On January 15, 2009… US Airways Flight 1549…experienced an almost complete loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City… The flight… had departed LGA about 2 minutes before the in-flight event occurred.

That’s from the 200-page report (NTSB/AAR-10/03) issued by the National Transportation Safety Board. Among the reasons I’ve been reading the report is to learn more about the interplay between training, learning, performance support, and the environment in which this emergency took place.

The NTSB report cites four major factors contributing to the survival of all 150 passengers and 5 crew members:

• The decisions and “crew resource management” of the flight crew
• The airplane itself, which was equipped with forward slide/rafts although these were not required on this flight
• The performance of the cabin crew in expediting the evacuation of the airplane
• The proximity and rapid arrival of emergency responders

A quick timeline:

• At 3:24 p.m. Eastern time, the tower cleared 1549 for takeoff.
• At 3:25:51, the captain reported the plain was at 700 feet, climbing to 5,000.
• At 3:27:10, “…the captain stated, ‘Birds.’ One second later, the CVR [cockpit voice recorder] recorded the sound of thumbs and thuds followed by a shuddering sound.”

The report notes that the altitude was 2,818 feet and that engine speed started to decelerate.

• At 3:27:23, the captain took over control of the plane from the first officer, telling him, ”Get the QRH [quick reference handbook] loss of thrust on both engines.”

Captain Chesley Sullenberger later reported that when he said this, First Officer Jeff Skiles already had the checklist out–showing how the two worked smoothly throughout the emergency.

• At 3:27:50, the first officer began calling out steps in the Engine Dual Failure checklist.
• At 3:29:11, the captain announced to the cabin, “Brace for impact.”
• At 3:30:41: the cockpit equipment broadcast “a 50-foot warning.” The flight data recorder reported 33 feet.

From impact to ditching, about three and a half minutes.

Who Does What, and What Gets Done?

In an interview with Air and Space Smithsonian, Sullenberger discussed his collaboration with First Officer Jeff Skiles. Typically, he said, the first officer flies the plane, and the captain monitors.  In this case, “even though Jeff was very experienced…[with] as much total flying experience” as Sullenberger, it was the first time Skiles had been on an Airbus A320 since training.  So Sullenberger decided “we were best served by me using my greater experience in the [A320] to fly the airplane.”

I also thought that since it had been almost a year since I had been through…recurrent training, and Jeff had just completed it…he was probably better suited to quickly knowing exactly which checklist would be most appropriate, and quickly finding it in this big multipage quick reference handbook that we carry in the cockpit.

Checklists and Focus

The NTSB report, in Appendix C, reprints the three-page Eng Dual Failure checklist.  Skiles and Sullenberger lacked time to get through more than the first page.  As it is, the checklist notes “optimal relight speed” [for the engines] is 300 nautical miles. Skiles at the time said, “We don’t have that.” The report states that the maximum airspeed after the bird strike was 214 knots.

The checklist also assumes far more altitude than 1549 had.  Step 3, on page 3 of the checklist, starts with what to do above an altitude of 3,000 feet.

Accidents and incidents have shown that pilots can become so fixated on an emergency or abnormal situation that routine items (for example, configuring for landing) are overlooked. For this reason, emergency and abnormal checklists often include reminders to pilots of items that may be forgotten. Additionally, pilots can lose their place in a checklist if they are required to alternate between various checklists or are distracted by other cockpit duties; however, as shown with the Engine Dual Failure checklist, combining checklists can result in lengthy procedures. [NTSB report, p. 92]

It seems clear to me that both captain and first officer believed that the engine-failure checklist was the best procedure to use.  While there is a procedure (a checklist) for ditching the A320, 1549′s crew never got to use it.  ”Time would not allow it,” Sullenberger said in the A&S interview.  ”The higher priority procedure to follow was for the loss of both engines.  The ditching would have been far secondary to that.”

Elsewhere the report notes that  ”low-altitude, dual-engine failure checklists are not readily available in the industry” — in other words, this is not limited to US Airways or to Airbus.

Adding to stress for the flight crew was an array of alarms and warnings.  The ditching checklist, which they had no time to consult, included steps “to inhibit the ground proximity warning system and terrain alerts.”  In other words, since you know you’re ditching, you can shut these alarms off.

Training

According to the NTSB report, training at US Airways for dual-engine failure involves a full-flight simulator in which the failure occurs at 25,000 feet.  No training scenarios involve “traffic pattern altitudes,” which I take to mean “near airports.”  In addition, “dual-engine failure scenarios were not presented during recurrent training.” A similar approach is true for Airbus’s training.

