Sullenberger Hudson, collective bargaining, inflight wifi, low cost carrier, Maui Hawaii, Mercator projection, New Urbanism, pattern recognition, race to the bottom, Skype, Tenerife airport disaster, US Airways Flight 1549, zero-sum game
You can see web videos of bird carcasses being fired from a sort of chicken-cannon to test the resistance of windshields, intakes, and so forth. I’ve personally experienced several strikes, and the result was, at worst, a minor dent or crease. I should hardly have to mention, however, that strikes are occasionally dangerous. This is especially true when engines are involved, as we saw in 2009 when US Airways flight 1549 glided into the Hudson River after colliding with a flock of Canada geese. Modern turbofans are resilient, but they don’t take kindly to the ingestion of foreign objects, particularly those slamming into their rotating blades at high speeds. Birds don’t clog an engine but can bend or fracture the internal blades, causing power loss. The heavier the bird, the greater the potential for harm.
Within an airline, all pilots are taught the same methods and will fly the same procedures at roughly the same angles, rates, and speeds. A particular angle of bank might seem capriciously steep, or a landing might be clumsy, but any number of factors could be at fault. The severity of a maneuver, whether perceived or actual, is not always a crewmember’s whim or lack of finesse. What are your thoughts on the alleged heroics of Captain “Sully” Sullenberger and the so-called Miracle on the Hudson? Chesley “Sully” Sullenberger was the US Airways captain who guided his suddenly engineless Airbus into the Hudson River on January 15, 2009, after striking a flock of Canada geese. Together with the majority of my colleagues, I have the utmost respect for Captain Sullenberger. But that’s just it: respect. It’s not adoration or a false, media-fattened misunderstanding of what he and his crew faced that day.
Adaptive Markets: Financial Evolution at the Speed of Thought by Andrew W. Lo
Albert Einstein, Alfred Russel Wallace, algorithmic trading, Andrei Shleifer, Arthur Eddington, Asian financial crisis, asset allocation, asset-backed security, backtesting, bank run, barriers to entry, Berlin Wall, Bernie Madoff, bitcoin, Bonfire of the Vanities, bonus culture, break the buck, Brownian motion, business process, butterfly effect, capital asset pricing model, Captain Sullenberger Hudson, Carmen Reinhart, Chance favours the prepared mind, collapse of Lehman Brothers, collateralized debt obligation, commoditize, computerized trading, corporate governance, creative destruction, Credit Default Swap, credit default swaps / collateralized debt obligations, cryptocurrency, Daniel Kahneman / Amos Tversky, delayed gratification, Diane Coyle, diversification, diversified portfolio, double helix, easy for humans, difficult for computers, Ernest Rutherford, Eugene Fama: efficient market hypothesis, experimental economics, experimental subject, Fall of the Berlin Wall, financial deregulation, financial innovation, financial intermediation, fixed income, Flash crash, Fractional reserve banking, framing effect, Gordon Gekko, greed is good, Hans Rosling, Henri Poincaré, high net worth, housing crisis, incomplete markets, index fund, interest rate derivative, invention of the telegraph, Isaac Newton, James Watt: steam engine, job satisfaction, John Maynard Keynes: Economic Possibilities for our Grandchildren, John Meriwether, Joseph Schumpeter, Kenneth Rogoff, London Interbank Offered Rate, Long Term Capital Management, loss aversion, Louis Pasteur, mandelbrot fractal, margin call, Mark Zuckerberg, market fundamentalism, martingale, merger arbitrage, meta analysis, meta-analysis, Milgram experiment, money market fund, moral hazard, Myron Scholes, Nick Leeson, old-boy network, out of africa, p-value, paper trading, passive investing, Paul Lévy, Paul Samuelson, Ponzi scheme, predatory finance, prediction markets, price discovery process, profit maximization, profit motive, quantitative hedge fund, quantitative trading / quantitative ﬁnance, RAND corporation, random walk, randomized controlled trial, Renaissance Technologies, Richard Feynman, Richard Feynman, Richard Feynman: Challenger O-ring, risk tolerance, Robert Shiller, Robert Shiller, short selling, sovereign wealth fund, statistical arbitrage, Steven Pinker, stochastic process, survivorship bias, The Great Moderation, the scientific method, The Wealth of Nations by Adam Smith, The Wisdom of Crowds, theory of mind, Thomas Malthus, Thorstein Veblen, Tobin tax, too big to fail, transaction costs, Triangle Shirtwaist Factory, ultimatum game, Upton Sinclair, US Airways Flight 1549, Walter Mischel, Watson beat the top human players on Jeopardy!, WikiLeaks, Yogi Berra, zero-sum game
This communication function is also a very effective antidote to chapter 10’s tyranny of complexity and elitism. Despite the extraordinary complexity of determining the causes of a plane crash, Fixing Finance • 381 the NTSB manages to communicate a definitive narrative that satisfies all stakeholders, not just those with specialized knowledge. A case in point is the water landing of USAir Flight 1549, piloted by Captain Chesley Sullenberger, in the Hudson River on January 15, 2009. Given the history of terrorist acts in New York over the years, you can imagine how New Yorkers might have reacted to an airplane crash landing within walking (or swimming) distance of the financial district. But that very afternoon, the NTSB issued a statement that, pending more detailed investigation, the initial best guess as to what happened was a bird strike that shut down both engines of Flight 1549.
