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The Biggest Disaster and Its Aftermath // Book Summary of Serhii Plokhy’s ‘Chernobyl: History of a Tragedy’

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I visited the Chernobyl Exclusion Zone last year. This 2,600 sq km (1,000 sq mi) region spanning Ukraine and Belarus is the ghastly site of the greatest peacetime nuclear disaster in history. Yes, it’s safe enough to visit—with precautions, of course. [Read travel writer Cameron Hewitt’s worthwhile trip-report.]

Chernobyl is a gripping testimony to the perils of hubris and a poignant monument to the untold misery it imposed upon swathes of people.

To round out my learning from the trip, I recently read Chernobyl: History of a Tragedy (2019,) Harvard historian Serhii Plokhy’s haunting account of the nuclear disaster.

Abandoned City of Pripyat Near the Chernobyl Facility

An Accident That Was Waiting to Happen

At 1:21 A.M. on 26-April-1987, an experimental safety test at Unit 4 of the Vladimir Ilyich Lenin Nuclear Power Plant complex in Chernobyl went dreadfully wrong. The test instigated a power surge. The reactor exploded and burst open, spewing a plume of radioactive elements into the atmosphere.

The discharge amounted to some 400 times more radioactive material than from the Hiroshima atomic bomb. Deputy Chief Engineer Anatoly Dyatlov, who was in charge of the calamitous test, called the ensuing meltdown “a picture worthy of the pen of the great Dante.” Sixty percent of the radioactive fallout came to settle in Belarus. Winds carried radioactive elements all the way to Scandinavia.

Right away, hundreds of firefighters and security forces consigned themselves to stabilize the reactor and stop the fires from spreading to the other reactors. In so doing, they exposed themselves to fatal doses of radiation, spending the rest of their lives grappling with serious health problems.

The world first learned of the accident when abnormal radiation levels were detected at one of Sweden’s nuclear facilities some 52 hours after the accident. It took the Soviet regime three days to acknowledge the meltdown publicly, “There has been an accident at the Chernobyl atomic-electricity station.” Soviet leader Mikhail Gorbachev addressed the nation 18 days after the accident, “The first time we have encountered in reality such a sinister force of nuclear energy that has escaped control.”

A Soviet Dream Town Then, a Graveyard of Dreams Now

Abandoned Contaminated School In Chernobyl Exclusion Zone The ghost town of Pripyat, a purpose-built workers’ settlement a mile from the nuclear plant, seized my mind’s eye. It was one of the Soviet Union’s most desirable communities, and 50,000 people lived there when the accident happened. Today, it’s a post-apocalyptic time warp—full of all kinds of dilapidated civic structures that once showcased the ideal Soviet lifestyle.

Pripyat was evacuated entirely on the afternoon of the disaster. Left to rot, the town has been completely overtaken by nature. A Ferris wheel—completed two weeks before the explosion, but never used—has become an enduring symbol of the inflictions. So have unforgettable images of deserted houses engulfed by forest, loveable stray dogs in dire need of medical attention, and a day-nursery strewn with workbooks and playthings.

Abandoned Pripyat Amusement Park: Graveyard of Dreams

A Human Tragedy: Disaster, Response, Fallout

Chernobyl: History of a Tragedy (2019) is a masterful retelling of the episode and its aftermath. Author Serhii Plokhy, who leads the Harvard Ukrainian Research Institute, grew up 500 kilometers south of Chernobyl. He later discovered that his thyroid had been inflamed by radiation.

Plokhy offers deeply sympathetic portrayals of the plant’s managers and engineers, the first-responders who risked their lives to contain the damage, and the civilians in the affected areas of Ukraine and Belarus.

New Safe Containment of the Chernobyl Nuclear Power Plant Drawing upon the victims’ first-hand accounts as well as official records made available only after Ukraine’s 2013–14 Euromaidan revolution, Plokhy meticulously reconstructs the making of the tragedy—from the plant’s hasty construction to the assembly of the “New Safe Containment” structure installed in 2019.

The cleanup of the radioactive fallout could continue for decades. Robotic cranes will work in intense radiation and dismantle the internal structures and dispose of radioactive remnants from the reactors. The damage from the disaster may last for centuries—the half-life of the plutonium-239 isotope, one constituent of the explosion, is 24,000 years.

Design Flaws, Not All Operator Errors

Plokhy shows how Chernobyl personified the Soviet system’s socio-economic failings. Chernobyl was a disaster waiting to happen—an absolute storm of design flaws and human error.

The Chernobyl nuclear plant was hailed as a jewel in the crown of the Soviet Union’s technological achievement and the lynchpin of an ambitious nuclear power program. The RBMK (high power channel-type reactor) was flaunted as more powerful and cheaper than other prevalent nuclear power plant designs.

Inside Chernobyl's Radioactive Ruins - Engulfed by Forest Anatoliy Alexandrov, the principal designer of the RBMK reactor and head of the Soviet Academy of Sciences, reportedly claimed that the RBMK was reliable enough to be installed on the Red Square. The communist czars skimped on protective containment structures in a great hurry to commission the Chernobyl reactors.

Commissars at the Ministry of Medium Machine Building, the secretive agency in charge of the Soviet nuclear program, knew all too well of the fatal flaws in the design and the construction of the RBMK reactors. Viktor Briukhanov, the Chernobyl plant’s director, had complained, “God forbid that we suffer any serious mishap—I’m afraid that not only Ukraine but the Union as a whole would not be able to deal with such a disaster.”

Yet, the powers-that-were assumed that clever-enough reactor operators could make up for the design’s shortcomings. Little wonder, then, that the Soviets ultimately attributed the accident to “awkward and silly” mistakes by operators who failed to activate the emergency systems during the safety test.

