Early on a Saturday morning in November 2013, the captain of a South Korean Sikorsky S-76 helicopter came to a decision. The weather in Seoul was entirely unsuitable for safe flight and the VIP task he was planning for his boss—the CEO of LG Electronics—would have to be cancelled.
Instability in the lower atmosphere had lowered visibility at Gimpo International Airport (their home base) to 700 metres. In the Hangang River Corridor (the intended flight route) the visibility was even worse—down to 200 metres. With weather as bad as this, the decision was a relatively easy one, especially when LG’s own operational regulations prohibited flight in the corridor with less than 1600 metres visibility. At 6:25 am, the captain called his first officer (FO) and in a rather under-stated way told him, ‘Let’s cancel the flight because it will be difficult’. He then asked the first officer to call the CEO’s office to notify them of the ‘no-go’.
The crew had accounted well for the weather and made a decision most of us would have made in the same circumstances. But they hadn’t accounted for something I’m calling ‘the CEO effect’. You’ve probably been there before. The big boss, the CEO or a General Manager, pays a visit to the workplace and brings with them a rapid and unambiguous climate change. You notice people previously quite vocal suddenly becoming more reserved and circumspect. Other people, normally rather critical, seem to have a more buoyant perspective while still others quietly fade to an inconspicuous corner of the work space. Others, keen for some ‘face time’ with the big boss, gravitate towards her or him hoping to make an agreeable impression while they’re still within effective range. If you’re wondering about the dynamics of the CEO effect, James Adonis, writing for the Sydney Morning Herald, has some useful insights—not the least of which is ‘opinion conformity’, a term coined by social psychologist Edward E. Jones. Opinion conformity, we are told, is when a person wanting to please (or wanting to avoid displeasing) a boss adopts the attitudes or beliefs of that boss; that is, they adopt an attitude that knows exactly when to nod their heads agreeably and when not to. For the crew of LG’s S-76—call sign HL9294—they’d rightly shaken their heads but management would soon insist on a nod.
A few minutes after the no-go call, head office made their own call—to the crew’s base manager. They were clear in their intent. ‘The first officer notified no-go, so please, accurately assess situation once again.’ The base manager dutifully offered to ring the captain but instead the deputy general manager from head office asked for the direct number of the captain’s phone. The captain might have thought his decision making for the day was done but on receipt of the call from the CEO’s office he was confronted with a fresh decision: continue to refuse to fly the mission or agree with his immediate manager and LG’s head office. He wisely went with the answer that would buy him some time telling his bosses he would re-assess in an hour or so. The hour came and went quickly, the bad weather did not.
Buckling to the pressure, the captain asked the first officer to call air traffic control and the capital defense command (CDC) which monitors air traffic around the capital Seoul. The CDC officer politely, but pointedly, queried the first officer about his intended flight plan which was still not cancelled. ‘Are you going to fly as planned when other scheduled flights are all cancelled?
The CDC officer was asking because the weather had worsened to the point where there was literally no-one else willing to negotiate the pea souper enveloping the city. The first officer’s response, conditioned by a recent conference call involving the captain, the base manager and Head Office, was in the affirmative. Despite the clear and present danger of the besetting fog, the conference call had seen the captain finally consent to the flight. When asked later why no-one else at the helicopter base had queried the decision, fellow pilots reported they didn’t speak up because the captain had previously flown in conditions below the required minimums and ‘he had more flight experience and better pilot proficiency than other pilots’. After he got off the phone with the CDC, the first officer, probably manifesting his discomfort at the idea of flying in terrible weather, rang ahead to Jamsil Heliport. Weather there was the same as Gimpo and the Hangang Corridor—appalling. Surprisingly, this was not passed on to the captain and at 8:45 am, HL9294 took off as planned and headed for Jamsil Heliport—its mission to pick up six senior company officials, including the vice-chairman and CEO of LG.
Apart from the possibility of being called a suck-up, opinion conformity in the work space is a relatively low-risk affair. A well-placed comment affirming the boss’s excellent judgment or a hearty laugh at the boss’s humour would hardly seem to constitute the preconditions for something deadly. But as HL9294 was about to demonstrate, opinion conformity in aviation can be a perilous affair. On departure from Gimpo, HL9294 was almost immediately flying in near-fog conditions. The tower controller at first refused an airways clearance informing the crew visibility was at 700 metres and only begrudgingly granting the clearance when the captain requested ‘Special VFR’. Clearing the low-lying fog at about 500 feet, the crew were happy to report visibility was greater than 10 kilometres and they made good time cruising at 130 knots towards Jamsil at about 1200 feet. But while the visibility ‘on top’ was good, the fog blanket below was so thick there was no useable ground features for the crew to navigate by and consequently the aircraft began to divert out of the Hangang Corridor and away from the flight-planned track. At this point, with zero visibility of the ground and therefore zero hope of successfully finding their destination, the crew of HL9294 could have exercised their right to cancel the flight and return to Gimpo using IFR. The instrument landing system and the high-intensity approach lights would have given them the best chance of getting visual and landing safely. But the CEO effect continued to exert its unremitting tug and the crew pushed on.
