AN EXAMINATION INTO UNITED 93
Fig 1 United 93 Movie Poster 2006 (IMBD)
INTRODUCTION
Our evaluation of the quality and safety issues in the movie “United 93” is focused on identifying the quality and safety issues that we observed in the various scenes of the movie and evaluating those issues using a number of evidence-based frameworks like the Garvin Model, Bird’s Triangle, the Hierarchy of Controls, the Five Hazards Framework, the Risk Scoring Matrix, and the Risk Assessment Tool.
We will discuss the theories and literature behind these tools and frameworks and explore their impact and significance for organizations and managers.
Our critical evaluation will identify a number of recommendations for improving or overcoming the quality and safety issues we have identified that will help readers and our audience be able to apply the same principles and tools to evaluating similar issues in their organizations, homes, and lives. Using the convening agent of a movie helps to improve the connection to the theoretical concepts. We will also use a number of diagrams and pictures to supplement our discussion and cater to some of our audience members who are more visually oriented.
At the end of this evaluation, we expect that readers will be able to: 1) Explain the 8 quality issues using the Garvin Model and assess quality issues in any product using the model; 2) Explain the five hazardous areas and identify hazards around them in all five areas; 3) Explain the risk assessment framework and the risk scoring tool and apply them to hazards that they face in their organizations and lives.
Before we share the outcomes of our critical evaluation, let us begin by providing a brief summary of the movie “United 93.”
SUMMARY – UNITED 93
United 93 was written and directed by Paul Greengrass in 2006. It is a movie about the events of September 11, 2001, now popularly referred to as “9/11.” On Sept. 11, 2001, terrorists seized control of United Airlines Flight 93 and three other airplanes. As realization of the imminent horror dawns on passengers, crew, and loved ones on the ground, the courageous acts by those held hostage in the air count down in actual time. United 93 tells the story of the passengers and crew, their families on the ground, and the flight controllers who watched in dawning horror as United Airlines Flight 93 became the fourth hijacked plane on the day of the worst terrorist attacks on American soil: September 11, 2001.
“United 93” recreates the doomed trip in actual time, from takeoff to hijacking to the realization by those onboard that their plane was part of a coordinated attack unfolding on the ground beneath them. The film attempts to understand the abject fear and courageous decisions of those who, over the course of just 90 minutes, transformed from a random assembly of disconnected strangers into bonded allies who confronted an unthinkable situation. Unfortunately, the movie ended with all the passengers and crew on the plane dead after it crashed into a field. This was significant because of the four airplanes that were hijacked that day; only United Flight 93 did not crash into its intended target due to the bravery of the passengers. The heroic acts of the passengers as depicted in the movie were recorded through the various phone calls that the passengers made to Air Traffic Control, family members, and friends during the flight. The events of 911 changed the world of risk management and safety, so this movie is certainly an appropriate selection that is closely related to safety and quality.
QUALITY ISSUES
Quality Issues in the Key Product – Air Travel
Air travel includes all customer experiences, from booking and purchasing an airline ticket to boarding the plane and all security and administrative protocols at departure and arrival airports, as well as the in-flight experience that passengers have.We will be evaluating the quality of air travel as the product of this movie using the Garvin Framework and will focus on five of the eight elements of quality based on this framework as they relate to air travel as it is depicted in the movie.
Quality helps a firm gain a competitive advantage by delivering goods to the marketplace that meet customer needs, operate in their intended manner, and continuously improve quality dimensions in order to “surprise and delight” the customer. According to the Garvin Framework, there are eight dimensions of quality that can be used to evaluate a product or service (Garvin, 1987; Syahrial et al., 2018). These dimensions are:
- Performance: the product’s primary operating characteristics
- Features: attributes that supplement the product’s primary operating characteristics.
- Reliability: the probability of a product failing within a specified time period.
- Conformance: the extent to which a product’s design and operating characteristics meet predetermined standards
- Durability: the amount of use a product offers a consumer before the product deteriorates
- Serviceability: How fast, how easily, and with what degree of courtesy and competence are repairs performed?