Memorial to the Victims of the Chernobyl Disaster

The Fallings of the Soviet System’s Internal Workings

Chernobyl: History of a Tragedy dwells on Soviet leadership and the ubiquitous disconnects and the vast dysfunctions in the Soviet state’s affairs.

Chernobyl is a metaphor for the failing Soviet system and its reflexive secrecy, central decision-making, and disregard for candor. The KGB worked systematically to minimize news of the disaster’s impact. KGB operatives censored the news of the lethal radioactive dust (calling it “just a harmless steam discharge,”) shepherded the tribunal hearings, and downplayed the political outcomes of the disaster.

Even the hundreds of thousands of Ukrainians, Belarusians, and Russians evacuated from the thirty-kilometer zone weren’t given full details of the tragedy for weeks. In the days following the accident, the Communist Party’s apparatus, well aware of the risks of radiation, did not curtail children’s participation in Kyiv’s May Day celebrations and parades.

Author Plokhy’s most insightful chapters discuss the historic political fallout of the disaster. Moscow downplayed the design flaws in the reactor and made scapegoats of a handful of the plant’s engineers and operators—just three men received 10-year prison sentences in 1987. One of the three, Deputy Chief Engineer Anatoly Dyatlov (whom I quoted above referring to Dante,) was granted amnesty after only three years. He died five years later from a heart failure caused by radiation sickness.

'Chernobyl History of a Tragedy' by Serhii Plokhy (ISBN 0241349028) Chernobyl’s outstanding narrative feature is the interpretation of the disaster in the framework of the fate of the Soviet Union. Plokhy explains how Chernobyl was a decisive trigger to the unraveling of the Soviet Union. Chernobyl served as an unqualified catalyst for Gorbachev’s policy of glasnost (“openness.”) Too, it fanned the flames of the nationalist movements in the soon-to-break-away republics of Ukraine, Belarus, and the Baltics.

Recommendation: Read This Captivating Account of a Great Human Tragedy

Serhii Plokhy’s Chernobyl: History of a Tragedy (2019) is a must-read record of human fallacies and hubris. It’s a poignant narrative of the courage and helplessness of the thousands of firefighters, police officers, doctors, nurses, military personnel, and the communities who risked their lives to mitigate the aftermath of the disaster, investigate, and “liquidate” the site. On top, Chernobyl is an edifying thesis on how the disaster accelerated the decline and the downfall of the Soviet Union.

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  2. How A Single Point of Failure Became The Boeing 737 MAX’s Achilles Heel
  3. Five Where Only One is Needed: How Airbus Avoids Single Points of Failure
  4. How Stress Impairs Your Problem-Solving Capabilities: Case Study of TransAsia Flight 235
  5. The Dramatic Fall of Theranos & Elizabeth Holmes // Book Summary of John Carreyrou’s ‘Bad Blood’

How Ritz-Carlton Goes the Extra Mile // Book Summary of ‘The New Gold Standard’

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Psychologist Joseph Michelli’s The New Gold Standard (2008) describes how luxury hotel chain Ritz-Carlton has programmed its organization to foster customer-centric behavior in employees at all levels.

'The New Gold Standard Ritz-Carlton' by Joseph Michelli (ISBN 0071548335) Ritz-Carlton’s clearly-defined and well-implemented cultural principles, called “Gold Standards,” enable the company’s employees to deliver the exceptional service that its refined customers have come to expect. Ritz-Carlton’s brand recognition is so deep-rooted that such phrases as “ritzy” and “putting on the ritz” have become part of the lexicon.

Values First

Ritz-Carlton propagates its customer-centricity goals by making a compact trifold “Credo Card” part of each employee’s uniform. These cards describe the “ultimate guest experience,” and they are shared with guests eagerly. Michelli writes, “Ultimately the value of the Credo or any other core cultural roadmap is the opportunity it affords those inside the business to realize how the ideal customer and staff experience looks and feels.”

Ritz-Carlton Gold Standards Credo Card - Customer Service Service Principle #10 of Gold Standards states, “When a guest has a problem or needs something special, you should break away from your regular duties to address and resolve the issue.” Irrespective of rank and title, every employee can spend as much as $2,000 per day per guest without a supervisor’s approval to solve a guest’s problem. This distinctive policy not only permits the employees to fulfill their guests’spoken and implied needs but also empowers employees to use their best judgment to create memorable and personal experiences for guests.

While some might think that this type of empowerment is both ill advised and financially irresponsible, leadership at Ritz-Carlton has determined the trust they place in employees is well founded. Rather than being extravagant with the resources entrusted to them, the employees tend to be very cautious … the advantage of the $2,000 staff empowerment is that the employees don’t have to delay a service response by taking it up to the next level in the organization, and they can take the initiative to enhance guest experiences.

Ritz-Carlton Gold Standards of Customer Service

Empowerment through Trust

Guided by co-founder Horst Schulze’s oft-cited business principle, “Ladies and gentlemen serving ladies and gentlemen,” Ritz-Carlton selects, trains, and cultivates a dedicated workforce of outstanding professionals who are just as deserving of respect as Ritz-Carlton’s upscale guests.

Ritz-Carlton’s customer-centric principles and culture inform its hiring and training processes and preside over the rewards and promotion systems. Managers use every opportunity to go over the company’s values and remind everybody to polish up on caring for guests. For example, at the start of each shift, everyone—from laundry staff to executives—participates in a 15-minute “lineup” to talk about the nitty-gritty of the Gold Standards.

Michelli observes, “When it comes to the Gold Standards, Ritz-Carlton leaders and frontline staff alike can appear, from an outsider’s perspective, to be teetering toward the fanatical.” No wonder, then, that Ritz-Carlton has become a paradigm for the highest level of sustainable customer experience. In the year 2000, the company launched the Ritz-Carlton Leadership Center to offer courses and to consult for anyone interested in its cult of customer service. In 2001, when Steve Jobs and Ron Johnson were preparing to launch Apple Stores, they sent executives to Ritz-Carlton’s leadership program to learn about offering the best customer experience. Apple’s notion of anticipatory customer service and the concept of Genius Bars originated from Ritz-Carlton.

