If Somebody Made a Mistake that Nearly Killed You…

In 1989 an air show was held at Brown Field in San Diego.

The test pilot Bob Hoover was taking thrill seekers for flights in his Shrike Commander, a small, piston powered, passenger plane.  The passengers were known as “Hoover’s Heavers” — more often than not they were sick during the flight.

On this occasion the Heavers got more of a thrill than they paid for.

When the plane had climbed to 300 feet it lost all power and gravity started to pull it relentlessly back to earth.  Bob Hoover managed to cut the air speed and safely crash landed the plane uphill onto the side of a ravine.  The plane was severely damaged, but he and his two passengers walked away.

What caused the power failure?

This was the question spinning in Bob Hoover’s mind as he sat on the hillside waiting to be rescued.  So he walked back to the plane and smelled the fuel.

Instead of gasoline it was jet fuel.  A member of the ground crew had mistaken the piston engined plane for a turboprop and mis-fuelled it.

A simple mistake, as easy as putting petrol in your diesel engine, but rather more dramatic.

Of course there were consequences:

The accident lead to a simple process improvement, the development of the Hoover Nozzle, a filling mechanism that prevents the inadvertent filling of a gasoline powered plane with aviation fuel.

But there was a more remarkable outcome

When he returned to the air field Bob Hoover walked over to the man who had nearly caused his death and, according to the California Fullerton News-Tribune, said:

“There isn’t a man alive who hasn’t made a mistake. But I’m positive you’ll never make this mistake again. That’s why I want to make sure that you’re the only one to refuel my plane tomorrow. I won’t let anyone else on the field touch it.”

Is it an urban myth?

Perhaps the story is a little too good to be true; the source is Bob Hoover’s own autobiography — in my autobiography I will also be a saintly hero — but half truth or not the really interesting questions are…

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Image by BonzoESC

Comments

  1. Hi James. Happy New Year!

    Thanks for sharing this story about Bob Hoover. His gesture was indeed a noble one. I know I would hesitate to place my life in the hands of someone who had nearly ended it — unless I knew that the risk of it happening again had been removed. I’m wondering, how could he know that the fueler would not become distracted somehow? Did he not realize that the same flaw that had allowed the error still existed? Guess it was a risk he was willing to take.

    As noble as his gesture was, it may not be best answer from an organizational standpoint — trusting that an operator has learned a lesson and will do better next time. The goal is to negate the chance of the mistake happening again, regardless of operator. His response was more operator-centered than process-based. Unfortunately, this is an all-too-frequent result of various root-cause analysis efforts — they center on the person, punishment, etc., rather than the process and environment that led to the error. Glad to hear the example above eventually led to a simple structural change to prevent the error from happening again. One less thing for the operator — and, in this case, the fliers/passengers — to remember and worry about.

    Thanks again for sharing.

    • James Lawther says:

      I totally agree Mark. I think the key is for the two approaches to go hand in hand. Don’t blame the person, fix the system.

      James

  2. Ilkka Toijala says:

    Hello James,

    Thank you for the story. For me it brings up a couple of very important points.
    The first is how we react on mistakes. I’m convinced and it is my experience that the vast majority of people want to do their job as good as possible. This means that in most cases we find the root cause of mistakes or bad performance in the way the work is organized, what kind of tools or facilities we have or how the people are trained.The blame culture seems somehow to be the natural reaction and it is not easy to keep the investigation of the issue on the facts without claiming the people. Here the behavior of the management is very important. It takes years of consistent work to create such a culture, but it does not take much to harm it. The reward is that the real reasons are understood and can be worked out. The way we react has a big influence in the working atmosphere. People who feel safe, fare handled and empowered feel good about the work and can and want to achieve excellent results.
    The other issue is that in some cases as in this story systems are designed so that a mistakes are just waiting to happen. When designing work processes, tools and systems we should always seek to minimize the risk of mistakes. In many cases simple low cost solutions may reduce the risk considerably.

    Regards
    Ilkka

    • James Lawther says:

      Ilkka,

      Thanks for your comment, I totally agree with your points, particularly how long it takes to create such a culture and how quickly it can be destroyed.

