By Mike Grice, Founder and President of The Decisive Leadership Group

Every organization experiences crisis, but not every bump in the road does a crisis make. Some crises, such as the sinking of the Titanic, are unique and existential while others, like power outages and supply chain interruptions, are of the small ankle-biter variety and can crop up on a daily basis.  What differentiates a crisis from any other problematic event is the effect that it can have on an organization; if the event is merely an annoyance, simply uncomfortable, or a predictably stressful part of the business then it is not a crisis.  If, however, the situation is both unexpected and threatening to the success of the the person or organization, then it is indeed a crisis.

A true crisis situation consists of three elements:

1)  It is unexpected

2)  It threatens the organization, team, or individual

3)  It requires timely and decisive action in order to be resolved.

At The Decisive Leadership Group we define crisis is an unexpected and threatening situation that requires decisive action to achieve successful resolution.  It doesn’t matter where a critical event occurs — on the assembly line or in the executive suite — because if it meets this definition then it is truly a crisis and it is a situation which requires action on someone’s part to correct.  But how do you know if you are the right person to make the decision?  Are you in the best position to fix the problem?  To help determine what you should do in a critical situation it is helpful to look at a historical case study and learn from the experience of others.  The story of Eastern Airlines Flight 401 is a great example of the roles and responsibilities that are necessary to successfully resolve a crisis:

          Late on a dark and cold December evening in 1972 a shiny and new widebody airliner took off from New York’s John F. Kennedy Airport.  Headed for the much warmer and sunnier climate of Florida, the Eastern Airlines Lockheed L-1011 lifted from the runway uneventfully and turned to the south.  Less than half full, the aircraft flew with 176 passengers and crew on board.  The modern three-engine jet had only been in service for four months and the crew that flew her was fully trained and rated to fly the aircraft.

       Captain Bob Loft commanded the flight that evening, with First Officer Albert Stockstill and Second Officer Don Repo filling the co-pilot and flight engineers seats respectively.  Also on the flight deck that evening was Angelo Donadeo, an Eastern Airlines technical officer, who by sheer happenstance sat in the cockpit’s jump seat as he returned home after completing an assignment for the company.  The cabin crew of ten was led by Adrienne Hamilton, an experienced lead flight attendant who led a tight-knit group of attendants as they tended to the passengers.

       Captain Loft was 55 years old, and had amassed nearly 30,000 hours behind the controls of various aircraft during his 30 year career.  With over 5,900 hours in the cockpit, 39 year old First Officer Stockstill was an experienced former Air Force pilot and flight engineer, and Second Officer Repo, age 51,  had almost 16,000 hours in the air.  They were all fully trained and certified to fly the then-new widebody L-1011.  They were a seasoned and experienced crew, flying a new and well maintained aircraft on an otherwise uneventful and routine run from one well established airport to another.

          The flight was routine until the aircraft approached the Miami International Airport.  As the crew prepared to land they went through the procedures necessary to complete the flight.  It was when the landing gear handle was placed in the “down” position, however, that the flight ceased to be typical.  A small green indicator light which would indicate that the aircraft’s nose landing gear was down and locked into landing position failed to illuminate.  The captain re-cycled the landing gear control handle, but the indicator light still remained unlit.

          In accordance with established procedures, the captain asked the Miami control tower for permission to circle the airport in order to get a green light on the landing gear.  At 11:34 pm, seconds after Captain Loft initiated his request, the tower directed the crew to climb to 2000 feet in altitude and to fly out over the Everglades in order to be clear of the landing pattern and to fix the landing gear problem.

          One minute later, at 11:35, the aircraft climbed to an altitude of 2000 feet and headed towards the pitch darkness that marked the Everglades.  A minute after that, copilot Stockstill engaged the autopilot at the direction of Captain Loft and changed the aircraft’s heading in accordance with the Tower’s instructions. 

          At 11:36 the copilot attempted to remove the indicator light’s cover assembly, but it jammed.  Unable to determine whether the indicator was at fault, the captain decided to have the Second Officer visually verify the status of the landing gear, and at 11:37 he directed Don Repo to go into the aircraft’s avionics bay (which contained a window through which the landing gear could be observed) in order to determine whether or not the nose gear was down and locked.  In that same minute of time the tower directed the crew to change their heading again, and the crew complied.  Also in that minute something else happened: as they wrestled with the light cover assembly one of the pilots nudged his control yoke, which despite being on autopilot placed the aircraft into an imperceptible nose-down attitude.  The aircraft, flying at only 2000 feet above the Everglades, began to descend at a rate of 250 feet per minute.

          As the pilot and copilot debated what to do with about the indicator light, the second officer left his station and proceeded to the avionics bay.   While he was gone, at 11:40, an audible “C chord” chime sounded for a half of a second to indicate that the aircraft had deviated from its set altitude by 250 feet.  With the flight engineer station empty and the pilots discussing what to do about the lightbulb, the warning chime’s sounding went unnoticed.

           At 11:41 Repo popped his head back into the cockpit to report that it was too dark for him to see whether the nose gear was in the proper position.  Technical Officer Danadeo then joined the second officer in the avionics bay to see if he could help determine the status of the landing gear.

          Also at 11:41, the tower controller asked how things were going, and in response the crew requested to turn to a new heading.  The request was granted, and at 11:42 the first officer turned to the controls in order to initiate the heading change.

           11:42:05, he announced to the captain that “we did something to the altitude”, to which the captain replied “what?”   The first officer responded with “we’re still at 2,000, right?” to which the captain exclaimed “Hey!  What’s happening here?”

