[Music]
one morning back in 1977 I was working
really hard to turn in an absolutely
perfect performance as a brand new Lee
mented pilot I was number three on the
pecking order in this Boeing 727 we had
a captain in the first officer a second
officer that was me
it was Braniff International and we were
on a routine flight from Chicago’s
O’Hare to Houston Intercontinental
Airport beautiful clear blue sky day we
were climbing through 10,000 feet when
we realized we had a problem this was
not an emergency it was not a major
emergency of any sort our tail skid had
failed to retract it’s just a little
thing back there in the back which
literally does what it would it’s
described as it would skid if you over
rotated the airplane and there’s no real
big problem here except that we’ll lose
about 2% of our fuel burn because it’s
hanging down on the Airstream but
there’s one other thing that you’ve got
to do and that is you’ve got to go to
the back and turn off a little spigot
because there’s a little valve right
ahead of that location on the bottom of
the fuselage where the tail skid is that
would be spewing water coming from the
drains and the back bathrooms onto that
thing and at minus 45 degrees
temperature and altitude you start
growing a big stalagmite and I tell you
this thing can be about ten feet long by
the time you’re two hours in the air and
it’s not leave early to drop something
like that into the community as you’re
making your approach so as the junior
guy it falls to be I was flying with a
wonderful captain this particular day
his name was Harold Mize we all called
him tiny big barrel chested guy weigh
over six feet wonderful individual and a
great pilot and he was very laid back he
turned around said okay John pull out
the manual tell us what we need to do so
I pulled out the manual and I saw a
couple of fuzzy pictures there about the
valves under the sink that I had to turn
wounding one it’s got to be careful
because the other one controlled all the
potable water for the airplane it’s a
morning flight we got a hundred and
forty-four people mostly businessmen and
I go to the back of the airplane in my
hat and coat this is back in the days
before 9/11 when you could actually
leave the cockpit
open the doors find the valve turned it
and as I’m walking back I remember so
clearly thinking that was a perfect
performance this is exactly what I was
hired to do I did it exactly right until
the lead flight attendant grabbed me by
the shoulder and said John we don’t have
any water
I had just succeeded in identifying the
wrong valve and dumping 200 gallons of
potable water over middle Illinois now I
probably contributed to the irrigation
of some of the crops down there but my
passengers were not amused no coffee no
tea six crew members and 144 disgruntled
passengers and I got on the PA to make
the explanation but it was embarrassing
that tiny was very nice about it he
turned around said hey it was probably
difficult to understand those pictures
in the book but both he and I knew that
I had just failed utterly and my number
one responsibility as a young flight
officer at Randolph which was to be
perfect absolutely perfect 100% of the
time and I had just proven that they had
hired less than the perfect pilot that
they thought they had hired and trained
very very embarrassing fortunately not a
fire in offense but in the next couple
of weeks as I was kicking myself around
the block and I did having made this
mistake embarrassing my crew and myself
there were a couple of questions I
started eating at the back of my mind
and these were embarrassing questions
because these were not the sort of that
like excuses they’re not the sort of
thing that somebody like me with a
military background should be engaging
in right because of the military
background you’re used to squaring your
shoulders when you make a mistake and
say no excuse sir and one of the
questions was exactly what tiny had kind
of indicated when he said you know maybe
the manual maybe it could have been
written better maybe it was slightly
contributory to my mistake because the
pictures were pretty fuzzy it was hard
to discern which side the bowel was
wrong and there was another one and that
was maybe tiny should have said John sit
on your hands for a few minutes it’s not
an emergency don’t run to the back until
you were absolutely sure maybe you want
to take the book with you but there was
a third one and this really bothered me
because I was at the start of what I
expected to be a 30 to 35 year career as
an airline pilot was I really suppose
to be absolutely perfect 100% of the
time every decision I made every switch
I threw every entry and the logbook
everything I did my god is that even
possible that was really eating at me
