one morning back in 1977 I was working really hard to turn in an absolutely
really hard to turn in an absolutely
really hard to turn in an absolutely perfect performance as a brand new Lee
perfect performance as a brand new Lee
perfect performance as a brand new Lee mented pilot I was number three on the
mented pilot I was number three on the
mented pilot I was number three on the pecking order in this Boeing 727 we had
pecking order in this Boeing 727 we had
pecking order in this Boeing 727 we had a captain in the first officer a second
a captain in the first officer a second
a captain in the first officer a second officer that was me
officer that was me
officer that was me it was Braniff International and we were
it was Braniff International and we were
it was Braniff International and we were on a routine flight from Chicago’s
on a routine flight from Chicago’s
on a routine flight from Chicago’s O’Hare to Houston Intercontinental
O’Hare to Houston Intercontinental
O’Hare to Houston Intercontinental Airport beautiful clear blue sky day we
Airport beautiful clear blue sky day we
Airport beautiful clear blue sky day we were climbing through 10,000 feet when
were climbing through 10,000 feet when
were climbing through 10,000 feet when we realized we had a problem this was
we realized we had a problem this was
we realized we had a problem this was not an emergency it was not a major
not an emergency it was not a major
not an emergency it was not a major emergency of any sort our tail skid had
emergency of any sort our tail skid had
emergency of any sort our tail skid had failed to retract it’s just a little
failed to retract it’s just a little
failed to retract it’s just a little thing back there in the back which
thing back there in the back which
thing back there in the back which literally does what it would it’s
literally does what it would it’s
literally does what it would it’s described as it would skid if you over
described as it would skid if you over
described as it would skid if you over rotated the airplane and there’s no real
rotated the airplane and there’s no real
rotated the airplane and there’s no real big problem here except that we’ll lose
big problem here except that we’ll lose
big problem here except that we’ll lose about 2% of our fuel burn because it’s
about 2% of our fuel burn because it’s
about 2% of our fuel burn because it’s hanging down on the Airstream but
hanging down on the Airstream but
hanging down on the Airstream but there’s one other thing that you’ve got
there’s one other thing that you’ve got
there’s one other thing that you’ve got to do and that is you’ve got to go to
to do and that is you’ve got to go to
to do and that is you’ve got to go to the back and turn off a little spigot
the back and turn off a little spigot
the back and turn off a little spigot because there’s a little valve right
because there’s a little valve right
because there’s a little valve right ahead of that location on the bottom of
ahead of that location on the bottom of
ahead of that location on the bottom of the fuselage where the tail skid is that
the fuselage where the tail skid is that
the fuselage where the tail skid is that would be spewing water coming from the
would be spewing water coming from the
would be spewing water coming from the drains and the back bathrooms onto that
drains and the back bathrooms onto that
drains and the back bathrooms onto that thing and at minus 45 degrees
thing and at minus 45 degrees
thing and at minus 45 degrees temperature and altitude you start
temperature and altitude you start
temperature and altitude you start growing a big stalagmite and I tell you
growing a big stalagmite and I tell you
growing a big stalagmite and I tell you this thing can be about ten feet long by
this thing can be about ten feet long by
this thing can be about ten feet long by the time you’re two hours in the air and
the time you’re two hours in the air and
the time you’re two hours in the air and it’s not leave early to drop something
it’s not leave early to drop something
it’s not leave early to drop something like that into the community as you’re
like that into the community as you’re
like that into the community as you’re making your approach so as the junior
making your approach so as the junior
making your approach so as the junior guy it falls to be I was flying with a
guy it falls to be I was flying with a
guy it falls to be I was flying with a wonderful captain this particular day
wonderful captain this particular day
wonderful captain this particular day his name was Harold Mize we all called
his name was Harold Mize we all called
his name was Harold Mize we all called him tiny big barrel chested guy weigh
him tiny big barrel chested guy weigh
him tiny big barrel chested guy weigh over six feet wonderful individual and a
over six feet wonderful individual and a
over six feet wonderful individual and a great pilot and he was very laid back he
great pilot and he was very laid back he
great pilot and he was very laid back he turned around said okay John pull out
turned around said okay John pull out
turned around said okay John pull out the manual tell us what we need to do so
the manual tell us what we need to do so
the manual tell us what we need to do so I pulled out the manual and I saw a
I pulled out the manual and I saw a
I pulled out the manual and I saw a couple of fuzzy pictures there about the
couple of fuzzy pictures there about the
couple of fuzzy pictures there about the valves under the sink that I had to turn
valves under the sink that I had to turn
valves under the sink that I had to turn wounding one it’s got to be careful
wounding one it’s got to be careful
wounding one it’s got to be careful because the other one controlled all the
because the other one controlled all the
because the other one controlled all the potable water for the airplane it’s a
potable water for the airplane it’s a
potable water for the airplane it’s a morning flight we got a hundred and
morning flight we got a hundred and
morning flight we got a hundred and forty-four people mostly businessmen and
forty-four people mostly businessmen and
forty-four people mostly businessmen and I go to the back of the airplane in my
I go to the back of the airplane in my
I go to the back of the airplane in my hat and coat this is back in the days
hat and coat this is back in the days
hat and coat this is back in the days before 9/11 when you could actually
before 9/11 when you could actually
before 9/11 when you could actually leave the cockpit
leave the cockpit
leave the cockpit open the doors find the valve turned it
open the doors find the valve turned it
open the doors find the valve turned it and as I’m walking back I remember so
and as I’m walking back I remember so
and as I’m walking back I remember so clearly thinking that was a perfect
clearly thinking that was a perfect
clearly thinking that was a perfect performance this is exactly what I was
performance this is exactly what I was
performance this is exactly what I was hired to do I did it exactly right until
hired to do I did it exactly right until
