I’ve always had a morbid fascination for air disasters. (Don’t ask me why; I have no idea.) I’m fascinated by shows such as Air Disasters, Why Planes Crash, and Mayday: Air Disasters. Whenever I hear about a plane going down, I’ll start thinking about what happened, clues, what might have caused it, and so on. There are times when I think I should have gotten a job with the NTSB.
Greg Moore has some publications in which he talks about lessons learned from aircraft accidents; his book partially discusses these lessons. He also has an excellent SQL Saturday presentation titled “Who’s Flying The Plane?” which talks about lessons learned from air disasters and how they can apply to IT. Go check it out if you have a chance; Greg gives a great presentation!
For the purposes of this article, however, I want to concentrate on a particular topic: how communication — or, the lack of — either contributed to or was the root cause of a disaster.
Last night, I watched an episode of Air Disasters that talked about the plane crash that took the life of professional golfer Payne Stewart. The plane went down after the cabin depressurized (the cause of which was never determined), the crew became incapacitated, and the plane ran out of fuel. What made it interesting to me was that bad documentation might have been one of the contributing factors to the accident. After the cabin lost pressure, the crew likely consulted a checklist, as is standard procedure for nearly any cockpit activity or incident. The checklist was poorly written and unclear. What should have been the very first instruction was, “put on your oxygen mask.” It was not. By the time the crew got to that instruction, it was too late; they were overcome by hypoxia.
It reminded me of a tenet that I preach in my documentation presentation: if, in a step-by-step instruction, an instruction cannot be understood within a few seconds, it has failed.
I also remember another Air Disasters episode that focused on Avianca Flight 52. In January of 1990, the plane, a Boeing 707 carrying 158 people, crashed on approach to Kennedy Airport in New York after running out of fuel, killing 73 people. There were numerous communication issues during the flight. Had any one of them been addressed, chances are the disaster never would have occurred.
How often have you been involved in some kind of activity where things were miscommunicated? How well did those activities go? I’m guessing that they didn’t go well. How often have they happened when deadlines were approaching? What was the mood of your organization? I’ll guess that it was likely one of high stress and low morale. And during that time, how smoothly did things go? Probably not very. I’ll bet that plenty of mistakes were made.
I’m painting this picture within a business environment. Imagine what these conditions are like when people’s lives are at stake.
The number of disasters that have occurred from poor communication are countless; entire studies have been dedicated to the subject. Indeed, numerous solutions and subcategories related to miscommunication have been devised. The airline industry developed the process of crew resource management. Extensive research has been done on the phenomenon known as groupthink. Even simple measures such as checklists have been studied and implemented.
The moral of the story: good communication, including documentation, is critical. The consequences of it can have adverse effects. At best, bad communication can disrupt your business. At worst, it can cost lives.