Delivering Wow!

During the “lineup” meetings, Ritz-Carlton managers and leaders also reinforce the customer-service principles by sharing “Wow!” stories of delighting guests. The internal communication department collects such stories each week and publishes them in the in-house newsletters. “Positive storytelling. The ability to capture, share, and inspire through tangible examples of what it means to live the Credo and core corporate values.”

The New Gold Standard includes many anecdotes from hotel guests, employees, managers, and executives to explain how Ritz-Carlton has “going above and beyond the call of duty” embodied in its culture.

  • A breakfast waiter scurried to a neighborhood grocery store to buy a guest’s preferred grape jelly when the dining room did not have it on hand.
  • At the Ritz-Carlton Dubai, a manager and a staff carpenter built a temporary access ramp made of wood boards to allow a guest and his wheelchair-bound wife to access the sandy beach, dine by the ocean, and watch the sun go down.
  • When a guest called the Ritz-Carlton Naples to notify that she had run out of gas, a doorman filled up a few five-gallon gasoline containers and drove 40 miles to help out the stranded woman and her children.
  • During Hurricane Katrina, employees of the Ritz-Carlton New Orleans pushed laundry carts loaded with luggage and guests through flooded streets to get them to safe locations.

Ritz-Carlton Leadership Center $2000 Empowerment Lest the reader dismisses these as cherry-picked examples of “overdoing it” in Michelli’s laudatory narrative, these cases in point are demonstrative of the Ritz-Carlton DNA. The employees feel thoroughly invested in and trusted by their employers. And Ritz-Carlton recognizes that customer loyalty is dependent upon the frontline employees who administer such sophisticated service daily.

Idea for Impact: Foster a foundation of customer-centricity

Speed-read Joseph Michelli’s The New Gold Standard. It offers ample insights into establishing your own gold standards for achieving excellence in customer service.

  • Create a customer-centric culture that identifies, nurtures, and reinforces service-excellence as a primary guiding principle. “Leadership often involves fostering the environment in which everyday creativity emerges in response to the needs of specific customer groups.”
  • Foster a culture where employees take up personal accountability for resolving customers’ problems.
  • Train employees to anticipate and fulfill the unmet—even unstated—needs of customers.
  • Reiterate that providing a ‘wow!’ experience should be each employee’s goal during every interaction with a customer.

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Five Where Only One is Needed: How Airbus Avoids Single Points of Failure

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In my case study of the Boeing 737 MAX aircraft’s anti-stall mechanism, I examined how relying on data from only one Angle-of-Attack (AoA) sensor caused two accidents and the aircraft’s consequent grounding.

A single point of failure is a system component, which, upon failure, renders the entire system unavailable, dysfunctional, or unreliable. In other words, if a bunch of things relies on one component within your system, and that component breaks, you are counting the time to a catastrophe.

Case Study: How Airbus Builds Multiple Redundancies to Minimize Single Points of Failure

As the Boeing 737 MAX disaster has emphasized, single points of failure in products, services, and processes may spell disaster for organizations that have not adequately identified and mitigated these critical risks. Reducing single points of failure requires a thorough knowledge of the vital systems and processes that an organization relies on to be successful.

How Airbus Avoids Single Points of Failure Since the dawn of flying, reliance on one sensor has been anathema.

The Airbus A380 aircraft, for example, features 100,000 different wires—that’s 470 km of cables weighing some 5700 kg. Airbus’s wiring includes double or triple redundancy to mitigate the risk of single points of failure caused by defect wiring (e.g., corrosion, chafing of isolation or loose contact) or cut wires (e.g., through particles intruding aircraft structure as in case of an engine burst.)

The Airbus fly-by-wire flight control system has quadruplex redundancy i.e., it has five flight control computers where only one computer is needed to fly the aircraft. Consequently, an Airbus aircraft can afford to lose four of these computers and still be flyable. Of the five flight control computers, three are primary computers and two are secondary (backup) computers. The primary and the secondary flight control computers use different processors, are designed and supplied by different vendors, feature different chips from different manufacturers, and have different software systems developed by different teams using different programming languages. All this redundancy reduces the probability of common hardware- and software-errors that could lead to system failure.

Redundancy is Expensive but Indispensable

The multiple redundant flight control computers continuously keep track of each other’s output. If one computer produces deviant results for some reason, the flight control system as a whole excludes the results from that aberrant computer in determining the appropriate actions for the flight controls.

How Airbus Avoids Single Points of Failure: Multiple Redundant Flight Control Computers By replicating critical sensors, computers, and actuators, Airbus provides for a “graceful degradation” state, where essential facilities remain available, allowing the pilot to fly and land the plane. If an Airbus loses all engine power, a ram air turbine can power the aircraft’s most critical systems, allowing the pilot to glide and land the plane (as happened with Air Transat Flight 236.)

Idea for Impact: Build redundancy to prevent system failure from the breakdown of a single component

When you devise a highly reliable system, identify potential single points of failure, and investigate how these risks and failure modes can be mitigated.

For every component of a product or a service you work on, identify single points of failure by asking, “If this component fails, does the rest of the system still work, and, more importantly, does it still do the function it is supposed to do?”

Add redundancy to the system so that failure of any component does not mean failure of the entire system.

If you can’t build redundancy into a system due to some physical or operational complexity, establish frequent inspections and maintenance to keep the system reliable.