Still unable to see the ground and nearing the location of the VIP pick-up, the captain initiated a slow descent in what he thought was the river corridor. He was attempting to gain visual cues with the ground so he could find his destination and his approving bosses. At 800 feet and still on descent, the aircraft decelerated from 130 to 68 knots, as the crew slowed in the thick fog. But they were not over the river—instead they were descending atop the exclusive high-rises of downtown Seoul. The captain, who was on the controls, was by now getting noticeably anxious. ‘Hangang in sight?’ he asked the first officer.
He was still hoping to sight the river. But the first officer couldn’t see outside any better than the captain could. It was literally the blind leading the blind. Despite this, and still maintaining his aviation bedside manner, the first officer asked the captain to fly a little further south.
‘Now … Hangang, we seem to be entering Hangang?’ asked the captain again, this time with increasing urgency. He would repeat his question several more times to no avail.
The crew’s plan had been as simple as it was dangerous: descend until they could see something useful. It had failed. Emerging out of the fog, with closure rate too fast to avoid, was one of the most expensive condominium buildings in Seoul. The building caretaker had been tasked with manually operating the hazard lights after the automatic switch had failed. On this particular morning, since it was daylight, he had turned the lights off. Without the warning lights, the crew had no chance of reacting in time to the shadowy hulk of the building.
With an explosive boom many residents mistook for the start of another Korean war, the left side of the rotor system struck the 26th floor. The rotors immediately fragmented and blade pieces penetrated the building’s apartments with the remainder falling to the street below. The decapitated fuselage began its downward plunge, the spinning blade roots and bucking cabin ravaging the 25th, 24th and 23rd floors. Inertial force from the sudden stoppage of the rotor swung the tail through 180 degrees causing the tail rotor to rupture the building walls a few dozen metres from the original impact point. With the catastrophic impact over, the helicopter became nothing more than a five-tonne rock, and tumbled ballistically down the side of the building. The fall to earth was as deadly as it was long. Both the captain and the first officer were killed by multiple fractures, and debris was scattered for hundreds of metres. Miraculously, no-one within the building or on the ground was injured. A kilometre or so away, the senior executives of LG Electronics waited for their helicopter.
From take-off to impact a mere eight minutes passed. Eight minutes of boss-pleasing, opinion-conforming ‘normal’ flight. From the initial no-go phone call to take-off, two hours passed. Two hours answering conference calls, updating weather reports and re-rationalising the original ‘no-go’ call. As an observer, you wish they’d gone with ‘plan A’. But that’s the power of the opinion conformity, that’s the power a boss can have on healthy decision making. In Adonis’s article he quotes Irish statesman Edmund Burke: ‘Flattery corrupts both the receiver and the giver’. While capitulation to the external pressures of a boss who insists on a ‘reassessment’ of the weather may not be the same as flattery, it’s definitely a close cousin. It emanates from the same part of us that wants to please, or avoid displeasing, a person who just happens to have a very real and tangible effect on our continued employment. But the lesson of the S-76’s collision with the condominium takes Edmund Burke’s statement to a new level: flattery (or non-assertiveness) not only corrupts both the receiver and the giver, in aviation it imperils both the receiver and the giver.
Of course it’s easy to look at the calamitous flight of LG’s corporate helicopter and dismiss the deficiencies in decision making as being for someone else. We might even be tempted to think our own strength of character insulates us from such weaknesses. But just as aerodynamics direct our flight characteristics, psychological biases can direct our decision-making characteristics: biases are, in fact, as real as the lift equation. We’ve all felt the pressure to please others and especially the pressure to please a boss, and while we haven’t experienced an accident, others have felt the same pressure and crashed just as badly as HL9294 (see ‘As you wish, my lord’ and ‘When ‘I can’t’ is a positive’). The fact is we’ll probably feel that pressure again. Hitch that pressure to something such as fatigue, or illness, or just good old fashioned world-weariness and we may find ourselves committing to a boss-pleasing flight on a bad weather day just like the crew of HL9294. And if on that day an accident occurs, the cruel irony will be that the boss won’t be pleased at all. Especially if he or she is a passenger.
The dynamics of the CEO effect by James Adonis
Reminds me of the 2010 Polish Air Force Tu-154 crash that killed many, including “the boss”; https://en.wikipedia.org/wiki/2010_Polish_Air_Force_Tu-154_crash – Wikipedia is perhaps not the most accurate account of what happened but it certainly gives a flavor. If memory serves me well, the accident was covered in a previous issue of Flight Safety.
I was flying a helicopter in Malaysia almost 50 years ago. I was tasked to fly from the west coast to a small, grassed, uncontrolled airstrip in the middle of the country early one morning. As I flew inland, low lying fog in the valleys and along waterways became obvious. When I reached my destination, there was low lying but wispy fog through which the airfield was visible from above. I decided to make a landing thinking visibility was okay. As soon as I entered the fog, I was immediately ‘whited out’. I immediately went onto my AH to keep wings level and kept airspeed up while recovering. Apart from the fright, the lesson I learnt from this was that visibility through fog from above did not translate into visibility IN fog
Reads like natural selection to me
First problem, and probably the main problem, I see is that the pilot delegated the flight cancel message rather than conveying it himself.