along with the fact of course that it
was embarrassing that I was even asking
myself these questions because I was
supposed to be perfect why is this
important I think this is important
because all of us no matter whether we
want to admit it or not all of us have
spent a lot of time in our lives and
even more so in some professions
wondering why we’re not measuring up
everybody else seems to be getting it
right but we keep making mistakes
everybody makes mistakes and this is the
dirty little secret while it looks like
you’re the only one who is because what
do we always do would it make a mistake
it’s us right it’s not them it’s us
they’re perfect no they’re not there is
no carbon-based human being out there in
any industry in any profession any walk
of life including just being nicely
retired or having fun or whatever it is
you’re doing who does not make mistakes
and the reason why is that and this is a
startling development but we’ve learned
in aviation especially but also in
nuclear power generation and other
high-risk industries the human beings
cannot be perpetually perfect now we can
be perfect part of the time might affect
some of us can actually manage to be
perfect for a whole career but here is
the kicker none of us has the ability to
look somebody else in the eye and say I
promise you that I am gonna be
absolutely perfect to my execution of
whatever it is I’m gonna do for the next
period of time ten minutes in hours ten
years whatever we can’t say that
honestly so where does that leave us
well we we know the extremes the extreme
over here is the one we’ve always had
which is we have to have perfect
performance from human beings a hundred
percent of the time and over here is the
laissez-faire attitude of hey dude
things happen we don’t want that
attitude in the operating room and we
sure don’t want it in the cockpits and
we don’t want it in the in the control
room of nuclear power plants so where is
the balance point in all this the
balance point is actually a new way of
looking at things because we have always
had this paradigm I you know I didn’t
just start with 1966 and Star Trek with
Captain Kirk
wonderfully by Bill Shatner who is the
progenitor of that wonderful Hollywood
organization known as over actors
anonymous but he was to prepare a dine
wasn’t he because he was omnipotent and
he was infallible and he was a bloody
fraud I don’t mean bill I mean the
character he was a fraud because none of
us can be perpetually perfect and as I
say we then have this dilemma where is
the balance point here is the balance
point it’s where we say I’m very good at
what I do but I know I’m a human being
and I know that there are not I know the
times that I’m not gonna hear things
right there time said I’m not going to
interpret it right I’m gonna make
mistakes that are purely a result of
being human not a result of being a bad
professional or a bad husband who
forgets to take out the trash but just
being human but I know that and I’m
honest enough to admit it then I have to
say how can I put a prophylaxis of one
sort or another in place how can I build
a structure around my potential for
human failure that is going to prevent
those failures from metastasizing into a
result I don’t want this was the key to
aviation safety and we didn’t know it
until the mid 80s this idea of being
able to look at human performance and
human failure and say hey we got to know
how we fail and guess what most of it is
inadvertent failure like the three guys
at Delta Airlines you all know Delta
they’re the ones that gave us that
wonderful phrase I don’t know where I’m
gonna go when I die but I do know I’ll
change in Atlanta
Delta is a great airline but 1987 they
had three very highly qualified
wonderful guys taxiing alpha takeoff
going up to Salt Lake City they crashed
the airplane on takeoff and killed 17
people because they had forgotten to put
the flaps in the right position those
are the big movable panels on the back
of the wing and the drooping panels on
the front they forgot even though all
three of them read the checklist and
responded 15 15 green when they were
zero zero and there had never been a
green light how does this happen well
nobody was on drugs nobody was drunk
nobody was unqualified they just
happened to be carbon-based human beings
old Star Trek term forgive me the thing
is we have to be serious about this in
an aviation we finally realized we have
to build a system but what’s the system
we’re going to build first we’re going
to fire Captain Kirk we’re gonna look at
that captain and say hey dude we’re on
to you you’re not perfect so if you
don’t create a team if you don’t have it
to where your copilot and your flight
engineer can speak to you you know don’t
give us this when I want your advice
I’ll ask for it boy did I hear that a
