managementÆs misuse of available resources 10

[boffintech]

This is a link to a story of management’s inability to properly use available resources.

http://www.airdisaster.com/cvr/cvr_ea401.shtml

It’s an extreme example; people died. The story illustrates a point: management is very often focused on the insignificant much to determent of the big picture and the little people.

I shared this story with my manager. To no one’s surprise he failed to see the analogy. They just do not want to hear it and especially not from a tech.

 

[ewh]

You would think that one of them would have noticed that the autopilot wasn't working, instead of all of that effort with a light bulb.

 

[HgTX]

Can someone translate that page for the aeronautically illiterate?

Hg

Eng-Tips policies: faq731-376

 

[ctopher]

Sounded like rookies. Anyone know what type of airplane it was?

Chris
Systems Analyst, I.S.
SolidWorks/PDMWorks 05
AutoCAD 05
ctopher's home site (updated 06-21-05)
FAQ559-1100
FAQ559-716

 

[boffintech]

It was a $30M+ L-1011 Tri-Star. The pilot had like 30K hours so these guys were not rookies. It was a top of the line aircraft with a top of the line flight crew.

BTW, the autopilot WAS working. The autopilot had two modes of operation. The accident investigation showed that while messing with the light bulb the yoke was bumped knocking it from one mode of autopilot to a second mode of autopilot.

At the end of the transcript the co-pilot is heard noticing that the aircraft was not at the correct altitude; he could see the reflection of their own lights in the swamp just 20 feet below. By then it was just too late. They had descended from 2K feet to 0 in abut 4 minutes while messing with the light bulb.

Basically no one was in charge of flying the aircraft; every one was messing with the 20 cent bulb which turned out to be bad and the landing gear was actually down and locked in place.

This just sooooo parallels most of the managers that I know.

 

[ctopher]

I flew on a L-1011 to Hawaii once. Nice plane.
Yes, I have seen managers like this before also.

Chris
Systems Analyst, I.S.
SolidWorks/PDMWorks 05
AutoCAD 05
ctopher's home site (updated 06-21-05)
FAQ559-1100
FAQ559-716

 

[kontiki99]

I don't get the original point.

Controlled flight into terrain (CFIT) accidents have been the focus of research for years. It's a non-trivial problem that's been very hard to eliminate.

With the mandate for Enhanced Ground Proximity warning systems over the last few years, the rates will hopefully drop further.

Unfortunately, it probably won't be perfect.

Flying is still the safest form of transportation.

 

[ScottyUK]

kontiki99,

I think point is that everyone including the guy whose job it was to fly the plane was messing about with the lightbulb instead of fulfilling their own roles to a high standard. Take a terrestrial equivalent from the real world where the MD and the senior managers spend all day pondering about trivia such as what colour to paint the factory gate while the company loses all its orders because the manufacturing equipment is broken down and the disgruntled staff are threatening to strike. Did the gate (or the lightbulb) really matter that much in the great scheme of things?


----------------------------------

I don't suffer from insanity. I enjoy it...

 

[boffintech]

The point of the story is the abject mismanagement of available resources. While management was focusing on a 20 cent bulb a $30M+ aircraft augered into a swamp.

 

[MikeHalloran]

Trying to teach a manager like yours is like trying to teach a pig to sing.

It wastes your time...

... and it annoys the pig.



Mike Halloran
Pembroke Pines, FL, USA

 

[jmw]

There are some things in life you just shouldn't try to share with management, not if you want your career to continue forward.
The truth is one of them, humour is another.... colds and flu are OK though.

Management dislike to be confronted with the truth.

At one company i worked they decided that the "Investors in people" program was the way to go because they would get a plaque to put up in reception and would make brownie points with the shareholders and have something to put in the newsletters to the clients.

Unfortunately this program involved a set of outside consultants coming in who actually spoke with the mushrooms.

They found that there was a communications problem. Management could just about handle that concept if it proved that the troops had a problem communicating (or listening). However the consultants discovered the problem lay with the managers and foolishly said so.

End of excercise.
End of consultants.

.... and I'll bet they changed their approach... once they realised who paid their bills.

And, yes, the pigs still just grunt and no one understands them or how they got their positions or how they keep them.

(I am cynical mode a lot these days, anyone else get like that?)


JMW

http://www.ViscoAnalyser.com

 

[ziggi]

jmw,
Basically the method of management, "lead by ignoring your own faults", is the western equivalent of third-world corruption, ie. it stunts company growth and keeps the incompetent in power.
That's why hard a**ed managers appeal to me, they tend to take the company on a strong route, little discussion required, and they tend to eliminate the weeds that don't want to improve themselves and who can't look down past their own pedestals.

 

[epoisses]

boffintech
Of course he doesn't want to hear from you that the way he is doing his job is analogous to killing a plane full of people!
IMHO managers are criticized a bit too easily. Being a manager is not easy at all. If you mess too much with details people say you don't see the big picture, if you focus on the big picture people say you don't care about details. And the "little people" always complain in any case.
Sometimes these people should get some credit for having a lot of responsibility on their shoulders and providing you with a good income. Sure there are bad managers but there are competent ones as well and they deserve to make more than their employees.
(Not that I'm a manager, just in case you'd doubt).

 

[kontiki99]

I think it's being taken out of context here.

The primary feedback to the crew for determining if the gear was down and locked was the lamp.

So the question was, is it the lamp or the gear?

No doubt there was a backup system that would have required the crew to pull back the rug and remove a coverplate in the passenger cabin, but from a human factors point of view, what they were doing was probably what 100s of pilots have done before.