hired to do I did it exactly right until the lead flight attendant grabbed me by
the lead flight attendant grabbed me by
the lead flight attendant grabbed me by the shoulder and said John we don’t have
the shoulder and said John we don’t have
the shoulder and said John we don’t have any water
any water
any water I had just succeeded in identifying the
I had just succeeded in identifying the
I had just succeeded in identifying the wrong valve and dumping 200 gallons of
wrong valve and dumping 200 gallons of
wrong valve and dumping 200 gallons of potable water over middle Illinois now I
potable water over middle Illinois now I
potable water over middle Illinois now I probably contributed to the irrigation
probably contributed to the irrigation
probably contributed to the irrigation of some of the crops down there but my
of some of the crops down there but my
of some of the crops down there but my passengers were not amused no coffee no
passengers were not amused no coffee no
passengers were not amused no coffee no tea six crew members and 144 disgruntled
tea six crew members and 144 disgruntled
tea six crew members and 144 disgruntled passengers and I got on the PA to make
passengers and I got on the PA to make
passengers and I got on the PA to make the explanation but it was embarrassing
the explanation but it was embarrassing
the explanation but it was embarrassing that tiny was very nice about it he
that tiny was very nice about it he
that tiny was very nice about it he turned around said hey it was probably
turned around said hey it was probably
turned around said hey it was probably difficult to understand those pictures
difficult to understand those pictures
difficult to understand those pictures in the book but both he and I knew that
in the book but both he and I knew that
in the book but both he and I knew that I had just failed utterly and my number
I had just failed utterly and my number
I had just failed utterly and my number one responsibility as a young flight
one responsibility as a young flight
one responsibility as a young flight officer at Randolph which was to be
officer at Randolph which was to be
officer at Randolph which was to be perfect absolutely perfect 100% of the
perfect absolutely perfect 100% of the
perfect absolutely perfect 100% of the time and I had just proven that they had
time and I had just proven that they had
time and I had just proven that they had hired less than the perfect pilot that
hired less than the perfect pilot that
hired less than the perfect pilot that they thought they had hired and trained
they thought they had hired and trained
they thought they had hired and trained very very embarrassing fortunately not a
very very embarrassing fortunately not a
very very embarrassing fortunately not a fire in offense but in the next couple
fire in offense but in the next couple
fire in offense but in the next couple of weeks as I was kicking myself around
of weeks as I was kicking myself around
of weeks as I was kicking myself around the block and I did having made this
the block and I did having made this
the block and I did having made this mistake embarrassing my crew and myself
mistake embarrassing my crew and myself
mistake embarrassing my crew and myself there were a couple of questions I
there were a couple of questions I
there were a couple of questions I started eating at the back of my mind
started eating at the back of my mind
started eating at the back of my mind and these were embarrassing questions
and these were embarrassing questions
and these were embarrassing questions because these were not the sort of that
because these were not the sort of that
because these were not the sort of that like excuses they’re not the sort of
like excuses they’re not the sort of
like excuses they’re not the sort of thing that somebody like me with a
thing that somebody like me with a
thing that somebody like me with a military background should be engaging
military background should be engaging
military background should be engaging in right because of the military
in right because of the military
in right because of the military background you’re used to squaring your
background you’re used to squaring your
background you’re used to squaring your shoulders when you make a mistake and
shoulders when you make a mistake and
shoulders when you make a mistake and say no excuse sir and one of the
say no excuse sir and one of the
say no excuse sir and one of the questions was exactly what tiny had kind
questions was exactly what tiny had kind
questions was exactly what tiny had kind of indicated when he said you know maybe
of indicated when he said you know maybe
of indicated when he said you know maybe the manual maybe it could have been
the manual maybe it could have been
the manual maybe it could have been written better maybe it was slightly
written better maybe it was slightly
written better maybe it was slightly contributory to my mistake because the
contributory to my mistake because the
contributory to my mistake because the pictures were pretty fuzzy it was hard
pictures were pretty fuzzy it was hard
pictures were pretty fuzzy it was hard to discern which side the bowel was
to discern which side the bowel was
to discern which side the bowel was wrong and there was another one and that
wrong and there was another one and that
wrong and there was another one and that was maybe tiny should have said John sit
was maybe tiny should have said John sit
was maybe tiny should have said John sit on your hands for a few minutes it’s not
on your hands for a few minutes it’s not
on your hands for a few minutes it’s not an emergency don’t run to the back until
an emergency don’t run to the back until
an emergency don’t run to the back until you were absolutely sure maybe you want
you were absolutely sure maybe you want
you were absolutely sure maybe you want to take the book with you but there was
to take the book with you but there was
to take the book with you but there was a third one and this really bothered me
a third one and this really bothered me
a third one and this really bothered me because I was at the start of what I
because I was at the start of what I
because I was at the start of what I expected to be a 30 to 35 year career as
expected to be a 30 to 35 year career as
expected to be a 30 to 35 year career as an airline pilot was I really suppose
an airline pilot was I really suppose
an airline pilot was I really suppose to be absolutely perfect 100% of the
to be absolutely perfect 100% of the
to be absolutely perfect 100% of the time every decision I made every switch
time every decision I made every switch
time every decision I made every switch I threw every entry and the logbook
I threw every entry and the logbook
I threw every entry and the logbook everything I did my god is that even
everything I did my god is that even
everything I did my god is that even possible that was really eating at me
possible that was really eating at me
possible that was really eating at me along with the fact of course that it
along with the fact of course that it