few times if you can’t create that
environment of a team a collegial
interactive team in which nobody would
have any hesitation to speak up if they
saw heard felt or even intuitive that
something is wrong then you’re not gonna
fly for us because we can’t trust you to
be perpetually perfect no matter how
well we trained you no matter how good
you are this is why you can go to the
airport this day and time and get on a
jetliner and get to the other end with
almost a in infinitesimal is the word
I’m trying to pull out of my mouth an
infinitesimal possibility of being hurt
will get you there okay not well fed not
well treated but okay that’s another
lecture for another day tradition it’s a
moral failure to make a mistake no the
reality is next time this happens to you
individually professionally and you’re
kicking yourself around the block stop
and think hey I’m already ahead of the
game because I realize this I’ve got a
message from the underlying system that
I can use to not only a suede my
feelings of inadequacy but to know that
everybody else is the same way my
strength is knowing how to apply that
how to build a system around me give you
an example my wife is absolutely
incredible she’s a nurse
she’s an author and lecturer she’s
incredible in knowing the calendar for
the next year she can remember
everything on that calendar without
looking at my schedule as well I am
exactly the opposite I can’t remember
what I’m doing next Monday I have to use
a calendar an electronic one but that is
my methodology of making sure that I
don’t spend half my life apologizing for
missed appointments and missed calls and
that’s really the key to this the next
thing what’s next is knowing ourselves
as humans and moving on with the ability
to be perfect because not we’re going to
zero out all our errors but because we
know how to absorb them another example
in the US Air Force I flew an airplane
called the Lockheed c-141 for many years
a big big beautiful airplane well only a
pilot would call it beautiful alright it
was big hulking thing with four engines
fluid for 23 years as I say and the
regulars in reserve and through two wars
and this big bird could carry an awful
lot of fuel and an awful lot of people
when I first became an aircraft
commander at the tender age of 25 I was
taught to be Captain Kirk I was talked
to walk in and tell everybody win
who how where and I’ll see you on the
ramp and now many years later in 1987
the day I want to tell you about I’m
walking in for a trip from Tacoma
Washington
McChord Air Force Base up to Elmendorf
Alaska and Anchorage it’s going to be a
three and a half hour trip it’s a
training mission we don’t have any cargo
big powerful jet 75,000 pounds of jet
fuel and 30 passengers in the back no
cargo and as I walk in to talk to my
crew who are all standing around a
circular table about chest high
I’ve been retrained totally retrained
Captain Kirk is not walking into that
room anymore
jean-luc Picard is to a certain extent
for those of you who follow on to the
next generation because my duty is now
to bind these people into a human team
and create a level of communication that
is going to assuage the possibility that
I could make a major mistake and so I
start by shaking everybody’s hand look
at him in the eye calling him by first
name exchanging personal information and
as I’m going through this when I get to
my number three guy oh boy do I have a
newbie today he’s 18 years old he’s in a
factory-fresh flight suit with knowing
so yeah he’s an airman basic I’m a
colonel when I shake his hand I got two
fried eggs looking back at me this guy
wants to this guy wants me to talk to
anybody but he and me scared the death
of me and I realize if I’m gonna bind
him into this team I’m gonna have to
work hard on it so I continue on around
the table copilot I flew with this guy
in Vietnam this fellas got ice water in
his veins if I win came off and we were
spiraling down we’re des guaranteed he’d
ask for coffee with cream on the way
down
absolutely imperturbable so we get ready
to finish this part of the brief and I
do the who what where when how and
Hawaiian normally most everybody else in
the old days would have just walked out
to the airplane now I’ve been taught to
do one other thing to step back and say
guys hold on for a second those of you
who flown with me have heard this spiel
and you know that I’m very serious those
of you who haven’t listened up because
I’m dead serious
you are my eyes in my ears okay I have a
very good aircraft commander I’ve been
at this a long time I don’t think I’m
gonna make a major serious possibly
deadly mistake today but there’s no way
I can look you in the eye and tell you
that that’s not possible so despite my
record despite my intention to do