The outcome

Sullenberger, Skiles, and the cabin crew (Sheila Dail, Donna Dent, and Doreen Walsh, each with at least 26 years’ experience with the airline) worked together to save the lives of 150 passengers.  Media reports tend to concentrate on the pilot’s actions, which were essential, since together with the first officer he was able to ditch the plane in a survivable manner.

The NTSB report notes that the accident “has been portrayed as a ‘successful’ ditching.”  It notes that the success “mostly resulted from a series of fortuitous circumstances” including these:

• An experienced flight crew
• Good visibility and calm water
• Extended-over-water equipment (e.g., rafts) on the plane though not required for this flight
• Nearness of vessels and responders available to rescue passengers and crew

Complex skills are…complex

I don’t have grand conclusions to put here.  I do think that the Sullenberger interview, and the details in the NTSB report, provide more balance than many mass-media “miracle on the Hudson” reports.  Clearly a success, in that everyone survived.  The causes of that success, and how to increase the likelihood of similar success in the future, are much more complex.

For example: Sullenberger at one time was a glider pilot.  A&S asked how that experience helped him.  ”I get asked that question…a lot,” he said, “But that was so long ago, and those are so different from a modern jet airliner, I think the transfer [of experience] was not large.”

For all of 1549′s crew–in the cockpit and in the cabin–performance resulted from experience, and experience was shaped not only through time in the air, but through regular training intended to focus on critical events, to provide feedback, and to increase the likelihood of success in critical, unpredictable situations.

Consider by way of contrast a large group of untrained people: only 77 passengers (just over half) evacuated with their seat cushions.  This seemingly small element is a performance challenge: most passengers pay little attention to the safety briefing, and almost no one reads the safety card.  The NTBS report suggests that those who took cushions did so because  all preflight briefings point out that the cushion “may be used as a flotation device.”  In other words, some passengers were apparently habituated to that information and able to recall it when needed.

Life vests were not mentioned in the preflight safety briefing because 1549 was not an “extended overwater” flight.  19 passengers attempted to retrieve life vests from under their seats; only 3 “were persistent enough to eventually obtain the life vest.”  30 others tried to put a vest on once outside the plane, but only 4 said they were able to do so properly.

Small, regular deposits

You’d be hard pressed to find a better summation of building your own expertise than the way Sullenberger expressed himself to Katie Couric of NBC News:

One way of looking at this might be that for 42 years, I’ve been making small, regular deposits in this bank of experience, education, and training. And on January 15 the balance was sufficient so that I could make a very large withdrawal.

One example comes in the first paragraph of Unhappy Meals, Michael Pollan’s January 2007 essay in The New York Times Magazine:

Eat food. Not too much. Mostly plants.

Definitely succinct.  To me, intriguing–well, of course you should eat food.  (Pollan advocates avoiding processed and manufactured food. He points out that produce doesn’t usually come with a label shouting “healthy!”)  As for mnemonic (in the sense of assisting memory), his three phrases epitomize the three main arguments in his essay.

I’ve written about weight management (here and here and here) and tried to explain effective, evidence-based approaches as a form of performance management.  Perhaps that’s made me all the more receptive to an item in Obesity Panacea. Part of the PLoS (Public Library of Science) blog network, OP examines “the science (or lack thereof) behind popular weight loss products,” as well as discussing other items related to weight.

The item? Can you limit your sitting and sleeping to just 23.5 hours a day?

Peter Janiszewski, who writes the blog along with Travis Saunders, highlights a video by Dr. Mike Evans of the Health Design Lab at the University of Toronto.  Evans effectively poses his question in a succinct, intriguing way, and then offering a summary of evidence to support the treatment he recommends.

I find myself wondering how much practical information I could share like this, together with evidence, in less than 10 minutes.  (Personally, I’d leave out the sketching-on-a-whiteboard–the images are engaging, but for me the sped-up drawing lost its charm quickly.  That’s nitpicking, though.)  In terms of mnemonic effect, the title and the recommendation definitely stay with me.

Or what I think he means, because, let’s face it, there’s a certain lack of specificity to “Hey, Dad, watch me while I synchronize the community.”

