Problem Solving

How You See is What You See

August 15, 2020 By Nagesh Belludi Leave a Comment

So very often, we don’t give ourselves to allow for new understandings, new perspectives, and new interpretations to emerge.

Three people were visiting and viewing the Grand Canyon—an artist, a pastor and a cowboy. As they stood on the edge of that massive abyss, each one responded with a cry of exclamation. The artist said, “Ah, what a beautiful scene to paint!” The minister cried, “What a wonderful example of the handiwork of God!” The cowboy mused, “What a terrible place to lose a cow!”

Idea for Impact: Work to overcome the strong waves of conditioning that you’ve been exposed to your whole life.

Take a step back and consider how you’re responding to a situation emotionally and intellectually.

Free up your mind from the conditioning that may be restraining it.

Don’t let your narrow perspectives—those comfortable walls within which you confine yourself—to make you lose touch with what’s possible.

Explore. Discover. Discern. Open your mind to new frontiers.

Overcoming Personal Constraints is a Key to Success

August 14, 2020 By Nagesh Belludi Leave a Comment

Why do some people reach ever-higher levels of achievement, while others struggle or just plug along?

Norman Vincent Peale, the doyen of the think-positive mindset, provides a particularly illustrative example in You Can If You Think You Can (1987):

In Tokyo, I once met an American, an inspiring man, from Pennsylvania. Crippled from some form of paralysis, he was on a round-the-world journey in a wheelchair, getting a huge kick out of all his experiences. I commented that nothing seemed to get him down. His reply was a classic: “It’s only my legs that are paralyzed. The paralysis never got into my mind.”

No matter how formidable your talents, you’ll be held back by certain attitudes and behaviors that limit your achievements.

Your personal constraints—some of them beyond your control—will determine your level of success. Identify those constraints and make a plan to triumph over them.

Idea for Impact: The more you can reframe your attitudes toward the past, future, and present, the more likely you’ll find a meaningful life. Don’t let your constraints lay down what you can achieve.

The Key to Reinvention is Getting Back to the Basics

August 6, 2020 By Nagesh Belludi 1 Comment

Leaders of turnarounds often succeed by putting the fundamentals on the table and insisting upon a greater emphasis on the basics.

The turnaround that CEO Brian Niccol has cooked up at Chipotle Mexican Grill [CMG] makes a great case study of the back-to-the-basics approach to management.

The Basics Often Get Lost in a Speedy World

To set the context, here’s a concise history of Chipotle: founded in 1993 by chef Steve Ells, Chipotle found great success in marketing its near-local sourcing of fresher ingredients, using naturally-raised proteins, and on-premises cooking.

Chipotle grew swiftly and established itself as the flag-bearer of the fast-casual trend that spurned fast-food orthodoxy. McDonald’s was a major investor from 1998 until 2006 when Chipotle went public.

In 2015, Chipotle’s star began to fade away when hundreds of its customers got sick from infections with salmonella, E. coli, and norovirus. Worried that this short-term rough patch can turn into a long-term downward slide, the company’s board recruited Niccol from Yum Brands’s Taco Bell division in 2018.

CEO Brian Niccol made Chipotle Fresh Again by Focusing on the Basics

In two short years as CEO, Niccol has returned Chipotle to industry-leading performance and positioned the company for above-industry growth. His Barron’s ‘Streetwise’ interview with the inimitable Jack Hough provides an insight into how strategic business leaders think and make decisions:

When I arrived at Chipotle, I discovered that it was a company full of ideas; it lacked discipline and the focus to figure out the few things we wanted to do really well. Chipotle had lost focus on executing the basics of running a great restaurant.

We modernized food safety practices and emphasized avoiding contamination and educating food suppliers and farmers.

We went back to following the original culinary on how to make great food: getting the right char on the chicken, the right amount of lemon, and the right amount of chopped jalapenos.

Idea for Impact: Getting the basics right is often the first essential step to building a greater organization.