- Aesthetics: this is the appeal of a product to the five senses.
- Perceived quality: the reputation, brand, image, or other inferences regarding the attributes of a product
When judging the passengers’ air travel in the movie, we found the following quality issues (both good and bad) and gave a brief explanation of each of the eight dimensions.
| Garvin Dimensions | Explanation | Positive | Negative |
| Performance | The Primary operating characteristics of the plane and flight | The sound test by hostesses to confirm that phones were working | The Plane was hijacked Hijackers got in with weapons despite security checks The plane crashed |
| Features | Secondary characteristics of the plane and flight that enhance the appeal | Drinks and meals on the plane Pillows and blankets for passengers Telephone to make calls in flight. Flight Attendant phoned United Airlines at their Speed Dial Fix number. | Privacy curtains prohibited passengers from witnessing what was taking place in 1st class |
| Reliability | The likelihood that the product will not fail and that expectations will be met | The plane was on time and passed safety checks for take off | Flight ended as a crash |
| Conformance | Extent to which the plane and flight meets established standards | Co-pilot supervising the fueling process The knocking protocol established for accessing the cockpit Safety demonstration was done properly | Cockpit was accessed by the terrorists No air marshalls on board the plane |
| Durability | The amount of value that we can get from the plane and flight before it deteriorates | Aircraft seats were strong enough to facilitate the weight of 3 men holding onto it | The aircraft could not withstand the downward crash |
| Serviceability | The ease with which customers get service | Detailed reporting and updates on the delays | The Military was only informed of the hijacked plane after it crashed |
| Aesthetics | How the airplane looks, feels, sounds , smells and so on. | Branding of the seat covers of the plane Nice branding on the exterior of the plane | Business class cabin did not have enough leg room and facilities |
| Perceived Quality | The reputation of the airline and the flight. | United is a well established brand with notable recognition for comfort and great service | After the plane was hijacked, customers feared traveling on board United planes’ |
Based on the foregoing quality issues, we propose the following recommendations to enhance air travel across five of the dimensions:
| Dimension | Recommendations | Expected Impact |
| Conformance | Install digital access code to the cockpit. Deploy armed air marshals on every flight. | Limited access to the cockpit and improved on-board security. |
| Performance | Enhanced screening and security protocols pre-boarding. | Reducer the likelihood of hijackers having weapons onboard the airplane. |
| Reliability | Improved intelligence gathering and cooperation between local and international intelligence and security agencies. | Identify potential threats to airlines earlier and mitigate them. |
| Features | Pull back privacy curtains separating the business and economy cabin. | Improve access to information and visibility for all issues taking place in the airplane. |
| Perceived Quality | Deploy an aggressive communication strategy on enhanced security protocols to allay the fears of potential travelers. | Provide assurance to customers and the general public and restore public confidence in air travel. |
Key Hazards in the Movie
Our review of the key hazards identified in the movie will begin with a review of relevant evidence-based concepts that practitioners use in the evaluation of hazards in any given situation. We will explain the Bird’s Triangle and the five types of hazards and then identify several examples of hazards across the five categories.
One of the earliest works done in the field of safety is attributed to Herbert W. Heinrich, who was a pioneering occupational health and safety researcher. His publication, Industrial Accident Prevention: A Scientific Approach, was based on the analysis of workplace injury and accident data collected by his employer, a large insurance company. This work, which continued for more than thirty years, identified causal factors for industrial accidents, including “unsafe acts of people” and “unsafe mechanical or physical conditions” (Heinrich, 1931). Heinrich also put forward the domino model of accident causation, a simple linear accident model.
The work was pursued and disseminated in the 1970s by Frank E. Bird, who worked for the Insurance Company of North America. F. Bird analyzed more than 1.7 million accidents reported by 297 cooperating companies. These companies represented 21 different industrial groups, employing 1.7 million employees who worked over 3 billion hours during the exposure period analyzed.The most famous result is the incident/accident pyramid, also known as the “safety pyramid,” the “accident triangle,” and “Heinrich’s law.”
