Lean Blog: Many Causes, Which is "Root?"

Crash Opinions: Technology/Human Factors

Flight 5191:

It is understandable to have questions and opinions..."who should have? who could have?" Why didn't technology fix this problem? All indications up to this point make it presumable that this tragedy was not a case of a tech breakdown, but instead, a basic...a very basic...series of teamwork, communication, leadership and execution failures.

No matter how sexy the bells and whistles in one's cockpit are, the human element still exists.

Today's Washington Post has a follow up article from Del Quentin Wilber ...Series of Errors...where it outlines the chain of mistakes that were key in facilitating this disaster.

The important thing to remember here is that there was not just one causal factor here. Here seem to be a few:

*A "rolling go" (hasty take off, no stop on the runway from the taxiway. Some carriers and departments do not allow this practice. On time departure and arrival stats are not always good measures for efficiency!)

*A sleepy crew (very difficult to control this. Impossible?)

*A confusing NOTAM (notice to airmen, re the lighting change on the rwys and altered taxi instructions)

*Failed/incomplete cockpit crosschecks

A] heading: rwy 22 should be oriented pretty closely to a 220 degree hdg, rwy 26 would be a 40 deg deviation from that: 260-ish hdg. Significant.

B] runway length remaining: next time you are on an airplane, look at the the big numbered signs that populate the sides of the runway, every thousand feet. These signs are "runway remaining" in thousands of feet, indicators. The pilots know by weight and temperature and power and elevation preflight calculations how far the plane will take to get airborne and at what speed they can safely rotate to fly away. They know, before the flight, at what speed and at what distance remaining they can safely abort the takeoff to avert catastrophe, such as this. Either this was not calculated, calculated properly, or cross-checked in the cockpit while on the takeoff roll.

*And finally, the last line of defense, an inattentive teammate in the tower.

There are more issues that will surface, I am certain. But for sure, this was a human error. It was a teamwork breakdown: pilot-copilot-controller. As mentioned in Mr. Wilber's Post article, any one link in this chain would have stopped this tragedy from occurring. It is a bitter pill to swallow.

sf,

Boom out
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Prepare for Experience or Experience to Prepare?

In today's Washington Post (Wednesday, August 30, 2006), staff writer: Mike Musgrove pens A Computer Game for Real-Life Crises. This is an account of a crisis preparation and management "tool" (exercise/game) that he and his company have designed, built and rolled out to cities across the US.

By the Post account, this game is a REHEARSAL mechanism that allows cities to exercise their plans, make mistakes, adjust as necessary and get tee'd up for the real thing, God forbid. Makes good sense.

This should not be too surprising. What may be MORE surprising is why businesses aren't doing the same thing? Look at law enforcement, first responders, the US military, firefighters, athletic teams, broadway troupes...all of these organizations do walk-throughs before the shows. REHEARSALS.

In the US Marines, we used a higher-level rehearsal, staff planning and execution exercise that we called a TEWT (tactical exercise without troops) to accomplish similar objectives. We used these in order to keep some of the human capital expense down. Allowed for the staff to be intellectually engaged, run through their paces while allowing the individual Marine to continue to train in tactics and techniques of warfare. I hear tell that in the Army they called these same exercises Practical Exercises Not Including Soldiers. Heh. I love acronyms.

Experiential activity serves as a rehearsal for life. A proven practice. Can this apply to your organization? Your business? Explore the concept. Imagine your business as a computerized "war" game. What would it look like? Can you prepare for business catastrophe before it hits? Can you plan for business success before it overwhelms you? Maybe a REHEARSAL will help.
sf all,

Boom out.

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Teamwork: Cliche? No, Life Saver.

...and nowhere is that more true and apparent than in the aviation and aerospace sector: civil, commercial, military, recreational, experimental, exploratory. TEAMWORK, high performance teamwork is required.

High performance?

The team must always be on their game as a team. If not, bad things, very bad things will happen. This is not like the teamwork required with a professional football or basketball team. This is genuine. The stakes are real and they are high.

Can you develop High Performing Team culture in your family? In your company? On your kid's youth sports team?

This story (Del Quentin Wilber Washington Post Staff Writer, Tuesday, August 29, 2006) begins to paint a picture of possible breakdowns in TEAMWORK. Undoubtedly, more detail will come out of the NTSB and FAA investigations, more detail that will outline who should have, could have been doing what, when, with whom and how in order to have kept this tragedy from happening. But in just reading this Post article, the layman will be self-hit with basic questions:

"Well why didn't the....?"

