Straighten Up and Fly Right

A Brave Pilot Teaches Us about Low Probability Compliance

NOTE: This article originally appeared in the January 2009 issue of Flawless Compliance, under the "What in the World" section. The link to the actual issue is at the bottom of this article.

This picture was taken from the Safety Reliability Methods, Inc. website. This is the consulting firm were Captain Sullenberger practices. Picture Source

I’m proud to say the Captain Sullenberger lives only minutes from my house in Danville, California. For obvious reasons, he’s a national hero as well as a hometown icon. Shortly after the Airbus 320 left the airport, it encountered a squadron of birds that took out both engines. By all accounts this should have been a catastrophic event; however, Captain Sullenberger had the presence of mind to pull the aircraft around for a water landing in the Hudson River. As dangerous as this maneuver is, it took only moments for Captain Sullenberger to realize this was the only option.

With no engines, the plane lost power quickly. Trying to land back at La Guardia Airport was too risky. The plane was facing the wrong direction, so he would need to successfully negotiate a U-Turn, then find his way back to the airport over a densely populated area. The plane was too low and too slow to pull this off. Another option would be to land at another nearby airport, however once again that would entail gliding over a densely populated area with no power. Once again, way too risky.

So, Captain Sullenberger announced to the air traffic controllers in a calm and controlled voice, “We’re gonna be in the Hudson.” What an existential moment.

With laser-like execution Captain Sullenberger accomplished the perfect water landing in the Hudson River. He eased the plane down, keeping the nose up. As the plane glided over the Hudson waters, Captain Sullenberger took great care to keep the plane straight and steady. The landing was so smooth the two cabin members didn’t even realize they had landed in the water! Maintaining his calm and collected composure, the Captain issued a one word command to the cabin crew, “Evacuate.” Within minutes all passengers were safely arranged on the wings of the plane awaiting rescue. The Captain was diligent on his passenger count, and made several passes to ensure that everyone was safe. Then and only then, did Captain Sullenberger depart the plane.

Thanks to YouTube and the US Coast Guard, you can watch the amazing video of the landing and the first responders coming to the rescue.

This truly amazing event illustrates some important realities that we must take to heart if we are to run an efficient compliance program:

Lesson #1: Risks with unbelievably low probabilities actually do happen sometimes

I’d like to profile this risk for you. Remember, risk is uncertainty, and the uncertain event I’d like to focus on is the risk that a flock of birds will take out all your engine power. With any risk comes three important properties; probability, detectability, and impact. Detectability in this case is off the charts high: 100%. Any pilot knows when both engines are gone, so this is not an issue.

Probability however is extremely low. To illustrate how dramatically low the probability is, if we ran a Six Sigma effort on this process, and we categorized a defect as a flock of birds taking out all engine power, this would in fact be a true six sigma process. That’s because experts say the probability that a flock of birds will take out all your engine power is less than one in one million! It can take up to 3 defects per million opportunities for a process to qualify as a six sigma process.

The impact however can be catastrophic: a loss of lives. That is why the airlines take such great pains to control for this risk in spite of the extremely low probability of occurrence. You need to take this same attitude with the risks in your compliance program. All high impact risks must be addressed.

Lesson #2: There’s no substitute for training and practice

Captain Sullenberger trained his entire adult life for a situation like this. Not only has he been a pilot since the age of 14, but he was a fighter pilot in the military, and actually trains pilots on risk and crisis management. Although he had never been in this actual situation before, he had simulated scenarios like this many times, and was well trained to handle the circumstance. Talk about the right person to pilot this plane!

For all of your high impact risks, setup training and simulations to see how you would respond. Try to make the simulations as realistic as possible. Invest the time in brainstorming and improving mitigation. Even if the risk event never shows up, you’ll earn big brownie points with your auditors.

Lesson #3: Don’t beat yourself up if you do everything right and the impact still shows up

The problem with extremely low probability risk events is that you never get a chance to practice with a real situation. As I’ve said many times, reality is the best teacher. Even with the best simulations, there may be conditions in reality that have overlooked. Or perhaps the mitigation just requires you to be a little lucky.

This was certainly the case with Flight 1549. The amazingly bad luck of losing both engines was counterbalanced with amazingly good luck. Since it was only 5 minutes after takeoff, everybody was still buckled in and nobody was wondering around. Although there was a current in the Hudson, there were no large swells that would have complicated the landing. As busy as the Hudson River can get at times, at the time of this crisis it was very clear to land where the Captain needed to land; however, there were a good number of rescue boats nearby to aid the rescue once the plane had landed.

Luck always plays a big role in the outcome. Even if you do everything right, things still might not line up for you. Swallow the sour pill, and move on.

It’s no doubt that Flighit 1549 will go down in history as one of the most amazing airline happenings of our time. In the face of possible catastrophe, Captain Sullenberger pulled off an amazing feat of skill and courage. Although you probably don’t have lives at stake at your company, you do have livelihoods. You have a financial responsibility to both your employees and your shareholders. In this day and age, it’s more important than ever to proactively take diligent steps to mitigate high impact risks: even if they probably won’t happen.