I don’t think of what I do as curation.  I think of it as putting stuff aside because I think it might have value for me.  In the olden days, when “bookmark” means something you slipped between the pages of a book, those things tended to go into file folders and bookshelves.  Now, when content is (mainly) digital and storage is (virtually) free, they go into files.

To be honest, they tend to stay there, too.  That isn’t the direction to take for things you want to learn, or learn from.  So, once again, I’m profiting from the example of Harold Jarche, who for some time has made a habit of posting Friday Finds: weekly compilations of insights and observations that he’s captured on Twitter.

• Via Kristina Halvorson (@halvorson), a link to Corey Vilhauer’s blog post, Building Confidence: The Hidden Content Deliverable.  The ostensible topic is content strategy (which is what both Halvorson and Vilhauer really do), but anyone working in learning or workplace performance could read the post in that particular light as well.  When we’re young and working as advisors, he says,

…We look down our nose. We assume our clients are dumb.  The faster this goes away, the faster we can start doing the real work: understanding and embracing the needs of our clients and organizations.

• From Yammer: The Blog, a post by Maria Ogneva, This is Not Your Parents’ Software Training. Nothing earthshaking, just a clear summary of alternatives to a bunch of same-time people in a bunch of same-time seats being told when and what to click.

• From Vicki Davis (@coolcatteacher), a link to Brett McKay’s post, 4 Sites for Free Vintage Photos.

• From Sweden, a 45-minute presentation at the Technical Communication UK Conference 2011 by Magnus Ohlsson and  Jan Fredlund of IKEA’s communications group.  The topic is how IKEA meets the challenge of 400 new sets of assembly instructions per year, plus revisions.  The presentation comes via Mediasite, and the interface allows you to click through the slides; the audio will jump automatically to stay in sync.  The first 18 minutes (slides 1-13) are background about the IKEA approach and the work of the group; starting at slide 14, there’s a more detailed look at what goes into the ubiquitous guides.

• Via Pascal Venier, Graham Allcott’s new productivity rules of the road. Allcott’s business is helping people and organizations become more productive (warning: you’ll find Getting Things Done stuff).  Among the thoughts that struck me–in part because you don’t often hear the relentlessly busy say things like these:

• Starting well: beginning the day with meditation, exercise, a hearty breakfast, and “consuming limited information of my own choosing.”
• Going dark: from 9 till 1, Allcott shuts his internet connection off.
• Making himself take lunch, and not work through it.

• Via @Evernote, 10 useful tips from Brandie Kajino, their “organization ambassador.”

…That’s the first installment of my shared keepers.  You can think of them as having been curated if you want. Posting them here for me is my reworking/reprocessing of things.  (I tossed a few others overboard–not everything labeled “keeper” merits being kept.)

His friend Gavin Hamilton, in whose memory I’ll have a little something this evening, suggested that Burns publish his poems “as a likely way of getting a little money to provide him… in necessaries for Jamaica.”

Poems, Chiefly in the Scottish Dialect appeared in July of 1786.  By September there was interest in a second edition.  Within six months he was a celebrated artist.  Jamaica was forgotten–until yet another of his loves, Agnes McLehose (known as Nancy to her friends), chose to rejoin her estranged husband… in Jamaica.

In a final letter before she left Scotland, Burns sent her the poem known as Ae Fond Kiss.  It’s his birthday today; not a bad way to celebrate.

Ae fond kiss, and then we sever;
Ae fareweel, alas, for ever!
Deep in heart-wrung tears I’ll pledge thee,
Warring sighs and groans I’ll wage thee!  (pledge)

Who shall say that Fortune grieves him
While the star of hope she leaves him?
Me, nae cheerfu’ twinkle lights me,
Dark despair around benights me.

I’ll ne’er blame my partial fancy;
Naething could resist my Nancy;
But to see her was to love her,
Love but her, and love for ever.

Had we never loved sae kindly,
Had we never loved sae blindly,
Never met—or never parted
We had ne’er been broken-hearted.

Fare thee weel, thou first and fairest!
Fare thee weel, thou best and dearest!
Thine be ilka joy and treasure,
Peace, enjoyment, love, and pleasure!