"Shouldn't it be that...?"

"Is it normal for the....?"

This story is a tragedy. But it is a catastrophe if we do not learn from it. And I don't just mean the airline industry or the aviation/aerospace sector.

In your business life, do you work with people? Can you imagine the worst business disaster that your team may endure? How could it happen? Piece it together...now, how can you KEEP it from happening? What steps can you take TODAY to develop and begin that plan of action? That will be High Performing Teamwork. Always on the ready, on the lookout. Always getting better.

God Bless the 49 perished souls of Delta/Comair flight 5191 and God Bless First Officer Polehinke; sincere and true wishes for a complete and timely recovery.

Another deadly Kentucky plane crash reported today...can you go through the same exercise here? What COULD have happened? How COULD it have been stopped? How can you apply these lessons in your personal or business life? 7 Die in Second Kentucky Plane Crash (News Wire Service, Aug 29 2006)

semper fi,

Boom

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The Airlines: What an Industry!

I am not much for unions, but they sure can come in handy at times, I guess. Here is a good example of one of those times, if it indeed works out in favor of the flight attendants.

According to The Washington Post (August 26, Tomoeh Murakami Tse) Northwest Airlines has been seeking to block a strike by their flight attendants. Judge Victor Marrero of NY has granted a temporary injunction by halting NWA FA's planned work stoppage; the strike has been temporarily stopped due to the heavy US travel flow right about now.

So what is the beef? Why are the flight attendants' stepping off (or at least trying to)? Well, due to the the Chapter 11 status of the airline, the flight attendants are susceptible to receiving as much as a 20% pay and benefits slash(es). Wow. Pay cuts. Cancellation of benefits. Ouch. But sadly, this has become everyday news from America's airline business.

What a way of life! There are not many industries that would be able to survive the manpower exodus that would ensue when repeated, regular pay CUTS are levied, employee furloughs (airline speak for "LAYOFF"...makes it sound like a vacation, eh?) are commonplace and bankruptcy after bankruptcy are the corporate norm! This thing has been mismanaged to the hilt, and NWA is only one of MOST airlines that are unforgivably guilty.

This service sector is in deep trouble and is only getting worse. This is just an example.

Hey- I wonder how many NWA senior execs are taking pay and benefit cuts?

sf,

Boom out.

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Communication

A key element in leadership, teamwork and execution: COMMUNICATION. Do your initiatives follow this pattern? Boom out. http://coastguard.boom-tv.com www.businessbattlefield.com

Ya Gotta Debrief!

The most important (and most often neglected) part of the execution of an initiative is the garnering of Lessons-Learned. Please turn up your speakers, punch the play button once connected with the link below. Follow the directions to then open the PowerPoint presentation to get a "primer" on how to, why to, when to debrief. And what to do with the data captured.

http://www.businessbattlefield.com/MODEL.html

sf,

Boom out. www.businessbattlefield.com

Does Every Action Hero Have to have an Asterisk?

Barry Bonds, Pete Rose, Marian Jones, Justin Gatlin (Washington Post 8/23/2006: Amy Shipley), Michael Irvin, Floyd Landis and myriad athletes who have come before are (and have been for years) tearing the very fabric from which their super hero capes are made. Whether it is drugs or money or sex or cheating or betting, isn't there a school that these super athletes attend that should indoctrinate them to the unwitting special trust and confidence that we parents put in them? Like Uncle Ben says in SpiderMan, "with great power comes great responsibility." Shouldn't there be a place where these grown up kids learn that?

Yes. At home. At church. At school. At little league. At Pop Warner League. At Babe Ruth League.

People are trying, but it takes some effort and for a lazy society, that means inaction.

We have a epidemic going here and it is spiraling out of control.

Boom out.

Taking Care of the Airline Troops

According to the Washington Post (Keith Alexander, Aug 23, 2006) the FAA is going to pay more attention to the men and women in the almost invisible trenches of America's massive airline industry. It is about time. With so much attention given to the health and welfare of the pilots and flight attendants, the troops on the ground, the grunts sort of get lost in the shuffle. After all, we rarely see them in our travel experience. Well maybe antiseptically through the climate controlled aperature of the aircraft tube's porthole.

"Look at those guys out there. Boy it's hot. Flight Attendant, can I get some water?"

"Billy close that window shade, it's hot in here."