The Bird Triangle depicted above proposes that for every 600 near-misses that take place, there are 30 accidents that cause damage, 10 minor injuries, and potentially one serious injury or death (Maklakovs et al., 2021). This framework challenges us to recognize the importance of paying attention to all hazards and safety issues because ignoring or trivializing them carries a statistical significance, as demonstrated in the model.
Building on the Bird Triangle Theory, researchers (Ossian, 2022; Reyes, 2022; and Martinelli, 2019) have identified five types of hazards as follows:
- Biological Hazard: Workplace biological risks, sometimes called occupational biological hazards, are things or creatures that endanger employees’ health. These dangers can take many different forms, such as bacteria, viruses, fungi, and poisons. From minor skin infections to fatal diseases, biological risks can cause a variety of ailments (Ossian 2022). Healthcare institutions, laboratories, and industrial sites are just a few examples of areas where biological risks can be present. Environmental elements like water or soil may include biological risks in rare circumstances. Contact with diseased people or animals can potentially expose workers to biological risks.
- Chemical Hazard: Any substance, regardless of form, that may endanger human physical safety and health or harm the environment is considered a chemical hazard. It can also be described as the actual risk posed by a particular chemical, such as the possibility of skin burns, long-term health consequences, irreversible environmental harm, fires, or even explosions (Reyes 2022).
- Ergonomic Hazards – Ergonomic hazards are environmental elements that might harm your musculoskeletal system. They are injuries induced by the body being exposed to ergonomic risks based on your sitting positions and the relationship between your body and your work tools and furniture. They are not usually immediately visible, making these dangers difficult to identify.
- Physical Hazards: Martinelli (2019) states that physical hazards are environmental elements that can hurt an employee with or without requiring them to contact them, such as heat, noise, radiation, and pressure, resulting in hazardous working circumstances. Tripping hazards could include exposed cables or a torn carpet, for example.
- Psychosocial Hazards – Psychosocial hazards or factors are features of work design or management that enhance the chance of a bad outcome resulting in job-related stress, increased non-work-related stress, or affect individual employees’ health and well-being. A stress response is a physical, mental, and emotional reaction that happens when a worker’s perceived job expectations exceed his or her abilities or resources to cope.
An inventory of the various hazards identified in the movie is captured in the table below
| Type of Hazard | Examples from the Movie |
| Physical | People carrying bags on both hands No place to keep hot drinks – could spillCrochet in flight – prick hazardlow doorway for entering the planelady sewing with needles on a flightflight attendant with lots of jewelry removal of shoes by flight attendantThose working in the building having to escapeeating in the cockpit while flyingGetting stabbed by a knifeTrying to fly a plane without proper lessonsFlying unbuckled while descending rapidlyErratic flying maneuversRolling beverage dispenser in the aislePlane crashing into the groundLoading fuel with the hose entangled |
| Chemical | Fueling the plane without mask or glovesSmoke from the buildingsBuilding a bomb without proper clothingSmoke emitted from the pentagonPepper spray in the cabin of the plane |
| Biological | Flight attendants using same phone for announcementsServing uncovered food and drinks on the planeBlood from open wound on the plane near other passengersUsing on phone planes that others have used without sanitizingFuel leaked into soil after the crash |
| Psycho-social | Gentleman who initially received the hijacking notice and no one listenedGentleman who was told about the hijacking very casually Watching the tower being crashed into on the TVGentleman who is dealing with multiple hijacked airplanes and is overwhelmedPeople having to watch the second plane crash into the tower, live on TVYoung lady in military having to give a report when she is emotional unsettledAir hostess and some passengers are very afraid of flyingHighup flight status guy (in the black suit) who got promoted and had to deal with this on his first dayHaving be on the plane during a hijacking and see a guy with a bomb strapped to himselfPeople talking over each other in Air Traffic Control – NoiseWatching someone’s throat being slitFlight attendant having to make calls to try to get through to someone but not being able to get throughHaving to watch crash footage of the pentagonHaving to make the call to shut down all aircraft coming into the country when it is not the popular decisionHaving to call loved ones to let them know about what you are experiencing and say goodbyeTrying to decide how to try to take the plane back over. |
| Ergonomic | Non-supportive chairsLow screen angle for neck healthDimly lit workspaceWomen sleeping with neck uncomfortably bentHunching over the tray table to work on the computerStanding for extended time under stressful work situations.Only one TV so people will have to sit in an awkward position to viewThe screen at Air Traffic Control required them to look down to see |
Some of the hazards are captured in the scenes from the movie depicted below.
