Jeff "Odie" Espenship

Approachability — The Last Domino

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.

Air Florida Flight 90 – crashed into the icy Potomac River January, 1982 (74 fatalities).
Comair Flight 5191 - departed from the wrong runway in Lexington KY on August, 2006 (49 fatalities)
PanAm & KLM 747 crash on the island of Tenerife – worst aviation accident in history (583 fatalities).

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

Captain: Stalling! We’re falling!”
Co-Pilot: Larry! We’re going down Larry!
Captain: I know it!

When employees in the field are unsure of what they are seeing or experiencing they either won’t speak up, for fear of looking stupid, or if they do speak up (which is the case with Air Florida) they may not be able to articulate exactly what they can or cannot see. It is difficult to clearly explain a bad feeling you are having, especially to a supervisor. So beware, approachability in the workplace may look or sound something like:

“Hey this doesn’t’ seem right, does it?”

“This light is uhh, isn’t this light usually off, the power is off - right?”

“These uhh, these uhh, are these the right fittings for this pipe?”

(Insert your own unsure/vague workplace example here)

BE ON THE LOOK OUT for the rhetorical question, the vague statement, or the unsure utterance. It might be your last domino.

Comair Flight 5191

The second accident I want to look at is the final moments of Comair Flight 5191. Three experienced pilots in the cockpit departed from the wrong runway in Lexington KY on August, 2006 - 49 fatalities.

It is early morning, and still dark out as the captain taxis the airplane to depart on runway 22 (see Figure 1). Instead he mistakenly turned onto runway 26, a runway that is too short for the required takeoff roll. How could this happen to a highly experienced captain at the tiller, to a normally alert copilot sitting next to him, and to another pilot sitting in the jumpseat?

BE ON THE LOOK OUT: Approachability might not come from a person, but from the job itself.

There are numerous non verbal hints and clues that we fail to act on when working. It might be a part on a machine that is missing; a wire is broken; the equipment is behaving strangely; lights that are normally on are off. The Comair flight 5191 crew was no different. Runway 26 had no runway lights on, which is required by FAA regulation for night operations. The runway itself was attempting to tell the crew that something is not right.

As they began their takeoff roll down the unlit, darkened runway, approximately 12 seconds into the work the first officer said,

“Is weird with no lights.”

“Yeah,” confirmed the captain. No response from any crew member again until 15 seconds later. The captain made an exclamatory “Whoa!” as the end of the short runway appeared. The sounds of the crash followed shortly thereafter.

As we read this, we might be thinking, “How could they be so stupid?” Why didn’t the pilots stop?! Intervention is not always cut and dry.

Let’s look at Situational Awareness (SA) for a moment. SA is the measuring stick for our perception of reality vs actual reality. Taxiing an airplane onto the correct runway can be perceived as a low risk event. Pilots always get it right. This perception lured all three crewmembers into a trap; they failed to verify the correct runway. Now, their perception of reality is lethally different than their actual reality.

The final domino – “Is weird, with no lights”

The lack of runway lights itself was trying to intervene, but the pilots failed to listen. Why? Simply because when hints, clues, or suggestions from our surroundings begin to show us that actual reality is different than our perception of reality, it is human nature to rationalize away and to not listen. The Comair crew knew there was construction going on at the Lexington airport. Perhaps the runway lights were off for that reason? We will never know. We do know they continued the takeoff, wanting to maintain their perception of reality as being real. In these cases, we want to be right, but if the job is hinting that “something isn’t right”, listen to the clues. It might be your last domino.

PanAm & KLM 747 crash on the island of Tenerife

The final accident is perhaps the saddest. It stands today as the worst aviation accident in history. Five hundred and eighty three people lost their lives when two 747 Jumbo jets collided on a fog enshrouded runway at Tenerife island in March 1977.

Artist rendition of the KLM 747 aircraft attempting to fly over but crashing into the Pan Am 747 jumbo jet.

I personally interviewed Capt. Robert “Bob” Bragg, now the only surviving pilot of this tragedy. Bob was the copilot onboard the Pan American 747 airplane when the KLM 747 emerged out of the fog, at over 150 MPH, in an attempt to takeoff. It failed to get airborne high enough, and slammed into the top of Capt. Bragg’s Pan American jet. I asked Bob to go back in time, and listen to the cockpit transcripts of the KLM 747 crew, and discuss the final dominos.

KLM Captain: “We’re going”
KLM Engineer: Is he not clear then?
KLM Captain: What do you say?
KLM Engineer: Is he not clear that Pan American?
KLM Captain: “Oh Yes!” (Emphatic)Oh yes. - emphatic}

In reference to the above transcript, Capt. Bragg said this of the KLM captain, “I think he got in too big of a hurry, trying to get back on schedule. He mistook his route clearance for a takeoff clearance. He then failed to listen to his engineer.”

Being in a hurry, on a foggy runway, and misunderstanding the control tower lead to degradation in overall cockpit situational awareness. The over bearing captain (supervisor), with a new copilot (new hire), and an unsure engineer (peer-to-peer) made a complete recipe for workplace disaster.

This tragedy laid the foundation for Cockpit Resource Management (CRM) for airline pilots. The lessons we have learned is now applied to businesses around the world.

Bottom up approachability can be difficult for the one who feels threatened or intimidated by another’s experience, skill, and knowledge. Supervisors, actively listen when others have questions. It might be you who is mistaken. No one wants to look stupid in front of their boss or their peers, so be sure to thank those who have the guts to bring up concerns. Take the time to listen to the ambiguous, odd, or vague statements. This encourages open communication. Ask probing questions. Make sure everyone has a high level of situational awareness. Never assume. Lastly, watch for clues from the job itself. It might be a light, a switch, a piece of equipment, a tool, or a procedure that is speaking up. It is always better to slow down and spend a few seconds of your life than lose your life in a few seconds.

BOTTOM LINE:
APPROACHABILITY is a personal mindset that every person on every job for the rest of your life has a piece of information that you need. Listen up. It might be your last domino.