everything right I need to know that you
are locked in with me in such a way that
if you saw or felt or intuited or
anything that something was amiss or you
were unsure of something I need you to
speak up instantaneously I’m gonna go
back around the table look everybody in
the eye I want a blood oath from you
that you can rise to this and if you can
no problem we’ll just get you on
somebody else’s airplane and yeah that’s
that no pejorative
so I started around the table of course
when I get to my new kid his stop is in
the air and he’s really nodding yes sir
we get out to the airplane it’s a big
windowless environment down there and
normally a new loadmaster would ride
down there for three and a half hours
and I wasn’t gonna have that I brought
him up on the flight deck I said you’re
gonna ride up here with us three and a
half hours with the headset on the
button and your finger all right under
your thumb I want you to talk to us
there are no dumb questions the only
thing I ask is that you not talk over
the air traffic controllers he said yes
sir he makes all the right noises 18
years old I wasn’t convinced I said I’m
beside him I said look I’m not sure you
can get past this Colonel thing okay he
stops me in mid-sentence I could
done this at age 18 facing a colonel he
says sir I got it it’s just like dealing
with my big brother as long as I show
him a modicum of respect I can tell him
anything I think he needs to know I said
well that’s a bit cheeky but that’s
pretty much what I wanted so I climb
under the seat it’s another clear blue
sky day we we blast off again we don’t
have any cargo and we’re a very very
powerful jet so as they turn us back
towards Seattle weren’t climbing to
17,000 we also call that one 7,000
that’s our clearance limit coming
through 14,000 100 feet like an
intercontinental missile climbing so
fast and all of a sudden I hear a click
on my headset in this timorous little
voice I recognize immediately as my new
visas 14 thousand two hundred fourteen
thousand three hundred and I’m thinking
yeah man he’s speaking up this is good
go ahead load this pilot fourteen
thousand four hundred fourteen thousand
five hundred Oscar 14,600 I’m probably
wrong 14700 but I could have sworn 14800
that they only cleared us to fifteen
thousand feet I looked over here by
copilot and he’s on it immediately
Seattle Center back five zero two three
five were clear two one seven thousand
seventeen thousand Roger
14900 14950 finally the voice of the
controller rather laconic and my memory
comes back negative Mackay are cleared
to fifteen good Lord pull the power back
push the airplane over zero g everybody
help
I got 30 floaters back here one guy had
not clicked his seatbelt his buddy had
to reach up and grab him and pull him
off the ceiling
I guess stopped about 15,300 heart rates
off the chart blood pressure is 2 and
I’m sneaking back to 15,000 feet hoping
that nobody saw this and I’m now
adrenalized you know everything is
running in slow motion and I’m thinking
about where I can buy this kid the
biggest steak in Anchorage I look over
at my imperturbable friend and all the
blood is drained out of this guy’s face
I have never seen this before and I’m
looking at him and wondering why finally
I follow his gaze and realize what his
kind of caused this he’s looking at the
belly of a Boeing 747-200 owned by
Northwest orient 336 people aboard
coming in from Tokyo we called and
checked later he’s at 16,000 feet right
over our heads we would have climbed
aggressively into his belly disassembled
both airplanes you don’t survive those
we would have rained passengers and
parts all over South Seattle and it
would’ve been the second worst accident
at an airline history and I wouldn’t be
standing here now it’d be wonderful to
be able to tell you because of my
prowess as a commander I had brought
this guy into the loop bull it’s because
we had some very smart people who had
begun to retrain us and the things that
we were learning in the aviation
industry
about human failure and about the fact
that the main buttress to human failure
is a team and if you don’t have the
luxury of a team at least systems like
my system of using the calendar see we
can’t go to what’s next successfully
whether it’s facing the singularity
whether it’s facing all sorts of a
political realignment we’re trying to
get as was stated and another wonderful
lecture about medicine and where we have
to go to have a system we can’t do any
of that unless we understand ourselves
and our failure modes and how to get
past them but the good news is we can do
this so easily it’s just about being
honest about who we really are
and how we can get to zero impact from
any failure that we can’t prevent thank
you so much
[Applause]
one morning back in 1977 I was working
