..in Southwest Montana, hard by the Crow agency, stands a prominent hill with a monument marking a mass grave which holds the remains of members of the 7th Cavalry. On a sunny day in Spring, I stood on that hill and saw what happened to Custer and his command in the Battle of the Little Bighorn.
They lost it. They lost it long before the last of them died on the hill, though. The evidence, especially the fact that the last of the command did die on the hill, is manifest on the surrounding landscape. Markers dot the ridge and valley leading to the site of the ‘last stand’ indicating the spots where men died along the way, died while standing separate from the command, or fell trying to flee the hill. Nobody could really know what transpired that day, but anyone could know, just by standing there, that the hill was a terrible place to be.
The view from the hill was panoramic. All the features of the terrain, including the perpendicular ridges which form the sides of surrounding gullies, were exposed. The commander of a military unit would naturally seek such a vantage point, due to both his training and a natural instinct to be able to see an oncoming threat. But even at the beginning of his maneuver to the hill, Custer had ceased to be the commander of a military unit trying to win a battle.
As his trained instinct to retreat and regroup was misplaced, so was his natural instinct to keep his enemy in view, for from an opponent’s perspective, anyone standing on the hill became a perfect target outlined against the sky. Any move to escape the hill could not be concealed. From the vantage point of those defending the command, targets seen from the hill had to be picked out from the background of grass and dirt on the slopes, if those targets were not completely hidden behind the perpendicular ridges. Custer’s maneuver to the hill was a mistake, but it was not the first such mistake in human history, nor the last. It was one of a surprisingly broad and common category of mistakes, which afflict the capable as easily as the bumblers among us.
Decades later, the pilots of Air France flight 447 experienced something very similar to Custer’s retreat up the hill. Just as the pilots were maneuvering through a series of thunderstorms, the airspeed sensors on the outside of the airliner froze over. The plane’s computer then shut off the auto pilot to avoid the automated system’s reacting to invalid data from the malfunctioning sensors. Now in control of the plane and unable to make sense of the numbers anymore than the computer could, the acting pilot reverted to instinct and training. His instinct was to get out of the situation. The first bit of training which came to mind for escaping a bad situation was one which told him to add power and pull the nose of the plane up. He even tried to confirm his instinct with his fellow pilot, at one point saying, “I’m in TOGA, eh?” – an acronym for ‘Take Off, Go Around’, a maneuver used to recover from an aborted landing, for example, by adding power and climbing. All the while, the stall warning was screaming, indicating a problem which demanded everything but elevating the nose of the plane and climbing.
I have great sympathy for the pilot of flight 447, because I have done what he did, but I was luckier. I was on one of my first long rock climbs with an equally inexperienced partner. We set out on a warm, clear day amid the long days of Northwest Summer on a route well within our capabilities. We knew we could climb it easily in a day, so we left without jackets, headlamps and extra food. However, the route was longer and more convoluted than we had anticipated. By the time we peeped over the summit for a view across the range to the sea, we had to shade our eyes from the lowering sun. We knew it was late, but had no idea how late, since we had left our watches with the headlamps. As we descended, which we had planned to do mostly by climbing down, it got dark and we were forced to use the rope more and more often.
For those who are unfamiliar with climbing techniques, descending by use of the rope involves doubling the line through a loop of nylon webbing anchored to the rock, with or without a metal ring to hold the rope off of the nylon, then using a friction device attached to one’s seat-harness to slide down the two sides of the doubled rope at once. Typically, the descending climber holds one hand above the friction device for balance while the other hand is on the rope below the device, controlling the rate descent by increasing or decreasing tension on the free end of the rope. Before coming to the end of the rope, the descending climber must find a new spot to anchor another loop of nylon. The second climber then comes down the rope to the new anchor, the team pulls the rope through the original anchor, doubles the line through the new anchor and repeats the process.