So many companies fail on their fundamentals—and don’t even realize it—especially when their businesses have grown, market conditions have changed, and the companies have taken on all sorts of complexities that have stumbled.

If you want your organization to pull through a slump or hit a new growth trajectory, consider cracking down on the basics.

Focus on your core values and your underlying business model, which are like beacons that can help steer you on the right track. Inquire why your organization exists. How should you operate? What is your market position? What matters to the organization’s mission and vision? Focus on doing the right thing—and doing it consistently over time.

A renewed emphasis on the strategic basics will put your company in the best possible position to navigate new strategic choices, as Niccol’s Chipotle has done.

Pulling Off the Impossible Under Immense Pressure: Leadership Lessons from Captain Sully

May 25, 2020 By Nagesh Belludi Leave a Comment

I recently watched Sully (2016,) the overrated Clint Eastwood-directed drama about the US Airways Flight 1549 incident, aka the “Miracle on the Hudson.”

In summary, on 15-Jan-2009, Captain Chesley “Sully” Sullenberger (played by Tom Hanks) heroically dead-sticked his Airbus A320 aircraft in New York City’s Hudson River after both the aircraft’s engines failed from a bird strike. He then helped get passengers and crew off uninjured.

Sully centers on Sullenberger’s post-decision dissonance. To spin the real-life six-minute flight and the 24-minute swift rescue into a 96-minute Holyrood extravaganza, the filmmakers devised an antagonist in the form of National Transportation Safety Board (NTSB) investigators who try hard to blame Sullenberger for the mishap.

Overdramatized Portrayal of the NTSB Investigators

On the screen, the smirking NTSB investigators use flight simulators and computer analysis to second-guess Sullenberger’s lightning-quick decisions. They would have rather he made it to an airport nearby—a possibility that he had instantly judged was not viable given his 40 years of flying experience.

Contrary to Sully‘s portrayal, the NTSB was unequivocal that landing the aircraft on the Hudson was the right call. In his memoir, Highest Duty: My Search for What Really Matters (2009,) Sullenberger mentions that he was “buoyed by the fact that investigators determined that [first officer] Jeff and I made appropriate choices at every step.”

In the course of the real-life 18-month investigation of Flight 1549, the NTSB did investigate the odds of landing the aircraft in a nearby airport. Exploring all possible flaws that contribute to a crash is part of the NTSB’s charter. The NTSB, like other accident-investigation agencies, concerns itself principally with preventing future accidents. It rarely seeks to assign blame, nor does it make the pilots justify their actions.

The Complex Leadership Requirements of Flying

Apart from the sensationalized portrayal of the NTSB investigators, Sully misses the opportunity to call attention to the complex leadership requirements of aviation. Flying a civil aircraft is characterized by a high level of standardization and automation, while still placing a strong emphasis on formal qualification and experience.

Today, highly trained pilots have to work with ever more complicated and autonomous technology. The routinization must be weighed up against deliberate action. On Flight 1549, the A320’s much-studied fly-by-wire system allowed the pilots to concentrate on trying to resurrect the engines, starting the auxiliary power unit (APU,) and deciding the flight path in the direction of the Hudson. Airbus’s legendary computer controls will not allow the pilots to override the computer-imposed limits even in an urgent situation. Sullenberger and others have commented that lesser human-machine interaction may perhaps have allowed him a more favorable landing flare and helped him temper the aircraft’s impact with the water.

Aircrews now consist of ad hoc teams working together typically only for a few flights. They build their team quickly and rely on the crew’s collective knowledge and experience to round out the high levels of standardization.

Due to the complex demands for leadership in aircrews, specialized training programs such as Crew Resource Management (CRM) are in place to improve crew communication, situational awareness, and impromptu decision-making. These systems were established to help crews when technical failures and unexpected events disrupt highly procedualized normal operations.