really hard to turn in an absolutely
perfect performance as a brand new Lee
mented pilot I was number three on the
pecking order in this Boeing 727 we had
a captain in the first officer a second
officer that was me
it was Braniff International and we were
on a routine flight from Chicago’s
O’Hare to Houston Intercontinental
Airport beautiful clear blue sky day we
were climbing through 10,000 feet when
we realized we had a problem this was
not an emergency it was not a major
emergency of any sort our tail skid had
failed to retract it’s just a little
thing back there in the back which
literally does what it would it’s
described as it would skid if you over
rotated the airplane and there’s no real
big problem here except that we’ll lose
about 2% of our fuel burn because it’s
hanging down on the Airstream but
there’s one other thing that you’ve got
to do and that is you’ve got to go to
the back and turn off a little spigot
because there’s a little valve right
ahead of that location on the bottom of
the fuselage where the tail skid is that
would be spewing water coming from the
drains and the back bathrooms onto that
thing and at minus 45 degrees
temperature and altitude you start
growing a big stalagmite and I tell you
this thing can be about ten feet long by
the time you’re two hours in the air and
it’s not leave early to drop something
like that into the community as you’re
making your approach so as the junior
guy it falls to be I was flying with a
wonderful captain this particular day
his name was Harold Mize we all called
him tiny big barrel chested guy weigh
over six feet wonderful individual and a
great pilot and he was very laid back he
turned around said okay John pull out
the manual tell us what we need to do so
I pulled out the manual and I saw a
couple of fuzzy pictures there about the
valves under the sink that I had to turn
wounding one it’s got to be careful
because the other one controlled all the
potable water for the airplane it’s a
morning flight we got a hundred and
forty-four people mostly businessmen and
I go to the back of the airplane in my
hat and coat this is back in the days
before 9/11 when you could actually
leave the cockpit
open the doors find the valve turned it
and as I’m walking back I remember so
clearly thinking that was a perfect
performance this is exactly what I was
hired to do I did it exactly right until
the lead flight attendant grabbed me by
the shoulder and said John we don’t have
any water
I had just succeeded in identifying the
wrong valve and dumping 200 gallons of
potable water over middle Illinois now I
probably contributed to the irrigation
of some of the crops down there but my
passengers were not amused no coffee no
tea six crew members and 144 disgruntled
passengers and I got on the PA to make
the explanation but it was embarrassing
that tiny was very nice about it he
turned around said hey it was probably
difficult to understand those pictures
in the book but both he and I knew that
I had just failed utterly and my number
one responsibility as a young flight
officer at Randolph which was to be
perfect absolutely perfect 100% of the
time and I had just proven that they had
hired less than the perfect pilot that
they thought they had hired and trained
very very embarrassing fortunately not a
fire in offense but in the next couple
of weeks as I was kicking myself around
the block and I did having made this
mistake embarrassing my crew and myself
there were a couple of questions I
started eating at the back of my mind
and these were embarrassing questions
because these were not the sort of that
like excuses they’re not the sort of
thing that somebody like me with a
military background should be engaging
in right because of the military
background you’re used to squaring your
shoulders when you make a mistake and
say no excuse sir and one of the
questions was exactly what tiny had kind
of indicated when he said you know maybe
the manual maybe it could have been
written better maybe it was slightly
contributory to my mistake because the
pictures were pretty fuzzy it was hard
to discern which side the bowel was
wrong and there was another one and that
was maybe tiny should have said John sit
on your hands for a few minutes it’s not
an emergency don’t run to the back until
you were absolutely sure maybe you want
to take the book with you but there was
a third one and this really bothered me
because I was at the start of what I
expected to be a 30 to 35 year career as
an airline pilot was I really suppose
to be absolutely perfect 100% of the
time every decision I made every switch
I threw every entry and the logbook
everything I did my god is that even
possible that was really eating at me
along with the fact of course that it
