Andrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final In front of you, and photographically outlined in Appendix A, is a representation of the six critical themes | took away from the Darden Leadership Residency Two, “Leading Change”. Five of the cube facets represent seminal aviation accidents that highlight five of the critical themes. The United States National Transpiration Board, responsible for investigating aviation accidents, identified similar if not exact change themes as directly causative to the accident. For many, aviation represents the dichotomy of hope and fear that change so frequently represents. Airplanes, ‘and airlines builtin the last century has brought us closer together in both time and space; a person can be almost anywhere on the planet in as itle as 24 clock hours. But flying is, for some, a terrifying activity: one banked turn away from a horrific end to life. The scale of an aviation accident dwarfs logical analysis: a person is twelve times more likely to die in an automotive accident, than in an airline accident, based on fatalities per millon miles. (NTSB, 2011 and NHTSA, 2011) Everyone is A Leader With Change: Air Florida 90, Washington, DC January 13th, 1982 Aheavy snow is blanketing Washington, DC's Regan National Airport, The crew of Air Florida Flight 90 have just arrived from Miami, landing in the heavy snow. The crew is to return to Fort Lauterdale, FL with 74 passengers, Regan had been closed for a periad of time earlier in the morning due to the snow, but had reopened for operations. During the accident flight's taxito the runway, the airplane stopped at a deicing station, to be sprayed with fluids meant to remove existing frozen precipitation, and also protect the airplane surfaces from further ice contamination. Ice on the wings disrupts airflow and can prevent the wing from generating lit, creating a dangerous aerodynamic condition. The ground crew improperly applied the de-icing mixture, using not only the wrong equipment, and the wrong mixture, but also failed to protect sensitive airplane equipment from damage ‘As the airplane took to the runway, First Officer Roger Pedit was responsible for flying the airplane. TheAndrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final airplane began to accelerate, yet something was amiss based on his readings. CAM-2 is the First Officer; CAM is the Captain 15:5 ):58 CAM.2 God, look at that thing. That don't seem tight, does it? Uh, that's not right. 16:00:09 CAM-1 Yes itis, there's eighty. 16:00:10 CAM.2 Naw, | don' think that's right. Ah, maybe itis. 16:0 :21 CAM-1 Hundred and twenty. 16:00:23 CAM.2 | don't know. 16:0 ):31 CAM-4 Vee-one. Easy, vee-two. (NTSBIAAR-22.08, 1982) Up until the fateful "Vee-one” and "Vee-two" calls, the First Officer could have elected to bring the airplane to a halt on the runway, taxi off, and investigate his concerns. However, at the time, the Captain was the ultimate authority, and what the Captain said, went, This was endemic to airline cockpit culture across the aviation industry. Exactly 30 seconds later, the Boeing 737 struck the 14th Street Bridge. 74 of the 79 souls on board perished The success of any change does not rest solely with the leader in charge of, or directing, the change initiative. ‘Success lies at al levels of the organization, from the the most senior executive, and to the most junior intern. We are all stakeholders. If something is wrong, amiss, or in need of attention, ignoring it due to your role or ttle can jeopardize the change. As leaders, itis our duty to let all stakeholders know their value and role in the change effort, and provide them an avenue to voice concerns, raise issues, and help influence the total direction of the change effort. Without it we increase not only our risk of failure, but also that of our firms. Understand Why You Change: US Airways 427, Aliquippa, PA September 8th, 1994 Boeing Aircraft Company had enjoyed decades of considerable success with i's commercial airplanesAndrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final business. From the piston-twin 337, to the first American jetliner, the 707, to the immensely popular 727 and 747's, Boeing had a track record of winning design, smart marketing, and outstanding engineering. In 1964, Boeing began the design and construction of their newest narrow-body airliner, the 737. Boeing leadership opted for a "clean sheet” design, whereby all components would be designed from the ground up, rather than derived of retrofited from an existing Boeing product For safety reasons, critical fight components are usually duplicated throughout the airframe. Control systems, fuel systems, and electronics have reliable, well-designed backups that can