Systems that issue nusiance alerts because they are known to be unreliable are very dangerous in some environments.

There may have been a requirement for specific procedures that were costly or hugely inconvienent mandated by a regulation over that foolish lamp.

It's a regulated industry, with monitoring and active enforcement.

It did get me curious about the facts, I couldn't find the NTSB report on a fast search.

I'm not defending management sillyness.

I wouldn't pass too harsh a judgement on the crew without more facts.

 

[Zapster]

boffintech, if an employee brought this transcript to my attention, I might say that he/she was the light bulb that should be working, and that I don’t have time to figure out why this article was relevant without running this business into the ground.

If you want to criticize the way management runs the show where you work, I recommend that you make specific recommendations for improvement. It does not do much good to try to cryptically criticize your boss through some analogy of a flight crew who lost sight of the big picture.

 

[boffintech]

kontiki99 wrote, "So the question was, is it the lamp or the gear?"

And they shouldn't have forgotten to fly the plane while answering this question!

And don't forget they had a 4th person in the cockpit: a aircraft maintenance specialist who was catching a ride home. The three flight crew guys could and should have FLOWN THE PLANE while the 4th guy fixed the lamp or went below to verify the landing gear was down.

The correct resources were available to correct the problem. The leader of the group ignored these resources, ignored his primary responsibilities, and crashed the plane.

I think many managers could learn a thing or two from this episode.

 

[MikeHalloran]

Okay, suppose the boss decides to resume flying the business, and start making good use of his resources, and look around and assess his situation.

He might well wonder why he's paying a tech to read about airplane crashes.

Be careful what you wish for.




Mike Halloran
Pembroke Pines, FL, USA

 

[epoisses]

boffintech, I guess EVERYBODY could learn from this episode, not just managers.
And in line with what kontiki wrote, this obviously assumes that from reading this transcript (which I personally don't understand much of) we have a good idea of what happened and why - a pretty doubtful assumption.

 

[debodine]

epoisses:

You bring up a valid point. Those of us in the aviation industry, who have some experience in accident/incident investigation, and have reviewed the NTSB report of this specific accident, have a good idea of what happened and why. You are entirely correct that anyone who read only this transcript and assumed they knew what happened and why would be quite uninformed. For example, who amongst us has not snickered when a new media person has attempted to relate a story in our own industry (whatever our own personal industries might be) but were not experts in that particular industry?

That being said, the main point raised by boffintech and others on this forum is that none of the members of that specific flight crew, who were charged with the safe operation of the aircraft, were aware that the aircraft was being operated unsafely due to fixation on a problem. That is one of the conclusions of the NTSB investigation.

Like all accidents, this one was a chain of related events. The primary cause (roughly paraphrasing the NTSB conclusions) was the failure of the pilot in command to either personally monitor or clearly delegate the responsibility for monitoring the progress of the aircraft. Other factors in the chain included the failure to use two specific resources that were appropriate for this incident: failure to assign the flight engineer the responsibility of determining if the light bulb had failed and could be replaced (the captain and first officer should not have been involved in attempting to change the light bulb with a qualified flight engineer on the crew), and failure to assign a crew member (should have been either the flight engineer, or the first officer, but preferably the flight engineer) to perform the backup procedure of viewing the landing gear status through the view window.

I think what boffintech's original point was intended to be is that whenever managers fixate on the minors but not the majors, all suffer. Someone has to monitor the overall direction, and getting bogged down in details can be detrimental to a company, just as it was fatal for the people on Eastern flight 401. However, it was a harsh and non-specific critcism of boffintech's boss, and I can't see a normal human boss responding to that analogy positively.

debodine

 

[debodine]

I would like to clear up one small point made early on by boffintech who said:

"BTW, the autopilot WAS working. The autopilot had two modes of operation. The accident investigation showed that while messing with the light bulb the yoke was bumped knocking it from one mode of autopilot to a second mode of autopilot."

While it is true the autopilot was working (I use the term to mean operational as opposed to broken), the statement "second mode of autopilot" could be misleading. In fact, the autopilot was disconnected when the yoke was bumped by one of the flight crew members while fiddling with the light bulb. The term disconnected (which could be construed as a "second mode", I suppose) means that the autopilot was disconnected from the servo-mechanisms that actually move the aircraft controls, which returns the aircraft to manual control by the pilot.

Consequently, Eastern flight 401 was then effectively "out of control" in the sense that no human being was controlling it, either manually or through the use of the autopilot. No one on the flight crew realized the autopilot had been disconnected. The aircraft, which had been trimmed efficiently by the autopilot before the disconnection, continued to fly smoothly for several more minutes as it imperceptably (to the non-attentive flight crew) lost altitude and finally crashed.

The automatic disconnection of the autopilot was ironically (in this case) a safety improvement so that any time a human being attempted to take control of the aircraft manually (e.g., moved the control wheel) the autopilot would immediately yield control of the aircraft to the pilot. Historically there have been cases where the autopilot would not reliquish control and the pilot had to fight the autopilot to control the aircraft.

One of the mandatory changes required by the FAA in response to this accident is that autopilot systems are now REQUIRED to visually and audibly alarm ANYTIME the autopilot disconnects no matter what the reason, and the flight crew, to silence the alarm/shut off the visual indication MUST acknowledge this alarm, usually my manually depressing the autopilot disconnect button.

Eastern flight 401 was not equipped (nor was it required to be at that time) with any time of signalling system to alert the flight crew to the fact that the autopilot was disconnected.

Sorry to ramble so, but because I find myself very interested in explanatory posts from knowledgeable persons in other industries, I would hope occasionally someone outside of aviation would benefit from my explanation.

debodine