was embarrassing that I was even asking
myself these questions because I was
supposed to be perfect why is this
important I think this is important
because all of us no matter whether we
want to admit it or not all of us have
spent a lot of time in our lives and
even more so in some professions
wondering why we’re not measuring up
everybody else seems to be getting it
right but we keep making mistakes
everybody makes mistakes and this is the
dirty little secret while it looks like
you’re the only one who is because what
do we always do would it make a mistake
it’s us right it’s not them it’s us
they’re perfect no they’re not there is
no carbon-based human being out there in
any industry in any profession any walk
of life including just being nicely
retired or having fun or whatever it is
you’re doing who does not make mistakes
and the reason why is that and this is a
startling development but we’ve learned
in aviation especially but also in
nuclear power generation and other
high-risk industries the human beings
cannot be perpetually perfect now we can
be perfect part of the time might affect
some of us can actually manage to be
perfect for a whole career but here is
the kicker none of us has the ability to
look somebody else in the eye and say I
promise you that I am gonna be
absolutely perfect to my execution of
whatever it is I’m gonna do for the next
period of time ten minutes in hours ten
years whatever we can’t say that
honestly so where does that leave us
well we we know the extremes the extreme
over here is the one we’ve always had
which is we have to have perfect
performance from human beings a hundred
percent of the time and over here is the
laissez-faire attitude of hey dude
things happen we don’t want that
attitude in the operating room and we
sure don’t want it in the cockpits and
we don’t want it in the in the control
room of nuclear power plants so where is
the balance point in all this the
balance point is actually a new way of
looking at things because we have always
had this paradigm I you know I didn’t
just start with 1966 and Star Trek with
Captain Kirk
wonderfully by Bill Shatner who is the
progenitor of that wonderful Hollywood
organization known as over actors
anonymous but he was to prepare a dine
wasn’t he because he was omnipotent and
he was infallible and he was a bloody
fraud I don’t mean bill I mean the
character he was a fraud because none of
us can be perpetually perfect and as I
say we then have this dilemma where is
the balance point here is the balance
point it’s where we say I’m very good at
what I do but I know I’m a human being
and I know that there are not I know the
times that I’m not gonna hear things
right there time said I’m not going to
interpret it right I’m gonna make
mistakes that are purely a result of
being human not a result of being a bad
professional or a bad husband who
forgets to take out the trash but just
being human but I know that and I’m
honest enough to admit it then I have to
say how can I put a prophylaxis of one
sort or another in place how can I build
a structure around my potential for
human failure that is going to prevent
those failures from metastasizing into a
result I don’t want this was the key to
aviation safety and we didn’t know it
until the mid 80s this idea of being
able to look at human performance and
human failure and say hey we got to know
how we fail and guess what most of it is
inadvertent failure like the three guys
at Delta Airlines you all know Delta
they’re the ones that gave us that
wonderful phrase I don’t know where I’m
gonna go when I die but I do know I’ll
change in Atlanta
Delta is a great airline but 1987 they
had three very highly qualified
wonderful guys taxiing alpha takeoff
going up to Salt Lake City they crashed
the airplane on takeoff and killed 17
people because they had forgotten to put
the flaps in the right position those
are the big movable panels on the back
of the wing and the drooping panels on
the front they forgot even though all
three of them read the checklist and
responded 15 15 green when they were
zero zero and there had never been a
green light how does this happen well
nobody was on drugs nobody was drunk
nobody was unqualified they just
happened to be carbon-based human beings
old Star Trek term forgive me the thing
is we have to be serious about this in
an aviation we finally realized we have
to build a system but what’s the system
we’re going to build first we’re going
to fire Captain Kirk we’re gonna look at
that captain and say hey dude we’re on
to you you’re not perfect so if you
don’t create a team if you don’t have it
to where your copilot and your flight
engineer can speak to you you know don’t
give us this when I want your advice
I’ll ask for it boy did I hear that a