along with the fact of course that it was embarrassing that I was even asking
was embarrassing that I was even asking
was embarrassing that I was even asking myself these questions because I was
myself these questions because I was
myself these questions because I was supposed to be perfect why is this
supposed to be perfect why is this
supposed to be perfect why is this important I think this is important
important I think this is important
important I think this is important because all of us no matter whether we
because all of us no matter whether we
because all of us no matter whether we want to admit it or not all of us have
want to admit it or not all of us have
want to admit it or not all of us have spent a lot of time in our lives and
spent a lot of time in our lives and
spent a lot of time in our lives and even more so in some professions
even more so in some professions
even more so in some professions wondering why we’re not measuring up
wondering why we’re not measuring up
wondering why we’re not measuring up everybody else seems to be getting it
everybody else seems to be getting it
everybody else seems to be getting it right but we keep making mistakes
right but we keep making mistakes
right but we keep making mistakes everybody makes mistakes and this is the
everybody makes mistakes and this is the
everybody makes mistakes and this is the dirty little secret while it looks like
dirty little secret while it looks like
dirty little secret while it looks like you’re the only one who is because what
you’re the only one who is because what
you’re the only one who is because what do we always do would it make a mistake
do we always do would it make a mistake
do we always do would it make a mistake it’s us right it’s not them it’s us
it’s us right it’s not them it’s us
it’s us right it’s not them it’s us they’re perfect no they’re not there is
they’re perfect no they’re not there is
they’re perfect no they’re not there is no carbon-based human being out there in
no carbon-based human being out there in
no carbon-based human being out there in any industry in any profession any walk
any industry in any profession any walk
any industry in any profession any walk of life including just being nicely
of life including just being nicely
of life including just being nicely retired or having fun or whatever it is
retired or having fun or whatever it is
retired or having fun or whatever it is you’re doing who does not make mistakes
you’re doing who does not make mistakes
you’re doing who does not make mistakes and the reason why is that and this is a
and the reason why is that and this is a
and the reason why is that and this is a startling development but we’ve learned
startling development but we’ve learned
startling development but we’ve learned in aviation especially but also in
in aviation especially but also in
in aviation especially but also in nuclear power generation and other
nuclear power generation and other
nuclear power generation and other high-risk industries the human beings
high-risk industries the human beings
high-risk industries the human beings cannot be perpetually perfect now we can
cannot be perpetually perfect now we can
cannot be perpetually perfect now we can be perfect part of the time might affect
be perfect part of the time might affect
be perfect part of the time might affect some of us can actually manage to be
some of us can actually manage to be
some of us can actually manage to be perfect for a whole career but here is
perfect for a whole career but here is
perfect for a whole career but here is the kicker none of us has the ability to
the kicker none of us has the ability to
the kicker none of us has the ability to look somebody else in the eye and say I
look somebody else in the eye and say I
look somebody else in the eye and say I promise you that I am gonna be
promise you that I am gonna be
promise you that I am gonna be absolutely perfect to my execution of
absolutely perfect to my execution of
absolutely perfect to my execution of whatever it is I’m gonna do for the next
whatever it is I’m gonna do for the next
whatever it is I’m gonna do for the next period of time ten minutes in hours ten
period of time ten minutes in hours ten
period of time ten minutes in hours ten years whatever we can’t say that
years whatever we can’t say that
years whatever we can’t say that honestly so where does that leave us
honestly so where does that leave us
honestly so where does that leave us well we we know the extremes the extreme
well we we know the extremes the extreme
well we we know the extremes the extreme over here is the one we’ve always had
over here is the one we’ve always had
over here is the one we’ve always had which is we have to have perfect
which is we have to have perfect
which is we have to have perfect performance from human beings a hundred
performance from human beings a hundred
performance from human beings a hundred percent of the time and over here is the
percent of the time and over here is the
percent of the time and over here is the laissez-faire attitude of hey dude
laissez-faire attitude of hey dude
laissez-faire attitude of hey dude things happen we don’t want that
things happen we don’t want that
things happen we don’t want that attitude in the operating room and we
attitude in the operating room and we
attitude in the operating room and we sure don’t want it in the cockpits and
sure don’t want it in the cockpits and
sure don’t want it in the cockpits and we don’t want it in the in the control
we don’t want it in the in the control
we don’t want it in the in the control room of nuclear power plants so where is
room of nuclear power plants so where is
room of nuclear power plants so where is the balance point in all this the
the balance point in all this the
the balance point in all this the balance point is actually a new way of
balance point is actually a new way of
balance point is actually a new way of looking at things because we have always
looking at things because we have always
looking at things because we have always had this paradigm I you know I didn’t
had this paradigm I you know I didn’t
had this paradigm I you know I didn’t just start with 1966 and Star Trek with
just start with 1966 and Star Trek with
just start with 1966 and Star Trek with Captain Kirk
Captain Kirk
Captain Kirk wonderfully by Bill Shatner who is the
wonderfully by Bill Shatner who is the
wonderfully by Bill Shatner who is the progenitor of that wonderful Hollywood
progenitor of that wonderful Hollywood
progenitor of that wonderful Hollywood organization known as over actors
organization known as over actors
organization known as over actors anonymous but he was to prepare a dine
anonymous but he was to prepare a dine
anonymous but he was to prepare a dine wasn’t he because he was omnipotent and
wasn’t he because he was omnipotent and
wasn’t he because he was omnipotent and he was infallible and he was a bloody
he was infallible and he was a bloody
he was infallible and he was a bloody fraud I don’t mean bill I mean the
fraud I don’t mean bill I mean the
fraud I don’t mean bill I mean the character he was a fraud because none of