function at 100% load in case of a failure, turning what was once an emergency into a unscheduled maintenance repair. The rudder system, used to control yawing movement of the tail and nose, was such a critical component. As such, the power control unit that turned human inputs into hydraulic force was duplicated on all Boeing aircraft However, Boeing's clean sheet mandate opened up design for a new method of building redundancy: instead of two distinct components, one single component would be engineered in a way to back itself up if the system failed Additionally, rather than using rubber gaskets to seal the system, gaskets which required periodic and expensive maintenance, the parts would be built to such tolerances that they would not leak fluid. What was not anticipated was how the system would behave if a critical component failed, and caused the primary and backup system to interact. US Airways 427 was such a Boeing 737, approaching to land Pittsburgh, PA from Chicago, IL. As the aircraft slowed for landing, the airplane entered a flight regime called “crossover speed”, where the rudder maintains more contral force than the other fight surfaces do. Therefore, the remaining control systems cannot overcome the forces generated by the rudder itself. Crossover speed is a natural part of the flying process; it is required to slow down the aircraft in preparation for a safe arrival. The pilot flying, the captain, is believed to have continued configuring the aircraft for arrival when the power control unit entered into the previously unknown failure mode: a blowover. Hydraulic fluid intended to keep the rudder moving left, as the pilot had commanded, was now causing the rudder to move right. As the pilot commanded moreAndrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final left rudder, the PCU commanded even greater right rudder. The rudder became fully deflected in the opposite direction of command, which started a roll of the aircraft towards inverted. The plane entered a near vertical dive, and impacted the earth 27 seconds later. The force of the impact was ‘0 great that wreckage was deposited eight feet below ground level. 132 souls lost their lives on that day. Change often means new, different. Some go so far as to construe change as"progressive”. There is often the temptation to change for the sake of change, to add or remove one more item while we're performing tasks under a larger umbrella. The unintended consequences of these actions can be equally thrilling as they are frightening. A leader must ask themselves: why am | changing? Under what pretext am | changing this particular item, this division, or this way of doing business? Is it congruent with the overall change | have planned out? If a leader cannot unequivocally answer these questions, then the leader must step back and reconsider their actions. Under the context of any other change reason, US 429 would be a tragic loss of life. But, in this particular case, the loss is even more tragic: something was changed for little reason beyond “we're changing” Plan, Practice, Execute: Japan Airlines 46 E (Cargo), Anchorage, AK March 31st, 1993 On departure from Ancorage, AK, JAL 46E encountered what is termed “severe” turbulence. Severe turbulence is defined by the FAA as "Turbulence that causes large abrupt changes in altitude/attitude: 1. In most cases, severe turbulence will be unanticipated 2. Unsecured items are tipped over or tossed about 3. Standing or walking is impossible without hold on to part of aircraft 4. Occupants are forced violently against seat belts” Encounters with severe turbulence typically require maintenance checks and an overall assessment of the plane for damage or over-stressed mechanical components. Severe turbulence is something that aviation engineers account for when building products, but itis not something that the airplanes are designed to regularly encounter.Andrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final The turbulence JAL 46 encountered was so severe that it immediately put the heavy 747 into a 50 degree bank Normally, atiners bank at approximately 15 degrees; a passenger begins to feel the effects of gravity at bank angles beyond 30 degrees. The force placed on the airframe by the wild turbulence caused the #2 engine to separate from its support structure, damaging the hydraulics and control surfaces on the front of the wing as it departed the airframe, JAL 46E was low, slow, and being beat by a powerful mountain rotor. Now, it had lost % of its available takeoff thrust and some ability to maneuver. The crew immediately responded and sprang into action. The crew, three flying officers and two off-duty flight officers, began running pre-rehearsed