Ae fond kiss, and then we sever!
Ae fareweel, alas, for ever!
Deep in heart-wrung tears I’ll pledge thee,
Warring sighs and groans I’ll wage thee! (pledge)

Let’s get something to eat

Think about what you see as critical to quality for your workday lunchtime experience.  For me, at least in part, that involves:

• Acceptable food (Bombay Bistro is great; I don’t demand two Michelin stars)
• A space that’s clean (I don’t want to clean a table)
• Room to eat without bumping other people
• A wait time that’s less than 10% of total time

I think many managers of cafeterias, coffee shops, and similar faster-food places would sign up for those as performance standards for their business.  That’s one reason they often have the touch-screen cash registers: the cashier can punch in items, and the machine does the pricing.  The idea is to produce a worthwhile accomplishment: fast, accurate billing.

In her new book, Design for How People Learn, Julie Dirksen talks about fast-food drink dispensers.  Sometimes, she says, you get a really skillful food worker:

She can start a drink pouring a the soda machine, turn to ring a customer, and know exactly how long she has before she needs to turn around and keep the cup from overfilling.  That’s the sign of an expert who really knows their job, and has internalized that knowledge over time.

That kind of skill is expensive to acquire, which explains the drink dispensers with size buttons. A worker can press “large” and move on to another part of the order.  The dispenser isn’t (usually) going to overfill the cup, and so it helps him produce a high-quality result–a fast, accurate meal–with less deliberate investment in skill development.

We presume accomplishment; we notice behavior

We tend to disparage that button-pushing, though. We like interacting with high-skill behavior.  It’s enjoyable and maybe reassuring to have our order handled by someone who’s clearly expert in her work.   Even if we get our order just as quickly from the press-the-size worker, we almost feel as if he’s cheating.  It’s the on-the-job equivalent of “he had to look it up.”

If you disagree, how do you feel about cashiers who have trouble making change on their own?  Admit it–it drives you nuts, because people ought to be able to make change.  And how hard can it be?

I tend to agree.  Making change seems like a straightforward application of match.  But I worked for years in a job where I had to make change, often. And I’ve had to teach people to make change accurately, for the sake of the customer and the sake of the business. If someone isn’t fluent at making change, it takes time to develop that fluency.

You know the project-management nostrum: things can be fast, good, and cheap.  Pick the two you want.

In the context of a fast(er) food business, it makes sense to have a cash register that does the change-computing task.  Otherwise, you have to hire people with more skill, or else devote time and energy to helping them acquire that skill.  (At the end of this post, I’ve written up one method for counting change.)

Change and accomplishment

You’d think that any fast-food place would want employees who can count change.  And maybe that’s true–the place wants them, but can’t always find them.  So it needs to hone in more on what the real accomplishment is: is it accurate change that’s handed to the customer quickly?  Do you need to crank in the behavior involved ( “employee calculates” versus “employee uses a tool” )?

Figuring out what results matter, so you can work on delivering them, is ultimately what work is about.  It’s easy to latch onto behavior, because it’s usually observable and seems obvious.  As Robert Mager says, people really oughta wanna do this.  I think accomplishment is a better guide, though it does require you to question assumptions and perhaps discard predispositions.

Change–it isn’t easy.  Take it from a guy who once said to a customer, “I’m sorry, I don’t have change for a ten, but I do have change for a twelve.”

Bonus Feature: the Count Up Twice method for making change

This example uses a small cash purchase, such as a fast-food meal, for which the customer is paying in cash, with one or more bills totaling more than the price of the meal.

1. State the amount of the sale.  (“That comes to $7.32.”)
2. Accept the customer’s payment.
3. Check the payment and state the amount.   (“Out of twenty dollars.”)
4. Set the payment down without putting it into the individual register spaces.
5. Make change by counting up to yourself from the amount of the sale as you remove money from the register.
• That’s $7.32… 33… 34… 35…
• 7.40… 45… 50…
• 7.75… 8…
• 9… 10…
• $20.00.
6. Count the change again for the customer, starting with the amount of the sale. Give the customer each coin and bill as you work toward the amount tendered.  Say the amounts out loud.
• That’s $7.32… 33… 34… 35…
• 7.40… 45… 50...
• 7.75… 8 …
• 9… 10…
• $20.00.
7. Thank the customer.
8. As the customer leaves, put the payment into the proper cash register spaces.

Note that I haven’t spelled out the rule of thumb that you should move to the next coin or bill size when the total so far allows you to. And I haven’t addressed complications like what to do if the customer offers bills and coins as payment ($10.50 for that $7.32 meal).  Nor have I address cash-register use, underpayment, or attempts by tricksters to trip up the cashier in mid-count.

CC-licensed images:
Cash register keys by zizzybaloobah.
Generic text by Yongho Kim.