In the growing dark, new anchor opportunities became harder and harder to find. We had to get down, because we planned to get down, because we felt an instinctive aversion to the prospect of being stuck on the face, and because my partner had to be at work the following morning. As I approached a wide ledge, I could not find an anchor. I swung back and forth across the face, letting a little more rope through my friction device on each pass to allow a wider and wider arc. Now past the ledge and increasingly desperate for an anchor point, I pushed back to the left one more time and felt the ends of the rope slip past my lower hand. My upper hand reflexively locked onto the rope above the friction device as the ends pulled free of the device. Luckily, my grip on the rope with the upper hand held and kept me from falling several hundred feet down the face.
Instantly, I forgot about the prospect of not finding an anchor, my partner’s missed work day, and the dreariness of being stuck out for the night. Climbing hand over hand back up the rope to the ledge, I was re-oriented to the situation. We were not racing to finish a successful climb or out of options because I couldn’t find an anchor by starlight. We were trying to descend a complex route in the dark, and had hit an endpoint. We would not die of cold or thirst or starvation that night. My partner joined me on the ledge. We secured the rope ends to a bush and then curled around the stem of the small plant as if it could provide some warmth and shelter. We shivered the night away and by morning’s light, found a large flake of rock ten feet right of our little bush to tie off as an anchor. My partner lost a vacation day, but kept his job.
As I climbed more, I spent fewer unprepared nights out, partially because I learned the hard way, but partially because I learned the checklists that all climbers employ. There is a packing checklist, a checklist for use prior to climbing onward from an anchor, a checklist for use prior to descending the rope, a checklist to run before pulling the rope through a top anchor, etc. Checklists have saved me on many occaisions.
A checklist almost saved flight 447, though they did not know they were using one. When the senior officer arrived in the cockpit, the pilot and co-pilot were racking their brains trying to sort out what had happened, even as they acted to achieve what they knew that they must achieve – making the plane climb instead of descend. When they asked the senior officer what they should do, he replied, “I don’t know.” In effect, he performed the most vital step in any checklist – he stopped himself and began to pay attention to what was going on right then, in his own head as well as in the airplane. Unfortunately, by the time he’d helped his fellow officers clarify their mental states and reconcile their actions with the events at hand, the airplane was one and a half seconds from the ocean. Even Custer might have been saved if he’d had a checklist, despite the more complicated nature of his situation.Custer faced a special challenge because his opponents had a keen understanding of the psychological elements which make a checklist so useful.
One element in particular is the key benefit of checklists and the one which we are in constant danger of forgetting. Even in the definitive popular treatment of checklists, Atul Gawande’s The Checklist Manifesto, the key element gets only superficial treatment. He touches on it in his description of the engine failure checklist for single engine planes.
It is slimmed down to six key steps not to miss for restarting the engine, steps like making sure the fuel shutoff valve is in the OPEN position and putting the backup feul pump switch ON. 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.
The admonition in step one of his example could be generalized to the statement: Remain oriented to your situation. Gawande can’t be blamed for focusing on the other utility of checklists – their ability to help us prioritize the necessary steps in a complex task and thus break the task into manageable bites. After all, he is primarily concerned with the application of checklists to prevent errors in the relatively controlled, but complex, environment of the operating room. However, his focus risks neglecting the source of our potential disorientation, a mental flaw which Custer’s antagonists at the Little Bighorn understood as vital, and which the course of the battle illustrated so well.
As opposed to Custer and his command, the warriors camped along the river were not soldiers. They had experience with war, but operated as a group of individuals rather than a formal unit. They had leaders, but no commanders. Their only training in the cooperative use of force came from hunting buffalo. Yet they understood their position. Management of the warriors’ psychological state was the leaders’ primary task. The leaders had to direct their warriors by example and exhortation. And from the buffalo hunts, they knew that if they could control their targets’ psychological state as well as their own, success was guaranteed. The assembled tribes had a method, but not a plan and part of their method was aimed at breaking all plans set against them.
When Custer moved against the encampment on the Little Bighorn, he had a plan. He planned to trap the band of wayward natives between the two elements of his command, preventing the Indians’ escape or forcing them to surrender and return to the reservation. His plan was one for a pursuing force, an aggressive force. It was a plan for a military unit, utilizing a military unit’s capacity for coordinated attack and maneuver. For a moment, it looked like the plan might work. The Indians were surprised by the force which crossed the river to attack from the South under the command of Reno. But the Indians had a larger contingent of warriors than expected. In the face of determined resistance, the Southern attack failed and the troopers fell back in disarray.
