Byron's Babbles

Whole System Leadership

Screen Shot 2016-08-28 at 1.11.49 PMOn a cool, clear December night in 1972, an Eastern Airlines L-1011 jumbo jet slammed into the Everglades 18 miles northwest of Miami. This crash is the focus of Lesson #10 in 52 Leadership Lessons: Timeless Stories For The Modern Leader by John Parker Stewart. A small $12 light bulb had gone out and preoccupied the crew of Flight 401. That triggered a series of Murphy`s Law-like consequences that ultimately killed 101 of the 176 people aboard. Now, almost 44 years later, the crash is still remembered for all its ironies, sadness and triumphs. After doing a little research I believe this crash still remains the worst aviation disaster in Florida history. The amazing part is still the fact that because the impact was cushioned by soft muck and Saw Grass, 75 people lived — some of them barely receiving a scratch.img_2083

Flight 401 originated at New York’s John F. Kennedy Airport (JFK), with a destination of Miami (MIA). The flight was uneventful until the approach into Miami. While preparing for landing and lowering the landing gear, the flight crew was unable to determine that the nose landing gear was fully extended and locked in the extended position. The green indicator light which would normally illuminate upon locking of the nose landing gear did not come on. After that, what happened is the subject of this blog post. While messing around trying to get the light to work, the autopilot that was supposed to be keeping the plane at 2,000 feet was turned off. Because everyone was preoccupied with one facet of the plane only, the green indicator light, n0-one was paying attention to anything else. It was not until the plane was at 900 feet and descending quickly that anyone even thought to ask if the altitude was correct. It was too late, however.

This crash has been the subject of books and movies. The primary cause of this accident was not the aircraft, but the crew — the human factor. Yes, the light bulb was not working, but that was the only thing. Even though the crew members were dealing with the landing gear indicator light, they still should have noticed their surroundings and been monitoring the aircraft’s altitude. Research (Robson, 2008) tells us  that as long as our stress levels are not to high we can notice things going on around us not related to the task at hand – in this case, working on the light bulb and noticing the altitude. Conversely, however, it is possible for cognitive tunneling to develop (Chou, Madhavan, & Funk, 1996). Cognitive tunneling (Chou, Madhavan, & Funk, 1996) happens when one thing we are doing is given all our attention while not watching anything else. Do you see the leadership connection here?

Cognitive tunneling (Chou, Madhavan, & Funk, 1996) can cause us all to focus on one task while missing the warning signs from other parts of the organization. As leaders this is dangerous, maybe not in the sense of Flight 401, but certainly in the success or failure of the organization. After this crash, the airline came up with what it calls Crew Resource Management (CRM). Basically, with CRM the captain is expected to continue to monitor all system while delegating specific indicators or fixing of challenges/problems to others. What does this mean? Someone is always flying the plane, or leading the organization.

The best historic example of CRM in action is US Airways Flight 1549 where Captain Chesley “Sully” Sullenberger successfully landed the disabled airplane he was leader of in the Hudson River. During that emergency landing Captain Sully flew the plane and gave First Officer Jeff Skiles the job of focusing on the reference handbook that included instructions for emergency situations. Two things that really jumped out to me while studying these events was the need for checks and balances in our organization. As leaders we need processes in place to make sure we have eyes on all facets of the organization enabling us to fly the plane without focusing on a single warning light.

“Always focus on the things that matter most.” ~ John Parker Stewart

Additionally, those we lead must have the professional development, education, and growth opportunities to handle the delegation of responsibilities. We can connect this back to a principle of intent-based leadership by which if our employees do not have the skills to handle what they are in charge of, chaos ensues. We need accountability measures that ensure our employees are able to handle the tasks and leadership they are responsible for.


CHOU, C., MADHAVAN, D., & FUNK, K. (1996). Studies of cockpit task management errors. International Journal of Aviation Psychology, 6(4), 307-320.

ROBSON, D. (2008). Human being pilot. Cheltenham, Australia: Aviation theory limited.


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