Cockpit to Boardroom - Series
Marine Lt. Jamie "Tilly" Tilden scanned the night for the tanker as his thoughts returned to the safety brief prior to the launch. He wondered if the safety officers Swiss Cheese Model really ever played it self out completely.
Even so, his safety record was perfect and he was confident in his ability to overcome anything the A4 could throw at him. He didn't need a class A mishap in his jacket from this or any future mission.
As he found and approached the tanker he went through his mental check list; maintain a15 degree turn over the boat, confirm upper and lower smacks, slide up for the join, confirm in line reference points, basket out, then confirm package check, gas flowing.
But, he realized he was way ahead of him self as he saw his closure rate picture was way to hot. He dumped power to avert a collision and pulled the nose up as his fuel probe speared the basket and threw it high and away before it dropped and shattered the canopy. At the same time his nose attitude suddenly caused the release of only the port slat.
The resultant asymmetrical flight quickly threw his jet into multiple ever tightening aileron rolls as he lost altitude. "Tilly" aggressively moved to regain control of his A4, fighting the rolling moment and ram air coming through his cockpit and the inability to completely move his left arm.He sorted through the priorities his emergency indicted in multiple red lights flashing before him on the instrument panel as he wrestled to gain control of his aircraft.
What did I hit, what hit me, why can't I move my left arm, he asked himself?
His first reaction came from his early cross service air force training. Remember to "wind the clock" to give yourself time to make the right decision.
He flew at the optimum angle of attack, trimmed out the adverse lateral control pressures and added an additional 20 knots to his airspeed even with the ram air driving through the smashed canopy. He had to get the errant slat in place. His immediate concern was to regain feeling back in his bloodied arm and then radio his intentions to the tanker for he needed gas immediately or his next call would be one he though he would never make.
He began his climb to the tanker while sorting out his predicament. For some reason the pre mission safety brief kept popping into his head. All the requirements of the human error Swiss Cheese Model uncannily fit his situation. He definitely had holes opening and shutting and shifting location, in his slices (barriers), and they were beginning to line up. He hoped the balance would not open and cause a bad outcome. But, he realized a trajectory of accident opportunity might bring damaging hazards into contact with himself. He asked himself, were the holes in his defenses now being caused by active failures (his in ability to fly the a/c to navy standards, blown out canopy) or some latent conditions (A4 design flaws, faulty slat, his fatigue and time pressures, this particular combat mission environment)?
Tilly ground his teeth and swore to himself that he would not let the word victim exist in his emergency... for forgetfulness, inattention, poor motivation; carelessness, negligence, and recklessness were not part of his flying makeup. It was the system that was driving this accident trajectory.
Four years later Jamie found himself employed as an automotive national service manager working on national retail sales and administration of service contract issues.
After many meetings with his retail solutions team he felt he finally had a handle on the lack of performance that was plaguing dealers in terms of their service contract KPIs. His identified human and systems problems existed against a division that felt it was going in the right direction with some of its key measures;
Jamie's thoughts returned to his military training on the Swiss Cheese Model. He knew his corporation's service contract defense barriers, represented as slices of cheese, with many holes that represented individual weaknesses in individual parts of the system were weak. He realized he could not wait this time for a possible alignment of the holes and the resultant failure when all the holes in each of the corporate slices might suddenly decide to align creating failure for his dealers, branches and the corporation.
Jamie knew he could have more impact on a systems approach rather than dealing with individuals and their fallibility. But looking back he realized that they were intertwined just as they had been in his flight emergency. He did not want to admit that his human variability was a force that opened several holes in his accident. He knew he had to deal with dealer personnel that carry out the divisions tasks and clarify the tasks the division assigns to each. He was determined to not let his corporate reporting culture get caught in recurrent error traps and not knowing where the "edge" was until the division fell over it.
Jamie thought to himself, I will not take the easy way out this time.
So he focused on the conditions under which dealer, wholesale and customers' service personnel worked to build defenses to avert errors. He recommended the initiation of a service contract process model be developed through direct interview with dealers personnel. As he thought of the tasks that wholesale and retail service writers and district managers performed and his ability to positively impact their efficiency, he remembered and knew from experience that often it is the best people who make the worst mistakes.
Jamie was in a jam, no other tanker could launch from the ship that night, his fuel state was beyond bingo, maybe good for one pass, a case III environment, no divert field in range and an injured arm that would not let him move the throttle effectively. His fuel state required him to get his crippled aircraft aboard.
After talking to "Red Crown he dialed in "strike." The air boss gave him one last chance to come aboard. The LSO was doing his best to bring Jamie's jet down safely but Tilly had enough. Jamie exploded through what was left of the canopy and would agonize forever if he was taking the easy way out of a bad situation by ejecting.
That night Jamie didn't get his "Ok 3," but carried a lesson that told him there would never be holes in his personal defenses again.
Give us a call (248 644 6190) for a free review of your risk management issues.
Marine Lt. Jamie "Tilly" Tilden scanned the night for the tanker as his thoughts returned to the safety brief prior to the launch. He wondered if the safety officers Swiss Cheese Model really ever played it self out completely.
Even so, his safety record was perfect and he was confident in his ability to overcome anything the A4 could throw at him. He didn't need a class A mishap in his jacket from this or any future mission.
As he found and approached the tanker he went through his mental check list; maintain a15 degree turn over the boat, confirm upper and lower smacks, slide up for the join, confirm in line reference points, basket out, then confirm package check, gas flowing.
