Small Failures Result in Big Crises – Insights by Guy Higgins
I recently read a post by Dr. Bob Chandler about an airline crash that killed 71 people in South America. This article will “pile on” Dr. Chandler’s article to place emphasis on the importance of plans and checklists.
The aviation community in general, and the airplane pilots of the crashed airliner in particular, were guilty of a common human failing – not paying attention to the details. They took off without enough fuel to travel to their destination. For you non-aviators out there, a pilot ALWAYS makes sure that the aircraft has at least the minimum fuel required. Specifically, that is the fuel needed under forecast weather conditions to arrive at your destination – plus the fuel needed to conduct the expected approach and landing – plus the fuel needed to fly to an alternative destination (if forecast weather at your destination is such that you must have an alternate destination) – plus the fuel required for an extra ten minutes of flight. The pilots took off without even having the fuel needed to fly to their destination.
Once they took off, they (at some point) recognized that they had less fuel than they needed because they discussed landing at an intermediate airport and gassing up. However, being human beings, they stuck with the status quo rather than doing the rational thing – that is, landing and fueling up (note: while running out of gas in your car is embarrassing, no one, to my knowledge, ever fell off the earth because they ran out of gas. Airplanes will, however, fall out of the sky if they run out of fuel – this is a bad thing and likely to ruin your entire day).
Why is this important for emergency planning, crisis management and recovery? It’s important for a number of reasons:
Emergencies and crises are high-stress periods and human beings revert to freeze, flee or fight responses under stress – those worked a million years ago – not so much now. Don’t think that you can develop a good, effective response ad hoc. It won’t happen.
Details are important – big crises result more often from an accumulation of small failures than they do from a single major event. In the case of the airliner crash, for example, the crash occurred not because the pilots didn’t pay attention to the gas gauge, but because:
- The pilots didn’t pay attention to the gas gauge; and
- The Brazilian Aviation Administration approved the flight plan when it showed insufficient fuel onboard; and
- The airline released the airplane for flight when they should have been aware of the inadequacy of the airplane’s fuel; and
- The pilots elected not to stop enroute to refuel; and
- The pilots didn’t notify their destination of their fuel state until it was too late.
- Change any one of those contributing factors and the crash wouldn’t have happened.
Plans are important because they are constructed in a measured and deliberate manner – under non-stress conditions. Details are included because details are important. Checklists are constructed to ensure that details are not forgotten. In 4,300 military flight hours, I can’t even think about how many times I’ve used the same challenge or response phrases – “landing gear?” “Down and locked.” For heaven’s sake, how could you possibly forget the landing gear? Well, it’s happened.
I have heard people say that, if they have the plans and the checklists and don’t follow them, they are legally liable. That’s certainly true, but the logical converse is not true – you are not absolved of liability if you don’t have a plan or a checklist. In fact, some sophisticated attorney may assert that you are guilty of culpable negligence in addition to being guilty of the organizational equivalent of landing with the gear up.
Can a checklist be daunting? Even intimidating? Sure. While I can recite Lewis Carroll’s Jabberwocky with all of its nonsense words, can you remember twenty steps in a checklist for something that you do two or three times a year? Faultlessly and under stress? Why bet on it when you can use a checklist and be sure? Being a leader means making plans and using checklists (even when you know that “no plan survives contact with the real world”) because without a plan (and supporting checklists where appropriate), you have no idea how lost and disorganized you are.
Details count – and someone’s safety or even their life may depend on those details
Predict and Plan – but be very sure to Perform.
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