“Don’t let a little distraction become the main attraction” — Deadly Distractions in the Workplace - The crash of Eastern 401
(Source: free-press-release.com)
This is a rare picture of the Lockheed L-1011, Ship# 310, that crashed into the Everglades. This picture was likely taken just weeks before the crash.
It is almost midnight, December 29, 1972, when Eastern Airlines ship #310 began her final approach to land at Miami International airport.
The captain, called Miami tower on the radio:
“Miami tower, Eastern 401, just turned on final.”
The captain then instructed the copilot to lower the landing gear,
”Go ahead and throw ‘em out.”
When the landing gear handle was lowered, the pilots checked to make sure there were three green lights, indicating that all three landing wheels are safely down and locked (as shown).
In this case, the flight crew did not receive a green nose gear light. This means one of two things, either the nose wheel is not safely down and locked, or the bulb is burned out.
At 11:34 p.m. the captain spoke into the radio,
“Well, ah, tower, this is Eastern 401, it looks like we’re gonna have to circle; we don’t have a light on our nose gear yet.”
Miami tower responded,
“Eastern 401 heavy, Roger, pull up, climb straight ahead to two thousand. Go back to approach control, 128.6.”
No doubt, this is an unwanted distraction that interrupted the normal work routine of these Eastern pilots. Interruptions to our normal work flow can be deadly, and how we deal with these situations when they pop up can be the difference between life and death.
To work the nose gear problem, the ill fated Eastern crew decided to enter holding and allow the autopilot to maintain the racetrack pattern at 2,000 feet. On the surface, this is a good plan. However, the breakdown occurred when the pilots became so engrossed at diagnosing and fixing the burned out light bulb, that they failed to monitor the actions autopilot.
Investigators determined that during the struggle to properly re-install the light bulb, one of the pilots inadvertently bumped the control wheel with enough pressure, it changed the autopilot logic. It went into “descent mode.” The pilots failed to notice as the autopilot put the airplane into a very slow insidious descent towards the Everglades.
Sometime later, the copilot finally decided to check on the status of the autopilot. What he saw shocked him. He expected to see it holding steady at 2,000 feet, instead he saw less than 100 feet and slowly descending.
Both pilots stare in disbelief. This is the final exchange between two highly skilled, very competent pilots (operators) who became so distracted by a 20 cent burned out light bulb, they crashed into the Everglades.
“We did something to the altitude,” said the copilot.
“What?” answered the surprised captain.
In complete bewilderment the copilot said, “We’re still at two thousand, right?”
“Hey, what’s happening here?” These were the final words spoken from the captain as the cockpit area microphone picked up the sounds of Ship 310 flying itself into the Everglades. 101 fatalities.
The cockpit of Ship #310 is clearly visible is this picture
Science is clear, humans are not as good at multitasking as we think we are. When someone tells me they are good at multitasking, I know they are good at doing multi-jobs poorly. Unplanned interruptions and distractions in the workplace are common. Employees must recognize these as leading indicators that can lead up to an incident or accident. We are essentially being forced to multitask.
Discuss possible situations and scenarios of where you and your people are most likely to face unwanted distractions. Have a plan in place when something unplanned pops up. Hindsight is always 20/20, but having foresight is 20/20/20. That means every 20 minutes, take 20 seconds, and look 20 feet around you. You might be surprised at what you see.
For those of us who work in a high risk work environment, it is imperative we keep our situational awareness congruent with reality. There is nothing more dangerous than someone who is clueless and doesn’t know it - yet. As an operator (airline pilot), anytime an unplanned interruption comes my way, I use the acronym SLAP to help me remember to stay focused:
S top the current path / work / progression while using Foresight 20/20/20.
L isten to others, gather information about the interruption.
A ssess the distraction. Decide to either discount, delay, or redirect the issue.
P roceed with the plan or rebrief a revised plan. Never assume everyone understands what you want. Be clear and concise. Ask probing questions.
By doing this, hopefully you will never allow a small distraction to become the main attraction.
