LMOL 607 - Pope - Assignment 1

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Church Leadership Lessons from Tragedy and Swiss Cheese Introduction On July 4, 2010, I set fire to the church where I served as the Senior Associate Pastor. I did not mean to, but I made multiple mistakes. It felt like Alexander in the movie "Alexander and the Terrible, Horrible, No Good, Very Bad Day" (Wikipedia, 2014). Edsel Murphy coined another saying: "If anything can go wrong, it will go wrong" (Angelo State University Faculty, n.d.). In 1977, there was a tragic plane crash in Tenerife, located in the Atlantic Ocean off northwest Africa. Tenerife is the largest of Spain's eight Canary Islands (Finlay, 2020). Two 747s full of people crashed into each other on the runway before either had taken off. How does something like that happen? How do people who have received massive amounts of training and are highly competent make such costly decisions (Flavin, 2020)? This article aims to help church leaders learn some valuable lessons as we look at this tragedy and eight of the many factors that led to it. In addition, we want to look at how two of those lessons apply to church leadership so that we do not have to experience a crash or a fire ourselves. Body March 27, 1977, two planes full of people headed to Las Palmas Airport in Spain's Canary Islands. One flight, KLM 4805, was headed from Amsterdam with people taking a vacation on the island. Pan Am 1736 was a chartered flight with passengers who would get on a cruise

ship on the island and head out to sea. Between the two flights, there were 644 passengers and crew. Before the sun would set that evening, 583 of them would lose their lives in the worst aviation crash in history (MentourPilot, 2021). Why did it happen? It happened because of a series of unique, cascading coincidences (CBS, 2017). We will look at eight of them. 1. Terrorist Act at Destination Airport Spain was in a transition from a dictatorship to a democracy in 1977. There was a group called MPAIAC, an independence movement for the Canary Islands (Bird, 2022). Two men left a backpack in the airport flower shop and departed the airport. A person claiming to be part of MPAIAC called the airport, claiming to have planted bombs in the airport and that they had fifteen minutes to clear. Fifteen minutes later, the bomb exploded, leading them to shut down the airport until they could clear it (MentourPilot, 2021). With Las Palmas closed, several incoming flights, including KLM 4805 and Pan Am 1736, were re-routed to Los Rodeos Airport in Tenerife (Finlay, 2020). 2. Re-routed Airport was Not Ideal March 27, 1977, was a Sunday. Tenerife was not accustomed to heavy daily traffic but ran with an even lighter staff on Sundays (Flavin, 2020). Los Rodeos was the nearest airport, but a better option was just minutes farther away in Fuerteventura. Los Rodeos also had a poor safety record, averaging one crash per year. During one stretch from 1965 to 1968, they had crashes that resulted in 98 casualties. They also built a new regional airport, the completion of which stalled due to politics. Because of that, they had not upgraded Tenerife with ground radar, and their centerline lights were inoperable (MentourPilot, 2021).

3. Weather When the planes landed, the weather and the visibility were favorable. However, with the delays from Las Palmas getting cleared, clouds rolled off the nearby mountains, and visibility became very poor. Without ground radar, the Air Traffic Controller could not see the planes at all, and the pilots and their crew had difficulty seeing the markers on the runway as they were to taxi (Finlay, 2020). 4. Time-Pressure for KLM Crew The mood on the Pan Am flight was light. The flight crew gave tours of the cockpit as they tried to make the best out of the situation. Not so on the KLM flight. The captain, first officer, and flight engineer fretted about the recent changes in Dutch flight time limitations (Finlay, 2020). If they did not get in the air soon, they might have to spend the night at Las Palmas instead of returning to Amsterdam. They were anxious to get going (MentourPilot, 2021). 5. KLM's Gamble to Refuel Due to the time crunch, Captain Van Zanten makes a fateful gamble. If they were to refuel now, in Tenerife, when they got clearance, they could fly to Las Palmas, disembark their passengers, and take to the air again quickly. He was betting that the delay would take an hour or longer. Another risk in refueling at Los Rodeos was making the 747 15% heavier, requiring a higher speed to take off. After just minutes of refueling, the crew gets word that Las Palmas has re-opened (MentourPilot, 2021). The KLM plane received its fuel in a way that unintentionally blocked Pan Am from traveling around it. Other smaller crafts could circumnavigate around it and get on their way. However, the Pan Am plane was too large (Finlay, 2020).

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Had Captain Van Zanten not made this decision to refuel, both 747s would have taken off in nearly perfect weather. Instead, while KLM was refueling, a thick blanket of fog rolled down from the mountains (Finlay, 2020). 6. Complex Plan to Taxi Once refueled, the plan was for the KLM crew to lead the Pan Am crew on a complex, coordinated maneuver called a 'back-taxi'(Flavin, 2020). This option is rarely used at commercial airports as it simultaneously puts two planes on the runway (Finlay, 2020). The plan was for KLM to taxi to the end, make a 180-degree turn, and prepare for takeoff, while Pan Am was to take the third exit and be off the runway before takeoff (MentourPilot, 2021). 7. Unclear Communication There needed to be more clarity about the Air Traffic Controller's directions regarding the complex taxiing maneuver. Language was also a factor, as the accent of the controller was challenging to understand. It was common back then to use radio systems like walkie-talkies. Two people conversing simultaneously could not hear the message (Flavin, 2020). When KLM said they were ready for takeoff, Pan Am responded that they were still on the runway, while the controller responded by asking them to wait for permission to take off. This created a loud squeal, and KLM missed the message and kept progressing (Finlay, 2020). When KLM completed its back-taxi action, they requested clearance for takeoff. The controller gives takeoff route clearance but not the takeoff clearance. However, Captain Van Zanten heard the word takeoff, assumed that clearance was permission to take off, and pushed the