Postscript: In people-management, make sure that no one person has sole custody of some critical institutional knowledge, creativity, reputation, or experience that makes him indispensable to the organization’s business continuity and its future performance. If he/she should leave, the organization suffers the loss of that valued standing and expertise. See my article about this notion of key-person dependency risk, the threat posed by an organization, or a team’s over-reliance on one or a few individuals.

Wondering what to read next?

  1. Lessons from the World’s Worst Aviation Disaster // Book Summary of ‘The Collision on Tenerife’
  2. Creativity by Imitation: How to Steal Others’ Ideas and Innovate
  3. How A Single Point of Failure Became The Boeing 737 MAX’s Achilles Heel
  4. How Stress Impairs Your Problem-Solving Capabilities: Case Study of TransAsia Flight 235
  5. What Airline Disasters Teach About Cognitive Impairment and Decision-Making Under Stress

Lessons from the World’s Worst Aviation Disaster // Book Summary of ‘The Collision on Tenerife’

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Jon Ziomek’s nonfiction history book Collision on Tenerife (2018) is the result of years of analysis into the world’s worst aviation disaster on Tenerife Island in the Canary Islands of Spain.

Distinct Small Errors Can Become Linked and Amplified into a Big Tragedy

On 27-March-1977, two fully loaded Boeing 747 passenger jets operated by Pan American World Airways (Pan Am) and KLM Royal Dutch Airlines collided on the runway, killing 583 passengers and crew on the two airplanes. Only 61 survived—all from the Pan Am jet, including its pilot.

These two flights, and a few others, were diverted to Tenerife after a bomb went off at the Gran Canaria Airport in Las Palmas, their original destination. Tenerife was not a major airport—it had a single runway, and taxi and parking space were limited. After the Las Palmas airport reopened, flights were cleared for takeoff from Tenerife, but the fog rolled in over Tenerife reducing visibility to less than 300 feet. Several airplanes that had been diverted to Tenerife had blocked the taxiway and the parking ramp. Therefore, the KLM and Pan Am jets taxied down the single runway in preparation for takeoff, the Pan Am behind the KLM.

Tenerife airport disaster: Pan Am and KLM Aircraft

At one end of the runway, the KLM jet turned 180 degrees into position for takeoff. In the meantime, the Pan Am jet was still taxiing on the runway, having missed its taxiway turnoff in the fog. The KLM pilot jumped the gun and started his take-off roll before he got clearance from traffic control.

When the pilots of the two jets caught sight of each other’s airplanes through the fog, it was too late for the Pan Am jet to clear out of the runway into the grass and for KLM jet to abort the takeoff. The KLM pilot lifted his airplane off the runway prematurely, but could not avoid barreling into the Pan Am’s fuselage at 240 kmph. Both the jets exploded into flames.

The accident was blamed on miscommunication—breakdown of coordinated action, vague language from the control tower, the KLM pilot’s impatience to takeoff without clearance, and the distorted cross-talk of the KLM and Pan Am pilots and the controllers on a common radio channel.

Breakdown of Coordination Under Stress

Sweeping changes were made to international airline regulations following the accident: cockpit procedures were changed, standard phrases were introduced, and English was emphasized as a common working language.

'Collision on Tenerife' by Jon Ziomek (ISBN 1682617734) In Collision on Tenerife, Jon Ziomek, a journalism professor at Northwestern University, gives a well-written, detailed account of all the mistakes leading up to the crash and its aftermath.

The surviving passengers’ first- and second-hand accounts recall the horror of those passengers on the right side of the Pan Am jet who saw the lights of the speeding KLM 747, just as the Pan Am pilot was hastily turning his airplane onto the grass to avoid the collision.

Ziomek describes how passengers escaped. Some had to make the difficult choice of leaving loved ones or friends and strangers behind.

Dorothy Kelly … then spotted Captain Grubbs lying near the fuselage. Badly burned and shaken by his jump from the plane, he could not move. “What have I done to these people?” he yelled, pounding the ground in anguish. Kelly grabbed him under his shoulders and urged “Crawl, Captain, crawl!”

Recommendation: Read Jon Ziomek’s Collision on Tenerife

Some of the bewildering details make for difficult reading—especially the psychological effects (post-traumatic stress syndrome) on the surviving passengers. But Jon Ziomek’s Collision on Tenerife is important reading, providing a comprehensive picture of the extensive coordination required in aviation, the importance of safety and protocols, and how some humans can freeze in shock while others spring into action.

The key takeaway is the recognition of how small errors and problems (an “error chain”) can quickly become linked and amplified into disastrous outcomes.

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Many Businesses Get Started from an Unmet Personal Need

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Many successful entrepreneurs never set out with the goal of launching a large company, let alone hiring scores of people. They are motivated enough to develop solutions to a direct problem they are facing. Before long, they discover that they are not the only ones with that problem—and, like so, a successful business is born.

How “The Cult of Lulu” Got Started

How 'The Cult of Lulu' Got Started Consider the genesis of Lululemon, the Canadian athletic apparel company (from The Atlantic‘s narrative of how sports changed the way Americans dress.)

In 1997, a retail entrepreneur in British Columbia named Chip Wilson was having back problems. So, like millions of people around the world, he went to a yoga class. What struck Wilson most in his first session wasn’t the poses; it was the pants. He noticed that his yoga instructor was wearing some slinky dance attire, the sort of second skin that makes a fit person’s butt look terrific. Wilson felt inspired to mass-produce this vision of posterior pulchritude. The next year, he started a yoga design-and-fashion business and opened his first store in Vancouver. It was called Lululemon.

[Yes, that’s the Chip Wilson who gained notoriety for blaming in-poor-shape women for ruining their Lululemon yoga pants by rubbing their thighs together too much. “Quite frankly, some women’s bodies just actually don’t work for it [his apparel],” he condescendingly declared on Bloomberg TV.]