character he was a fraud because none of
character he was a fraud because none of us can be perpetually perfect and as I
us can be perpetually perfect and as I
us can be perpetually perfect and as I say we then have this dilemma where is
say we then have this dilemma where is
say we then have this dilemma where is the balance point here is the balance
the balance point here is the balance
the balance point here is the balance point it’s where we say I’m very good at
point it’s where we say I’m very good at
point it’s where we say I’m very good at what I do but I know I’m a human being
what I do but I know I’m a human being
what I do but I know I’m a human being and I know that there are not I know the
and I know that there are not I know the
and I know that there are not I know the times that I’m not gonna hear things
times that I’m not gonna hear things
times that I’m not gonna hear things right there time said I’m not going to
right there time said I’m not going to
right there time said I’m not going to interpret it right I’m gonna make
interpret it right I’m gonna make
interpret it right I’m gonna make mistakes that are purely a result of
mistakes that are purely a result of
mistakes that are purely a result of being human not a result of being a bad
being human not a result of being a bad
being human not a result of being a bad professional or a bad husband who
professional or a bad husband who
professional or a bad husband who forgets to take out the trash but just
forgets to take out the trash but just
forgets to take out the trash but just being human but I know that and I’m
being human but I know that and I’m
being human but I know that and I’m honest enough to admit it then I have to
honest enough to admit it then I have to
honest enough to admit it then I have to say how can I put a prophylaxis of one
say how can I put a prophylaxis of one
say how can I put a prophylaxis of one sort or another in place how can I build
sort or another in place how can I build
sort or another in place how can I build a structure around my potential for
a structure around my potential for
a structure around my potential for human failure that is going to prevent
human failure that is going to prevent
human failure that is going to prevent those failures from metastasizing into a
those failures from metastasizing into a
those failures from metastasizing into a result I don’t want this was the key to
result I don’t want this was the key to
result I don’t want this was the key to aviation safety and we didn’t know it
aviation safety and we didn’t know it
aviation safety and we didn’t know it until the mid 80s this idea of being
until the mid 80s this idea of being
until the mid 80s this idea of being able to look at human performance and
able to look at human performance and
able to look at human performance and human failure and say hey we got to know
human failure and say hey we got to know
human failure and say hey we got to know how we fail and guess what most of it is
how we fail and guess what most of it is
how we fail and guess what most of it is inadvertent failure like the three guys
inadvertent failure like the three guys
inadvertent failure like the three guys at Delta Airlines you all know Delta
at Delta Airlines you all know Delta
at Delta Airlines you all know Delta they’re the ones that gave us that
they’re the ones that gave us that
they’re the ones that gave us that wonderful phrase I don’t know where I’m
wonderful phrase I don’t know where I’m
wonderful phrase I don’t know where I’m gonna go when I die but I do know I’ll
gonna go when I die but I do know I’ll
gonna go when I die but I do know I’ll change in Atlanta
Delta is a great airline but 1987 they
Delta is a great airline but 1987 they had three very highly qualified
had three very highly qualified
had three very highly qualified wonderful guys taxiing alpha takeoff
wonderful guys taxiing alpha takeoff
wonderful guys taxiing alpha takeoff going up to Salt Lake City they crashed
going up to Salt Lake City they crashed
going up to Salt Lake City they crashed the airplane on takeoff and killed 17
the airplane on takeoff and killed 17
the airplane on takeoff and killed 17 people because they had forgotten to put
people because they had forgotten to put
people because they had forgotten to put the flaps in the right position those
the flaps in the right position those
the flaps in the right position those are the big movable panels on the back
are the big movable panels on the back
are the big movable panels on the back of the wing and the drooping panels on
of the wing and the drooping panels on
of the wing and the drooping panels on the front they forgot even though all
the front they forgot even though all
the front they forgot even though all three of them read the checklist and
three of them read the checklist and
three of them read the checklist and responded 15 15 green when they were
responded 15 15 green when they were
responded 15 15 green when they were zero zero and there had never been a
zero zero and there had never been a
zero zero and there had never been a green light how does this happen well
green light how does this happen well
green light how does this happen well nobody was on drugs nobody was drunk
nobody was on drugs nobody was drunk
nobody was on drugs nobody was drunk nobody was unqualified they just
nobody was unqualified they just
nobody was unqualified they just happened to be carbon-based human beings
happened to be carbon-based human beings
happened to be carbon-based human beings old Star Trek term forgive me the thing
old Star Trek term forgive me the thing
old Star Trek term forgive me the thing is we have to be serious about this in
is we have to be serious about this in
is we have to be serious about this in an aviation we finally realized we have
an aviation we finally realized we have
an aviation we finally realized we have to build a system but what’s the system
to build a system but what’s the system
to build a system but what’s the system we’re going to build first we’re going
we’re going to build first we’re going
we’re going to build first we’re going to fire Captain Kirk we’re gonna look at
to fire Captain Kirk we’re gonna look at
to fire Captain Kirk we’re gonna look at that captain and say hey dude we’re on
that captain and say hey dude we’re on
that captain and say hey dude we’re on to you you’re not perfect so if you
to you you’re not perfect so if you
to you you’re not perfect so if you don’t create a team if you don’t have it
don’t create a team if you don’t have it
don’t create a team if you don’t have it to where your copilot and your flight
to where your copilot and your flight
to where your copilot and your flight engineer can speak to you you know don’t
engineer can speak to you you know don’t
engineer can speak to you you know don’t give us this when I want your advice
give us this when I want your advice
give us this when I want your advice I’ll ask for it boy did I hear that a
I’ll ask for it boy did I hear that a
I’ll ask for it boy did I hear that a few times if you can’t create that