When the initial thrust of Reno’s force stalled, a number of the warriors still mobilizing in the camp stopped to perform ceremonial rites. Crazy Horse in particular took so long in ritual preparations for battle that the younger men following him became impatient. Perhaps the drama was part of his plan too, orchestrated to focus and rouse his entourage. At any rate, Crazy Horse’s rituals were vital for his own role in the fight. The preparations served as Crazy Horse’s checklist, to protect him from the very thing he would soon attempt to do to his enemies – turn them from men into buffalo. When he emerged from his lodge, he was ready to fight his way. During the subsequent action, he would ride back and forth in front of the enemy lines blowing an eagle bone whistle, drawing fire. He would cut through a line of moving soldiers and lead his band of warriors in among the enemy forces. His actions would serve to prevent concerted action by his foes and force them to fall back on the familiar and the comfortable – predictable instinct and the rote lessons of training.
Custer’s attack never really got started. Confronted by a large force rallied to face him, he seems to have had difficulty orienting himself to the new situation. He doesn’t even seem to have had that critical moment which flight 447’s senior officer provided when he said, “I don’t know.” Instead, he retreated toward the hill. In a subsequent interview, Hollow Horn Bear, a warrior who witnessed the battle gave this description:
Interviewer: After the soldiers got to the ridge, did they keep together in one body, or did some of them make a stand to give the others a chance to select a position?
Hollow Horn Bear: Soldiers kept together all during the fight. The soldiers would shift positions, but no stand was being made to do so.
Another witness, a warrior named Two Moons, gave a more incisive analysis:
…Custer was a brave man. I give him credit for attacking a people that vastly out numbered his – but something was the matter with his men. They did not run nor seek shelter, but stayed right out in the open where it was easy to shoot them down. Any ordinary bunch of men would have dropped into a watercourse, or a draw, where they could have fought for a long time. They acted and shot their guns like something was wrong with them. They surely had too much of that whiskey. That bunch of men should have fought for a long time, but it did not take long to kill them all.
Most telling was the view from the perspective of the encampment, as witnessed by Julia Face:
Interviewer: Did the Indians reach the high ridge ahead of Custer, and did he at any time charge them and drive them off?
Julia Face: None of the warriors reached the high ridge ahead of Custer. The Indians acted just like they were driving buffalo to a good place where they could be easily slaughtered. Custer never charged.
Maybe Custer had no choices that day. But maybe the one critical step in any checklist, the pause to reorient, would have helped his command acquit itself better even if it could not have saved him and his men. Because that one step is the only thing that can save the human part of the mind from itself. Without the jolting stop at the start of a checklist, the part of us that thinks will dwell on its plans and motivations rather than wading into the delays and discomforts immediately before it. A pilot’s mind, focused on the goal of gaining altitude, will tune out the stall warning since it is not helping him achieve his desire. A climber’s mind will forget about the end of the rope since it is not helping him find the next anchor. Then, with the human part of the mind occupied with its own concerns, the buffalo mind is left to act in its place. According to its nature, the buffalo mind just does something. It reacts to the anxiety assailing it from within and the simple cues coming from the outside with a series of programmed behaviors which ignore the future and the immediate past. It functions as a behavioral “Hail Mary” when the thinking part of the mind has checked out. It may freeze in the face of an immanent threat and not fly the plane. It may run over the edge of a cliff to escape. Even without encouragement, the buffalo mind, with its unselected, rote behaviors, will often lead us to a good place where we can easily be slaughtered.
Notes: Interviews are obtained from the books, Indian Views of the Custer Fight by Richard G. Hardorff, Lakota Noon by Gregory F. Michno, and Lakota Recollections of the Custer Fight by Richard G. Hardorff. Further information is available at the Custer Battlefield in South Central Montana via our wonderful, woefully underfunded National Park Service