178 – Don’t lose sight of the collective impact of your decisions
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Don’t get lax; keep up your level of focus. Listen to hear how a series of isolated decisions led to the crash of Alaska Airlines Flight 261.
Having spent 20 years in the airforce, Mark is always intrigued by a story from the aviation industry. In 166 – Don’t let money be your purpose, he shared a story about how focusing on money made Boeing responsible for the deaths of hundreds of people. In this episode, he shares the story behind another crash, which has some valuable lessons.
The story suggests that because it’s easy to make decisions in isolation, we must ensure we don’t lose sight of their collective impact.
For your story bank
Tags: big picture, danger, death, decision-making, focus, long-term planning, safety
This story starts at 01:46
On the 31st of January, 2000, Alaska Airlines Flight 261 crashed into the ocean off the coast of California, killing all 83 passengers and five crew members.
The aircraft had been flying from Mexico to Seattle via San Francisco and was in the first leg of its journey when the pilot reported a sudden loss of control of the tailplane. The tailplane allows an aircraft’s nose to move up and down. Without it, controlled flight is impossible.
It took months for authorities to recover the aircraft and discover what went wrong. The jackscrew, which allows the tailplane to move up and down, had failed.
The failure had been partial, prompting the pilot to try flying the plane upside down, but became a complete failure, causing the crash.
It was a common category failure—mechanical failure due to poor maintenance. Essentially, the jackscrew wasn’t lubricated.
When the jackscrew was first released, the plane manufacturer, McDonnell Douglas, recommended it be lubricated every 300-350 hours. Over time, decisions gradually increased that interval to 2550 hours.
Every decision that increased the maintenance interval could be justified and approved in isolation. McDonnell Douglas and the Federal Aviation Administration (FAA) had approved them. But when combined, the decisions caused a disaster.
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