few times if you can’t create that
few times if you can’t create that environment of a team a collegial
environment of a team a collegial
environment of a team a collegial interactive team in which nobody would
interactive team in which nobody would
interactive team in which nobody would have any hesitation to speak up if they
have any hesitation to speak up if they
have any hesitation to speak up if they saw heard felt or even intuitive that
saw heard felt or even intuitive that
saw heard felt or even intuitive that something is wrong then you’re not gonna
something is wrong then you’re not gonna
something is wrong then you’re not gonna fly for us because we can’t trust you to
fly for us because we can’t trust you to
fly for us because we can’t trust you to be perpetually perfect no matter how
be perpetually perfect no matter how
be perpetually perfect no matter how well we trained you no matter how good
well we trained you no matter how good
well we trained you no matter how good you are this is why you can go to the
you are this is why you can go to the
you are this is why you can go to the airport this day and time and get on a
airport this day and time and get on a
airport this day and time and get on a jetliner and get to the other end with
jetliner and get to the other end with
jetliner and get to the other end with almost a in infinitesimal is the word
almost a in infinitesimal is the word
almost a in infinitesimal is the word I’m trying to pull out of my mouth an
I’m trying to pull out of my mouth an
I’m trying to pull out of my mouth an infinitesimal possibility of being hurt
infinitesimal possibility of being hurt
infinitesimal possibility of being hurt will get you there okay not well fed not
will get you there okay not well fed not
will get you there okay not well fed not well treated but okay that’s another
well treated but okay that’s another
well treated but okay that’s another lecture for another day tradition it’s a
lecture for another day tradition it’s a
lecture for another day tradition it’s a moral failure to make a mistake no the
moral failure to make a mistake no the
moral failure to make a mistake no the reality is next time this happens to you
reality is next time this happens to you
reality is next time this happens to you individually professionally and you’re
individually professionally and you’re
individually professionally and you’re kicking yourself around the block stop
kicking yourself around the block stop
kicking yourself around the block stop and think hey I’m already ahead of the
and think hey I’m already ahead of the
and think hey I’m already ahead of the game because I realize this I’ve got a
game because I realize this I’ve got a
game because I realize this I’ve got a message from the underlying system that
message from the underlying system that
message from the underlying system that I can use to not only a suede my
I can use to not only a suede my
I can use to not only a suede my feelings of inadequacy but to know that
feelings of inadequacy but to know that
feelings of inadequacy but to know that everybody else is the same way my
everybody else is the same way my
everybody else is the same way my strength is knowing how to apply that
strength is knowing how to apply that
strength is knowing how to apply that how to build a system around me give you
how to build a system around me give you
how to build a system around me give you an example my wife is absolutely
an example my wife is absolutely
an example my wife is absolutely incredible she’s a nurse
incredible she’s a nurse
incredible she’s a nurse she’s an author and lecturer she’s
she’s an author and lecturer she’s
she’s an author and lecturer she’s incredible in knowing the calendar for
incredible in knowing the calendar for
incredible in knowing the calendar for the next year she can remember
the next year she can remember
the next year she can remember everything on that calendar without
everything on that calendar without
everything on that calendar without looking at my schedule as well I am
looking at my schedule as well I am
looking at my schedule as well I am exactly the opposite I can’t remember
exactly the opposite I can’t remember
exactly the opposite I can’t remember what I’m doing next Monday I have to use
what I’m doing next Monday I have to use
what I’m doing next Monday I have to use a calendar an electronic one but that is
a calendar an electronic one but that is
a calendar an electronic one but that is my methodology of making sure that I
my methodology of making sure that I
my methodology of making sure that I don’t spend half my life apologizing for
don’t spend half my life apologizing for
don’t spend half my life apologizing for missed appointments and missed calls and
missed appointments and missed calls and
missed appointments and missed calls and that’s really the key to this the next
that’s really the key to this the next
that’s really the key to this the next thing what’s next is knowing ourselves
thing what’s next is knowing ourselves
thing what’s next is knowing ourselves as humans and moving on with the ability
as humans and moving on with the ability
as humans and moving on with the ability to be perfect because not we’re going to
to be perfect because not we’re going to
to be perfect because not we’re going to zero out all our errors but because we
zero out all our errors but because we
zero out all our errors but because we know how to absorb them another example
know how to absorb them another example
know how to absorb them another example in the US Air Force I flew an airplane
in the US Air Force I flew an airplane
in the US Air Force I flew an airplane called the Lockheed c-141 for many years
called the Lockheed c-141 for many years
called the Lockheed c-141 for many years a big big beautiful airplane well only a
a big big beautiful airplane well only a
a big big beautiful airplane well only a pilot would call it beautiful alright it
pilot would call it beautiful alright it
pilot would call it beautiful alright it was big hulking thing with four engines
was big hulking thing with four engines
was big hulking thing with four engines fluid for 23 years as I say and the
fluid for 23 years as I say and the
fluid for 23 years as I say and the regulars in reserve and through two wars
regulars in reserve and through two wars
regulars in reserve and through two wars and this big bird could carry an awful
and this big bird could carry an awful
and this big bird could carry an awful lot of fuel and an awful lot of people
lot of fuel and an awful lot of people
lot of fuel and an awful lot of people when I first became an aircraft
when I first became an aircraft
when I first became an aircraft commander at the tender age of 25 I was
commander at the tender age of 25 I was
commander at the tender age of 25 I was taught to be Captain Kirk I was talked
taught to be Captain Kirk I was talked
taught to be Captain Kirk I was talked to walk in and tell everybody win
to walk in and tell everybody win
to walk in and tell everybody win who how where and I’ll see you on the