Furthermore, individual and organizational learning from accidents was institutionalized through mandatory reporting of incidents—not only within the airline involved but also across the aviation community.

Leadership Lessons on Acting Under Immense Pressure: The Context of Success

Owing to intuition, experience, and quick coordination, Sullenberger was able to “land” the aircraft on the Hudson within four minutes following the bird strike and have his passengers and crew quickly evacuated onto the aircraft’s wings and onto rafts.

The rapid and highly complex coordination required for this extraordinary achievement was only achievable because of exceptional leadership, exemplary decision-making under stress, and the technical skills of both the cockpit- and cabin-crew.

The pilots were highly experienced—Sullenberger even had experience as a glider pilot. Further contextual factors—the calm weather on that afternoon and the proximity of NY Waterway ferries—helped bring this accident to a good end. All this facilitated the almost immediate rescue of passengers and crew from the rapidly sinking aircraft and the frigid water.

On Another Note, Sullenberger’s memoir, Highest Duty (2009,) is passable. The most interesting part of the book is the last fourth, where he discusses Flight 1549 and what went through his mind. Interestingly, Sullenberger writes that even after he realized that the plane was in one piece after hitting the water, he worried about the difficulties that still lay ahead. The aircraft was sinking: everyone had to be evacuated quickly. The passengers could survive only for a few minutes in the frigid waters of the Hudson.

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

May 11, 2020 By Nagesh Belludi Leave a Comment

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.

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

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.

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.

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.

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.

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’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.

Make ‘Em Thirsty

May 6, 2020 By Nagesh Belludi Leave a Comment

Sony’s Akio Morita, like Apple’s Steve Jobs, was a marketing genius. Morita’s hit parade included such iconic products as the first hand-held transistor radio and the Walkman portable audio cassette player.

Key to Morita’s success was his mastery of the art of the pitch. Morita pushed Sony to create consumer electronics for which no obvious need existed and then generated demand for them.

The best marketing minds know how to create a customer—previously unaware of a problem or an opportunity, she becomes interested in considering the opportunity, and finally acts upon it.

Coca-Cola marketers are but creating a thirst by showing the fizzle a freshly poured glass in Coke ads. “Thirst asks nothing more,” indeed.

The marketing guru Seth Godin has said, “So many people are unhappy … what they have doesn’t make them unhappy. What they want does. And want is created by the marketers.” Recall the old parable,

A sales trainee was trying to explain his failure to close a single deal in his first week. “You know,” he said to his manager, “you can lead a horse to water, but you can’t make him drink.”

“Make him drink?” The manager sputtered. “Your job is to make him thirsty.”

Idea for Impact: Whether you realize this or not, you’re in marketing, as is everybody else. You’re constantly pitching your ideas, skills, time, appeal, charm, and so forth. Study the art of the pitch. Master the art of generating demand for whatever it is you have to offer. Learn to “make ’em thirsty.” Marketing is everything.

A Superb Example of Crisis Leadership in Action

May 4, 2020 By Nagesh Belludi Leave a Comment

It is in a crisis that leaders show their mettle. The New York Times notes,

The master class on how to respond [to a crisis] belongs to Jacinda Ardern, the 39-year-old prime minister of New Zealand. On March 21, when New Zealand still had only 52 confirmed cases, she told her fellow citizens what guidelines the government would follow in ramping up its response. Her message was clear: “These decisions will place the most significant restrictions on New Zealanders’ movements in modern history. But it is our best chance to slow the virus and to save lives.” And it was compassionate: “Please be strong, be kind and united against Covid-19.”