checklists. Loss of an engine on takeoff is a well-worn drill itis one of the most frequently practiced emergency situations amongst aircrews. With the immense level of practice, preparation, and coordination in play between the fight crew, the plane quickly and safely returned to Anchorage airport Change is a dynamic situation, and leadership tendencies in dynamic situations is to lead from the seat. Quick reactions. Gut instincts. What ifthe Japan Airlines crew relied on their gut? Would they have been able to land safely, and without further incident? The great challenge leaders face is finding the environment to safely and repeatedly practice change. Air crew have hyper-realistic fight simulators where they can explore even the most dangerous regions of the flight envelope, without ever leaving the ground. Global Tech, and similar simulation products, can provide leaders with a framework for exploring change themes. Leaders can create simulation environments and leverage business school cases to bring teams together to jointly think through problems. With enough practice leaders can build teams that function together in the most dynamic situations, and function very well Use All of Your Tools: United Airlines 232, Sioux City, IA July 19th, 1989 United Airlines 232 is etched into many American's memories as the first crash “to be televised”. The fiery cartwheel of the DC-10 across the Sioux City runway brought the horrors of an aviation accident right into many livingAndrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final rooms. United 232 suffered a catastrophic failure of all hydraulic systems, the result of an explosion in the tail of the airplane. Engineers had set the risk of a hydraulic failure due to an explosion at “above 1 in 1,000,000" (NTSB/AAR- ‘$0/06, 1990). The airplane was rendered uncontrollable by any conventional means. ‘As the Captain, Al Haynes, diagnosed the problem with his flight crew, an off duty check airman approached the cockpit. Check airmen are airline personnel who evaluate aircrews to fly various airline equipment. In the Air Florida days, such an offer would be rebuffed. But the Captain invited the airman in, and included him in the diagnosis team. The aircrew determined that, with the limited control authority they had, they could use the throttles to control the airplane ~ decreasing throttle to drop the nose, increasing throttle to lft the nose, more left throttle to turn right, more right throttle to turn left. However, the Captain couldn't do this reliably by himself, so the check aizman volunteered to sit and control the throttles alone, while the rest of the crew focused on various landing tasks. The aircrew used every tool at their disposal, including unorthodox application of basic flight mechanics and extra crew who happened to be on the flight, to get United 232 to the ground. The airframe was basically unstable frequently departing controlled fight into violent oscilations that the crew struggled to control, Sadly, 111 lives were lost when the airplane cartwheeled across the runways, but through the actions of the aircrew, 185 lives were saved. Leaders have a huge wealth of tools available to them. Organizations staffed with bright, capable associates. The academy's leading research and thought leadership. Financial and mathematical analysis. The tools available are inumerable. When considering change, or being presented with change, leaders must look at every resource available to them, Our best developed tools, ike our biases towards analysis or interpersonal communications, clearly need to be considered. But do not immediately discount other options, instead, consciously think: how can | use these tools to effect change? Can | improve outcomes with a different set of tools, or perspectives? Provide a Path Forward: US Airways 1549, Weehawken, NJAndrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final January 15th, 2009 The Miracle on the Hudson, as US 1549 is known, has provided much fodder for popular press and television. The captain, Chelsey “Sully” Sullenberger, has become synonymous with coo-under-fre leadership and capable airmanship. However, the immediate post-landing actions of the cabin crew bear special note The amount of time between the goose strike and the water is measured in minutes. The aircrew was rapidly attempting to restart the affected engines, and determine an alternate place to land. The captain had time only for a short “brace for impact” over the public address system. With a paucity of information, the cabin crew began calling out the familiar “head down, arms out, head down, arms out" to the frightened passengers. After the aircraft struck the water, the crew quickly discussed egress - should they open the doors? Arm the slides? Passengers panicked in the cabin, opening doors they were not supposed to, removing clothes, and leaving their life vests behind, As water rushed in the back of the plane, the cabin crew loudly encouraged passengers waiting to depart the wing exits to “climb over the seats”, ignoring standard instructions. The crew enlisted passengers to help hold doors open and help less able passengers. The crew took the chaos of a water landing and provided the cabin passengers with a path forward, a way out ‘As we lead change, we must provide a path to members of our teams. But first we have to understand the tools we have, the situation at hand, we have to have practiced and considered the emotional state of our team, and know why we have to do what we have to do. A passenger panicked and opened a rear door; this accelerated the flow of water into the airframe. Building a solid path forward helps our employees get to the destination in the safest, quickest, and most positive manner. The effusive praise for the aircrew overshadows the outstanding accomplishments of the US 1549 cabin crew. They built the path out of the cabin for each passenger; all 155 passengers lived to see another dawn. Change Begins With You: Leadership ReflectionAndrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final Present Day ‘As you reflect on the previous five vignettes, consider your role. An effective leader defies a simple cliche However, an effective leader embodies the spit of change, which is my greatest professional aspiration: be dynamic. be prepared, look to the future, and honor the past. As you view this work, ask yourself: how can |, as a leader, learn from these incidents? What incidents in my lfe, career, or industry are seminal, and therefore noteworthy? When I look in the mirror, | can see my challenges clearly: provide the path and understand why you change Prof. Alec Horniman gave a compelling presentation that highlights the value of understanding the environment and ‘mental framework each employee carties with them. | am too quick to downplay emotion and give credence to the feels of my employees. Would | have succeeded in the varied emotional environment of US 1549? | hope so, but to improve, | need to spend the time furthering my emotional intelligence. | am also a fervent believer in change for change's sake. Some would call me intellectually progressive. But, as US 427 ably demonstrates, this attitude can quickly get us into trouble. | need to leverage the reflective processes instilled during our ethics class, coupled with interrogative nature of James Scott to question why I pursue certain changes. If, after that process, | can't justify why I'm advocating for a change, why should | pursue it? Needless change introduces turbulence at best, and, at worst, can carty grave unintended consequences jography NTSB/AAR-10 /03: Loss of Thrust in Both Engines After Encountering a Flock of Birds and Subsequent Ditching on the Hudson River US Airways Flight 1549, Vol. 1 (Washington, DC: National Transportation Safety Board, 2010. htto:// www ntsb gov/publictn/2010/AAR 1003.pdf accessed March, 2011) National Transportation Safety Board. "NTSB Aviation Accident Statistics’, NTSB website. htto-Jiww3 ntsb gov! aviationstats him , accessed March, 2011 National Highway Transportation Safety Administration. “Fatality Analysis Reporting System Data Analysis Website’ NHTSA website. http /www-fars.nhtsa.dot aow/Main/index.aspx , accessed March, 2011Andrew R. Stanley, 6466-84359 MBA for Executives Class of 2012 LR2 Final NTSB/AAR-SO/06: UNITED AIRLINES FLIGHT 232, Vol. 1 (Washington, DC: National Transportation Safety Board, 1990) NTSB/AAR-99/0: UNCONTROLLED DESCENT AND COLLISION WITH TERRAIN USAIR FLIGHT 427, Vol. 1 (Washington, DC: National Transportation Safety Board, 1999. htto-/Avwww3.ntsb.govs ‘publictn/1999/AAR9SO1 pdf accessed March, 2011) NTSB/AAR-82-08: COLLISION WITH 14TH STREET BRIDGE, AIR FLORIDA FLIGHT 90, Vol. 1 (Washington, DC National Transportation Safety Board, 1982) NTSB/AAR-93-06: In-Flight Engine Separation Japan Airlines, Inc., Flight 46E, Vol. 1 (Washington, DC: National Transportation Safety Board, 1993) Krums, Janis. There's a plane in the Hudson. I'm on the ferry going to pick up the people. Crazy. California: Twitter, Ine. 2009. January 15th, 2009. “We'te Going Down, Larry.” Time Magazine, (February, 15, 1982) Ymeti, Sokol. JL6421 Airborne on runway 32 to FranKiurt FRA. New York: Demand Media, Inc. 2007. March 29, 2007. The Aviation Speakers Bureau: List of Speakers, “Capt. Al Haynes photograph”, Aviation Speakers Bureau website httovwww_aviationspeakers com/Speaker-Pics/T-HiRes-Pictures/Al%20Haynes jpg , accessed March, 2011