Problem Solving

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.

What James Watt and the Steam Engine Teach You about Creativity and Invention

December 9, 2019 By Nagesh Belludi Leave a Comment

Necessity is the Mother of Invention

The arc of development of the technique to harness the properties of steam to power mechanical devices embodies the notion that “necessity is the mother of invention” (Latin: “necessitas ingenium dedit.”)

Towards the end of the 17th century, Britain faced the problem of pumping and draining water out of mine shafts. In response, the military engineer Thomas Savery (1650–1715) invented an “engine to raise water by fire” in 1698. However, the “Savery Pump” was limited in practical usage to 20–25 feet of suction. Savery’s rudimentary pressurized boiler was liable to explode, particularly under high-pressure steam (over 8 to 10 atmospheres.)

Independently, and later in partnership with Savery, blacksmith Thomas Newcomen (1664–1729) developed the more practical—and more successful—atmospheric-pressure piston engine in 1698. Newcomen’s engine solved the limitation of the Savery Pump by having atmospheric pressure push the cylinder’s piston down after the condensation of steam had created a vacuum in the cylinder. Therefore, the pressure of the steam did not limit the intensity of pressure.

For five decades, Newcomen’s engine was the most complex technological object of its time anywhere in the world.

Difficulties Compel People to Found Creative Solutions to Problems

Then came along the Scottish instrument maker James Watt (1736–1819.) At age 21, Watt opened a shop in 1757 at the Glasgow University to make quadrants, compasses, scales, and other mathematical instruments.

Watt was tasked with repairing a Newcomen Engine at the university for a lecture-demonstration. He initially had difficulty getting the Newcomen Engine to work because its parts were poorly constructed. When he finally had it running, he was surprised at its efficiency. However, the engine was constantly running out of coal because every cycle required the heating and the cooling of the cylinder, thus resulting in a large waste of energy.

In 1769, Watt devised a system whereby the cylinder and the condenser were separate, making it unnecessary to heat and cool the cylinder with each stroke. Watt’s invention of the separate-condenser steam engine (also called the “double-acting” steam engine) decreased fuel costs by 75 percent.

Watt’s “steam engine” was able to produce continuous rotary motion and expanded its use far beyond pumping water. Continuous rotary motion sparked the transition from hand-production methods to machine-power and became the driving force of the Industrial Revolution. Playwright George Bernard Shaw even declared in Man and Superman (1903,) “those who admire modern civilization usually identify it with the steam engine.”

The steam engine continued to power industry and transportation during much of the 19th century and early 20th century, at the same time as engineers developed the internal-combustion engine. Towards the end of the 19th century, with the invention of the first practical steam turbine by English engineer Charles Parsons (1854–1931,) turbines started replacing reciprocating steam engines in power stations.

Reference: Richard L. Hills’s Power from Steam: A History of the Stationary Steam Engine (1989.)

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

November 5, 2019 By Nagesh Belludi 1 Comment

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.

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.

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.

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

October 1, 2019 By Nagesh Belludi Leave a Comment

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

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:

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.
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.
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.”
The aircraft continued its descent. The pilots rushed to restart engine #1, but the remaining altitude was not adequate enough to recover the aircraft.
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.

Small Steps, Big Revolutions: The Kaizen Way // Summary of Robert Maurer’s ‘One Small Step Can Change Your Life’

June 18, 2019 By Nagesh Belludi Leave a Comment

Most intentions for change seek a transformative change—something significant to be achieved once and for all, in a short period. “Big, bold steps” is the mantra of many a self-help book or motivational guru du jour.

Real change, however, takes time and is difficult. You become overwhelmed with the magnitude of the effort and persistence required to lose twenty pounds, save up for retirement, change jobs, or stabilize a sinking relationship.

As with most New Year resolutions, you’ll meet with success temporarily, only to find yourself slipping back into our old ways as soon as the initial burst of enthusiasm fades out.

Gradual Improvement, Not Radical Change

UCLA clinical psychologist Dr. Robert Maurer’s One Small Step Can Change Your Life: The Kaizen Way (2004) conceives transformative change as an endless, continuous process of gradual improvements.

By breaking daunting tasks into absurdly little steps, you feel little resistance to change.