who how where and I’ll see you on the
who how where and I’ll see you on the ramp and now many years later in 1987
ramp and now many years later in 1987
ramp and now many years later in 1987 the day I want to tell you about I’m
the day I want to tell you about I’m
the day I want to tell you about I’m walking in for a trip from Tacoma
walking in for a trip from Tacoma
walking in for a trip from Tacoma Washington
Washington
Washington McChord Air Force Base up to Elmendorf
McChord Air Force Base up to Elmendorf
McChord Air Force Base up to Elmendorf Alaska and Anchorage it’s going to be a
Alaska and Anchorage it’s going to be a
Alaska and Anchorage it’s going to be a three and a half hour trip it’s a
three and a half hour trip it’s a
three and a half hour trip it’s a training mission we don’t have any cargo
training mission we don’t have any cargo
training mission we don’t have any cargo big powerful jet 75,000 pounds of jet
big powerful jet 75,000 pounds of jet
big powerful jet 75,000 pounds of jet fuel and 30 passengers in the back no
fuel and 30 passengers in the back no
fuel and 30 passengers in the back no cargo and as I walk in to talk to my
cargo and as I walk in to talk to my
cargo and as I walk in to talk to my crew who are all standing around a
crew who are all standing around a
crew who are all standing around a circular table about chest high
circular table about chest high
circular table about chest high I’ve been retrained totally retrained
I’ve been retrained totally retrained
I’ve been retrained totally retrained Captain Kirk is not walking into that
Captain Kirk is not walking into that
Captain Kirk is not walking into that room anymore
room anymore
room anymore jean-luc Picard is to a certain extent
jean-luc Picard is to a certain extent
jean-luc Picard is to a certain extent for those of you who follow on to the
for those of you who follow on to the
for those of you who follow on to the next generation because my duty is now
next generation because my duty is now
next generation because my duty is now to bind these people into a human team
to bind these people into a human team
to bind these people into a human team and create a level of communication that
and create a level of communication that
and create a level of communication that is going to assuage the possibility that
is going to assuage the possibility that
is going to assuage the possibility that I could make a major mistake and so I
I could make a major mistake and so I
I could make a major mistake and so I start by shaking everybody’s hand look
start by shaking everybody’s hand look
start by shaking everybody’s hand look at him in the eye calling him by first
at him in the eye calling him by first
at him in the eye calling him by first name exchanging personal information and
name exchanging personal information and
name exchanging personal information and as I’m going through this when I get to
as I’m going through this when I get to
as I’m going through this when I get to my number three guy oh boy do I have a
my number three guy oh boy do I have a
my number three guy oh boy do I have a newbie today he’s 18 years old he’s in a
newbie today he’s 18 years old he’s in a
newbie today he’s 18 years old he’s in a factory-fresh flight suit with knowing
factory-fresh flight suit with knowing
factory-fresh flight suit with knowing so yeah he’s an airman basic I’m a
so yeah he’s an airman basic I’m a
so yeah he’s an airman basic I’m a colonel when I shake his hand I got two
colonel when I shake his hand I got two
colonel when I shake his hand I got two fried eggs looking back at me this guy
fried eggs looking back at me this guy
fried eggs looking back at me this guy wants to this guy wants me to talk to
wants to this guy wants me to talk to
wants to this guy wants me to talk to anybody but he and me scared the death
anybody but he and me scared the death
anybody but he and me scared the death of me and I realize if I’m gonna bind
of me and I realize if I’m gonna bind
of me and I realize if I’m gonna bind him into this team I’m gonna have to
him into this team I’m gonna have to
him into this team I’m gonna have to work hard on it so I continue on around
work hard on it so I continue on around
work hard on it so I continue on around the table copilot I flew with this guy
the table copilot I flew with this guy
the table copilot I flew with this guy in Vietnam this fellas got ice water in
in Vietnam this fellas got ice water in
in Vietnam this fellas got ice water in his veins if I win came off and we were
his veins if I win came off and we were
his veins if I win came off and we were spiraling down we’re des guaranteed he’d
spiraling down we’re des guaranteed he’d
spiraling down we’re des guaranteed he’d ask for coffee with cream on the way
ask for coffee with cream on the way
ask for coffee with cream on the way down
down
down absolutely imperturbable so we get ready
absolutely imperturbable so we get ready
absolutely imperturbable so we get ready to finish this part of the brief and I
to finish this part of the brief and I
to finish this part of the brief and I do the who what where when how and
do the who what where when how and
do the who what where when how and Hawaiian normally most everybody else in
Hawaiian normally most everybody else in
Hawaiian normally most everybody else in the old days would have just walked out
the old days would have just walked out
the old days would have just walked out to the airplane now I’ve been taught to
to the airplane now I’ve been taught to
to the airplane now I’ve been taught to do one other thing to step back and say
do one other thing to step back and say
do one other thing to step back and say guys hold on for a second those of you
guys hold on for a second those of you
guys hold on for a second those of you who flown with me have heard this spiel
who flown with me have heard this spiel
who flown with me have heard this spiel and you know that I’m very serious those
and you know that I’m very serious those
and you know that I’m very serious those of you who haven’t listened up because
of you who haven’t listened up because
of you who haven’t listened up because I’m dead serious
I’m dead serious
I’m dead serious you are my eyes in my ears okay I have a
you are my eyes in my ears okay I have a
you are my eyes in my ears okay I have a very good aircraft commander I’ve been
very good aircraft commander I’ve been
very good aircraft commander I’ve been at this a long time I don’t think I’m
at this a long time I don’t think I’m
at this a long time I don’t think I’m gonna make a major serious possibly
gonna make a major serious possibly
gonna make a major serious possibly deadly mistake today but there’s no way
deadly mistake today but there’s no way
deadly mistake today but there’s no way I can look you in the eye and tell you
I can look you in the eye and tell you
I can look you in the eye and tell you that that’s not possible so despite my
that that’s not possible so despite my
that that’s not possible so despite my record despite my intention to do
record despite my intention to do