          Seconds later, at 11:42:10, altimeter warnings began to beep only to be cut off by the sounds of impact as the aircraft disintegrated into the Everglades, killing 101 passengers and crew.

          What had happened?  How could a highly skilled and experienced crew allow a passenger aircraft fly into a swamp and kill two thirds of the people on board?

          The answer lies in how the crew responded to the unlit landing gear indicator light.

           In every crisis there are actions which must be taken to achieve a successful resolution.  Failure to take appropriate action invariably results in a less than optimal outcome, and in the case of Flight 401 the actions taken by the flight crew that dark December night provides us with a stark case to study how roles and responsibilities are a critical part of successful crisis resolution.  

          The crew of Flight 401 was confronted with a crisis when the landing gear indicator light failed to illuminate.  At that moment, the normality of a routine flight from New York to Miami became abnormal, and consistent with their training and experience, the flight crew responded to the problem.  Not having the nose landing gear in the down and locked position prior to landing the aircraft was clearly a critical situation that required resolution.

          The captain focused on the problem.  The first officer focused on the problem.  The second officer focused on the problem.  Even the hitch-hiking technical officer focused on the problem. 

          Unfortunately, in doing so, nobody focused on the larger situation: bringing 176 people safely to their destination.  Instead, everyone focused on the status of a $12 light bulb, which the investigation later determined to have been burned out.

          As it happened the night of the crash was moonless, and the swampy area over which the aircraft was flying was devoid of artificial lighting which could have visually alerted the crew to the change in altitude.  Even though the crew could not see outside the cockpit and see the ground due to the darkness, it was not as though there were no indications or warnings that the aircraft was in danger.  Myriad instruments such as altimeters, vertical speed indicators, airspeed indicators, pitch attitude indicators, and vertical speed selectors showed that the aircraft was not in level flight.  In addition to the visual instruments, the altitude change alerting ½ second C-chord chime announced the deviation in altitude.

          As experienced aircrew, the pilots and flight engineer were trained to scan their instruments routinely in order to see if there are any circumstances that require their attention.  Unfortunately, in this instance, the cockpit crew was so myopically focused on the nose gear situation that they failed to follow one of the basic rules of a pilot’s craft: keep an eye on your instruments.  They collectively failed to observe what their airplane was clearly trying to tell them.  Had just one of them paid attention to just one of the indicators and warnings the crash could have been averted.  Unfortunately, none of them did.

By solely focusing on the landing gear crisis the crew failed to accomplish their real objective, which was to bring the aircraft and the people aboard safely to Miami.  While they got pretty close to solving the problem with the landing gear, they utterly failed at landing the plane safely.  They did not perform the actions necessary to achieve a successful resolution to the crisis.

There are essentially three roles that must be filled in order to successfully resolve a crisis. A leader must take charge and define the successful resolution to the crisis, the crisis itself must be resolved, and normal operations must continue to be performed.  In a nutshell, successful crisis resolution relies on a triad of roles: Taking Charge, Attacking the Crisis, and Minding the Store.

Captain Loft was the designated leader of Flight 401.  Among his other responsibilities Loft was singularly responsible for the success or failure of the flight.  As the captain, he had the duty to ensure that any emergent crisis would be resolved in such a manner that the passengers and crew would be safely delivered to their destination.  He was responsible for establishing the Resolution Imperative, with is the overarching purpose of the endeavor, and in this case the endeavor was landing the aircraft in Miami.

The leader exercises his responsibility for crisis resolution by ensuring that the resolution imperative is fully understood and by aligning the others in the organization towards meeting the resolution imperative. He or she also assigns the roles and responsibilities necessary to ensure that the resolution imperative is met: Attacking the Problem and Minding the Store.

Attacking the problem is self-evident.  Captain Loft clearly attacked the problem and also had the rest of the flight crew attack the problem too.  The problem with having everyone attack the problem is that only the emergent problem was addressed; the resolution criteria of landing the plane safely was missed entirely as they all worked on the emergent crisis by monkeying with the  lightbulb assembly or trying to visually confirm the status of the landing gear.  All of the cockpit’s eggs were in the “Attacking the Problem” basket.

None of the eggs were in the Minding the Store basket.  Minding the Store is the performance of duties required to keep the enterprise functioning outside the realm of the emergent crisis.  In terms of Flight 401, Minding the Store would have been to have someone cognizant and responsible for ensuring that the aircraft remained in flight.  In this case, the responsibility for flying the aircraft was delegated from the co-pilot (who was the last pilot to handle the controls) to the plane itself in the form of the autopilot, and with that assignment unfortunately came the abdication of responsibility of any of the crew to make sure that the plane remained in the air.

Flight 401 is a remarkable case study that clearly articulates the need for those in crisis to fill all three roles (taking charge, attacking the crisis, and minding the store).  By focusing solely on the status of the landing gear, all of the flight crew became decisively engaged in attacking the crisis.  With nobody taking charge and reinforcing the resolution criteria and with nobody minding the store the minor crisis, a malfunctioning $12 lightbulb, became catastrophic.

The importance of roles and responsibilities in critical situation is something that we can learn from the tragedy that was Flight 401.  From the lessons learned so painfully on that dark December night, you should ask yourself what you will do when the next crisis hits: Will you take charge?  Mind the Store?  Attack the Problem?

It is worth spending a few minutes to think about it.  After all, crisis only occurs when you least expect it, and you probably won’t have time to think about it when the next one erupts.