Risk Assessment of the Hazards
To undertake a risk assessment of the hazards in the movie, we will be relying on a number of evidence-based tools: the hierarchy of controls, the risk scoring matrix, and the risk assessment table. We will explain each of these tools and provide our assessment of one of the hazards that we identified earlier in each of the categories.
The hierarchy of controls is an important tool used in risk management that helps practitioners identify the different interventions that can be used to mitigate risk. It challenges practitioners to focus on the interventions that are higher up on the hierarchy first and select the lower interventions where necessary. At the higher levels are interventions that deal with more strategic issues that have a wider-reaching impact, like eliminating the hazard or substituting another one.
In the middle are more tactical interventions like engineering and administrative controls, and at the bottom are more operational interventions like the use of personal protective equipment (PPE), which should be your last resort. The hierarchy of controls guides the quality and efficacy of remedial actions that practitioners put in place to mitigate risks.
The risk scoring matrix is another tool that practitioners use in carrying out a risk assessment. It provides a scoring system that can be used to determine the likelihood and impact of the hazard. The risk scoring matrix is a 3 by 3 matrix that measures the likelihood of the risk and its potential impact across three scales (high, medium, and low) and provides nine risk ratings as depicted in the chart below.
The green areas are low-risk, the yellow areas are medium-risk, and the red areas are high-risk. Each hazard will therefore be evaluated for its likelihood and severity using the scales provided by this tool. Several variations of this tool are used to assess risks in different sectors and contexts. One that you are no doubt familiar with is the weather alert system used by the meteorological agency here in Trinidad and Tobago and in countries all over the world. It is also used in security threat assessments at airports and important government buildings, following the events of 911.
The risk assessment table is the final tool that is required in this risk assessment process. It consists of the hazards, the persons who may be impacted, the risk rating from the risk rating matrix, the actions to reduce the risk from the hierarchy of controls, the date or timeline for implementing, and the status indicator for approval or completion. Our assessment of the hazards identified in the movie across each of the five hazard areas is captured below.
| What Hazards? | Who Might be Harmed and How? | Risk Rating: Likelihood and severity | Actions to Reduce Risk- ALARP | Person Responsible for Action | Due By Date | Signed Off as Done on Date |
| Use of crochet on a flight (Physical hazard) | Passengers sitting close by may be hurt unintentionally. It could also be weaponized to harm others intentionally | 2 | Eliminate this by preventing passengers from boarding with such items | Airport Security | T + 2 days | CEO, Airports Authority |
| Serving uncovered food and drinks in the plane (Biological) | Contamination and air borne diseases can spread to passengers and crew including the pilot | 6 | Substitute the existing catering arrangements with pre-packaged meals and drinks | Head – Guest Services | T+ 1 month | Director – Customer Service |
| Fueling the airplane with masks or gloves (Chemical) | Fuel attendant could inhale chemical fumes | 6 | Provide PPE – masks and gloves to fuel operators | Head – Flight Maintenance | T+ 5days | GM Safety |
| Air hostess and some passengers are very afraid of flying (Psychosocial) | The fear of the air hostess could affect her concentration and she may transfer that fear to other passengers and ruin their comfort | 3 | Provide counselling and pre-flight screening for air hostesses | Head – Training Academy | T + 2 months | Director – Human Resources |
| Dimly lit workspace (Ergonomic) | The poor lighting may cause errors in the Control Room when reading off the screens and monitoring planes | 6 | Install new lights in ATC Office | Head – Maintenance | T+3 days | GM Facilities |
Recommendations
Based on the quality evaluation and risk assessment that we have undertaken; we are pleased to summarize our key recommendations as follows:
Quality Issues
- Install digital access code to the cockpit.