At present, Lululemon has the highest sales-per-square-foot of any American apparel retailer. Its pricey workout clothing has become a wardrobe staple, prompting other retailers to launch competing apparel lines to cash in on the growing market.

Lululemon kindled the prevailing fixation on a healthy appearance. Its brand continues to be an elite fitness status symbol for the skinny and wealthy set. More broadly, over the last two decades, Lululemon has redefined how the current generation dresses and lives. The company pioneered the “athleisure” fashion revolution, which has blurred the lines between yoga-and-spin-class outfits and regular street clothes.

Sara Blakely’s Personal Undertaking Morphed Spanx into a Big Business

Sara Blakely's entrepreneurial journey for Spanx In a similar vein, entrepreneur Sara Blakely started the Spanx hosiery company after searching for a solution to improve the way she looked in a pair of her cream-colored pants. Blakely started her wildly successful entrepreneurial journey by making sure that the specific type of undergarment she ideated to solve her clothing problem did materialize commercially. From her biography on Wikipedia,

Forced to wear pantyhose in the hot Floridian climate for her sales role, Blakely disliked the appearance of the seamed foot while wearing open-toed shoes, but liked the way that the control-top model eliminated panty lines and made her body appear firmer. For her attendance at a private party, she experimented by cutting off the feet of her pantyhose while wearing them under a new pair of slacks and found that the pantyhose continuously rolled up her legs, but she also achieved the desired result.

Idea for Impact: Learn to Pay Attention to the Subtle Clues to Opportunities All-Around

Many entrepreneurs initially got their start by first recognizing and responding to a personal need or a localized problem and later discovering that they struck a universal chord.

If you want to become an entrepreneur, find out if you can solve a problem that you’ve personally experienced. Uncover opportunities that you may otherwise have missed by asking, “Does this have to be time-consuming, arduous, expensive, or annoying?” “How can I improve on this?” and “Can I do this better or different from the other fellow doing it over there?” Then expand your opportunity by asking, “Who else may be experiencing the same problem?”

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How Stress Impairs Your Problem-Solving Capabilities: Case Study of TransAsia Flight 235

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As I’ve examined previously, airline disasters are particularly instructive on the subjects of cognitive impairment and decision-making under stress.

Stress Can Impair Your Acuity: Case Study of TransAsia Flight 235

Consider the case of TransAsia Airways Flight 235 that crashed in 2015 soon after takeoff from an airport in Taipei, Taiwan. Accident investigations revealed that the pilots of the ATR 72-600 turboprop erroneously switched off the plane’s working engine after the other lost power. Here’s a rundown of what happened:

  1. About one minute after takeoff, at 1,300 feet, engine #2 had an uncommanded autofeather failure. This is a routine engine failure—the aircraft is designed to be able to be flown on one engine.
  2. The Pilot Flying misdiagnosed the problem, and assumed that the still-functional engine #1 had failed. He retarded power on engine #1 and it promptly shut down.
  3. With power lost on both the engines, the pilots did not react to the stall warnings in a timely and effective manner. The Pilot Flying acknowledged his error, “wow, pulled back the wrong side throttle.”
  4. The aircraft continued its descent. The pilots rushed to restart engine #1, but the remaining altitude was not adequate enough to recover the aircraft.
  5. In a state of panic, the Pilot Flying clasped the flight controls and steered (see this video) the aircraft perilously to avoid apartment blocks and commercial buildings before clipping a bridge and crashing into a river.

A High Level of Stress Can Diminish Your Problem-solving Capabilities

Thrown into disarray after a routine engine failure, the pilots of TransAsia flight 235 did not perform their airline’s abnormal and emergency procedures to identify the failure and implement the required corrective actions. Their ineffective coordination, communication, and error management compromised the safety of the flight.

The combination of sudden threat and extreme time pressure to avert a danger fosters a state of panic, in which decision-makers are inclined to commit themselves impulsively to courses of action that they will soon come to regret.

Idea for Impact: To combat cognitive impairment under stress, use checklists and standard operating procedures, as well as increased training on situational awareness, crisis communication, and emergency management.

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  4. Lessons from the World’s Worst Aviation Disaster // Book Summary of ‘The Collision on Tenerife’
  5. Lessons from the Princeton Seminary Experiment: People in a Rush are Less Likely to Help Others (and Themselves)

Your Product May Be Excellent, But Is There A Market For It?

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Akio Morita, the visionary co-founder of Sony, liked to tell a story about recognizing opportunities and shaping them into business concepts.

Two shoe salesmen … find themselves in a rustic backward part of Africa. The first salesman wires back to his head office: “There is no prospect of sales. Natives do not wear shoes!” The other salesman wires: “No one wears shoes here. We can dominate the market. Send all possible stock.”

Morita, along with his co-founder Masaru Ibuka, was a genius at creating consumer products for which no obvious demand existed, and then generating demand for them. Sony’s hits included such iconic products as a hand-held transistor radio, the Walkman portable audio cassette player, the Diskman portable compact disk player, and the Betamax videocassette recorder.

Products Lost in Translation

As the following case studies will illustrate, many companies haven’t had Sony’s luck in launching products that can stir up demand.

In each case in point, deeply ingrained cultural attitudes affected how consumers failed to embrace products introduced into their respective markets.

Case Study #1: Nestlé’s Paloma Iced Tea in India

Marketing and Product Introduction Failure: Nestle's Paloma Iced Tea in India When Swiss packaged food-multinational Nestlé introduced Paloma iced tea in India in the ’80s, Nestlé’s market assessment was that the Indian beverage market was ready for an iced tea variety.

Sure thing, folks in India love tea. They consume it multiple times a day. However, they must have it hot—even in the heat of the summer. Street-side tea vendors are a familiar sight in India. Huddled around the chaiwalas are patrons sipping hot tea and relishing a savory samosa or a saccharine jalebi.

