Making the complex simple is
something I do for my clients. You see, I want to leave my clients
self-sufficient after my work is done. If things are too complex, not
well understood, and not sustainable, the outcome of my work is either
dependency on me or confusion. Dependency on me or confusion that
lingers after I am gone means I have not lived up to my own expectations
when I accepted an assignment nor has my client received the value I
believe they should have.
Pilot error caused the July 2013
crash of an Asiana Airlines Boeing 777 that hit the seawall just prior
to landing at San Francisco International Airport resulting in the
deaths of 3 teenage passengers (who were not wearing their seat belts at
the time of the crash and whose bodies were thrown onto the tarmac) and
injured 187 other passengers. Here is what news reports offered:
"In this instance, the pilots
over relied on systems they did not understand and flew the aircraft too
low and slow, colliding with a seawall at the end of the runway," said
Christopher Hart, acting director of the National Transportation Safety
Board, during a long-awaited hearing into the cause of the July 6
catastrophe.
Flight 214 was inbound to San
Francisco on a clear day from Seoul, South Korea, with an experienced
pilot being trained to fly the 777, and his instructor sitting next to
him. As the aircraft passed over the San Mateo Bridge, about 5 miles
from the runway, the pilot executed a series of commands that caused it
to lose speed rapidly, a problem the pilot discovered too late to
execute a go-around for another try at landing.
What caused the confusion in the
cockpit has been a key issue of concern, with much of the focus on the
technology that has been added to airlines in recent decades to assist
pilots.
Asiana has said the accident
probably was caused by its flight crew's failure to monitor and maintain
safe airspeed during the landing and that a contributing factor was the
crew's "failure to execute a timely go-around" as required by company
procedures. But the airline also faulted the Boeing 777's complex
automation controls for contributing to the accident, claiming
"inconsistencies in the aircraft's automation logic" led the crew to
believe that the airplane was maintaining a safe airspeed. It added that
warnings from the aircraft that something was wrong were "inadequate."
This is horrifying. The fact that
the pilot, co-pilot and training pilot did not have a sound
understanding of the automated systems that assist them in flying a
Boeing 777 is malpractice. Did the passengers and crew understand this
when they boarded the plane? Or, did they assume the pilots were
experts? How could the training not take the complexity out of the
sophisticated systems such that it was simple for the pilots to
understand?
The Boeing 777 is, based on its
track record, one of the safest aircraft ever designed and manufactured.
As of May 2014, over 1,200 have been manufactured. It was first placed
in service in July 1995. The Asiana Airlines crash at San Francisco was
the first ever for the Boeing 777 wide-body aircraft. The second
incident is Malaysia Airline Flight 370 which disappeared after leaving
Kuala Lumpur.
Other airlines and their flight
crews seem to be able to manage the 777 well and understand the
�complexity� associated with the Boeing 777 flight systems. Why did
Asiana pilots have confusion? It seems to me people did not speak up
about issues they encountered during their training and
re-qualification. If there was confusion amongst Asiana pilots, the
airline should have spoken up before an incident occurred, not after the
fact. Why did not their flight crews refuse to fly the 777 aircraft if
they had discomfort? The flying public has to expect pilots to be
completely comfortable with the aircraft they fly.
As a former Top Gun Navy pilot who
launched his plane from aircraft carriers related to me a day after the
accident, �Anyone who is unable to land an airplane on a 12,000 ft
runway that is not moving on a beautiful visual flight rules day (VFR)
needs to find another line of work!�
There is tremendous value in
simplifying the complex. To do anything less creates ambiguity and
confusion � and good things seldom flow from these states.
David
J.
Gardner
is a Fellow of The Business Forum Institute and held senior management positions in Product Development,
Manufacturing, Sales, Marketing, Customer Service and
Product Management. He joined Tandem Computers in 1979 where
he was responsible for Corporate Documentation Standards for
Tandem's highly configurable and expandable computer
systems. In 1983, he designed and implemented a
Configuration Guide for Dialogic Systems instituting a
process that greatly simplified a complex, modular product
such that the field sales organization and international OEM
customers could easily define their order requirements. This
methodology satisfied the product definition needs of sales,
marketing, engineering, manufacturing, customer service and
finance. David founded his consulting practice in 1991. He
is a graduate of San Jose State University (BA) and Santa
Clara University (MBA). David is a member of the Society for
the Advancement of Consulting (SAC) and has been Board
Approved in the Area of Configurable Product & Services
Strategy and Implementation. In 2010, he was inducted in the
Million Dollar Consultant� Hall of Fame. Out of
over 1,000 consultants who have completed Alan Weiss�s
mentoring program, only 26 have been inducted into the Hall of
Fame.
Note:-- Dave Gardner can be
reached on
Twitter
and you can check out his
video describing why he
is in business.