Our political leaders’ responses to the current COVID-19 crisis are particularly instructive about how leaders should act in a crisis:

Lead from the front. Initiate quick, bold, and responsible action, even when it carries political risk. Don’t be overcome by panic.
Think the crisis through. Weigh your options carefully, and then make the call confidently. Stay focused. Don’t let stress impede your problem-solving capabilities.
Avert an information vacuum. Any gap in the available information will be filled by guesswork and speculation.
Provide an accurate picture of what’s going on. Be transparent and honest right from the beginning. Acknowledging the gravity of the situation and being clear about how you’re going to collectively address the crisis leaves your constituencies with a sense of confidence in your message.
Choose your words carefully. Don’t create a false sense of security. Avoid making throwaway comments that might be misconstrued.
Communicate often. Fine-tune your message. Update your analysis and reaffirm your assurance of support. Keeping everyone in the loop diffuses fears and uncertainties.
Empower employees to be part of the solution. Invite and respond to employees’ feedback and concerns. They’ll need to know they’re being heard.

Idea for Impact: When a crisis hits, constituencies fall back on their leaders for information, answers, confidence, and direction. Set the appropriate tone for the organizational response by being supportive, factual, transparent, open-minded, calm, and decisive.

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

April 6, 2020 By Nagesh Belludi Leave a Comment

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.

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.

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.

The Boeing 737 MAX’s Achilles Heel

January 7, 2020 By Nagesh Belludi Leave a Comment

Two thousand nineteen was one of the most turbulent years in Boeing’s history. Its 737 MACS (pardon the pun) troubles went from bad to worse to staggering when aviation regulators around the world grounded the aircraft and a steady trickle of disclosures increasingly exposed software problems and corners being cut.

The flaw in this aircraft, its anti-stall mechanism that relied on data from a single sensor, offers a particularly instructive case study of the notion of single point of failure.

One Fault Could Cause an Entire System to Stop Operating

A single point of failure of a system is an element whose failure can result in the failure of the entire system. (A system may have multiple single points of failure.)

Single points of failures are eliminated by adding redundancy—by doubling the critical components or simply backing them up, so that failure of any such element does not initiate a failure of the entire system.

Boeing Mischaracterized Its Anti-Stall System as Less-than-Catastrophic in Its Safety Analysis

The two 737 MAX crashes (with Lion Air and Ethiopian Airlines) originate from a late-change that Boeing made in a trim system called the Maneuvering Characteristics Augmentation System (MCAS.)

Without the pilot’s input, the MCAS could automatically nudge the aircraft’s nose downwards if it detects that the aircraft is pointing up at a dangerous angle, for instance, at high thrust during take-off.

Reliance on One Sensor is an Anathema in Aviation

The MCAS was previously “approved” by the Federal Aviation Administration (FAA.) Nevertheless, Boeing made some design changes after the FAA approval without checking with the FAA again. The late-changes were made to improve MCAS’s response during low-speed aerodynamic stalls.

The MCAS system relied on data from just one Angle-of-Attack (AoA) sensor. With no backup, if this single sensor were to malfunction, erroneous input from that sensor would trigger a corrective nosedive just after take-off. This catastrophe is precisely what happened during the two aircraft crashes.

The AoA sensor thus became a single point of failure. Despite the existence of two angle-of-attack sensors on the nose of the aircraft, the MCAS system not only used data from either one of the sensors but also did not expect concurrence between the two sensors to infer that the aircraft was stalling. Further, Lion Air did not pay up to equip its aircraft with a warning light that could have alerted the crew to a disagreement between the AoA sensors.

Boeing Missed Safety Risks in the Design of the MAX’s Flight-Control System

Reliance on one sensor’s data is an egregious violation of a long-standing engineering principle about eliminating single points of failure. Some aircraft use three duplicate systems for flight control: if one of the three malfunctions, if two systems agree, and the third does not, the flight control software ignores the odd one out.

If the dependence on one sensor was not enough, Boeing, blinded by time- and price-pressure to stay competitive with its European rival Airbus, intentionally chose to do away with any reference to MCAS in pilot manuals to spare pilot training for its airline-customers. Indeed, Boeing did not even disclose the existence of the MCAS on the aircraft.

Boeing allows pilots to switch the trim system off to override the automated anti-stall system, but the pilots of the ill-fated Lion Air and Ethiopian Airlines flights failed to do so.

