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Finishing

Talking about finishing seems vaguely inappropriate this time of year when everyone is using the turn of the New Year to set new goals and begin new courses of action. But a couple of observations over the past holiday season brought the subject forward for consideration.

The first was the abnormally large number of college and professional football teams that folded like a house of cards under pressure during the final days and weeks of the 2009 season. Out of respect, I won’t name the teams, but living just south of Denver, one Orange and Blue clan comes to mind. I don’t use the word “quitters” very often, but I’m not able to come up with a better term to describe what I witnessed down the stretch of the 2009 season, when several college and professional teams seemed to lie down in front of the competition.

When it comes to finishing things, I live in a glass house, so the stone I throw shatters my world as well. Like many of you, I use the New Year to set new goals and adjust my course. Each January, as I write my latest New Year’s goals, I take a look back at how I performed on the previous year’s objectives. This year I discovered I had achieved just one of eight goals I set for 2009 – and even that one – which was finishing my new book Blue Threat - was a two time “rollover” from 2007.

It’s not so much that I mind not achieving every goal I set. If I did I would be probably be setting my goals too low, but 1 of 8 is a .125 batting average, and no one stays in the big leagues long with that kind of performance. So my big questions is “WHY?” Why do good athletic teams fade down the stretch? Why am I batting .125 on well thought out and presumably achievable goals? Why don’t people finish well?

At the risk of mixing too many sports metaphors, let’s turn to baseball, or more specifically to two moments in professional baseball history. It was the fifth inning of Game 5 of the 1968 World Series, and my beloved Detroit Tigers were down three games to one to the St. Louis Cardinals, when speedster Lou Brock decided he did not need to slide at home plate when trying to score from second base. Tiger catcher Bill Freehan took the throw, blocked home plate, and the fastest man in baseball was called out as he tried to dance around the tag. Detroit won by scoring three runs in the seventh inning, and went on to take the last two games to win the Series.

Fast forward two years to the 1970 Major League All Star game – a meaningless competition to showcase the game’s best players. With the score tied 4-4 in the seventh. Pete Rose is on second base when Jim Hickman lined a single to center field. Amos Otis fielded the ball cleanly and came up throwing. As Rose rounded third, Coach Leo Durocher waved him home at full speed. As Rose neared home plate, he started to crouch for his patented head first slide, but seeing the catcher come up the third base line to block his slide, Rose changed his tactics and crashed headlong and under full power into Fosse, dislocating Fosse’s shoulder – an injury the Cleveland Indians’ catcher would never fully recover from. The umpire signaled “safe” (the throw went over Fosse’s head) and Rose’s team won the game by one run.

Why didn’t Lou Brock slide during a critical game of the World Series? Why did Pete Rose intentionally collide with Ray Fosse in a meaningless All Star game? More to the point, why do some of us finish stronger, and more often than others? I know the answers lies in words like planning, perseverance, prioritization and overcoming procrastination. But it seems like there is something more elemental, but I just can’t put my finger on it. I would greatly appreciate any thoughts the readers might have on the subject. In the meantime, I am making a personal committment to a .750 completion batting average as one of my 2010 goals. I'm not betting my next month's paycheck on that one, but we need to hurry, because if the Mayans have it right, we may only have two more New Years to get it all done!

Aviation professionalism: Why we can’t go back to basics

Recently, we've heard a lot about a lack of professionalism in all sectors of aviation. Professional pilots landing on taxiways, drunk in the cockpit and overflying destinations while playing with their laptop computers. It has been a bad few weeks, but these high visibility outcomes are very likely just the tip of a much more dangerous iceberg.

On November 4th, FAA Administrator Randy Babbitt said “there is an extreme need to refocus on professionalism" citing the "sad example" of the crew who "lost total situational awareness" and overflew their intended destination with an airliner full of passengers. "I can't regulate professionalism," he lamented. "With everything we know about human factors, there are still those who just ignore the common-sense rules of safety." A year ago, U.S. Air Force Chief of Staff General Norton Schwartz echoed a similar concern following an embarrassing string of incidents in his organization related to nuclear weapons handling. In a speech in October 2008, General Schwartz, said "We collectively need to back a little bit toward something called compliance. We must, do the right thing and do the right thing right. That's as simple as it gets."

Administrator Babbitt and General Schwartz both point to the key aspect of this challenge and any potential solution – it revolves around personal integrity, accepting responsibility for our actions, and a willingness to hold ourselves and our peers to professional standards. But these are not simple fixes because words like integrity, responsibility and standards are not standard issue in modern society.

