Lack of Intention, Leadership Accountability and Safety- Mercedes Ramirez Johnson
On my 21st birthday, I survived a Boeing 757 plane crash that killed my parents and 160 other souls on board in the Colombian Andes in 1995. Pilot error was ruled as the reason this 757 loaded with families on December 20th collided into a mountain, having veered over 130 miles off course unbeknownst to both the pilot and co-pilot of this ill-fated flight. Upon a 5 year independent investigation conducted by the FAA and the NTSB, the pilots had been found to have disregarded over 60% of standard operating procedures which authorities declared could have prevented the accident if those procedures would have been safely executed.
I harbor no negative feelings nor I blast any blame on these gentlemen who flew our plane that day. They were good men who were beloved fathers, husbands, friends, and sons to countless people who still love and miss them to this day. They didn’t intentionally fly our plane into a mountain. They were just two good men who had a really bad day at work due to their lack of intention in the cockpit that night. Since then I’ve been a passionate advocate in educating organizations around the globe about leadership accountability and workplace safety. I’ve used the flood of short cuts and mistakes that caused this crash as a metaphor for how we all can unintentionally go off course throughout our days when we work on autopilot.
No matter how many cautionary tales we see in the news or witness in our communities, the fact remains: if we don’t invest our time and focus on doing the “little things” right, we’ll eventually get smacked in the head with a mountain of consequences.
Case in point, back in mid-February of this year, the U.S. Air Force refused to take any additional refueling tanker orders from Boeing (KC-46 tankers) due to the brand new tankers being delivered with leftover tools and debris inside the planes. In aviation, the garbage left behind by frontline workers is known as FOD (Foreign Object Debris). Although FOD is not regarded as a safety issue in and of itself, it does shine a light on bigger issues of employees not following standard operating procedures and not taking care of the small details when delivering a multimillion-dollar aircraft to a client. The Air Force’s main concern was if the small details weren’t being taken care of (picking up their lunch trash, taking out all the tools they had used when finishing up their work, etc) what other bigger things weren’t being taken care of? Boeing’s upper management scrambled to make things right with the Air Force, promising more stringent quality control and better-automated checks and balances to ensure this wouldn’t be a recurring problem.
But hasn't this already been a recurring problem for Boeing? Remember this spring when all the new Boeing 737 Max planes had to be grounded due to unexplained crashes? Originally Boeing’s official statements asserted that a software patch would be rolled out to fix the problem within a couple of weeks. Many months later with consumer confidence lost, airlines losing millions of dollars for scrambling to adjust to a drastically smaller fleet of available planes, we still do not have a fix for any of it. Whether it’s the grounded new 737 Max planes or the Airforce’s KC-46 tanker planes — the common thread of rushed production, broken leadership and weak safety culture all come together to cast the blame on Boeing while the entire world is watching.
When a plane goes down anywhere around the world, I take pause because it brings all the memories back of my ill-fated flight. Any careless decisions made that can compromise safety I take quite personally because I’ve learned first hand that rushed mistakes of others can have dire consequences. Any systemic disregard for standard operating procedures, any dismissal of safety over profits and any agendas the stakeholders may harbor should not come anywhere near endangering the lives of the pilots, crew members and passengers who place blind faith within the aircraft they are traveling.
I only can hope that every person at Boeing (from the top executives all the way to the frontline workers and regulators) experience a flood of introspection and become inspired to do better and be better. I wholeheartedly believe that Boeing did not intentionally roll out unsafe planes, but their lack of intention throughout the process has created a dangerous culture that we ALL hope they can fix soon — for their sake and for ours.
Workplace safety isn’t about hard hats, OSHA posters or preventing injuries — it’s about taking pride and ownership in doing all the little things right. It’s about everyone (from the CEO all the way to the front line workers) to place their focus on doing the right thing, no matter how big or small that may be. Every product and service we consume is a result of all the little choices that were made to bring you that product or service. As consumers we are at the mercy of everyone that had a hand in the cars we drive, the buildings we work in, the food we eat, and the services we use. We’re all in this together to create more transparent and safer communities for ourselves and our loved ones. Let’s all just do the right thing and together we’ll no longer have to fear being another cautionary tale.
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