When we hear “how are your margins” in business we often think of profit Margins and why wouldn’t we? All organizations want to be as efficient as possible so that they can return the most profit/ROI for its stakeholders. Business schools spend countless hours teaching us how different methods of how to achieve max profit and in a global economy it may mean mere survival. Most companies I have worked with have used Industrial Engineering, Six Sigma or other process improvement programs to become as efficient as possible, and that is a good thing. However, leaders must also keep an eye on their Safety Margins as well.
Today most organizations are very efficient and have taken out all of the “extra” and are operating at max efficiencies with little margin for error and the front line employees feel it.
Even the military, which has no profit motivation, has gotten in on the act and has been for some time. In the 80’s and 90’s we moved from two seat fighter Jets to single seat jets. As a single seat Hornet pilot we were told the engineers figured that to operate the airplane at its max capability actually required 1.2 pilots. Well, being .8 of a pilot on a good day, this made me nervous.
The Military spent many hours discussing safety and how to cope when you were feeling Overcome By Events (OBE). They said you are most likely to become OBE during irregular operations (something is not going as planned) and are feeling pressure to fix the issue and get back on track. During these times we were taught to Aviate, Navigate and Communicate, in that order. In other words, fly the plane, and then get it headed where you intend to go then tell someone what is going on. These simple steps saved countless lives in single seat fighter aviation as it predicted this feeling of being overwhelmed, said it was OK to feel that way and provided a strategy to cope.
As leaders it is important that we look ahead and try to predict when our employees may feel OBE and discuss what to do in those cases. Unfortunately many well-intentioned workers have been injured or killed trying to fix a problem while not costing production.
As Odie would say,” they were doing the wrong thing for the right reasons”. So, I encourage you to take the time to discuss with your employees the “what ifs” and how to handle them before they happen on the job.
Lets keep the Safety Margins High.
Lt. Col Wes “Dahmer” Sharp
Safety Speaker, Target Leadership
When working in the field, Target Leaders know to watch out for the phrase, “I’ll Be Careful.” Someone is about to do something Dumb, Dangerous, or Different! It can kill you.
In February 1989 at Eielson AFB in Fairbanks, Alaska I was flying the venerable A-10 “Warthog” on a routine training mission. It was a beautiful winter morning flying that day when I first uttered the words, “I’ll be Careful.” It almost cost me my life.
Camera Footage of Iditarod Sled Dog race - February 1989
Why do smart, highly skilled, very competent people do DUMB things? If we look within ourselves, we will find that we are not “dumb people”, but we will commit dumb, errant, or unsafe acts. Why? The simple answer is this. The more we work our jobs the more successful, capable, and competent we become at performing each task. Naturally, as our skill and experience rises, so does our confidence level. As our confidence rises, we must remain vigilant to not allow ourselves or those around us to become overly confident or too self-assured when performing our duties. When our confidence exceeds our ability, bad things happen. Smart people do dumb things.
My dumb act began that fateful day as I was flying down the frozen Yukon River on a Low Altitude Tactical Navigation (LATN) training mission. I was cruising along at 300 feet and 400 mph, approximately ½ mile in trail of my flight leader. Suddenly, my radio crackles with his voice, “Odie! Sled dog team ahead.”
The 1989 Iditarod race was taking place. Three time champion Susan Butcher was defending her title that year. Millions of T-Shirts sold exclaiming, “Alaska – Where men are men and women win the Iditarod”
When my flight leader announced that a sled dog team was just ahead, I thought to myself, “I’ve got to get that sled dog team on film.” I happened to be carrying an inert-practice B Model Maverick missile, the type that functions only while attached to the airplane and has no propellant or explosives. Fighter pilots use them to practice switchology in locking up targets. After the mission, we review the gun camera film to measure a successful target lock.