It’s no wonder, then, that, despite all the marketing efforts, Paloma turned out to be a debacle. Nestlé withdrew the product within a year.

Case Study #2: Kellogg’s Cornflakes in India

The American packaged foods multinational Kellogg’s failed in its initial introduction of cornflakes into the Indian market in the mid ’90s. Kellogg’s quickly realized that its products were alien to Indians’ consumption habits—accustomed to traditional hot, spicy, and heavy grub, the Indians felt hungry after eating a bowl of sweet cornflakes for breakfast. In addition, they poured hot milk over cornflakes rendering them soggy and less appetizing.

Case Study #3: Oreo Cookies in China

Marketing and Product Introduction Case Study: Oreo Green-tea Ice Cream Cookies in China When Kraft Foods, launched Oreo in China in 1996, America’s best-loved sandwich cookie didn’t fare very well. Executives in Kraft’s Chicago headquarters expected to just drop the American cookie into the Chinese market and watch it fly off shelves.

Chinese consumers found that Oreos were too sweet. The ritual of twisting open Oreo cookies, licking the cream inside, and then dunking it in milk before enjoying them was considered a “strangely American habit.”

Not until Kraft’s local Chinese leaders developed a local concept—a wafer format in subtler flavors such as green-tea ice cream—did Oreo become popular.

Idea for Impact: Your expertise may not translate in unfamiliar and foreign markets

In marketing, if success is all about understanding the consumers, you must be grounded in the reality of their lives to be able to understand their priorities.

  • Don’t assume that what makes a product successful in one market will be a winning formula in other markets as well.
  • Make products resonate with local cultures by contextualizing the products and tailoring them for local preferences.
  • Use small-scale testing to make sure your product can sway buyers.

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Microsoft’s Resurgence Story // Book Summary of CEO Satya Nadella’s ‘Hit Refresh’

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Leader as Sense-Maker and Cultural Curator

Microsoft CEO Satya Nadella is an exemplar of a leader as sense-maker. He has revitalized how Microsoft’s strategy, mission, and culture connect people, products, and services—inside and outside his company.

'Hit Refresh' by Satya Nadella (ISBN 0062959727) Nadella has a success story to tell, and his Hit Refresh: The Quest to Rediscover Microsoft’s Soul and Imagine a Better Future for Everyone (2017, with two co-authors) highlights how he is a different kind of leader transforming Microsoft into a different kind of company.

Hit Refresh‘s broad objective is to lay out a vision for the future of the company. The book is aimed at people who work at or with Microsoft. Many employees were given a special imprint of book with Nadella’s faux-handwritten annotations in the margins and highlighted snippets.

The book’s narrative arc shifts from a personal memoir to a management how-to, and then to technological futurism. The latter—and perhaps the least interesting—portion features Nadella’s forethoughts on artificial intelligence, augmented reality, and quantum computing, as well as their socio-economic implications.

Satya Nadella Shook Things Up by De-Ballmering Microsoft

Nadella took Microsoft’s reins in February 2014 after long-time CEO Steve Ballmer resigned in August 2013. Under Nadella’s watch, Microsoft quickly became more open and more nimble as an organization. Its cloud computing, Office 365, and gaming platform franchises are all running remarkably well.

Microsoft pivoted its business model around subscription products that produce recurrent revenue. It acquired Mojang (creator of the popular Minecraft videogame title,) LinkedIn, and GitHub. It ditched Nokia and embraced open source software—it’s even including a Linux kernel in a future Windows release.

Today one of my top priorities is to make sure that our billion customers, no matter which phone or platform they choose to use, have their needs met so that we continue to grow. To do that, sometimes we have to bury the hatchet with old rivals, pursue surprising new partnerships, and revive longstanding relationships. Over the years we’ve developed the maturity to become more obsessed with customer needs, thereby learning to coexist and compete.

Satya Nadella and Microsoft's Transformation Story

A Renewed Sense of Purpose: The Leader’s Tone Steers the Organizational Culture

Hit Refresh‘s foremost take-away is how the tone at the top sets an organization’s guiding values. Properly contemplated, propagated, and nurtured, Nadella’s approach became the foundation upon which the culture of Microsoft has been remade.

With “the C in CEO is for curator of culture,” Nadella’s dominant mission has been to recreate Microsoft’s underlying beliefs, values, and expectations in the eyes of its employees, business partners, customers, investors, and the society. This culture is to be consistent within Microsoft and characterize all the discernable patterns of behavior across the organization.

When I was named Microsoft’s third CEO in February 2014, I told employees that renewing our company’s culture would be my highest priority. I told them I was committed to ruthlessly removing barriers to innovation so we could get back to what we all joined the company to do—to make a difference in the world.

Nadella’s playbook has consisted of challenging complacency, instituting a “growth mindset,” being open-minded enough to welcome new technology and collaborate with Microsoft’s traditional competitors (“frenemies,”) and shifting from a “know it all” to a “learn it all” mindset.

I had essentially asked employees to identify their innermost passions and to connect them in some way to our new mission and culture. In so doing, we would transform our company and change the world.

“Driven by a Sense of Empathy and a Desire to Empower Others”

Satya Nadella Says wife Anu and their children's challenges taught him empathy Core to Nadella’s framework is his conviction that individuals are wired to have empathy. “The alchemy of purpose, innovation, and empathy” is indispensible “not only for creating harmony within organizations but also for creating products that resonate.”

Nadella describes how caring for a special-needs child and his wife Anu’s sacrifices for the family made him become conscious of the significance of empathy. Specifically, Anu helped him recast these setbacks as opportunities to expand his worldview.