      James

  3. Hi James,
    Your story reminds of a situation in the second season of The Wire (I’m currently ploughing through the box set), where Lt. Cedric Daniels brings Sgt. Ellis Carver back onto his team after his was disloyal in the first series. Lt. Daniels’ rationale was that Carver, currently on traffic duty, was less likely to make the same mistake twice.

    Like Hoover’s situation, this illustrates the perspectives that Hoover and Daniels take when it comes to people….believing that is does not good to rest on blame and positively believing in the potential of people.

    Fixing the system is one thing but to get the most out of people we also have to believe in them.

    Adrian

  4. Hello James

    I thank you for sharing this story. I find myself touched by the story and in particular Bob Hoover’s behaviour. It occurs to me that I would love to imagine myself acting as calmly-generously as Bob Hoover did. The reality, is that just about every part of my being would be screaming at the “idiot’ who almost got me killed.

    Stepping beyond the gap between my being and Bob Hoover’s being, it occurs to me that Bob Hoover has a deep insight into human nature. It occurs to me that he is operating from the stance that being cooperative is as fundamental to a human being as is being competitive. And there is absolutely that generates trust-gratitude then being forgiven (for a huge mistake) and being trusted with one’s life. Imagine you were the guy who had put the wrong fuel in. That you realised what you had done. And Bob related-interacted with you as he describes in his autobiography. How would you go about refuelling his plane? Would you not take every care in the world? Would you want to let Bob down?

    All the best
    maz

  5. James,

    I am really not sure whether I can be very cool headed at that time. As human beings we all tend to lose control at times but I feel it is natural. I can be “reactive or responsive” based on the situation and act accordingly.

  6. All
    I have worked for many managers, the ones that have moved me forward as a worker & person were the ones that never apportioned blame. they were pragmatic, first reactions were deal with mistake, 2nd what did you(we) learn, finally don’t make the same mistake again, closed & move on!

    When the blame game starts or people constantly work in a way that enables them to “CYA” all sensible productivity is lost in route causing, learning & building relationships of trust. You end up with “villains” & “hero’s”, who always need to be seen in the limelight as the go to people for solving everything.

    Culture drives this within companies, do as I do not do as I say, lead by example as from the film Remember the Titan’s “Attitude reflects leadership”.

  7. James Lawther says:

    It is very difficult, I think Peter explains the way we should behave, but Bindiya explains the way most of us do.

    I suppose the trick is to go out and take a — long — walk before you respond.

    Easier said than done.

  8. Luke Pollard says:

    Great story. We have a term on the Blue Bus for this we call an “Excellent Failure”.
    If Hoover didn’t see this simple error as an Excellent Failure a few things may have happened;
    1) They would have sacked the fuel fuel boy as the answer/ solution.
    2) Someone else would have had to invent the Hoover nozzle to eliminate it happening again.
    3) They would have implemented a checklist, & a check the check list, & an audit to make sure the correct process was being followed.
    All 3 actions unfortunately lead to waste & mediocrity.

  9. Hoover is well known to embellish stories. The crash did in fact happened but the rest is probably tale.

  10. James,

    You’ve made an error in writing at your website that Bob Hoover had an accident in his Rockwell International Shrike Commander in 1989 at San Diego Brown Field. It’s understandable, considering that Mr. Hoover, himself, writes that it occurred in 1989 in “Forever Flying”, his autobiography.

    The accident actually occurred on May 27, 1978, according to NTSB records:

    http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=42434&key=0&queryId=e2107cea-4764-402b-b0c9-08de9f277398&pgno=1&pgsize=20

    Bob and I discussed the event. He now recalls that it indeed did occur in 1978 and not 1989.

    All the best from San Diego, some 25 miles north of Brown Field.

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  1. […] In 1989 an air show was held at Brown Field in San Diego. The test pilot Bob Hoover was taking thrill seekers for flights in his Shrike Commander, a small, piston powered, passenger plane. The pas…  […]

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