“It’s perfectly safe to film this sled dog team,” I thought. My over-confidence and perceived skill to operate a piece of equipment in a very short amount of time while flying the jet overcame my sense of good judgment. The problem with being over-confident is that you don’t know what you don’t know. You have just enough ability and skill to get yourself into a situation that ultimately requires you to rely on lady luck to bail you out. Not good!
As I locked the eyes of the missile squarely on the sled dog team and began filming, I thought to myself: “I’ll be careful”
As an overly confident A-10 pilot, I am now staring at the TV monitor inside the cockpit completely oblivious to the surrounding mountains and trees approaching me at over 400 mph.
My internal alarm clock began ringing. This internal safety timer is a device similar the hairs that stand up on the back of one’s neck after spending too much time heads down texting and driving. The timer says, “Hey dummy! You might want to look up and see what’s in front of you.”
Like a massive semi truck stopped dead in the road directly in front of me, a mountain ridgeline was directly ahead. Seeing this can only be described as an underwear changing event.
“WHOA!” Max power! Pull back on the control stick! Turn! Lady luck please don’t fail me now! If you have ever seen an A-10 perform at an air show, then you have seen the incredible flying capability of the airplane. I managed to clear the ridgeline before I became “pink mist” among the wreckage. My overly confident perception of my “I’ll Be Careful” ability put me into a situation that pure luck got me out of. Lady luck saved me from becoming another headline in the newspaper: “Fighter pilot killed today while on a routine training mission.”
Routine jobs become less safe when we allow ourselves to believe our skill, knowledge, and experience is better than what the plan, procedure, or job briefing calls for. Neither the plan nor the briefing called for practicing Maverick missile lockups on a sled dog team. My emotional snap decision triggered by a confidence that exceeded my ability almost killed me.
Target Leaders know that over confidence left unchecked will turn to arrogance. Arrogant people fail to learn, listen, and grow. In their mind they are eight feet tall and bullet proof. They are never wrong. They fight to be right, not for what is right. Target Leaders understand that people will operate to the level that is tolerated. My commanding officer quickly refocused my attitude and work behavior to operate at a much higher level - what is expected, not accepted. “I’ll Be Careful” means someone is about to rationalize away proven methodologies and correct procedures in order to “blend” proper techniques with personal techniques. How your team operates when no one is looking defines your work culture.
Remember, your work is just as dangerous and hazardous as flying a fighter jet. However, as experienced, confident, and professional people, we know that our work is VERY safe because of the training, technology, planning, and layers of protection that is built into getting the job done. There is not a rule, tool, technique, policy, or procedure invented or implemented that will protect you if you decide to commit an errant or unsafe act by saying, “I’ll be careful.” It can kill you!
Target Leaders in any profession, whether working in aviation, utility power companies, manufacturing plants, construction sights, petroleum refineries, or in hospitals have similar objectives…influence and motivate employee groups and individuals to get the job done safely and with operational excellence!
As a safety speaker, leadership consultant, and having worked with many of our nations top corporations, it is my good fortune to witness a wide range of effective leadership traits, styles, and behaviors. Each organization has different process challenges, but when it comes to human behaviors the overriding concern is, “How can we inspire our employees to create and maintain a high level of safety, quality, and operational excellence in the workplace?”
As an observer of human behavior, I have noticed the following to be true: high performing organizations actively promote and support Target Leaders who are exceptional at:
1) …emulating the organizations values and beliefs to make safety and operational excellence the overriding priority among the employees.
2) …maintaining a balanced and healthy working relationship between the company and the employees doing the work.
The byproduct of these two items yields work behaviors from employees which ultimately defines the organization’s job culture. Target Leaders establish and maintain the culture of an organization, and the workers will work within the norms of that culture.
As a Target Leader, creating and maintaining a balanced and healthy working relationship with your employees means figuring out when to be a manager-leader (i.e. directive, assertive, task-focused) and when to be a people-leader (i.e. dialogue, listen, solicit input, inspire). Having leadership balance means being perceived by your employees as being competent, forthright, not afraid to say “I don’t know,” approachable, non-judgmental, even tempered, personable, and most importantly, having integrity.
