Controlled Flight into Terrain
Controlled Flight into Terrain
Entering a holding pattern on a project can give you the opportunity to gather additional information about a problem. But, sometimes, holding consumes valuable resources with disastrous consequences.
Just for fun, I often browse the shelves of the local university library looking for something that catches my eye. Recently, an interesting book jumped off the shelf and into my hands (perhaps its bright pink and orange cover helped). Controlling Pilot Error: Controlled Flight Into Terrain by Daryl Smith is about poor decisions made by pilots under extreme pressure.
After reading "A controlled flight into terrain (CFIT) is an accident in which an otherwise serviceable aircraft, under the control of the crew, is flown unintentionally into terrain, obstacles, or water, with no prior awareness on the part of the crew of the impending collision," it occurred to me that if you substitute "serviceable project" for "serviceable aircraft," you have a description of many software project disasters.
Consider this example: "We were preparing for the approach at Belize City. Small thunderstorms were in the area. There was no moon, no approach lighting system, and no visual approach slope indicator due to an outage on the ground. There were no surrounding lights and it was very dark. At 5 miles inbound rain started falling heavily. We had the runway in sight ... We were at 350 ft. Suddenly we were at 240 ft. We saw that we were low and both the captain and I pushed the power up to max. As the aircraft accelerated we felt an impact and a loud thump. The lighting was so poor at Belize that we decided not to make another approach so we diverted to Merida. Immediately after our landing and parking at the gate, we conducted a post-flight inspection. We saw a leading edge wing slat dented from a tree strike and tree branches stuck in the landing gear."
These pilots felt strong pressures to land: the importance of doing their job, meeting their commitments, and not seeming to be incompetent. However, when the situation deteriorated, they had another option—they could have entered a holding pattern. Often just waiting a few minutes can allow uncertainties to clear. Sometimes we need to do that with our projects—wait for a while until additional information becomes available. Generally, executing "the plan" is not more important than your organization's success. You can always do a mental cost-benefit analysis. What's the cost if you wait? What’s the benefit of pressing on? What's the cost if you fail?
Here’s another example, this one with tragic consequences. On December 28, 1978, United Airlines flight 173 departed Denver, CO for Portland, OR with 189 persons on board. Approaching Portland, the first officer, who was flying the aircraft, requested the wing flaps be extended to fifteen degrees and the landing gear lowered. The captain complied with both requests. As the landing gear was lowered, both pilots heard a loud noise and felt a severe jolt. The aircraft yawed to the right. However, the “nose gear down” light was green. The crew put the plane into a holding pattern over the ocean, and for the next twenty-three minutes, the flight crew discussed and performed emergency and precautionary procedures to assure that all landing gear were locked in the full down position. The aircraft continued to circle within twenty miles of the airport. Thirty-four minutes after the "jolt," the first officer asked the flight engineer, "How much fuel we got?" He responded, "Five thousand [pounds]." The first officer acknowledged his response. Meanwhile, the flight crew continued to have discussions about the landing gear. Four minutes later, the captain asked how much fuel they would have left after fifteen more minutes of holding. The flight engineer responded, "Not enough, fifteen minutes is gonna really run us low on fuel here."
Sixteen minutes later, the first officer told the captain, "We're going to lose an engine." The captain replied, "Why?" The first officer replied, "Fuel." The captain repeated his question, and the first officer repeated his answer. Finally, sixty-one minutes after the indication of a potential problem, the first officer called Portland Tower, “United 173 heavy, Mayday. We're ... the engines are flaming out. We're going down. We're not going to be able to make the airport.” The plane ran out of fuel and crashed, killing ten and injuring twenty-four people.
While entering a holding pattern can allow us to gather additional project information, we must remember that we cannot hold forever. Holding consumes valuable resources. When dealing with a problem, don't allow your attention to be so channeled that it pushes other concerns aside. In this example, at no time did any of the crew translate “pounds of fuel remaining” into "minutes of flying remaining." Make someone responsible to call out the project's vital signs. Remember, you have the ethical responsibility to speak up. Vague hints about project status don't always get the job done. Your job is to keep the main thing the main thing.