Airbus A320, Apple's 1984 Super Bowl advert, bank run, banking crisis, bonus culture, call centre, Captain Sullenberger Hudson, collapse of Lehman Brothers, collateralized debt obligation, corporate governance, credit crunch, Credit Default Swap, credit default swaps / collateralized debt obligations, financial innovation, fixed income, glass ceiling, high net worth, Long Term Capital Management, mass affluent, Mexican peso crisis / tequila crisis, Plutocrats, plutocrats, Ronald Reagan, six sigma, sovereign wealth fund, technology bubble, too big to fail, US Airways Flight 1549, yield curve
The bank announced that it would move its earnings announcement up from inauguration day, January 20, to the next day, Friday, January 16. That evening, Ken Lewis held a conference call with his board of directors. The meeting was surreal. A few hours earlier, a Charlotte-bound U.S. Airways flight experienced engine trouble after taking off from LaGuardia Airport in New York. The captain, Chesley “Sully” Sullenberger, made a split-second decision to ditch the airplane, an Airbus A320, in the Hudson River rather than take a chance on being able to get back to an airport. More than a dozen BofA employees were on the flight, heading back to Charlotte after a four-day workweek in New York. Miraculously, the plane landed intact on the Hudson and stayed afloat for hours, allowing rescue teams to get everyone out alive.
3D printing, additive manufacturing, Airbus A320, Albert Einstein, Amazon Web Services, Any sufficiently advanced technology is indistinguishable from magic, asset-backed security, augmented reality, barriers to entry, bitcoin, bounce rate, business intelligence, business process, business process outsourcing, call centre, capital controls, citizen journalism, Clayton Christensen, cloud computing, credit crunch, crowdsourcing, disintermediation, en.wikipedia.org, fixed income, George Gilder, Google Glasses, high net worth, I think there is a world market for maybe five computers, Infrastructure as a Service, invention of the printing press, Jeff Bezos, jimmy wales, London Interbank Offered Rate, M-Pesa, Mark Zuckerberg, mass affluent, Metcalfe’s law, microcredit, mobile money, more computing power than Apollo, Northern Rock, Occupy movement, optical character recognition, peer-to-peer, performance metric, Pingit, platform as a service, QR code, QWERTY keyboard, Ray Kurzweil, recommendation engine, RFID, risk tolerance, Robert Metcalfe, self-driving car, Skype, speech recognition, stem cell, telepresence, Tim Cook: Apple, transaction costs, underbanked, US Airways Flight 1549, web application
When that deal fell through, Yahoo tried a counter-offer of $1 billion—unsurprisingly it was declined. By 2007, when Apple released the iPhone, Facebook was already outperforming MySpace in terms of monthly visitors. One year later, Facebook had 200 million users, twice the size of MySpace. In 2008 Facebook tried to buy the rapidly growing social network and microblogging service, Twitter, for $500 million.5 In the same year, Tumblr launched. On 15 January 2009, US Airways Flight 1549, flying from LaGuardia Airport in New York to Charlotte, North Carolina, crashed in the Hudson River six minutes after take-off. Both engines of the Airbus A320 were disabled due to birdstrike by a flock of Canadian geese during its climb out. At 3:31pm, the plane made an unpowered ditch landing in the Hudson River. At 3:33pm (two minutes later) Jim Hanrahan (Twitter handle @highfours) tweeted the following: In February 2008, in the run-up to the US presidential elections, John McCain raised US$11 million through campaign fundraisers6 to support his nomination.
What in God's Name: A Novel by Simon Rich
He was suspended for three days, but he returned more brazen than ever. On a sunny afternoon in May, he guided a flock of geese into the path of a 747 jet. As the plane plummeted from the sky, he weaved it between two skyscrapers and directed it into the Hudson River. There were dozens of injuries but no fatalities—making it the most “miraculous” crash landing in memory. The event was so spectacular, even the media had to acknowledge heaven’s hand. “Miracle on the Hudson!” raved the tabloids. It was God’s best press in years. As soon as he saw the headlines, he gave Vince a promotion to the executive wing, where he’d been ever since. Vince squinted across the room at Craig. He was disgusted by the Angel’s physical appearance. His coffee-stained khakis clung unflatteringly to his hips and his wrinkled blue Oxford was missing at least one button. His filthy brown hair was speckled with visible dandruff flakes.
