On November 2, 2007, an experienced pilot was sitting confidently in charge of the US Air Force’s formidable fighter, an F-15C, zooming over the prairies of Missouri powered by two Pratt & Whitney F100 engines, capable of producing up to 47,000 pounds of afterburning thrust. But what surely seemed like an ordinary mission catastrophically exploded into the most extraordinary event in this pilot’s life. Unexpectedly, while performing a routine maneuver which this agile fighter had executed countless times in its long and distinguished air superiority role, the aircraft literally began to break apart. Although the pilot sustained injuries to his left shoulder and arm, he acted “focused, precisely and appropriately” according to the accident board, and successfully ejected from the flying hunks of metal. The several pieces of the 41.7 million USD aircraft thankfully only caused minimal private property damage as they plummeted to the ground.
If it ain’t broke, don’t fix it!
How many times have you heard the saying, “If it ain’t broke, don’t fix it”? (In Thai, อะไรที่มันไม่ได้เสีย ก็อย่าไปซ่อม) It implies, of course, that we should not make adjustments to processes or possessions that have been continuously functioning well. But that is a philosophy of complacency, being too comfortable with the status quo, which will catch us reacting to problems rather than proactively preventing them. Colin Powell has counseled aspiring leaders, “Keep looking below the surface appearances. Don’t shrink from doing so just because you might not like what you find.” Things may be looking normal, like the routine mission of the F-15C, but closer inspection may find preventable problems.
In a high-performance aircraft, the metal structure of the plane experiences many cycles of extreme force, and when metal is stressed repeatedly it can become “fatigued,” or weakened. Aircraft manufacturers perform extensive tests to find the limits of the stress that aircraft parts can take, such as in this test-to-failure of the Boeing 777 wing.
In the aging fleet of F-15s, which had been produced since the 1970s, a critical structural part that ran along the length of the body of the plane, called a longeron, was experiencing this weakening. According to the accident investigation report of this incident, “a technical analysis of the recovered F-15C wreckage determined that the longeron didn’t meet blueprint specifications. This defect led to a series of fatigue cracks in the right upper longeron. These cracks expanded under life cycle stress, causing the longeron to fail, which initiated a catastrophic failure of the remaining support structures and led to the aircraft breaking apart in flight.”
That’s a little technical talk, but what it really spells is “one bad day for a pilot.” The particular part in question was designed to be able to take forces on the aircraft of twelve times the force of gravity (or 12 Gs). (If you’ve ever ridden a roller coaster, that force that you feel pushing you into your seat when you go around a sharp curve is a kind of G-force. Someone who weighs 100 kilograms at one G would feel like they weigh 1200 kilograms at 12 Gs). In the several months of investigation after the accident and report, in which the F-15 fleet was grounded, some longerons were found to be out of tolerance of specified structural requirements by as much as 40%, apparently due to production problems from the supplying factory. That means there was possibly a decades-long chain of people not looking “under the hood” of normal operations to find this potential problem.
Was it because of complacency, fear of finding a complicated problem, or just lack of anticipation? In any case, the incident teaches a great lesson of a leadership action that helps keep operations running smoothly and safely: Anticipation
Fix it before it breaks!
One of the learnable, practical actions of a talented leader is anticipation of future events, or being proactive. Anticipating involves the following elements:
Elements of Anticipation
- Continuously examine data and the environment to anticipate problems or changes.
- Always have a questioning attitude.
- Look for leading signals, rather than lagging ones.
- Reinforce early reporting of details that might signal a problem. Encourage dissenting or alternate opinions.
In high-reliability operations, in which a single incident can have catastrophic consequences, it’s essential to anticipate possible root causes of potential incidents. Taking the time to visualize things that might go wrong, and doing a root cause analysis before an accident, can pay huge dividends. There are many techniques to do a root cause analysis, but in a simple version, you can focus on these three types of causes:
3 Types of Causes of Incidents
- Physical cause: equipment failure.
- Human Cause: person did or did not do something.
- System Cause: A management system component that failed to support the correct human behavior.
As General Powell said, we can’t shrink from looking below the surface just because we’re too lazy or too afraid to find something we don’t like. When things are going well is exactly the time to anticipate our future.
Copyright © 2017 by Robert Cummings All rights reserved.