At end of a foggy runway_ a KLM Boeing 747 sat ready for takeoff by keara


									At end of a foggy runway in Spain’s Canary Islands, a KLM Boeing 747 was ready for
takeoff. 1200 meters away, out of sight in the fog, a Pan Am Boeing 747 was moving off
the main runway to a side taxiway. One minute and six seconds before the deadliest
aviation disaster in history, the KLM radioed to the control tower:

        The KLM 4805 is now ready for takeoff, and we are waiting for our ATC
        [air traffic control] clearance.

    The control tower responded that the KLM flight pattern after takeoff was clear.
    The KLM first officer (co-pilot) repeated back their after-takeoff flight pattern, then
added, “We are now taking off.” The KLM’s brakes were released. The KLM captain
said, “Let’s go—check thrust,” and began to take off.
    The KLM officers then heard the control tower respond: “Okay.” They then heard a
radio transmission from the Pan Am airliner: “Clipper 1736.”
    The KLM officers didn’t hear the rest of these two radio transmissions, because the
control tower and Pan Am airliner transmitted at the same time. What the control tower
tried to transmit to the KLM airliner was, “Okay. Stand by for takeoff. I will call you.”
What the Pan Am airliner tried to transmit was, “And we’re still taxiing down the
runway, the Clipper 1736.”
    25 seconds before impact, the control tower broadcast, “[Pan Am] 1736, report
runway clear.”
    The Pan Am airliner responded, “Okay, will report when we’re clear.”
    This exchange was heard in the KLM cockpit. The KLM flight engineer raised a
question, “Is he not clear, then?”
    The KLM captain responded, “What do you say?”
    The flight engineer repeated his question: “Is he not clear, that Pan American?”
    The KLM captain responded, “Jawel—Oh, yes.”
    Fourteen seconds later the KLM airliner crashed into the Pan American airliner. All
248 people aboard the KLM airliner died. On the Pan American airliner, 335 people died.
61 people on the Pan American airliner survived, all in the front of the aircraft, including
the pilots.
Why did the flight engineer, the lowest-ranking officer in the cockpit, recognize that the
runway wasn’t clear, when the captain and first officer (co-pilot) didn’t? How could the
person with the least expertise be right, when the persons with the most expertise were
   The KLM airliner was piloted by Captain Jacob van Zanten. Captain van Zanten
wasn’t just any pilot. He was the head of KLM’s Flight Training Department. For six
years he’d been the expert pilot who trained other pilots to fly the Boeing 747—the
largest airliner ever made. KLM featured Captain van Zanten in its magazine ads. Is it
more than a coincidence that one of the very best pilots caused the worst aviation disaster
in history?
   The KLM crew had been on duty for nine hours and twenty minutes and so may have
been fatigued. Captain van Zanten, with the most responsibilities, was under more stress
than the other officers. The weather was changing, possibly for the worse. The crew was
approaching their duty time limits. The delay was costing the airline money. An analysis
of the Tenerife disaster suggested that this stress may have caused Captain van Zanten to
hear only what he wanted to hear and shut out anything that may have interfered with his
plan.i A later chapter of this book describes this hedgehog behavior:

         In my 40-year fight for the role of human factors in aircraft accidents to be
         recognized, I have found that one of the very strongest of human factors is
         the resolute determination not to want to know, particularly if that
         knowledge is disturbing [and] discomforting and could be costly and
         embarrassing to take required action on.
                        — David Beaty, British Airways Flight Deck, Autumn 1993

David Halberstam won a Pulitzer Prize for his reporting on the Vietnam War. The thesis
of his 1972 book The Best and the Brightest was a seeming paradox: how did the most
intelligent, best-educated, and well-connected men in America devise a disastrous war
that killed more than 58,000 Americans and an estimated two million Vietnamese? How
could the most qualified experts make not just one mistake, but a series of colossal
blunders over eight years?
   More recently, George W. Bush’s decision to invade Iraq was based largely on expert
advice that Iraq was developing weapons of mass destruction. Specifically, Bush’s
January 28, 2003 State of the Union Address to Congress stated, “Saddam Hussein
recently sought significant quantities of uranium from Africa.” This statement was
supported by National Security advisor Condoleezza Rice, who said that the statement
had been authorized by the Central Intelligence Agency; and by the British Prime
Minister Tony Blair and Foreign Secretary Jack Straw.ii As I write, American deaths in
Iraq approach 3,000; and Iraqi deaths are estimated at 650,000.iii

       “Intelligence has been the asset most lacking in this campaign.”
                                                — Colin Powell, October 27, 2003

In 1978, veterinarian Richard Pitcairn tried a radical idea. Instead of ignoring nutrition, as
his veterinary school training had done, he told his clients to feed their dogs and cats
fresh meat, whole grains, and fresh vegetables. Within months, chronically ill pets were
healthy and happy. He felt “baffled” by conventional veterinary medicine’s focus on
drugs and surgery. He found that
       Knowledge was fragmented, and specialists clung to narrow academic
       disciplines. For example, one group of immunologists would hold a
       particular viewpoint on disease mechanisms and a second group, a
       different view. It seemed that no effort was being made to reconcile the
       opposing positions. And then there were the microbiologists, the
       virologists, the biochemists, the pathologists, and a host of others, all of
       whom tended to see things through different sets of filters! Our research
       aims had become so narrowly defined and carried out that we were
       missing the whole picture. [Instead, I began to] read broadly in many
       fields and from many sources to get a larger scope of concepts and ideas.iv