Largely, the "on time departure" "on time arrival" wars are waged on the battlefield of the gates, ramps and carousels that make up these warriors' surfaces and gaps (a basic combat concept, explained here briefly in a USMC warfighting publication). Because they are effectively waging war on inefficiency using the weapons of process and process improvement/lean they are constantly in a state of race. Continuously conquering inefficiency is tough, but throw the other demon in there: WORKPLACE ACCIDENTS, and it is really tough. Throw a third: SECURITY and it becomes almost impossible without outside attention and help.

Boom's way of saying GOOD and IT'S ABOUT TIME.

Boom out.

It's That Time of Life

It is mid August of 2006 and all the recently-graduated seniors are getting ready to push off to universities and colleges across the nation. They are about to mount the first rung of their new seniority ladder, having just jumped from the top of the smaller HS ladder into that refreshing swimming pool of accomplishment. Having taken the NesTea Plunge (dating myself here, anyone remember Dandy Don Meredith and his NesTea Plunge?), these second-time freshmen have now toweled off and are abuzz with anticipation. Here is a new ladder, curiously bigger and more substantial, that sits before them. They are going off to college and life will never be the same.

Good? Surely.

Fun? Of course.

Educational? In many more ways than one.

Successful? We hope.

It will never be the same for these new freshmen. In maybe more profound ways, it will never be the same for their parents. While we talk about growing these kids up and prepping them for life beyond SLHS; while we wonder when they are going to grow up; while we want them to take care of themselves and to problem-solve on their own, to figure-it-out (a favorite thing for me to tell my new freshman)...our home will never be the same without them flubbing it up, leaving the milk out, not cleaning up after themselves, asking for movie money and last minute "Can Tim and Nate sleep over?"s.

Recently I have reflected much on this launching of a child. Too much, maybe. I keep coming up with this: I liken sending a "child" off to college (and thusly life) without us to losing a tooth as an adult, with no dentist in town to replace it. You know, one of those big incisors, where it's really noticeable. We have other teeth, and we have utensils to help us get the job done. But we will never be the same. It's just that time of life. Another ticket punched, another tooth lost.

The other day my oldest boy (Bud) was packing up for school and found a box of laundry detergent that my wife (Cathy) had put with his collection of take-to-college stuff. It was a different product than what we use at home, but it was a perfectly fine, competitive brand, it was on sale and it smelled good. The conversation....

Bud: "Mom, what is this?"

Cathy: "That's the detergent I bought for you."

Bud: "But it's not the kind we use?"

Cathy: "No, but it smelled good and it was on sale."

Bud: "Mom, I don't care if it smells good, I want it to smell like home."

It's that time of life and it is bittersweet.

Boom out.

To Tap or Not To Tap? That is the Question

And a silly question, it is.

Someone please tell me, if our intelligence resources (read: limited domestic wiretapping) had saved our Twin Towers and some 2800+/- lives on September 11, 2001, would this be an issue now?

A rogue judge in MI decides to wave political colors in the name of civil liberty and in one ignorant, aggressive swordswing threatens to take the canines out of our domestic protection bite. Ugly move madam. Thank God for an appeals system that may allow us to turn her sword into Nerf.

So, isn't what this country stands for Civil Liberty?
Life, Liberty and the Pursuit of Happiness? Yep, but which comes first?

LIFE.

And the man at the controls in this cockpit is responsible to do all that he can, make all the tough calls he must to preserve it (LIFE). Even when shrill Sheehans and aggressive adversaries are in his knickers, his charge is to land this jet safely. Our airplane is on fire and some IAP's (immediate action procedures...no kidding "gotta do NOW's") must be employed, didn't anyone tell us?

Give me some alligator clamps and some headphones and let me help douse the flames. Oh, and I can help you land this puppy, skipper. Just say the word.

So many metaphors, not enough time.

Boom out.

AUDIO FEED!

hit the play button above to listen to the article:
Leadership for the Battlefield of Business

featured in ASTD's March 2006 issue of its trade publication: T+D
written and narrated by Boom

sf,

Boom out.

Situational Awareness

Clearly a victim of low situational awareness. This goalie was OBE'd (overcome by events). See www.businessbattlefield.com to keep this from happening to you in your business life!

In Any Day's Work:

A win? A close game? A game where all participate and learn? Good fun to be had by all?
In the end, or as the cliche goes at the end of the day, what was supposed to have happened?

This key question will drive:
how we prepare- ORGANIZE and PLAN
how we execute- DO with DISCIPLINE
and how we learn- DEBRIEF, DOCUMENT and PUSH INTELLIGENCE

So the essence of the initiative, whatever it is, in whatever industry or sector it exists is this:

When the smoke clears, what should the battlefield look like?

And then we take it from there.

Boom out.