The way we never were

There has been a lot of discussion in aviation circles in recent weeks about a need “to get back to basics.” That won’t work.

Our society (in general) and aviation specifically, has never been really serious about compliance. We pay lip service to trite phrases like “an uncompromising commitment to safety” but then go about business as usual, with frequent errors and casual violations. The attitude seems to be “so far no harm, therefore no foul” – and no real need to change.

According to the Josephson Institute of Ethics, a non-profit think tank that has measured the ethical fitness of American youth since 1992, "the hole in the moral ozone seems to be getting bigger — each new generation is more likely to lie and cheat than the preceding one." In short, the gene pool from which we draw our pilots (and maintainers, support personnel, dispatchers, managers and executives) is in a state of moral decay. Administrator Babbitt called the recent events of unprofessional behavior "bumps in the road." But if the only fix is another call for a "return to professionalism," the road ahead will get rougher and more lethal.

The noncompliance problem is not getting better, it is getting worse. In the not too distant past, the pilot error/violation accident rate was blurred by other causes such as improper maintenance, component failure or weather. Now that the engineering and systems flaws have been aggressively addressed, the last flaw standing is the so-called “professional pilot.” To add to the problem, advances in technology have made the modern cockpit so error tolerant that a pilot can make literally hundreds of errors and commit scores of violations without serious consequence. Experience – once the great teacher – now teaches pilots that errors and violations don’t really matter. Unwittingly, we may have engineered ourselves into a culture of noncompliance.

The real reason a back to basics approach won't work is that we can’t go back to a place we have never been. If we are to seriously address the most foundational remaining cause of compromised safety, we must go forward to the basics, to create a cadre of professionals that don’t wink at noncompliance and who are willing to admit that we have some heavy lifting to do. Professional ethics is not a core skill for aviators, but it needs to be. Contrary to popular opinion, ethics is neither instinctive nor intuitive. It must be taught and learned until a common baseline is established and peer to peer accountability kicks in for real.

Although accurate self assessment and leveraging negative feedback are not core skills sets in most pilots, we all need a cold slap of reality if we hope to turn this around.

- We are not so good that an occasional violation of the sterile cockpit procedure is OK – ever
- We are not so good that we can take flight planning and preparation briefings for granted
- We are not so good that we can fly in a physiologically impaired state – either fatigued or from playing too close to the bottle to throttle time line

Maybe we are not so good – period.

Or perhaps, as a collective, we don’t have the moral fiber it will take to tackle this challenge at all - in which case, we are begging the regulator to step into our ethical vacuum. The first step must be overcoming the denial of the problem. Let’s face facts, far too many so called professionals operate on the fringes of compliance. There is a simple answer to this problem. Ethics for all - a serious train up of why compliance matters and how to engage in peer to peer empowered accountability. In the meantime, it is well past professional midnight and time for every aviator worth his or her salt to “man up,” look in the mirror, and then each other in the eye, and demand that we act like the professionals the world believes us to be.

A Shaky Alliance

Most of us live and work in a world where safety and security is primarily provided by others. Even those of us who fly airplanes, fight fires or work in other so-called high risk industries are surrounded by devices, processes, and procedures that have been developed and refined over decades to keep us safe and secure while we go about working and playing in our day to day lives. The world seems stable, so our situational awareness grows dull, and we lose our respect for things that can bite. We trust that the world will stay tame – as it always has for us up to this point. This is a shaky alliance at best, but one we grow increasingly reliant upon as we gradually lose our edge. When it goes bad, it goes bad quickly, ends badly and usually leaves a humbling epitaph.

For those of us who work and play in lower risk environments, the problem is even worse. We become so far removed from the mental possibility of having to perform at our best – we can’t comprehend that danger lurks nearby. We text as we drive, ignore dark corners of the parking lots, and allow our skills and awareness to atrophy as if tomorrow is guaranteed.

It is not.

Over the past few weeks, I have reviewed a few tragic endings where good men were overwhelmed by conditions they should have been able to handle. Out of respect for their memories, I will not go into further detail here. It is sufficient to say, that they had the training and technology to handle the situations they were put in, but when the world turned on them, they did not respond with their best - or what should have been their best based on their training and experience - and they died ingloriously. They also took others with them.

To put a somewhat finer grained analysis to this line of thinking, I believe many of us have lost the distinction between accuracy (good enough to get by) and precision (as good as I can be). Or perhaps better said, we have lost sight that precision is important in life - or worth the effort. Or maybe, in a world where competition is devalued and every kid in Little League gets a trophy - we never understood the importance or value of staying at the top of our game the first place.