But, he realized he was way ahead of him self as he saw his closure rate picture was way to hot. He dumped power to avert a collision and pulled the nose up as his fuel probe speared the basket and threw it high and away before it dropped and shattered the canopy. At the same time his nose attitude suddenly caused the release of only the port slat.
The resultant asymmetrical flight quickly threw his jet into multiple ever tightening aileron rolls as he lost altitude. "Tilly" aggressively moved to regain control of his A4, fighting the rolling moment and ram air coming through his cockpit and the inability to completely move his left arm.He sorted through the priorities his emergency indicted in multiple red lights flashing before him on the instrument panel as he wrestled to gain control of his aircraft.
What did I hit, what hit me, why can't I move my left arm, he asked himself?
His first reaction came from his early cross service air force training. Remember to "wind the clock" to give yourself time to make the right decision.
He flew at the optimum angle of attack, trimmed out the adverse lateral control pressures and added an additional 20 knots to his airspeed even with the ram air driving through the smashed canopy. He had to get the errant slat in place. His immediate concern was to regain feeling back in his bloodied arm and then radio his intentions to the tanker for he needed gas immediately or his next call would be one he though he would never make.
He began his climb to the tanker while sorting out his predicament. For some reason the pre mission safety brief kept popping into his head. All the requirements of the human error Swiss Cheese Model uncannily fit his situation. He definitely had holes opening and shutting and shifting location, in his slices (barriers), and they were beginning to line up. He hoped the balance would not open and cause a bad outcome. But, he realized a trajectory of accident opportunity might bring damaging hazards into contact with himself. He asked himself, were the holes in his defenses now being caused by active failures (his in ability to fly the a/c to navy standards, blown out canopy) or some latent conditions (A4 design flaws, faulty slat, his fatigue and time pressures, this particular combat mission environment)?
Tilly ground his teeth and swore to himself that he would not let the word victim exist in his emergency... for forgetfulness, inattention, poor motivation; carelessness, negligence, and recklessness were not part of his flying makeup. It was the system that was driving this accident trajectory.
Four years later Jamie found himself employed as an automotive national service manager working on national retail sales and administration of service contract issues.
After many meetings with his retail solutions team he felt he finally had a handle on the lack of performance that was plaguing dealers in terms of their service contract KPIs. His identified human and systems problems existed against a division that felt it was going in the right direction with some of its key measures;
- Customer focused with,
- Many dealer communications improvements,
- Noted for their prompt claim payment,
- Overall customer satisfaction levels (CSC) continued to increase,
- New dedicated field force poised for sales and service excellence,
- A lean competitive departmental work force with sales revenue (profit per employee and revenue per employee) per employee was improving and claims expense continued to decrease while sales contract growth and profit and income continued to increase and,
- Contract coverage mix and content seemed to be well balanced for growth and getting more productive.
Recent market research findings told another story as some holes in dealer administration and sales were becoming apparent.
- Service contract retail coverage determination and verification continued to be a perceived retail problem for dealer service writer/administrators driven by frustration at getting quick answers to coverage questions from the OEM,
- A need to be more specific and provide briefer and simpler OEM communications in order to clear up gray areas and provide greater understanding,
- Over a quarter of retail service writers do not understand the OEM divisional administration process.
The one key concern Jamie had was his perception, from meetings with upper management that their isolation was a cause for loosing track and not having a clear vision for future improvement. They also did not place enough weight on the lowest level of decision making.
Jamie's thoughts returned to his military training on the Swiss Cheese Model. He knew his corporation's service contract defense barriers, represented as slices of cheese, with many holes that represented individual weaknesses in individual parts of the system were weak. He realized he could not wait this time for a possible alignment of the holes and the resultant failure when all the holes in each of the corporate slices might suddenly decide to align creating failure for his dealers, branches and the corporation.
Jamie knew he could have more impact on a systems approach rather than dealing with individuals and their fallibility. But looking back he realized that they were intertwined just as they had been in his flight emergency. He did not want to admit that his human variability was a force that opened several holes in his accident. He knew he had to deal with dealer personnel that carry out the divisions tasks and clarify the tasks the division assigns to each. He was determined to not let his corporate reporting culture get caught in recurrent error traps and not knowing where the "edge" was until the division fell over it.
Jamie thought to himself, I will not take the easy way out this time.
So he focused on the conditions under which dealer, wholesale and customers' service personnel worked to build defenses to avert errors. He recommended the initiation of a service contract process model be developed through direct interview with dealers personnel. As he thought of the tasks that wholesale and retail service writers and district managers performed and his ability to positively impact their efficiency, he remembered and knew from experience that often it is the best people who make the worst mistakes.
Jamie was in a jam, no other tanker could launch from the ship that night, his fuel state was beyond bingo, maybe good for one pass, a case III environment, no divert field in range and an injured arm that would not let him move the throttle effectively. His fuel state required him to get his crippled aircraft aboard.
After talking to "Red Crown he dialed in "strike." The air boss gave him one last chance to come aboard. The LSO was doing his best to bring Jamie's jet down safely but Tilly had enough. Jamie exploded through what was left of the canopy and would agonize forever if he was taking the easy way out of a bad situation by ejecting.
That night Jamie didn't get his "Ok 3," but carried a lesson that told him there would never be holes in his personal defenses again.
Give us a call (248 644 6190) for a free review of your risk management issues.
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