Boring but Deadly: Roles and Responsibilities

I am a good boss

I run a fair-sized team.  I like to think I am a good boss, reasonable, fair, open-minded.  Perhaps I am kidding myself.

There is however one thing I do that drives my team nuts, makes them apoplectic, I have an infuriating habit of asking two people to do the same thing (maybe three or four if I want it in a hurry).

I read a story today that might just make me change my ways:

101 die

On the 29^th of December 1972 three experienced pilots were flying Eastern Airlines Flight 401 from New York to Miami.

The plane flew straight into the Florida Everglades.

101 people died.

On their approach to the runway one of the crew flicked a switch to lower the landing gear.  An indicator light should have flashed on to show that the wheels had safely locked into place.  But it didn’t.

The problem solvers among you will quickly jump to the conclusion that this was due to one of two reasons:

• The landing gear hadn’t locked into place
• The bulb had blown

Unsurprisingly knowing which of these it was became of pressing importance to the crew.

To find out was quite simple.  All they had to do was remove the bulb from the dashboard and see if it was blown.  The voice recording from the “black box” flight recorder tells us that this is exactly what they were doing.

The pilots last words:

Flight Engineer: Do you want me to test the lights or not?

Captain: Yeah, check it:

First Officer: It could be the light.  Could you jiggle the light?

Captain: It has got to come out a little and then snap in.

Captain: See if you can pull that light out…

First Officer: You got a handkerchief or something so I can get a little better grip on this?  Anything I can do it with.  This damn thing just won’t come out.  If I had a pair of pliers I could…

First Officer: It’s got to be a faulty light.  This damn thing just won’t come out.

The fatal mistake

This little drama started out whilst the plane was cruising 600 meters above the Everglades on autopilot.

Some how somebody managed to disengage the autopilot.  It stopped flying the plane.

Nobody else was either.

The plane gradually glided down 600 meters until it hit the swamp.

The most tragic part of the affair is that the black box recorder shows that 8 seconds before the collision one of the crew noticed that the autopilot was off.

First Officer: We did something to the altitude.

Captain: What?

First Officer: We’re still at two thousand, right?

Captain: Hey, what’s happening here?

Nothing else was recorded.

If they had responded they could have saved everybody.  But they were all too busy checking the light bulb.

Roles and responsibilities matter

It is human nature to focus on the issue at hand.  You only have to watch a bunch of 5 year olds playing football or “magnet-ball” to see that.

If the captain had been clear on roles and responsibilities the tragedy wouldn’t have happened.

Maybe I will change my ways.

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Image by kafoster27

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