Character is to the Leader as Culture is to the Work Group
Integrity as a person and the operational systems you endorse are the fundamental foundations of your relationship with your people. These qualities make up your character. As a rule, workers will emulate the character of their leader. When character is in question, the overall job performance and safety record is also in question. As Target Leaders, we must be mindful of our thoughts. Thoughts frequently turn into words; words naturally turn into deeds, and deeds serve as an outward disclosure of who we are and what we are about. What you believe is what you exude. What you exude is what people see. What people see is what they believe. This manifestation openly shows our character not only as an individual, but also to an entire group. Ultimately, we are judged by what is observed, not heard.
My brother observed me take a short cut. Six months later, he took the same short. He paid with his life.
This is a tragic, yet valuable lesson to Target Leaders. We should do the right thing not because someone is looking over our shoulder, but simply because it’s the way we do it around here. This ultimately defines the character of the job.
Create a Culture of Open Communication
“Tell me what I need to hear, not what I want to hear!”
As a Target Leader, you must work at being an excellent communicator. This builds trust. Trust gets your people to honestly open up with you and share work issues, problems, or near misses. Keep it a conversation, not a confrontation. Accept what you need to hear.
“Tell me what I need to hear, not what I want to hear” were words often spoken by one of my favorite airline fleet chief pilots. As a Target Leader, he was perceived by the entire team of airline pilots as having a culture of open communication. He wanted to hear it all - the good, the bad, the ugly. We felt at ease discussing anything, including our own mistakes. We openly discussed problem areas, near misses, and procedural missteps in order to improve the overall system. He skillfully crafted a culture of accountability and responsibility among the rank and file pilots. We knew the difference between being blamed and being accountable and responsible.
A Culture of Blame is toxic to company culture
Creating a culture of blame within an organization is certainly unintentional by leaders, but is none the less very harmful. This toxic culture is often created when after something happens, leadership seeks answers to:
“Who is at fault?”
This culture looks for a culprit instead of a cure. Employees are unwilling to reflect inward for solutions for fear of being made a scapegoat. They will not come forward and admit mistakes or close calls. If questioned about an incident /accident, they look to blame the equipment, someone else, lack of training, poor management, you name it. Getting employees to open up and discuss near misses, non-injury events, or close calls is vital as theses events usually serve as a precursor to future problems. Investigations often reveal that a few close calls happened before the actual mishap occurred. When the investigator asks the worker, “Why didn’t you speak up?” Answers generally range from: “I thought they knew about it” (cop out) to “they would fault me for making a mistake” (culture of blame). As a Target Leader, you are the “they” the employees are referring to.
A culture of accountability & responsibility is the opposite. When a mishap or near miss occurs, this culture seeks answers to:
“How do we prevent this from happening again?”
Creating this type of culture among your workforce is probably one of the biggest challenges you will face as a Target Leader. If mastered, you will truly rise to the top in overall operational excellence and safety. Responsible employees reflect inward for continuous personal and process improvement. They consider themselves as part of an overall system. They intermingle, react, respond, and behave within that system. Target Leaders embed the notion to be accountable, not held accountable. There is a difference. Each employee understands that they are a critical variable of the entire operational system, and each part within the system elicits and brings out certain human behaviors. A responsible work culture means each person is accountable unto themselves with the company’s equipment, training, rules, and policies.
Maintaining a culture of accountable and responsible employees in your work force is not easy! As a Target Leader, keep your brain ten steps ahead of your people’s bodies. Be proactive. Think ahead. Recognize the pressure points and address those areas before someone does something dumb, dangerous, or different. Start with communicating a vision of where you are and where you want to go. Once that vision is clearly defined, empower your employee group to help get you there. The task may seem impossible at first, but set your expectations high.
President John F. Kennedy set soaring expectations when he proposed the impossible, “To send a man to the moon and safely return him to the earth before the decade is out.” He empowered a people to make the impossible happen by clearly communicating his vision to them.