Being a husband and a father has taken me on an emotional journey. It has helped me develop a deeper understanding of people of all abilities and of what love and human ingenuity can accomplish. … It’s just that life’s experience has helped me build a growing sense of empathy for an ever-widening circle of people. … My passion is to put empathy at the center of everything I pursue—from the products we launch, to the new markets we enter, to the employees, customers, and partners we work with.

The most interesting section of Hit Refresh is Nadella’s personal journey growing up in India, migrating to America, and working his way up the career ladder at Microsoft. The only child of a Sanskrit scholar and a civil servant, Nadella was hooked on cricket (it taught him how to compete vigorously, the virtue of working in teams, and the importance of leadership direction.)

Recommendation: Satya Nadella’s Hit Refresh is a satisfactory first take on his remarkable revamp of the culture of a company that had become set in its ways. Microsoft’s transformation has been nothing short of dramatic—there’s a lot more to be done and written about.

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Creativity by Imitation: How to Steal Others’ Ideas and Innovate

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Innovation by Imitation: Many Innovations Come from the Outside---How Henry Ford Developed the Moving Assembly Line for the Model T

Emulating others’ ideas is an underappreciated learning tool. Many creative innovators set forth as remarkably astute mimics of others. “Good artists copy, great artists steal,” prods a creator’s maxim often misattributed to Picasso.

Imitation is a leading pathway to business innovation, even if being an imitator is anchored by a sense of derision. Ever more businesses are nicking great ideas wherever they can obtain them—in their own industries or beyond. Hospitals have adapted safety and efficiency procedures from the military and the airline industry. Aircraft manufacturers have adopted the car industry’s lean supply chain management concepts. Ritz-Carlton, the luxury chain of hotels and resorts, runs the Ritz-Carlton Leadership Center that has helped trained its legendary cult of customer service and employee empowerment best practices to managers from companies across industries.

Creativity by Taking Existing Ideas: Applying Them in a New Context

The most prominent example of innovating by imitation is Ford’s development of the automobile assembly line—a system Henry Ford copied (and improved) from the Chicago meat processing business.

Innovation by Imitation: Genesis of the Moving Assembly Line Henry Ford’s relentless ambition to build his Model T a high-volume-low-cost automobile, together with his engineering knowledge and manufacturing experience provided the leadership and creative environment that nurtured the development of the moving mechanical assembly line. Today, the moving assembly line is the epitome of manufacturing. Almost everything that is now industrially manufactured—automobiles, aircrafts, toys, furniture, food—passes down assembly lines before landing in our homes and offices.

The genesis of the moving assembly line is in the American agricultural products industry. During the late 18th century, the movement of grains changed from hand labor to belts and later moving hoppers.

Innovation by Imitation: Many Innovations Come from the Outside

Innovation by Imitation: Chicago Slaughter Houses Pioneered the Moving Disassembly Line Before Henry Ford Started His Assembly Line By 1873, Chicago’s meat-processing industry adapted belts and hoppers to transform beef and pork production into a standardized, mechanized, and centralized business. After cows and pigs travelled to their fate in train cars from farms throughout the Midwest, they were dropped into hoppers and killed. Conveyor belts then moved carcasses past meat cutters, who progressively removed various sections of the animal, cut them into appropriate sizes, and repackaged and dispatched processed meat across the United States.

The meat processors’ task was disassembly (as opposed to putting together automobile parts in Ford’s plants.) Each worker had a specific, specialized job. Production moved swiftly. The American writer Upton Sinclair famously described this industry’s ghastly working conditions in his acclaimed novel The Jungle and said, “They use everything about the hog except the squeal.”

Chicago Slaughter Houses Were the Pioneers of the Moving Disassembly Line Before Henry Ford Started His Assembly Line

In the early 1900s, when Henry Ford wanted to keep Model T production up with demand and lower the price, Ford’s team explored other industries and found four ideas that could advance their goal: interchangeable parts, continuous flow, division of labor, and cutting wasted effort. Ford’s engineers visited Swift & Company’s Slaughterhouse in Chicago and decided to adopt the “disassembly line” method to build automobiles.

The introduction of the moving assembly line process in 1913 enabled increased production up to 1,000 Model Ts a day and decreased assembly time from 13 hours to 93 minutes. Additional refinement of the process, thanks to reliable precision equipment and standardized shop practices, shortened production time radically: within a few years, a new Model T rolled off the assembly line every 24 seconds. First produced in 1908, the Model T kept the same design until the final one—serial number 15,000,000 rolled off the line in 1927.

Auschwitz-Birkenau and Victims of the Holocaust

Sadly, just as Henry Ford copied the Chicago meat processing and perfected the moving assembly line, the Nazi apparatus copied Ford’s methods of mass production to massacre six million people. While Midwestern butchers processed the livestock carcasses, the Nazis systematically handled corpses of the victims of the Holocaust. Nazi operatives removed victims’ hair, clothing, shoes, gold teeth, hairbrushes, glasses, suitcases, and anything of value to be repurposed for the Reich. The atrocities of this inexpressibly shocking disaster are on display at the train tracks and the museums of Auschwitz-Birkenau, Poland.

Formal Strategic-Benchmarking Programs

Smart businesses have formal strategic-benchmarking programs to achieve significant efficiency improvements: they pinpoint the strategic capabilities that matter most to their businesses, seek out companies or businesses that currently manage those capabilities best, and try to copy and deploy those capabilities as rapidly as possible. But time is of the essence for the success of these undertakings, as the management guru Tom Peters warns,

I hate Benchmarking! Benchmarking is stupid! Why is it stupid? Because we pick the current industry leader and then we launch a five-year program, the goal of which is to be as good as whoever was best five years ago, five years from now. Which to me is not an Olympian aspiration.

Imitation is a Key Characteristic of Highly Creative People: The Case of Steve Jobs Copying from Xerox

One of the key characteristics of highly creative people is their exposure to and experience with working in several related domains. They are very good at crossing domain boundaries, relating their creativeness in new and perhaps unexpected ways, and adapting knowledge into new domains. The following case of one of history’s most famous innovators illustrates this distinguishing characteristic.

