Deadly Distractions - The Crash of Eastern 401
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.
Balanced Qualities of a Target Leader
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!
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.
Active Listening Builds Trust and Saves Lives
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.
Odie uses his background in both commercial and military aviation to motivate and inspire individuals to embrace a zero-accident safety culture. 