In truth, striving for precision is seldom critical to either safety or success. Good enough is usually good enough. But not always, and the time of reckoning is not of our choosing. The world is not bound by any law to stay stable or safe for us or those we protect. Rogue waves – once thought to be a myth of drunken sailors – exist everywhere in our world. There are times when the alliance will be broken and we will be given one chance to respond with our best judgment and our most refined skills.

On the back side of this challenge – we will be judged.

The Janus of Close Calls: A Tale of Two Mishaps

By now everyone in the world has heard about the heroic actions of the Captain and crew of US Airways Flight 1549 – now simply referred to as the “Miracle on the Hudson.”

But I doubt that most readers are aware that an eerily similar accident occurred in the spring 1999 in Eastern Europe, when TransGlobal Airlines Flight 1144 experienced dual engine failure shortly after takeoff out of Chelyabinsk International Airport after flying through a flock of migrating birds. The IL–113 aircraft – a clone of the Airbus 320/319 series – was forced to ditch in Lake Ostrovo four miles off the end of the Runway 33. The aircraft was successfully brought to rest in the lake and initially stayed afloat for about twenty minutes, but the pilot’s failure to activate the pre-ditching switch on the overhead panel resulted in the aircraft’s outflow valves remaining open, eventually sinking the aircraft before help could arrive and resulting in the drowning and exposure deaths of 78 passengers and all five members of the flight crew. Forty three passengers survived in emergency and make shift life rafts until they were rescued by fishing boats only moments after the aircraft sank.

In the subsequent investigation by the Eastern European Aviation Investigation Board (EEAIB), multiple factors were identified as contributing causal factors including (1) poorly designed procedures that required the pilots to go deep into a confusing automated checklist to find the emergency procedure that required the pre-ditching switch activation, and (2) the failure of TransGlobal Airlines to adequately train emergency ditching procedures in the simulator. While these factors were contributory, the proximate causal factor was pilot error. In a statement issued from the EEAIB lead investigator, the Captain was singled out as “being put in a very difficult situation, but one that was survivable for all on board, if the procedures had been followed.” The local prosecutor stated that he would have seriously considered charging the Captain with manslaughter had he survived, and was now looking at the potential culpability of the airline and aircraft manufacturer. "With a tragedy of this magnitude, someone has to be held accountable," the prosecutor said.

In both of these cases (if the NTSB early reports on Flight 1549 are accurate), the pilots failed to activate the "ditching switch" prior to a water landing. The major difference between these two accidents was not the skill or expertise of the Captain or crew, but rather the circumstantial factors that surrounded them. In one case, rescuers were on the scene in a matter of minutes, in the other, they could not reach the aircraft until it went under.

Another major difference is that one mishap actually occurred and the other is purely the work of my imagination. There is no TransGlobal Airlines, IL-113, EEAIB, Lake Ostrovo or Runway 33 at Chelyabinsk. This was written merely to prove a very important point about performance and lessons learned. Outcomes should not be used to evaluate our need to improve or make changes. Please understand that this is not intended to take anything away from the stellar crew of Flight 1514. It is intended to cut through the media fueled hype to take advantage of some free lessons.

In Roman mythology, Janus is the god of gates, doors, beginnings and endings. He is typically seen as having two faces looking in opposite directions, representing moments of choice. The lessons of Flight 1549 will take time to sort themselves out but had it ended differently, the drum for “someone to be held accountable” would be beating loudly and the FAA would be holding hearings on pending rulemaking. Let’s not be blinded by success or failure in our search for opportunities to improve. If checklist modifications and/or training improvement opportunities come out of this recent success – we have two great stories to tell.

So let me summarize this flight of fancy with three main points. First, life itself a mission simulator. Second, free lessons are there for the taking every day and everywhere if we will just look for them and not be blinded by outcome bias, and finally, not all mandates for improvement need to be written in blood.

By the way, nice job Captain Sullenberger and crew.

Freedom of a Locked Room

I picked this short article up yesterday and will use it to leverage a short discussion on compliance, judgment, and the difference between the terms capable and qualified. Here it is:

Pilot Tells Passengers 'I'm Not Qualified to Land Plane'
Thursday, December 18, 2008

A pilot with more than 30 years experience was forced to turn his plane around — because he was not qualified to land in fog, an airline confirmed Thursday. Passengers on the 8:45 AM Flybe flight to Paris were just minutes away from landing at their destination when they were told they would have to go all the way back to Cardiff, England.