few times if you can’t create that
environment of a team a collegial
interactive team in which nobody would
have any hesitation to speak up if they
saw heard felt or even intuitive that
something is wrong then you’re not gonna
fly for us because we can’t trust you to
be perpetually perfect no matter how
well we trained you no matter how good
you are this is why you can go to the
airport this day and time and get on a
jetliner and get to the other end with
almost a in infinitesimal is the word
I’m trying to pull out of my mouth an
infinitesimal possibility of being hurt
will get you there okay not well fed not
well treated but okay that’s another
lecture for another day tradition it’s a
moral failure to make a mistake no the
reality is next time this happens to you
individually professionally and you’re
kicking yourself around the block stop
and think hey I’m already ahead of the
game because I realize this I’ve got a
message from the underlying system that
I can use to not only a suede my
feelings of inadequacy but to know that
everybody else is the same way my
strength is knowing how to apply that
how to build a system around me give you
an example my wife is absolutely
incredible she’s a nurse
she’s an author and lecturer she’s
incredible in knowing the calendar for
the next year she can remember
everything on that calendar without
looking at my schedule as well I am
exactly the opposite I can’t remember
what I’m doing next Monday I have to use
a calendar an electronic one but that is
my methodology of making sure that I
don’t spend half my life apologizing for
missed appointments and missed calls and
that’s really the key to this the next
thing what’s next is knowing ourselves
as humans and moving on with the ability
to be perfect because not we’re going to
zero out all our errors but because we
know how to absorb them another example
in the US Air Force I flew an airplane
called the Lockheed c-141 for many years
a big big beautiful airplane well only a
pilot would call it beautiful alright it
was big hulking thing with four engines
fluid for 23 years as I say and the
regulars in reserve and through two wars
and this big bird could carry an awful
lot of fuel and an awful lot of people
when I first became an aircraft
commander at the tender age of 25 I was
taught to be Captain Kirk I was talked
to walk in and tell everybody win
who how where and I’ll see you on the
ramp and now many years later in 1987
the day I want to tell you about I’m
walking in for a trip from Tacoma
Washington
McChord Air Force Base up to Elmendorf
Alaska and Anchorage it’s going to be a
three and a half hour trip it’s a
training mission we don’t have any cargo
big powerful jet 75,000 pounds of jet
fuel and 30 passengers in the back no
cargo and as I walk in to talk to my
crew who are all standing around a
circular table about chest high
I’ve been retrained totally retrained
Captain Kirk is not walking into that
room anymore
jean-luc Picard is to a certain extent
for those of you who follow on to the
next generation because my duty is now
to bind these people into a human team
and create a level of communication that
is going to assuage the possibility that
I could make a major mistake and so I
start by shaking everybody’s hand look
at him in the eye calling him by first
name exchanging personal information and
as I’m going through this when I get to
my number three guy oh boy do I have a
newbie today he’s 18 years old he’s in a
factory-fresh flight suit with knowing
so yeah he’s an airman basic I’m a
colonel when I shake his hand I got two
fried eggs looking back at me this guy
wants to this guy wants me to talk to
anybody but he and me scared the death
of me and I realize if I’m gonna bind
him into this team I’m gonna have to
work hard on it so I continue on around
the table copilot I flew with this guy
in Vietnam this fellas got ice water in
his veins if I win came off and we were
spiraling down we’re des guaranteed he’d
ask for coffee with cream on the way
down
absolutely imperturbable so we get ready
to finish this part of the brief and I
do the who what where when how and
Hawaiian normally most everybody else in
the old days would have just walked out
to the airplane now I’ve been taught to
do one other thing to step back and say
guys hold on for a second those of you
who flown with me have heard this spiel
and you know that I’m very serious those
of you who haven’t listened up because
I’m dead serious
you are my eyes in my ears okay I have a
very good aircraft commander I’ve been
at this a long time I don’t think I’m
gonna make a major serious possibly
deadly mistake today but there’s no way
I can look you in the eye and tell you
that that’s not possible so despite my
record despite my intention to do
everything right I need to know that you
