Okay, I finally was able to go see the new Tom Hanks movie, "Sully" with my wife yesterday evening. We both enjoyed the movie. If you haven't seen it (and if you are planning on seeing it), perhaps you shouldn't read any further (SPOILER ALERT). The movie tells the story of the "Miracle on the Hudson" and Captain Chesley "Sully" Sullenberger. Sullenberger was the captain of US Airways Flight 1549 on January 15, 2009. Shortly after taking off from New York's LaGuardia Airport en route to Charlotte Douglas International Airport (about 3 minutes into the actual flight), the plane struck a flock of Canadian geese, which caused both engines to immediately lose power. As Sullenberger and First Officer Jeffrey Skiles ran through their checklists to determine what had gone wrong, they made the incredibly difficult decision to ditch the plane in the Hudson River. All 155 passengers and crew remarkably survived the forced water landing. The movie tells of the subsequent investigation by the National Transportation Safety Board (NTSB accident report) and the initial effects of what can only be described as post-traumatic stress disorder on both Sullenberger and Skiles. I don't know if the events happened exactly as portrayed in the film, but the story suggests that the NTSB initially felt that the forced water landing was not necessary and that the plane could have been landed safely at either LaGuardia or nearby Teterboro Airport. The NTSB had conducted several computer models and simulations to back up their initial impression, though as the movie progresses to its climax, they eventually side with Sullenberger and Skiles and conclude that it was only through Sullenberger's crisis leadership that the 155 passengers and crew survived. One of the NTSB officials states, "Remove you from the equation and the math fails." True to most crisis leaders, Sully responds, "It was all of us. We did this together. We were a team. We did our job."
One of the most important plot points in the movie was the fact that Sully and Skiles had a grand total of 208 seconds after the bird strike to (1) figure out what had happened, (2) determine what systems were still operational, (3) decide whether they had enough power and altitude to return to LaGuardia or an alternative airport, and (4) after deciding that they did not have sufficient power and altitude, conduct a controlled water ditch on the Hudson River. Military strategist and former Air Force colonel, John Boyd, would describe their decision making process as a perfect example of his now famous OODA loop (Observe, Orient, Decide, Act). As the movie suggests, initial computer models using all of the information obtained from the flight recorder, coupled with the pilots' description and clarification of the events suggested that the plane had sufficient forward momentum and altitude to allow a safe landing at either LaGuardia or Teterboro Airport. A subsequent simulation performed by test pilots also confirmed this initial impression. However, as Sully emphasizes in direct testimony in the movie's climactic scene, these test pilots had been fully briefed on what had happened (in fact, they had even been told where to land the plane) and were fully expecting the initial bird strike (the element of surprise was completely removed from the simulation itself). Even with all of that information, they were only able to successfully land the plane in 8 out of 15 attempts (again, after being fully briefed and told exactly how to respond to the bird strike). Sully says that in the actual event, "There was no time for calculating." He and his first officer had to rely upon their experience, their "gut feeling", and the only available information they had - the data on the instruments right in front of them. He told the NTSB, "If you are looking for human error, make it human." When the test pilots were forced to wait 35 seconds before starting their landing sequence (the approximate time that both Sullenberger and Skiles spent trying to figure out what had happened), they were unsuccessful in landing the plane. As it turns out, Sullenberger had made the right decision and was the hero after all.
So what lessons does this movie have for us? First, in a crisis, it is best to remain calm and follow standardized procedures. Immediately after the bird strike, Sully assumed control of the plane ("My plane") and asked First Officer Skiles to pull out the specific checklist for how to respond. As they worked through the checklist, Sully quickly reviewed all of the information available, reviewed his options with the Air Traffic Control tower (see the audio recording of the conversation with the flight controller here), and made the decision to ditch the plane on the Hudson. Second, during a crisis, it is best to defer to the expertise of the leaders on the front line. Sully was fully accountable for the decisions that he made (which took an emotional toll on him in the days and weeks following the rescue), but the important concept is that he had the authority to make those decisions. This is a perfect example of the "deference to expertise" that characterizes high reliability organizations (more about HRO's in later posts!). Third, Sully recognized the contributions of all the members of his team - in the movie's final scenes, he tells the NTSB investigators that everyone involved, including the flight attendants, the passengers, the rescuers (police, fire, Coast Guard, passenger boats from the New York Port Authority) were all responsible for the fact that everyone survived the accident. Fourth, we see here the example of the so-called "sterile cockpit." Communication is clear, concise, and direct. During the emergency, there is no wasted conversation other than what is relevant to the situation. Even when Sully talks to the passengers, his communication is clear, pointed, and specific ("Brace for impact.").
Finally, I think that another important lesson here is that simulations should include the human element and should try to replicate, as closely as possible, all of the nuances of actual events. In my own work, we use simulation to prepare health care providers to respond to medical emergencies. The lesson for us here, is that these simulations should be as realistic as possible and include the element of surprise, as much as possible.
No comments:
Post a Comment