The Great Fragmentation: And Why the Future of All Business Is Small by Steve Sammartino
3D printing, additive manufacturing, Airbnb, augmented reality, barriers to entry, Bill Gates: Altair 8800, bitcoin, BRICs, Buckminster Fuller, citizen journalism, collaborative consumption, cryptocurrency, David Heinemeier Hansson, Elon Musk, fiat currency, Frederick Winslow Taylor, game design, Google X / Alphabet X, haute couture, helicopter parent, illegal immigration, index fund, Jeff Bezos, jimmy wales, Kickstarter, knowledge economy, Law of Accelerating Returns, lifelogging, market design, Metcalfe's law, Metcalfe’s law, Minecraft, minimum viable product, Network effects, new economy, peer-to-peer, post scarcity, prediction markets, pre–internet, profit motive, race to the bottom, random walk, Ray Kurzweil, recommendation engine, remote working, RFID, Rubik’s Cube, self-driving car, sharing economy, side project, Silicon Valley, Silicon Valley startup, skunkworks, Skype, social graph, social web, software is eating the world, Steve Jobs, survivorship bias, too big to fail, US Airways Flight 1549, web application, zero-sum game
Social media as an industrial-system protest The seminal moments in social media that made global populations sit up and pay attention weren’t the heady valuations of the technology companies serving up new social tools. (Remember when Microsoft bought a microshare of Facebook, valuing it at US$15 billion?) They weren’t even the moments of celebrity endorsement resulting from celebrities using the new tools and gathering swarms of followers. It was the instant global awareness brought to events that impacted real people’s lives, such as the Miracle on the Hudson, which was first reported via a tweet by people escaping an airbus sinking in New York’s Hudson River. It was the immediate global reporting of the terrible tsunami in Japan and the initial reports of explosions during the Boston marathon. But most of all, social-media uptake is an industrial-system protest that says we want more than the one-way monologue served up by traditional media during the ‘TV-industrial complex’.1 This couldn’t be better exemplified using social media tools than in what we saw during the Arab Spring.
The Crash Detectives by Christine Negroni
Air France Flight 447, Airbus A320, Captain Sullenberger Hudson, Checklist Manifesto, computer age, crew resource management, crowdsourcing, low cost carrier, Richard Feynman, Richard Feynman, South China Sea, Tenerife airport disaster, Thomas Bayes, US Airways Flight 1549
Keith, R.A. Bush Pilot With a Briefcase: The Incredible Story of Aviation Pioneer Grant McConachie. Vancouver, Canada: Douglas & McIntyre, 1972. Kemp, K. Flight of the Titans: Boeing, Airbus and the Battle for the Future of Air Travel. London: Virgin Books, 2006. Kohli, S. Into Oblivion: Understanding #MH370. CreateSpace, 2014. Langewiesche, W. Fly by Wire: The Geese, The Glide, The Miracle on the Hudson. London: Picador, 2010. Levine, S. The Powerhouse: Inside the Invention of a Battery to Save the World. New York: Viking, 2015. Lindbergh, C. A. Of Flight and Life. New York: Charles Scribner’s Sons, 1948. Long, E. M. and M. K. Long. Amelia Earhart: The Mystery Solved. New York: Simon & Schuster, 1999. Mahon, P. Report of the Royal Commission Crash on Mt. Erebus. Wellington, New Zealand: Hasselberg Government Printer, 1981.
Hatching Twitter by Nick Bilton
4chan, Airbus A320, Burning Man, friendly fire, index card, Jeff Bezos, John Markoff, Kevin Kelly, Mahatma Gandhi, Mark Zuckerberg, pets.com, rolodex, Ruby on Rails, Saturday Night Live, side project, Silicon Valley, Skype, social web, Steve Ballmer, Steve Jobs, Steven Levy, technology bubble, traveling salesman, US Airways Flight 1549, WikiLeaks
The same fans who now lived on Venice Beach, in Los Angeles. Noah’s new neighbors. Soon, just as in San Francisco, the blue bird appeared. “Hey, have you ever heard of Twitter?” people asked Noah in bars along the Venice boardwalk. “Whoa, why do you have so many followers?” they said in coffee shops on Abbot Kinney Boulevard. Twitter’s prominence in the headlines reached a pinnacle during an event dubbed “Miracle on the Hudson,” when an Airbus A320 with 155 passengers on board took off from New York’s LaGuardia Airport and was struck by a flock of birds. It landed safely in the Hudson River. A picture of the passengers escaping from the downed plane landed on Twitter, taken by a tourist on a ferry who had snapped a photo with his phone. And then it was all over the Web, magazines, and the nightly news. Twitter.