Steve Jobs of Apple introduced the revolutionary Lisa computer in 1983. It featured such innovations as the graphical user interface, a mouse, and document-centric computing. Jobs had taken—and refined—all these inventions from Xerox’s PARC research labs and introduced by Xerox on its commercially-unsuccessful Alto and Star computers in 1981. The biographer Walter Isaacson writes in his best-selling Steve Jobs: “The Apple raid on Xerox PARC is sometimes described as one of the biggest heists in the chronicles of industry.” Isaacson cites Jobs: “Picasso had a saying—‘good artists copy, great artists steal’—and we have always been shameless about stealing great ideas… They [Xerox management] were copier-heads who had no clue about what a computer could do… Xerox could have owned the entire computer industry.”

Innovation by Imitation: Steve Jobs of Apple copied Xerox's PARC innovations in graphical user interface, a mouse, and document-centric computing

Idea for Impact: Borrow Ideas from Others and Combine Them with Your Own Creativity

Interestingly, many “benchmarking” exercises in the world of business—even academia—do not come “top-down” out of strategy. In other words, innovations by imitation are typically not driven from the top down. Instead, they materialize from everyday operational challenges—those painful experiences that send managers scuttling for solutions in a hurry.

Look outside your industry. To improve your creativity, try spending time researching other smart companies—even those outside of your industry. Learning directly from other companies is a useful, underutilized form of research for finding ways to improve performance.

Attend to developments at your competitors and in other industries. Look for potential opportunities that have been discovered elsewhere. Avoid the “not invented here” syndrome—don’t reject other’s great ideas. Keep an open mind.

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The Dramatic Fall of Theranos & Elizabeth Holmes // Book Summary of John Carreyrou’s ‘Bad Blood’

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The Fall of Theranos and Elizabeth Holmes

Bad Blood: Secrets and Lies in a Silicon Valley Startup (2018) is Wall Street Journal investigative reporter John Carreyrou’s remarkable exposé on Theranos, the former high-flying Silicon Valley tech startup founded by Elizabeth Holmes.

Theranos formally dissolved last week after a high-profile scandal revealed that the company not only deceived investors, but also risked the health of thousands of patients.

A Gripping Narrative, A Charismatic CEO, and A Big Fraud

In 2015, Theranos was one of Silicon Valley’s superstars. Valued at some $9 billion, Theranos claimed an out-and-out disruption of the $73-billion-a-year blood testing industry. Elizabeth Holmes pitched a revolutionary technology that could perform multiple tests on a few drops of capillary blood drawn by a minimally invasive finger prick, instead of the conventional—and much dreaded—venipuncture needle method.

The Story of Theranos and Elizabeth Holmes received much adulation by the media Theranos has its origins in 2004, when the brilliant Holmes, then a 19-year old Stanford sophomore, dropped out of college to start the company. Her missionary narrative swayed just about everyone to believe in the potential she touted.

Over the years, Theranos attracted a $1 billion investment, an illustrious board of directors, influential business partners (Walgreens, Safeway, Cleveland Clinic,) and significant amounts of adulation by the media—all of this lent credence to Holmes’s undertaking. She was celebrated as the youngest, self-made female billionaire in the world.

Nobody Asked the Hard Questions

Theranos’s castle in the air started to crumble in October 2015, when Carreyrou’s first Wall Street Journal article reported that the company was embellishing the potential of Theranos’s technology. Based on past employees’ disclosures, the article also cast serious doubts on the reliability of Theranos’s science. Behind the scenes, Theranos performed a majority of its blood tests with commercial analyzers purchased from other companies.

The persistent question in Carreyrou’s Bad Blood is how the many smart people who funded, endorsed, defended, and wrote about this company never set aside their confidence in Holmes’s persuasions and looked beyond her claim of “30 tests from one drop of blood.”

Without much independent due diligence, Theranos’s supporters possibly assumed that everyone else had checked out the company, its founders, and its science. Theranos got away with its actions for as long as it did because no one could conceive of the idea that the business would simply lie as much as it did.

The Story of Theranos and Elizabeth Holmes Appeared so Promising That Everybody Wanted it to Be True

Bad Blood also draws attention to Silicon Valley’s many failings, including the cult of the celebrity founder. Holmes’s smoke and mirrors was enabled by the notion of a “stealth mode” in which many Silicon Valley startups operate to protect their intellectual property. Theranos never proved that its testing technology really worked. It was performing tests on patients without having published peer-reviewed studies, getting FDA certification, or carrying out external evaluation by medical experts.

'Bad Blood' by John Carreyrou (ISBN 152473165X) Carreyrou acknowledges that Holmes’s initial intentions were honorable, even if naïve. What triggered Holmes’s downfall was the characteristic entrepreneurial “fake it till you make it” ethos—it inhibited her from conceding early on that her ambitions were simply not viable.

When things didn’t go as intended, Holmes exploited the power of storytelling to get everyone to buy into her tales. She continued to believe that the reality of the technology would catch up with her vision in the future. Trapped in a web of hyperbole and overpromises, Holmes and her associate (as well as then-lover) Sunny Balwani operated a culture of fear and intimidation at Theranos. They went as far as hiring superstar lawyers to threaten and silence employees and anyone else who dared to challenge the company or expose its deficiencies.

Book Recommendation: Bad Blood is a Must-Read

Every inventor, entrepreneur, investor, and businessperson should read Bad Blood. It’s a fascinating and meticulously researched report of personal and corporate ambition unraveled by dishonesty. This page-turner is a New York Times bestseller and is expected to be made into a movie.

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Here’s a prayer to help you deal with annoying people. Learn from the Stoics!