One passenger from Bristol missed a job interview in France because of the incident. Cassandra Grant explained: "Twenty minutes outside Paris, the captain said, 'Unfortunately I'm not qualified to land the plane in Paris. They are asking for a level two qualification and I only have a level five. We'll have to fly back.'"

A spokeswoman for the airline said Flybe, a low-cost airline, backed the pilot's decision "100 percent." He had recently switched from flying a Bombardier Q300 to a Bombardier Q400 and has not completed the "requisite low-visibility training," she said. The dense fog covering Charles de Gaulle airport had not been there when the flight took off, she added. The plane was already three hours late due to bad weather in Wales. The pilot's situation is "quite unusual but probably not unheard of," according to the Civil Aviation Authority.

The obvious slant of this article – and the initial reaction from many readers – is “What kind of pilot with 30 years of experience can’t land in low visibility conditions?” The key to answering this question lies in defining the difference between what an individual is capable of doing, and what he is formally qualified to do.

Capabilities > Qualifications = Discipline and Compliance

There are many times when your capabilities will exceed your qualifications. I suspect this was likely the case with the airline Captain in this article. Although frustrating, this was a non-decision for the pilot. The decision was made for him by policy. Unfortunately, not everyone has the level of maturity or understanding to see the world though the simple but powerful lens of compliance.

Individuals who have this type of uncompromising personal and professional discipline operate with purpose and clarity – what I often call the “freedom of a locked room.” Absent an emergency situation, the rules make the decision for you, as well as protecting you from the second guessing of armchair quarterbacks operating at groundspeed zero. Compliance is the link between good policy and safe mission accomplishment. There is no need to ponder unauthorized options based on what your physical skill set might or might not be on any given day. In an ironic twist to the angle of this article – a less professional airman might have flown the approach into Paris and made the landing.

Qualifications > Capabilities = Courage and Judgment

But there are also times when our qualifications exceed our capabilities – and this is a much more difficult test of professionalism. Let’s assume for the moment that this Captain was qualified to fly to the lower visibility minimums, but was having difficulty flying a stabilized approach on this particular day due to any one of a hundred factors. Would he try to will the aircraft to the ground by continuing an unstabilized approach because his qualifications said he should be able to fly it – or execute a missed approach and proceed to an alternate based on his subjective evaluation of his limited abilities on this day?

Qualification levels are fixed sums – coldly objective, they not affected by mission or peer pressures or the urgency of the moment. Or at least they shouldn't be. Capabilities on the other hand, are subjective, and by definition can be altered by different states of personal readiness (physiological or psychological) or internal or external pressures to perform. Accurately ascertaining our capability level in real time is true connoisseurship, and the decision to admit when personal proficiency is the limiting factor is one of the most distinguishing marks of a true pro.

What kind of pilot tells his passengers he “can’t land the plane?” Whether the decision is based on professional discipline, compliance or personal self-awareness, the answer is the same - a professional one. Well done, Captain.

The Gift of Borrowed Time

I let yesterday pass without comment, just like the 9,131 days that preceded it since 9 Dec 1983. On that memorable date 25 years ago yesterday, I was at the controls of a KC-135A air refueling tanker and was involved in a human error induced mid-air collision with an E-3 AWACs with a call sign of Sentry 99. Without going into grisly detail - miscommunication, poor risk management, oversized egos and an inexperienced 2nd Lieutenant with less than 500 hours flying time (that would be me) combined into a sequence of events that put two very large, fast moving aircraft at the same exact coordinates of time and space. It was a severe collision that ripped large pieces off of both aircraft. It is no exaggeration to state that it was an event no one should have survived. Yet we all did. For some unknown – and perhaps unknowable – reason, I was spared from an event that should have taken my life.

From my perspective, I have lived on borrowed time since that moment.

Only from this side of the last 25 years can I gauge the magnitude of this gift. Sons that would never have been born, achievements that would have never been realized, love and life that would have never been experienced – all turned on that 11 seconds of metal on metal over the skies of the Persian Gulf.

In 1898, The English Dialect Dictionary defined the phrase borrowed time this way. "A man who lives on borrowed time lives on trespass-ground." To me this means that those of us whose time on earth has been extended through no fault of our own, need to earn our keep.

I have had one or two other near death experiences since then, but none quite so spectacular. My quest since that fateful day has been to discover and fulfill the reason for this gift and to “pay my way forward.” I’m not sure what this experience might mean to others, but I do see a difference between those who see their time on earth as a right of birth vs. a gift. I have no such burden of expectation that life owes me anything. For me, it will always be the other way around and for that clarity and every future moment, I am grateful.