To initiate a worthwhile exercise regimen, for example, Maurer suggests that you start exercising by marching in front of the television for one minute for a day or two. Then, little by little, ask, “How could I incorporate a few more minutes of exercise into my daily routine?” Such modest questions help you seek the next proverbial baby step and “allow the brain to focus on problem-solving and action.”

To tidy up your home, pick an area of your home, set a timer for five minutes, and tidy up. Stop when the timer goes off. [This is similar to my ’10-Minute Dash’ technique to overcome procrastination.]

One small step leads to the next, which leads to one more, and so on—finally leading you to your goal of transformative change.

“Little Steps Add Up to Brilliant Acceleration”

Maurer relates this approach to Kaizen, the famed Japanese system of obsessive tinkering and continuous, incremental improvement. This idea is actually American in origin—it was brought over by American efficiency and quality experts such as W. Edwards Deming who were helping Japan rebuild its industrial strength after World War II.

Kaizen involves making continual, small adjustments to production techniques to not only improve speed and quality, but also save resources. That is to say, it is a relentless pursuit of perfection by breaking it down into incremental improvements.

At companies that have embraced Kaizen and other Total Quality Management (TQM) approaches, employees come to work every day determined to become a little better at whatever it is they are doing than they were the day before. Katsuaki Watanabe of Toyota, the poster-boy of TQM, has acknowledged,

There is no genius in our company. We just do whatever we believe is right, trying every day to improve every little bit and piece. But when 70 years of very small improvements accumulate, they become a revolution.

Small Kaizen questions help you determine the next baby step and allow the brain to focus on problem-solving and action

“Little and often” empowers you to “tiptoe past fear”—your brain stops putting up resistance because it is tricked into thinking that you’re embarking only on something minuscule.

All changes are scary, even positive ones. Attempts to reach goals through radical or revolutionary means often fail because they heighten fear. But the small steps of Kaizen disarm the brain’s fear response, stimulating rational thought and creative play.

You can thus triumph over fear and the subsequent inaction that fear causes.

Small steps rewire your nervous system, create new connections between neurons so that the brain enthusiastically takes over the process of change and you progress rapidly toward your goal.

Minimalist, steady, incremental change helps your brain overcome the fear that impedes success and creativity

To avoid failure at keeping your resolutions despite your best intentions, don’t push yourself to somehow become different rapidly. Instead, pledge to achieve positive, enduring life changes one powerful baby step at a time.

Other prominent insights in Maurer’s One Small Step Can Change Your Life:

“Small actions satisfy your brain’s need to do something and soothe its distress.”
“If you are trying to reach a specific goal, ask yourself every day: What is one small step I could take toward reaching my goal?”
“Small actions are at the heart of Kaizen. By taking steps so tiny that they seem trivial or even laughable, you’ll sail calmly past obstacles that have defeated you before. Slowly—but painlessly!—you’ll cultivate an appetite for continued success and lay down a permanent new route to change.”
If you hit a wall of resistance, “don’t give up! Instead, try scaling back the size of your steps. Remember that your goal is to bypass fear—and to make the steps so small that you can barely notice an effort.”
When we face crises, “the only concrete steps available are small ones. When our lives are in great distress, even while we are feeling out of control or in emotional pain we can try to locate the smaller problems within the larger disaster … to help move us slowly in the direction of a solution. But if we are blind to the small, manageable problems, we are more likely to slip into despair.”

Recommendation: Speed-read One Small Step Can Change Your Life: The Kaizen Way. It will help if you or a loved one is stuck in the rut of goal failure.

Take really small steps towards every significant change you want to make. The cumulative benefits of small improvements do have the power to produce large, transformative change. Let Kaizen be a routine that is never done.

« Previous Page

Problem Solving

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?

Necessity is the Mother of Invention

Difficulties Compel People to Found Creative Solutions to Problems

Wondering what to read next?

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

Breakdown of Coordination Under Stress

Recommendation: Read Jon Ziomek’s Collision on Tenerife

Wondering what to read next?

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

Wondering what to read next?

Gradual Improvement, Not Radical Change

“Little Steps Add Up to Brilliant Acceleration”

Small Kaizen questions help you determine the next baby step and allow the brain to focus on problem-solving and action

Minimalist, steady, incremental change helps your brain overcome the fear that impedes success and creativity

Wondering what to read next?