record despite my intention to do everything right I need to know that you
everything right I need to know that you
everything right I need to know that you are locked in with me in such a way that
are locked in with me in such a way that
are locked in with me in such a way that if you saw or felt or intuited or
if you saw or felt or intuited or
if you saw or felt or intuited or anything that something was amiss or you
anything that something was amiss or you
anything that something was amiss or you were unsure of something I need you to
were unsure of something I need you to
were unsure of something I need you to speak up instantaneously I’m gonna go
speak up instantaneously I’m gonna go
speak up instantaneously I’m gonna go back around the table look everybody in
back around the table look everybody in
back around the table look everybody in the eye I want a blood oath from you
the eye I want a blood oath from you
the eye I want a blood oath from you that you can rise to this and if you can
that you can rise to this and if you can
that you can rise to this and if you can no problem we’ll just get you on
no problem we’ll just get you on
no problem we’ll just get you on somebody else’s airplane and yeah that’s
somebody else’s airplane and yeah that’s
somebody else’s airplane and yeah that’s that no pejorative
that no pejorative
that no pejorative so I started around the table of course
so I started around the table of course
so I started around the table of course when I get to my new kid his stop is in
when I get to my new kid his stop is in
when I get to my new kid his stop is in the air and he’s really nodding yes sir
the air and he’s really nodding yes sir
the air and he’s really nodding yes sir we get out to the airplane it’s a big
we get out to the airplane it’s a big
we get out to the airplane it’s a big windowless environment down there and
windowless environment down there and
windowless environment down there and normally a new loadmaster would ride
normally a new loadmaster would ride
normally a new loadmaster would ride down there for three and a half hours
down there for three and a half hours
down there for three and a half hours and I wasn’t gonna have that I brought
and I wasn’t gonna have that I brought
and I wasn’t gonna have that I brought him up on the flight deck I said you’re
him up on the flight deck I said you’re
him up on the flight deck I said you’re gonna ride up here with us three and a
gonna ride up here with us three and a
gonna ride up here with us three and a half hours with the headset on the
half hours with the headset on the
half hours with the headset on the button and your finger all right under
button and your finger all right under
button and your finger all right under your thumb I want you to talk to us
your thumb I want you to talk to us
your thumb I want you to talk to us there are no dumb questions the only
there are no dumb questions the only
there are no dumb questions the only thing I ask is that you not talk over
thing I ask is that you not talk over
thing I ask is that you not talk over the air traffic controllers he said yes
the air traffic controllers he said yes
the air traffic controllers he said yes sir he makes all the right noises 18
sir he makes all the right noises 18
sir he makes all the right noises 18 years old I wasn’t convinced I said I’m
years old I wasn’t convinced I said I’m
years old I wasn’t convinced I said I’m beside him I said look I’m not sure you
beside him I said look I’m not sure you
beside him I said look I’m not sure you can get past this Colonel thing okay he
can get past this Colonel thing okay he
can get past this Colonel thing okay he stops me in mid-sentence I could
stops me in mid-sentence I could
stops me in mid-sentence I could done this at age 18 facing a colonel he
done this at age 18 facing a colonel he
done this at age 18 facing a colonel he says sir I got it it’s just like dealing
says sir I got it it’s just like dealing
says sir I got it it’s just like dealing with my big brother as long as I show
with my big brother as long as I show
with my big brother as long as I show him a modicum of respect I can tell him
him a modicum of respect I can tell him
him a modicum of respect I can tell him anything I think he needs to know I said
anything I think he needs to know I said
anything I think he needs to know I said well that’s a bit cheeky but that’s
well that’s a bit cheeky but that’s
well that’s a bit cheeky but that’s pretty much what I wanted so I climb
pretty much what I wanted so I climb
pretty much what I wanted so I climb under the seat it’s another clear blue
under the seat it’s another clear blue
under the seat it’s another clear blue sky day we we blast off again we don’t
sky day we we blast off again we don’t
sky day we we blast off again we don’t have any cargo and we’re a very very
have any cargo and we’re a very very
have any cargo and we’re a very very powerful jet so as they turn us back
powerful jet so as they turn us back
powerful jet so as they turn us back towards Seattle weren’t climbing to
towards Seattle weren’t climbing to
towards Seattle weren’t climbing to 17,000 we also call that one 7,000
17,000 we also call that one 7,000
17,000 we also call that one 7,000 that’s our clearance limit coming
that’s our clearance limit coming
that’s our clearance limit coming through 14,000 100 feet like an
through 14,000 100 feet like an
through 14,000 100 feet like an intercontinental missile climbing so
intercontinental missile climbing so
intercontinental missile climbing so fast and all of a sudden I hear a click
fast and all of a sudden I hear a click
fast and all of a sudden I hear a click on my headset in this timorous little
on my headset in this timorous little
on my headset in this timorous little voice I recognize immediately as my new
voice I recognize immediately as my new
voice I recognize immediately as my new visas 14 thousand two hundred fourteen
visas 14 thousand two hundred fourteen
visas 14 thousand two hundred fourteen thousand three hundred and I’m thinking
thousand three hundred and I’m thinking
thousand three hundred and I’m thinking yeah man he’s speaking up this is good
yeah man he’s speaking up this is good
yeah man he’s speaking up this is good go ahead load this pilot fourteen
go ahead load this pilot fourteen
go ahead load this pilot fourteen thousand four hundred fourteen thousand
thousand four hundred fourteen thousand
thousand four hundred fourteen thousand five hundred Oscar 14,600 I’m probably
five hundred Oscar 14,600 I’m probably
five hundred Oscar 14,600 I’m probably wrong 14700 but I could have sworn 14800
wrong 14700 but I could have sworn 14800
wrong 14700 but I could have sworn 14800 that they only cleared us to fifteen
that they only cleared us to fifteen
that they only cleared us to fifteen thousand feet I looked over here by
thousand feet I looked over here by
thousand feet I looked over here by copilot and he’s on it immediately
copilot and he’s on it immediately
copilot and he’s on it immediately Seattle Center back five zero two three
Seattle Center back five zero two three