   Twenty-eight years later, Dr. Pitcairn’s Complete Guide to Natural Health for Dogs
& Cats has sold over 400,000 copies. My dog refused to eat dry or canned dog food. Now
that I follow the recipes in Dr. Pitcairn’s book he licks his bowl clean.
   My area of expertise is stuttering. I’ve written two books on the subject. Over the
fourteen years I’ve worked in this field I’ve been frustrated by the “intelligence failures”
of the experts in this field. These “experts” are typically Ph.D.-level speech-language
pathologists, along with the directors of non-profit organizations for stutterers, who
typically aren’t speech-language pathologists. These people shut down at the suggestion
of ideas other than their own ideas. They refuse to read studies published in peer-
reviewed scientific journals about treatments other than what they practice, or studies that
show that their own treatments are ineffective. They’re not interested in how similar
symptoms in related disorders such as Tourette’s syndrome are routinely treated. If
they’re university professors, they work to suppress knowledge, not to educate. If they
work for a non-profit organization, they’re devoted to keeping people stuttering and
oppose treating stuttering. They prefer to fight other experts whose views are different,
rather than co-operate to find common solutions to problems.
   In contrast, I enjoy working with master’s degree-level speech-language pathologists,
especially those that work in schools. These individuals (almost all of whom are women)
are enthusiastic when we discuss how to improve the effectiveness of stuttering
treatments. They’re interested in trying new ideas, especially new treatments that are
more effective, easier to practice, and cost less than previous treatments. When a
treatment works with one disorder or with one child, they try to it with related disorders
or with other children. They’re grateful, not angry, when I suggest better ways to do their

Not all fields are dysfunctional. You’ll be pleased to know that airline pilots are now
trained to have good communication skills. There have been recent years without any
airline crashes. Experts in physics, mathematics, and computer science, in general,
welcome new ideas and enjoy working with related fields (e.g., many physicists are
interested in computer science, and vice versa). This book will show why physics,
mathematics, and computer science and other fields are functional; when politics,
psychology, and many medical fields are dysfunctional.
   This book will also show how to solve problems associated with expertise, that is, to
make the dysfunctional fields functional. Gordon Rugg, a psychologist at England’s
Keele University, is developing what he calls the Verifier Method to critically re-assess
previous research into difficult problems, such as causes and treatments for Alzheimer’s
disease. The Verifier Method begins with developing a “knowledge map” of a field by
interviewing experts in the field, using elicitation methods similar to those used by
market researchers or by individuals gathering requirements for software development.
The goal is to map not only the facts of the field (which can be found in any textbook)
but also the field’s assumptions and normal working practices. Next, the verifiers look for
errors associated with expertise, and then test whether such errors have occurred. v The
Verifier Method aims for breakthroughs in moribund fields, not by doing new research,
but by showing gaps in a field’s knowledge map, that experts’ narrow focuses have
   This book will also explore the development of wikimedia. Can co-operating non-
experts create materials as accurate or more accurate than expert-created materials?

On a far smaller scale, my first job out of college was at a bike shop. As the lowest-
ranking employee I fixed the inexpensive bicycles customers brought in for repairs.
Occasionally I had to replace a bent fork. The universal forks had to be cut to fit each
bike. I measured each one three times, knowing that a mistake would mean throwing
away a $20 fork, which was about what I was paid in a day. I never cut a fork too short.
   That year, Alexi Grewal won the Olympics bike race, riding a Pinarello racing bike.
Pinarellos were the most in-demand bike that year, costing many thousands of dollars,
with a six-month waiting list to get one. One of our customers had ordered one. Finally
the bike arrived. Our bike shop’s head mechanic assembled the bike himself, not leaving
the task to any of us less-experienced mechanics. He eyeballed the fork, thought it looked
too long, and hacksawed off an inch. Inserting the fork into the frame he realized that the
factory had sent the right-length fork—and now the fork was an inch too short. He called
the customer, apologized, and told the customer he would have to wait another six
months to ride his new bike.
      The three of us who were hired that year made no mistakes that I can remember. Of
the two mechanics who had several years of experience, I can only recall one mistake,
which involved fixing a bike too well, and going over the limit the customer had said he
wanted to spend. The only stupendous bike-repair disaster of the summer was the fault of
the best, most experienced bike mechanic I’ve ever known.
      Several years later I bought a motorcycle chain at a motorcycle store. I asked the have
the chain cut to 100 links. When I got home and tried to install the chain, I discovered
that it had been cut to 98 links. When I tried to return the chain, the store owner refused
to take the chain back, saying that the chain had been cut by their head mechanic who had
twenty years experience, so he couldn’t have cut it to the wrong length, so I must have
shortened the chain after I left the store. I responded that I didn’t own the tool to cut a
motorcycle chain, which was why I’d asked the store to cut it for me. The store owner
insisted that his highly experiences mechanic was infallible and accused me of trying to
rip off his store.

           Bruggink, Gerard M. “Remembering Tenerife,” Air Line Pilot, August 2000, page
            “September Dossier,”
            “Iraq War,”
        Pitcairn, Richard H. Dr. Pitcairn’s Complete Guide to Natural Health for Dogs &
Cats, Third Edition (ISBN: 1-57954-973-X; 2006), page 6.
        “Gordon Rugg,”

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