The Prison of Precision – A Case Study
Here’s a story about me and you. It’s about commercial aviation, and I’ve tried to include all the relevant facts for you to draw conclusions. But it’s all about me and you. I am Captain Michel Asseline. You are Captain Michel Asseline. Any doctor who tries to practice in medicine today, except for my colleagues in Direct Primary Care, live in the world of Captain Michel Asseline every day. Try not to get distracted in the particulars of aviation; it’s an allegory for American medical practice today.
The Facts
On June 26, 1988, a very special Airbus A320 left Basel-Mulhouse Airport in Habsheim, France. It was a demonstration charter flight, Air France Flight 296. It was piloted by a premier captain of Air France, Captain Michel Asseline, with over10,000 air hours, and led the training division of Air France for qualifying pilots on the Airbus 320. He was the lead test pilot for the A320 in its development. His craft was the third Airbus ever built.
The A320 had been recently introduced, and Flight 296 was the first passenger flight of the A320. Today, they would perform a flyover at the Habsheim Air Show at the Habsheim Aerodrome and go on to a sightseeing tour of Mont Blanc. The flight would take 130 passengers and 6 crew aloft. All the passengers were specially selected for the trip. The press was aboard.
The flight plan originally filed did not include the flyover of the Habsheim Air Show, which was added on the morning of the flight. The orders were not particularly explicit – fly to the Habsheim Aerodrome and go low and slow over Runway Ought-2 to show off for the spectators.
Air France was especially impressed with the A320, which was the first fly-by-wire airplane ever to carry passengers. Fly-by-wire, only previously used in military craft, was a sophisticated design in which the software could override human inputs to prevent pilot error. Its systems would not allow for mistakes.
The overflight of the airfield at the Aerodrome was to take place at alpha-max, the lowest speed at which a craft could fly without stalling. Fly-by-wire was perfect for this precision maneuver of an aircraft. Everyone thought it was a no-brainer for the A320 to wow this crowd.
After takeoff, eight minutes away, the Aerodrome came into view. The plan was to overfly Runway Ought-2; the aircraft was configured for a low-altitude overflight. But upon seeing the Aerodrome, the pilot saw that the audience were gathered elsewhere, on Runway 34R. The captain made a last-second turn and approach to overfly Runway 34R.
Due to the many demands of redirection and reconfiguration, the craft flew above Runway 34R at 30 feet, not the usual 100 feet which is standard for low-altitude demonstration overflight. Overflight at this altitude made the demonstration to the crowd even more awe-inspiring.
The pilot pulled up on the yoke to ease the plane up over the hundred-foot-tall woods at the end of the runway. Since the plane was going slow, the computer overrode his input, and denied the maneuver. Ascending at such an angle would lead to the plane’s stalling within minutes. The computer didn’t know he meant just to pop up a few hundred feet. The pilot called out to the co-pilot for emergency power. Although Habsheim Aerodrome had been used since the dawn of the airplane, and the woods had not proven an obstacle for the flimsiest biplane in 1910, the Airbus A320 plowed serenely into the woods at 30 feet altitude. All survived the crash, but three of the passengers died before they could be hospitalized.
The Aftermath
The pilot and copilot were charged and convicted of three counts of involuntary manslaughter in the French criminal courts. Captain Michel Asseline served a year in prison. The crash was a great embarrassment to Air France and Airbus, a European company with deep roots in France. It threatened to ruin the reputation of the A320, potentially losing many millions of dollars in sales.
Christian Roger, a professional pilot, complained energetically about the fact-finding process around the crash. He was leader of the French air force's aerobatics team and, later, a Boeing 747 Flight Captain with Air France. He was President of the leading French pilots' union, the SNPL, at the time an Airbus A320 crashed into trees at Habsheim in Eastern France in June 1988. “He exposed multiple anomalies, not to say lies, in the experts' evidence and in the data of the crash all of which pointed to a very high level, state inspired plot to whitewash the aircraft in the crash and confirmed what the pilot had been saying all along.” He joined the pilot's defense team. A website, http://www.crashdehabsheim.net/ has been set up to analyze the scandal.
The Outrage
Aside from the strong evidence that Air France, Airbus and the nation itself may well have had a hand in falsifying data related to the crash, there are several very important points to take away in this very sad and tragic story.
Captain Michel Asseline got thrown under the Airbus. He gave the best he could to make it fly. His job was to find its limitations, but one slipped past him, and Airbus and all the designers and engineers. Who went to prison? Captain Michel Asseline. If you change the pilot’s cap for a lab coat, aren’t you Captain Michel Asseline, too?
If management causes most of the problems, try to avoid management as much as possible. ”I should estimate that in my experience most troubles and most possibilities for improvement add up to the proportions something like this: 94% belongs to the system (responsibility of management), 6% special.” Page 315 of Out of the Crisis by Dr. W. Edwards Deming. He said this at least a decade before the Airbus crash. If you remove management edicts and substitute human judgment, you can eliminate 19 out of 20 errors.
Defects come in all shades. Captain Michel Asseline got burnt doing a routine, everyday maneuver that his plane just couldn’t handle, one that an open-cockpit biplane could. He wanted to pop up 70 feet to get over the trees. The Airbus A320 couldn’t handle it. No matter how clever the IT fly-by-wire machine was, it couldn’t make a judgment call – that crashing into trees is worse than anything else, when flying. The plane crashed because of a design defect; but because it was software and not metal, it was ignored.
Management often screws around. Captain Asseline was flying to Mont Blanc, period. Some faceless desk-pilot added on a trip to a tiny airfield on the day of the flight but did not bother to do the hard work of preparing the particulars necessary to do so. The pilot was told, word-of-mouth, to do so. He was not given a map and route. He had to spot the airfield from the air and prepare to do the overflight. Any experienced pilot, or physician for that matter, smells disaster. Not only was he told to go there, he was told the wrong runway to overfly. In order to accomplish the desk-pilot’s orders, the pilot’s valuable time was spent jiggering the preparations for the overflight, not allowing him to evaluate strategic details like – why fly a plane at 30 feet if there are 100-foot trees at the end? Wouldn’t a 200-foot overflight be nearly as spectacular? He was never given the chance. Nor, then, were his passengers.
Who’s going to fly the goddamn airplanes in the future? Why be a sucker? If you get blamed for everything, it’s better to do nothing. Get a job criticizing – nobody blames you for doing that.
There are many more lessons to be learned about the practice of medicine from the story of Prisoner Michel Asseline – sorry, Captain Michel Asseline. Respond with some you can think of! But the take home message, why do you spend every day at work in the cross-hairs of numerous non-producers who can’t do the job, but are stalking you? Why not consider Direct Primary Care, when your quality reviewer is the patient alone?