Seattle Center back five zero two three five were clear two one seven thousand
five were clear two one seven thousand
five were clear two one seven thousand seventeen thousand Roger
seventeen thousand Roger
seventeen thousand Roger 14900 14950 finally the voice of the
14900 14950 finally the voice of the
14900 14950 finally the voice of the controller rather laconic and my memory
controller rather laconic and my memory
controller rather laconic and my memory comes back negative Mackay are cleared
comes back negative Mackay are cleared
comes back negative Mackay are cleared to fifteen good Lord pull the power back
to fifteen good Lord pull the power back
to fifteen good Lord pull the power back push the airplane over zero g everybody
push the airplane over zero g everybody
push the airplane over zero g everybody help
help
help I got 30 floaters back here one guy had
I got 30 floaters back here one guy had
I got 30 floaters back here one guy had not clicked his seatbelt his buddy had
not clicked his seatbelt his buddy had
not clicked his seatbelt his buddy had to reach up and grab him and pull him
to reach up and grab him and pull him
to reach up and grab him and pull him off the ceiling
off the ceiling
off the ceiling I guess stopped about 15,300 heart rates
I guess stopped about 15,300 heart rates
I guess stopped about 15,300 heart rates off the chart blood pressure is 2 and
off the chart blood pressure is 2 and
off the chart blood pressure is 2 and I’m sneaking back to 15,000 feet hoping
I’m sneaking back to 15,000 feet hoping
I’m sneaking back to 15,000 feet hoping that nobody saw this and I’m now
that nobody saw this and I’m now
that nobody saw this and I’m now adrenalized you know everything is
adrenalized you know everything is
adrenalized you know everything is running in slow motion and I’m thinking
running in slow motion and I’m thinking
running in slow motion and I’m thinking about where I can buy this kid the
about where I can buy this kid the
about where I can buy this kid the biggest steak in Anchorage I look over
biggest steak in Anchorage I look over
biggest steak in Anchorage I look over at my imperturbable friend and all the
at my imperturbable friend and all the
at my imperturbable friend and all the blood is drained out of this guy’s face
blood is drained out of this guy’s face
blood is drained out of this guy’s face I have never seen this before and I’m
I have never seen this before and I’m
I have never seen this before and I’m looking at him and wondering why finally
looking at him and wondering why finally
looking at him and wondering why finally I follow his gaze and realize what his
I follow his gaze and realize what his
I follow his gaze and realize what his kind of caused this he’s looking at the
kind of caused this he’s looking at the
kind of caused this he’s looking at the belly of a Boeing 747-200 owned by
belly of a Boeing 747-200 owned by
belly of a Boeing 747-200 owned by Northwest orient 336 people aboard
Northwest orient 336 people aboard
Northwest orient 336 people aboard coming in from Tokyo we called and
coming in from Tokyo we called and
coming in from Tokyo we called and checked later he’s at 16,000 feet right
checked later he’s at 16,000 feet right
checked later he’s at 16,000 feet right over our heads we would have climbed
over our heads we would have climbed
over our heads we would have climbed aggressively into his belly disassembled
aggressively into his belly disassembled
aggressively into his belly disassembled both airplanes you don’t survive those
both airplanes you don’t survive those
both airplanes you don’t survive those we would have rained passengers and
we would have rained passengers and
we would have rained passengers and parts all over South Seattle and it
parts all over South Seattle and it
parts all over South Seattle and it would’ve been the second worst accident
would’ve been the second worst accident
would’ve been the second worst accident at an airline history and I wouldn’t be
at an airline history and I wouldn’t be
at an airline history and I wouldn’t be standing here now it’d be wonderful to
standing here now it’d be wonderful to
standing here now it’d be wonderful to be able to tell you because of my
be able to tell you because of my
be able to tell you because of my prowess as a commander I had brought
prowess as a commander I had brought
prowess as a commander I had brought this guy into the loop bull it’s because
this guy into the loop bull it’s because
this guy into the loop bull it’s because we had some very smart people who had
we had some very smart people who had
we had some very smart people who had begun to retrain us and the things that
begun to retrain us and the things that
begun to retrain us and the things that we were learning in the aviation
we were learning in the aviation
we were learning in the aviation industry
industry
industry about human failure and about the fact
about human failure and about the fact
about human failure and about the fact that the main buttress to human failure
that the main buttress to human failure
that the main buttress to human failure is a team and if you don’t have the
is a team and if you don’t have the
is a team and if you don’t have the luxury of a team at least systems like
luxury of a team at least systems like
luxury of a team at least systems like my system of using the calendar see we
my system of using the calendar see we
my system of using the calendar see we can’t go to what’s next successfully
can’t go to what’s next successfully
can’t go to what’s next successfully whether it’s facing the singularity
whether it’s facing the singularity
whether it’s facing the singularity whether it’s facing all sorts of a
whether it’s facing all sorts of a
whether it’s facing all sorts of a political realignment we’re trying to
political realignment we’re trying to
political realignment we’re trying to get as was stated and another wonderful
get as was stated and another wonderful
get as was stated and another wonderful lecture about medicine and where we have
lecture about medicine and where we have
lecture about medicine and where we have to go to have a system we can’t do any
to go to have a system we can’t do any
to go to have a system we can’t do any of that unless we understand ourselves
of that unless we understand ourselves
of that unless we understand ourselves and our failure modes and how to get
and our failure modes and how to get
and our failure modes and how to get past them but the good news is we can do
past them but the good news is we can do
past them but the good news is we can do this so easily it’s just about being
this so easily it’s just about being
this so easily it’s just about being honest about who we really are
honest about who we really are
honest about who we really are and how we can get to zero impact from
and how we can get to zero impact from
and how we can get to zero impact from any failure that we can’t prevent thank
any failure that we can’t prevent thank
any failure that we can’t prevent thank you so much
you so much
you so much [Applause]
”
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