10 Business lessons from an air crash disaster.

I recently watched an air crash investigation documentary about Korean Air Cargo Flight 8509 that claimed the lives of all four crew on board on 22 December 1999 shortly after take-off from London Stansted Airport. The airplane crashed under a minute of take off at Hatfield Forest.

I admit, I’ve watched many of these disaster investigation documentaries but this caught my attention – because of the lessons we can learn for overall safety and success in our businesses, families and personal lives.

The Story in a nutshell

The plane had initially departed from Tashkent, today the capital of Uzbekistan, to London Stansted. One of the inertial navigation units (INU) had partially failed, providing an erroneous roll data to the captain’s attitude director indicator (ADI). The first captain’s and backup ADIs we correct (three in total), and because it was light of day they were able to respond correctly and land safely.

At Stansted, the engineer attempted to repair the ADI. He thought it was the connectors at the back of the device and repaired that. It responded correctly. He did not realise that the source of the data (INU) being fed was the problem. The engineer did not have the correct Fault Isolation Manual available and did not think of replacing the INU.

Enter the new crew: 57-year-old Captain Park Duk-kyu, 33-year-old First Officer Yoon Ki-sik, 38-year-old Flight Engineer Park Hoon-kyu and 45-year-old maintenance mechanic Kim Il-suk.

The flight was bound for Milano-Malpensa Airportbound. They had to wait an hour or so for clearance. The Captain was somewhat irate by the delay. As the flight took off, and gained altitude – the Captain’s ADI gave an incorrect reading. The Captain tried to bank (act of “rolling”) the plane to the left to correct the discrepancy, but his instrumentent showed it not banking and the comparator alarm sounded repeatedly.

The flight engineer called out “bank”, but the captain did not respond and continued banking further and further left until it plunged to the ground at 200 to 300 knots, exploding on impact and creating a large crater.

I left out a crucial piece of information above: As the Captain continued to bank the airplane, the first officer’s ADI read correctly on his and the back up instrument, BUT the recording on the blackbox showed that he said nothing to correct the Captain or take over the airplane.

Why?

The Captain had previously worked in the Korean miltary. Such an environment used an autocratic, hierarchical style of leadership. The Korean aviation training was was also found to foster this unequal, hierachial relationship. This was probably rooted in old traditions and customs in Korea. It was not open communication and team work. This was an example of an older, autocratic, visibly impatient captain and a subservient, obliging first officer who, in a real sense chose to value silence and obedience rather than death or fatality.

There are always lessons to learn from failures

Both instrument failure and human error were to blame for this disaster. After the investigation, the Air Accidents Investigation Branch of the UK issued recommendations to Korean Air to revise its training program and company culture, to promote a more free atmosphere between the captain and the first officer.

10 Lessons for businesses

1. A company’s culture is influenced by its leaders and the ideology of its values. Rigid hierarchical cultures do not encourage open communication and teamwork.
2. Societal cultures can influence business dealings and practices, regardless of a company’s stated values.
3. Values are verbs, values are not nouns. It’s what we do that counts, not what we say.
4. We can observe various styles of leadership in organisations, three common types: autocratic, democratic and laisse faire. Each can have usefulness, advantages, disadvatages and limitations in specific environments/ contexts.
5. Good leaders listen and ask for feedback. Good followers want to help where ever they can. They are not willing to see things go wrong, and do nothing.
6. Disasters can happen quick. It took about 55 seconds for the disaster above to happen once it left the ground. Likewise, never underestimate emergency plans, plan B and C thinking. Decision making is an important quality of great leaders.
7. Corporate culture should be influenced by what matters most. If that answer is safety, then customs, traditions and habits must be subordinate to what is more useful and wise.
8. Diversity awareness is a useful exercise in multicultural corporations
9. Emotions should be better managed, especially in environments where safety and risk are a priority. Our emotional intelligence can be developed.
10. Never judge a company by the mistakes they make, but how they respond to it. If you make mistakes, learn from them. Resolve to esteem and deliver excellence and quality in all that you do.

Korean Air has not had a single crash since this accident in 1999. Today, it is among the top 20 airlines in the world in terms of passengers carried and is also the top-ranked international cargo airline.