Communication lessons from air disasters

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 groupthinkEven 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.

Memories of Pan Am 103

Today represents a somber anniversary. I’m reblogging an article I wrote back in August in which I talk about what I was doing exactly thirty years ago today.

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(Photo source: Wikipedia)

There are moments in your life when you remember exactly what you were doing as though it happened yesterday, even if it happened many years ago.  I previously wrote about what I was doing on 9/11.  Likewise, I remember other events, such as the Challenger disaster (I was a freshman at Syracuse having lunch in my dorm dining hall).  In this article, I want to write about another such fateful day.

Yesterday, with only a day to go before Syracuse opens its football season at Western Michigan, I went poking around a couple of websites for more information about the upcoming game.  I went to the Daily Orange‘s website, and in doing so, I stumbled upon this article, which I was not expecting to see.  As soon as I saw it, memories from nearly thirty years ago suddenly came back to me.

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Memories of Pan Am 103

(Photo source: Wikipedia)

There are moments in your life when you remember exactly what you were doing as though it happened yesterday, even if it happened many years ago.  I previously wrote about what I was doing on 9/11.  Likewise, I remember other events, such as the Challenger disaster (I was a freshman at Syracuse having lunch in my dorm dining hall).  In this article, I want to write about another such fateful day.

Yesterday, with only a day to go before Syracuse opens its football season at Western Michigan, I went poking around a couple of websites for more information about the upcoming game.  I went to the Daily Orange‘s website, and in doing so, I stumbled upon this article, which I was not expecting to see.  As soon as I saw it, memories from nearly thirty years ago suddenly came back to me.

On December 21, 1988, I was winding up the fall semester of my senior year at Syracuse University.  I was living in a house that I shared with six other guys only a block off-campus.  It was finals week.  That evening, I was in my room, studying for one of my final exams.  I decided to take a study break and went downstairs to the kitchen to get myself a snack.

As I made my way down the stairs, I saw my housemates in the living room, gathered around the TV.

“What’s going on?” I asked.

“A plane crashed, and there were Syracuse students aboard,” I was told.

I was in shock.  To be honest, I don’t think I got back to studying that night.  I took a seat in the living room with my housemates and was glued to the TV, watching the news for the rest of the night.

The phone started ringing.  A number of band alumni friends (all of us in the house were members of the marching band) had just heard the news, and were calling to ask if any band members were on board.  (Those of you who know about marching band culture understand that band members consider each other to be family.)  At that point, news was just trickling in, and we were not aware of who was on the plane.  I remember hearing that SU students were aboard, but there was no information as to how many of our classmates were affected.  We heard varying numbers: ten, fifteen, nineteen.

I went for a walk around campus the next day.  The campus was eerily deserted, except for a few news trucks parked around the campus to cover the breaking story.  For such a large campus like Syracuse, the entire place felt like a ghost town.  With the nearly empty campus, combined with the cold December air, it was probably the only time I ever felt unnerved walking around the campus.

It turned out that there were thirty-five Syracuse students on Pan Am 103.  Thirty-five of my classmates were gone.  Although I didn’t know any of them, I now feel as close to them as I do any of my friends from college.

Syracuse played a home basketball that night.  As a member of the pep band, I could’ve attended the game, but I opted not to go, since I still had final exams to study for.  I understand that SU got a lot of flak for not canceling the game in light of the tragedy.  They did observe a moment of silence at the beginning of the game.

The marching band did have an opportunity to recognize the tragedy a couple of weeks later.  The Orange football team had played its way to a 9-2 regular season, good enough for a berth in the Hall of Fame (now Outback) Bowl in Tampa, FL.  We wore black ribbons on our uniforms for the game, and observed a moment of silence on the field during our pre-game show.  After the game, I took some White-Out and wrote “PA103” on one half of the ribbon, and “12-21-88” on the other.  I still have that ribbon.

Syracuse University has since paid tribute to the disaster by building a memorial, setting up a scholarship fund, and setting aside a Remembrance Week commemoration each year.  Whenever I’m back on campus, I try to take a moment to spend some time at the memorial as I remember my thirty-five fallen classmates.

Part of my reason for writing this post is so I can go back to that article I found.  At some point, I want to travel to Scotland and take a trip to Lockerbie — a pilgrimage, if you will.  I feel a need to connect with my classmates at the place where they died nearly thirty years ago, as well as pay tribute to the small town that was affected by the tragedy.  The article helped me better understand the town of Lockerbie, which would enable me to better respect the people there who have since moved on from that fateful day.