Idea for Impact: Redundancy is the Sine Qua Non of Reliable Systems

In preparation for airworthiness recertification for the 737 MAX, Boeing has corrected the MCAS blunder by having its trim software compare inputs from two AoA sensors, alerting the pilots if the sensors’ readings disagree, and limiting MCAS’s authority.

One key takeaway from the MCAS disaster is this: when you devise a highly reliable system, identify all single points of failure, and investigate how these risks and failure modes can be mitigated. Examine if every component of a product or a service you work on is a single point 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?”

Two Leadership Lessons from United Airlines’ CEO, Oscar Munoz

December 12, 2019 By Nagesh Belludi 1 Comment

United Airlines announced last week that CEO Oscar Munoz and President Scott Kirby would transition to new roles as executive chairman and CEO respectively in May 2020.

Two Leadership Lessons from United Airlines' CEO, Oscar Munoz Munoz was very good for the airline. He deserves kudos for getting United back on track, for improving the company’s culture, employee morale, brand image, and customer experience, and for hiring Kirby.

Munoz, who came to United from the railroad company CSX, had hitherto gained considerable experience while serving for 15 years on United’s (and its predecessor Continental’s) board. But, when he became CEO in 2015, he stated that he hadn’t realized how bad things had got at United. That admission reflects poorly on his board tenure—board members are expected to be clued-up about the day-to-day specifics of the company and have more visibility into the pulse of the company’s culture beyond its senior management. Alas, board members not only owe their cushy jobs to the CEOs and the top leadership but also build long, cozy relationships with them.
Munoz will be remembered chiefly for the David Dao incident and the ensuing customer service debacle. The video of Dao being dragged out of his seat screaming was seen around the world. While the dragging was not Munoz’s fault (the underlying problem wasn’t unique to United,) the company’s horrendous response to the incident was. However, Munoz is worthy of praise for using the event as a learning exercise and an impetus for wholesale change in United’s operations and employee culture. In the aftermath of the incident, many customers vowed to boycott United flights, but that sentiment passed as the backlash over the incident waned. Even so, the David Dao incident need not have happened for United’s operational and cultural changes to materialize.

Scott Kirby is a hardnosed, “Wall Street-first, customer loyalty-last” kinda leader. Even though Kirby has made United an operationally reliable airline, his manic focus on cost-cutting has made him less popular with United’s staff and its frequent fliers. Let’s hope he’ll keep the momentum and preserve the good that Munoz has wrought.

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Problem Solving

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The Basics Often Get Lost in a Speedy World

CEO Brian Niccol made Chipotle Fresh Again by Focusing on the Basics

Idea for Impact: Getting the basics right is often the first essential step to building a greater organization.

Wondering what to read next?

Overdramatized Portrayal of the NTSB Investigators

The Complex Leadership Requirements of Flying

Leadership Lessons on Acting Under Immense Pressure: The Context of Success

Wondering what to read next?

An Accident That Was Waiting to Happen

A Soviet Dream Town Then, a Graveyard of Dreams Now

A Human Tragedy: Disaster, Response, Fallout

Design Flaws, Not All Operator Errors

The Fallings of the Soviet System’s Internal Workings

Recommendation: Read This Captivating Account of a Great Human Tragedy

Wondering what to read next?

Wondering what to read next?

Wondering what to read next?

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

Redundancy is Expensive but Indispensable

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

Wondering what to read next?

One Fault Could Cause an Entire System to Stop Operating

Boeing Mischaracterized Its Anti-Stall System as Less-than-Catastrophic in Its Safety Analysis

Reliance on One Sensor is an Anathema in Aviation

Boeing Missed Safety Risks in the Design of the MAX’s Flight-Control System

Idea for Impact: Redundancy is the Sine Qua Non of Reliable Systems

Wondering what to read next?

Wondering what to read next?