- Deploy armed air marshals on every flight.
- Enhanced screening and security protocols pre-boarding.
- Improved intelligence gathering and cooperation between local and international intelligence and security agencies.
- Pull back privacy curtains separating the business and economy cabin.
- Deploy an aggressive communication strategy on enhanced security protocols to allay the fears of potential travelers.
Safety Issues
- Install new lights in ATC Office
- Provide counselling and pre-flight screening for air hostesses
- Provide PPE – masks and gloves to fuel operators
- Substitute the existing catering arrangements with pre-packaged meals and drinks
- Eliminate this by preventing passengers from boarding with such items
Conclusion
The critical evaluation of the quality and safety issues in the movie United 93 has explored the evidence-based theories and frameworks that practitioners can use in managing quality and risk in their organizations, including Bird’s Triangle, Garvin’s 8 quality dimensions, the Five Hazards Framework, the Risk Scoring Matrix, the Hierarchy of Controls, and the Risk Assessment Table. The movie that was used as a convening agent or case study for this evaluation provided valuable examples that practitioners can relate to and apply.
We identified a number of safety issues using the eight dimensions of safety proposed by Garvin and assessed the hazards across the five hazard areas. Our review also highlighted positive areas in terms of quality, which can serve as good examples for practitioners. We also provided recommendations to address both the quality and safety issues.
We are confident that as you reflect on the ideas and analysis that we have provided, you will be able to apply these tools to your organization and life and improve your ability to offer quality products and services to your customers and prospects and manage risk in all facets of your life.
Please feel free to share your thoughts, comments, and feedback, as well as your experiences regarding applying these tools, in the comments section that follows. Also, kindly share this article with family, friends, and colleagues so that we can build a strong community of quality and safety practitioners in our society.
References
Forker, Laura B., Shawnee K. Vickery, and Cornelia LM Droge. “The contribution of quality to business performance.” International Journal of Operations & Production Management (1996).
Garvin, David. “Competing on the eight dimensions of quality.” Harv. Bus. Rev. (1987): 101-109.
Maklakovs, Juris, Aleksandrs Bitins, Ruta Bogdane, and Vladimir Shestakov. “Using heinrich’s (Bird’s) pyramid of adverse events to assess the level of safety in an airline.” Transactions on Aerospace Research (2021).
Marczewska-Kuźma, Roma. “Correlation Approach in Defining Organizational Health and Safety Management Strategies.” European Research Studies 24, no. 2B (2021): 904-914.
Martinelli, Katie. 2019. “A Guide to the Most Common Workplace…” The Hub | High Speed Training. High Speed Training. January 7, 2019. https://www.highspeedtraining.co.uk/hub/hazards-in-the-workplace/.
Ossian. 2022. “Biological Hazards in the Workplace | Guide.” DATAMYTE. October 12, 2022. https://datamyte.com/biological-hazards-in-the-workplace/.
Reyes, Jaydee. 2022. “Chemical Hazards: Definition & Types.” SafetyCulture. October 17, 2022. https://safetyculture.com/topics/chemical-hazards/.
Stewart, Mark G., and John Mueller. Are We Safe Enough?: Measuring and Assessing Aviation Security. Elsevier, 2017.
Syahrial, Erialdi, Hideo Suzuki, Shane J. Schvaneveldt, and Mitsuki Masuda. “Customer perceptions of mediating role of ownership cost in Garvin’s dimensions of quality.” Journal of Japan Industrial Management Association 69, no. 2E (2018): 95-112.
Contributors
BARROW, Omagbitse (816038418)
GILBERT, Rae Kelly (94733327)
JAIRAM, Anuja (816001707)
KRAMMES, Ryan(816035855)
SEDENO, Azekel (816012160)
THONG-REIS, Nicholas (816036085)
Strat Matters 