When empowering employees to take you to the moon in operational excellence and safety, it is important that you stay actively engaged in the process. Provide feedback. Give updates. Be open and ready for change.
Change might be what is needed. Peter Drucker, well known business author, management consultant, and professor who made famous the term knowledge worker, said leaders “need to be ready to change everything about how they are doing business.”
“Management is doing things right; leadership is doing the right things.”
Peter Drucker
To do the right things, Target Leaders must keep the index finger of one hand pressed firmly on the pulse of the company’s values and beliefs. At the same time, they must also keep the index finger of the other hand firmly pressed on the pulse of the people. In so doing, you are best able to recognize, address, and correct issues and behaviors that fall outside of the safety norms, expectations, and vision you and your organization sets.
Feeling both sets of pulses allows your people to understand the vision of where you are and where you need to go. They see what goes on everyday when you are not around. They hear about the near misses and non-injury events. They are closest to the problem; they often have the best solutions to fix those problems. By you actively soliciting their thoughts and ideas on how to accomplish the vision creates their buy-in. Give them ownership of the process, and I promise they will take pride in producing lofty results.
As a balanced Target Leader, this is how you get your people to the moon with safety and operational excellence!
I have compiled a Top 10 list of why I think smart people do dumb things. In no particular order…
1. Poor Perspective or Lack of Objectivity: Didn’t see the forest for the trees. Need to step back and get a view from 20,000 feet so to speak. Been there!
2. Pressure to Perform: It is usually from within ourselves or outside pressure from supervisor or company. Often happens when we feel the pressure to fix a problem, or get back on schedule. Been there!
3. Interruptions and Distractions: Things are often on our mind other than the task at hand. Not paying attention. Resuming work when going on/coming from vacation, or even lunch. Reminds me of Eastern flight 401 being distracted by a burned out light bulb. Been there!
4. Poor Situational Awareness: Where I think I am vs. where I actually am. We fight to be right, so we rationalize away hints and clues that keep trying to tell us, “Hey Dummy, you’re a smart person doing something dumb.” Been there!
5. Making Assumptions: We know what happens when we “ASS-U-ME”. When we make decisions based on one or a series of assumptions, the decision to act in a certain manner may seem perfectly logical. BUT, if the assumptions are wrong, the results of our actions may be disastrous. Been there!
6. Ego-Ability Exceeds Capability: Overconfidence in our ability to perform an action. It is usually prefaced with “Watch this” or “I’ll be careful”. Reminds me of the Bud Holland B-52 crash, or being a teenager again. Been there!
7. Snap Decisions: Are usually driven by panic or pure emotions. Acting without processing logical or rational thoughts. Slow down! Take a breath. Think. Communicate with others… then proceed. Been there!
8. Complacency: “The Silent Killer” has many facets, yet it has tagged many smart people. Reminds me of the Thunderbird accident. “Ho-hum” routine jobs hurt smart people every day. Pay attention. Been there!
9. Lack Of A Moral Compass: Bernie Madoff and Enron are examples of smart people or entities who did dumb things. I don’t steal from people, but I need to keep adjusting my moral compass when I run a yellow light… or speed… or “text and drive”… or… Been there!
10. Drugs & Alcohol: This certainly impairs ones ability to think or act smartly. Dumb acts have been committed by many smart people due to impaired thinking/ability. Been there, and, thank goodness, I don’t go there anymore!
What is interesting about each of these is… When a smart person is doing something dumb, they either do not realize it OR they don’t think they will get caught / hurt / killed!
Nearly every supervisor in the workplace feels they can be approached by others, but are they really “approachable?” What does “intervening” in the workplace mean to you as a supervisor or foreman? What does it mean to the one being supervised?
In this article, we will examine the final moments of three aviation accidents in an attempt to get at what makes approachability in the field so difficult. How can we become more approachable from the bottom up, from the top down, and peer to peer?
When the dominoes begin falling, accident investigations often reveal that someone on the job could have intervened with a critical piece of information but either did not speak up or was not listened to.