are locked in with me in such a way that
if you saw or felt or intuited or
anything that something was amiss or you
were unsure of something I need you to
speak up instantaneously I’m gonna go
back around the table look everybody in
the eye I want a blood oath from you
that you can rise to this and if you can
no problem we’ll just get you on
somebody else’s airplane and yeah that’s
that no pejorative
so I started around the table of course
when I get to my new kid his stop is in
the air and he’s really nodding yes sir
we get out to the airplane it’s a big
windowless environment down there and
normally a new loadmaster would ride
down there for three and a half hours
and I wasn’t gonna have that I brought
him up on the flight deck I said you’re
gonna ride up here with us three and a
half hours with the headset on the
button and your finger all right under
your thumb I want you to talk to us
there are no dumb questions the only
thing I ask is that you not talk over
the air traffic controllers he said yes
sir he makes all the right noises 18
years old I wasn’t convinced I said I’m
beside him I said look I’m not sure you
can get past this Colonel thing okay he
stops me in mid-sentence I could
done this at age 18 facing a colonel he
says sir I got it it’s just like dealing
with my big brother as long as I show
him a modicum of respect I can tell him
anything I think he needs to know I said
well that’s a bit cheeky but that’s
pretty much what I wanted so I climb
under the seat it’s another clear blue
sky day we we blast off again we don’t
have any cargo and we’re a very very
powerful jet so as they turn us back
towards Seattle weren’t climbing to
17,000 we also call that one 7,000
that’s our clearance limit coming
through 14,000 100 feet like an
intercontinental missile climbing so
fast and all of a sudden I hear a click
on my headset in this timorous little
voice I recognize immediately as my new
visas 14 thousand two hundred fourteen
thousand three hundred and I’m thinking
yeah man he’s speaking up this is good
go ahead load this pilot fourteen
thousand four hundred fourteen thousand
five hundred Oscar 14,600 I’m probably
wrong 14700 but I could have sworn 14800
that they only cleared us to fifteen
thousand feet I looked over here by
copilot and he’s on it immediately
Seattle Center back five zero two three
five were clear two one seven thousand
seventeen thousand Roger
14900 14950 finally the voice of the
controller rather laconic and my memory
comes back negative Mackay are cleared
to fifteen good Lord pull the power back
push the airplane over zero g everybody
help
I got 30 floaters back here one guy had
not clicked his seatbelt his buddy had
to reach up and grab him and pull him
off the ceiling
I guess stopped about 15,300 heart rates
off the chart blood pressure is 2 and
I’m sneaking back to 15,000 feet hoping
that nobody saw this and I’m now
adrenalized you know everything is
running in slow motion and I’m thinking
about where I can buy this kid the
biggest steak in Anchorage I look over
at my imperturbable friend and all the
blood is drained out of this guy’s face
I have never seen this before and I’m
looking at him and wondering why finally
I follow his gaze and realize what his
kind of caused this he’s looking at the
belly of a Boeing 747-200 owned by
Northwest orient 336 people aboard
coming in from Tokyo we called and
checked later he’s at 16,000 feet right
over our heads we would have climbed
aggressively into his belly disassembled
both airplanes you don’t survive those
we would have rained passengers and
parts all over South Seattle and it
would’ve been the second worst accident
at an airline history and I wouldn’t be
standing here now it’d be wonderful to
be able to tell you because of my
prowess as a commander I had brought
this guy into the loop bull it’s because
we had some very smart people who had
begun to retrain us and the things that
we were learning in the aviation
industry
about human failure and about the fact
that the main buttress to human failure
is a team and if you don’t have the
luxury of a team at least systems like
my system of using the calendar see we
can’t go to what’s next successfully
whether it’s facing the singularity
whether it’s facing all sorts of a
political realignment we’re trying to
get as was stated and another wonderful
lecture about medicine and where we have
to go to have a system we can’t do any
of that unless we understand ourselves
and our failure modes and how to get
past them but the good news is we can do
this so easily it’s just about being
honest about who we really are
and how we can get to zero impact from
any failure that we can’t prevent thank
you so much
[Applause]
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