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,

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