When I speak to groups of CEOs and senior executives about agility all over the world, I bring it down to the bottom line by finishing with the story of Eastern Airlines Flight 401 December 29th 1972. My book starts with this story (download Free E-Book in right-hand sidebar) and here is the extract:
Extract from Chapter 1 of My Book: Wheel$pin: The Agile Executive’s Manifesto
December 29, 1972, Eastern Airlines Flight 401 is at 2,000 feet on final approach into Miami International Airport. It’s nighttime and the aircraft is an L-1011 TriStar, the latest generation technology jet of its time, with three crew members in the cockpit. They reach that phase of approach in which the captain pushes the lever to get all three landing gears down (the nose gear and the two lateral gears), expecting three green lights to confirm they are down and locked. Instead, the captain sees two greens and one bulb that fails to illuminate. The captain recycles the landing gear to try again, in case it was just a transient fault. He does so, but no luck. Still two greens and one bulb that fails to illuminate. So the captain says, “Put this darn thing on autopilot and let’s figure out why this light won’t go on.”
Let’s pause at this point. I ask you to consider the sequential path of goals that the crew had in mind at this point in their journey:
• Goal No. 1: Fix the bulb
…and after that…
• Goal No. 2: Recycle the landing gear and get three greens
…and after that…
• Goal No. 3: Land safely, relatively on time, and ready for what’s next, with passengers none the wiser and everyone continuing on with their journey. After that everyone continues having a nice life and the crew having a nice career.
Let’s resume our tragic story.
With the autopilot engaged and holding altitude, all three members of the flight crew began to focus on the detail of fixing the bulb, as their sequential goal #1. It was a little bit tight in the cockpit, and, as they concentrated their focus on the bulb, one of them nudged the yoke. In those days, nudging the yoke disengaged the autopilot from its altitude-hold mode. Kind of like dabbing the brake when you are in cruise control in your car. The autopilot obliged.
The plane went into a very gradual, imperceptible descent. It was nighttime, and the plane had been diverted out into the darkness over the Florida Everglades. They couldn’t see the horizon as a reference point but, sure enough, the altimeter showed that they were slowly losing altitude. The crew remained focused on the detail of fixing the bulb. The imperceptible descent continued.
At 150 feet, one of the crew spotted the altimeter (indeed, reading 150 feet) and disbelievingly said, “We did something to the altitude… we’re still at two thousand (feet), right?” A few seconds later, the aircraft crashed, traveling at 227 miles per hour and 18.7 miles short of the runway. A total of 101 crew members and passengers died. Tragic. Thankfully, 69 of the 163 passengers and six of the 13 crew survived.
Recovering and listening to the cockpit voice recorder (CVR), the National Transportation Safety Board (NTSB) concluded in its final report that the cause of the crash was pilot error and specifically:
The failure of the flight crew to monitor flight instruments during the final four minutes of flight and to detect an unexpected descent soon enough to prevent impact with the ground. Preoccupation with a malfunction of the nose landing gear position indicating system distracted the crew’s attention from the instruments and allowed the descent to go unnoticed.
In other words, the cockpit crew became so focused on the detail of fixing the bulb (“malfunction of the nose landing gear position indicating system”) that they became distracted from flying the plane (“monitoring the flight instruments” and “allowing the descent to go unnoticed”).
Their attention to their No. 1 goal on their sequential path of goals undermined the subsequent goals in their journey, with disastrous results, for which they were held responsible. In that cockpit that day, their organizational agility got tested, initially only mildly (it’s just a bulb) but then brutally (at 150 feet). Tragically, they failed the test. I don’t want that happening to you with your business.
How many Eastern Airlines scenarios have we seen in business lately? Big banks (Bear Stearns, Lehman Brothers, Washington Mutual), retailers (Circuit City), automotive companies (General Motors and Chrysler going into bankruptcy, and Toyota with its 2010 recalls and crisis of public confidence), and BP, with the 2010 Gulf of Mexico oil spill and its subsequent handling of the crisis, are all current examples.
These are all terrible scenarios in which organizational agility failed the test, and, therefore, to some degree, they can also be attributed to pilot error! They all involved an imperceptible descent, followed by a nosedive, followed by a tailspin, followed by a smoking hole in the ground—a smoking gun of pilot error and a lack of organizational agility to cope, no matter what.
Don’t be an Eastern Airlines!
You must be “Fixing Bulbs” AND “Flying the Plane” as an AND-Proposition not an OR! Read More.