Our purpose here is to not pick apart each falling domino, but simply to look at the final moments, the end game, “the last domino” — Approachability.
Reflect inward and ask yourself, what does “approachability” really look like, sound like, or feel like in the field? What you may find is that being approachable and intervening on the job is not as clear cut as you might think.
Rescue attempts by news helicopter of Air Florida Flt 90 passengers from the icy Potomac River.
In each exampe, the pilots (workers) had the power to stop the work before disaster, but failed to do so. Why?
Air Florida Flight 90
Let’s look at the final dominos of Air Florida Flight 90. Just as they begin the work, the takeoff roll:
Cockpit Voice Recorder Transcripts
Co-Pilot : God, look at that thing. That don’t seem right, does it? Uh, that’s not right. (Referring to engine gauges)
Captain: Yes it is, there’s eighty. (Referring to airspeed)
Co-Pilot: Naw, I don’t think that’s right. Uhhh, maybe it is.
Captain: Hundred and twenty. (Referring to accelerating airspeed)
Co-Pilot: I don’t know?
NOW BARELY AIRBBORNE, THE SOUND OF THE “STICKSHAKER” (warns pilots of impending stall) HEARD CONTINOUSLY UNTIL IMPACT
“By far one of the best keynotes we have ever heard! Your Operational Excellence presentation at our Chevron GATOR gathering was absolutely on the mark!”
— 
“Odie, I can’t tell you how much we were impressed by your presentation and your work on the Panel Discussion. The feedback was overwhelmingly positive.”
— 
After personally interviewing Capt. Bob Bragg, the last surviving pilot involved in what still stands today as the “worst aviation accident in history.”, I am reminded that active listening saves lives. Capt Bragg was the copilot on board a Pan American 747 jumbo jet when a KLM 747 jet collided with him on the runway on the island of Tenerife in 1977.
The runway was shrouded in fog as the captain of the KLM aircraft advanced the throttles for takeoff. He refused to listen to his crew members when they first protested by saying, “we don’t have clearance,” then followed up by asking, “is the Pan Am clear?”
The KLM captain emphatically stated that Pan Am was clear. History clearly shows otherwise as Copilot Bob Bragg saw the KLM abruptly appear out of the fog, and attempt to fly over the top of his aircraft. They didn’t make it, and 583 people lost their lives as a result.
Time and again we see errors in communication, misunderstanding, and assuming.
In complex operations, changes in work activity happen all the time, yet hazards abound.
At the top of the list is having a leader in charge who refuses to listen to others before making a decision that directly affects other people lives. These leaders feel their situational awareness is good, yet their perceptions of reality vs actual reality is incongruent. Only by actively listening to others can these leaders make correct decisions.
The Tenerife disaster has clearly taught us that everyone, no matter their rank or experience, has a piece of information that might be the critical piece, the last chain link, or final domino in a chain of events that prevents disaster.
As an airline copilot, I had the pleasure of working with a senior airline captain who embodied active listening. When the flight operation was being hampered by bad weather, or mechanical problems, or passenger issues, before he made final decisions that affected the lives of others, he employed these three active listening techniques in sequential order, to solicit information from his team:
1) “What I Heard You Say Is….”
2) “Did I Get That Right?”
3) “Is There More?”
For example, when the captain finished listening to critical information, he made the statement, “What I Heard You Say Is…” and he would proceed to parrot back the information without putting his spin, thoughts, or opinion on the subject. The captain then followed up with, “Did I get that right? “. Once the captain heard the answer to number 2 as, “Yes,” he would move on to number 3 by asking, “Is there more?”
I witnessed many amazing transformations in body language and tone of voice when he employed this methodical listening process. It was especially effective with upset passengers.
As a safety professional, anytime communication is turning from conversation to confrontation, try using this captain’s proven listening technique before making critical decisions. This technique even works well with teenagers. Although they may not like your decision, they are far more likely to support you because they have been heard, and being heard builds trust with leadership.