throttle forward to start accelerating. The explanations, directions, and communication were ineffective, resulting in inappropriate actions (Denton, 2012). 8. Team Dynamics for KLM flight Captain Van Zanten was the face of KLM Airlines, literally. He was on their billboards and magazine ads (CBS, 2017). He was the most experienced KLM airline pilot and a senior training captain. How did that impact the flight deck (Gilbert, 2022)? He was the trainer, the model, and his word was correct. Interestingly, when KLM headquarters heard that one of their planes was involved in a crash, they searched for Captain Jacob Van Zanten to investigate what happened (CBS, 2017). The flight engineer from KLM heard Pan Am say they were still on the runway, and he asked, "Is he not clear then?" Captain Van Zanten responds "Yes" with certainty and rushes into tragedy (Bird, 2022). This is where the Swiss Cheese comes in. The Swiss Cheese Model (see image) points out that mistakes, accidents, or tragedies are believed to occur when multiple defense systems fail. The metaphor pictures a stack of sliced Swiss cheese, where each slice represents a barricade, and each hole represents some gap or failure in the system. An error can pass through all the layers when the holes align, resulting in tragedy (Pugliese & Barton, 2023, p. 997).

Multiple systems and barriers failed simultaneously, allowing the holes to align and form a perfect "trajectory of accident opportunity" (Bird, 2022). Recommendations How does this tragedy as a metaphor affect church leadership? There are multiple ways, but here are two highlights: The Importance of an Open Leadership Culture Out of the Tenerife tragedy came the development of Crew Resource Management. Former pilot Peter Docker described how he relayed that responsibility to his first officer. "Your job is to watch me and catch me if I make a mistake or say something that you think is incorrect. Your job is to speak up. You got it" (Gilbert, 2022). Church leadership aims to foster a culture where the team feels empowered to state their opinions to leaders without fear (Flavin, 2020). It creates lots of trust when the team knows their leader will not only listen but seek input from them and will act on their suggestions (Denton, 2012, p. 19). That kind of culture is what Patrick Lencioni describes with five phrases:  They trust one another – They can admit mistakes.  They can have healthy conflict – There is an atmosphere where all opinions are expected and welcome.  They commit to the decisions made – This can only happen when everyone feels that the group and the leader have adequately heard their opinion.  They hold one another accountable – Has everyone done what they said they would?

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 They focus on results –How the organization does rather than how well one individual performs over another (Lencioni, n.d.). When the team can be honest, transparent, and ego-free, it creates high trust and an open leadership culture that closes some of the holes in the Swiss cheese. That dynamic was missing on the KLM flight. Creating this kind of culture on the team requires humility by the leader. The type of humility that Jesus exhibited, and Paul taught when he said, "Do nothing out of selfish ambition or vain conceit. Rather, in humility value others above yourselves" (Bible, 2011, Philippians 2:3). Clear Communication There were multiple places where miscommunication resulted in this terrible crash at Tenerife. From the unclear words chosen to the squeal on the radio to the heavy accents to using the word takeoff but only talking about the route clearance, to being in a rush and needing to verify that they heard what they thought they heard thoroughly. In communication, there is the transmission and the reception. The speaker must transmit a clear message, and the receiver must also receive it (Gilbert, 2022). What the team hears is essential, but what they understand is more important. Thus, a good practice is to have them explain what they believe was meant (Bird, 2022). Communication is only complete once both parties have a shared understanding. Daily, that requires the leader or the follower to ask for clarification and not be embarrassed to ask questions of anyone, whether above or below them on the org chart (Denton, 2012, p. 21). Conclusion

There is a saying, "God never wastes a pain." Taking the time to evaluate tragedies like the Tenerife crash of 1977 and looking for what we can learn from that terrible event will help us lead in better ways that put a barrier up so that the Swiss cheese holes do not align. Remember this tragedy and the important lessons it has. To maintain an influential leadership culture, you must be able to communicate clearly with your team and be mindful of the potential for high costs if you do not. That will help you never to have a terrible, horrible, no- good, very bad day. References Angelo State University Faculty. (n.d.). Cheap Thoughts - Murphy's Laws . Retrieved from Angelo State University: https://www.angelo.edu/faculty/kboudrea/cheap/cheap3_murphy.htm Bible. (2011). New International Version. Grand Rapids: Zondervan. Bird, E. (2022, March 8). Tenerife — A Tragedy of Errors 1977 The Many Causes of the Deadliest Aviation Disaster . Retrieved from Medium.com: https://medium.com/lessons-from- history/tenerife-a-tragedy-of-errors-1977-21530b65430 CBS. (2017, March 27). CBS Remembers Deadliest Aviation Disaster at Tenerife . Retrieved from YouTube.com: https://www.youtube.com/watch?v=bJkLrLwmV0Y de Kok, K., van der Scheer, W., Ketelaars, C., & Leistlkow, I. (2023). Organizational attributes that contribute to the learning & improvement capabilities of healthcare organizations: a scoping review. BMC Health Services Research , 1-14. Denton, D. K. (2012). ‘‘Let me make this clear’’: creating high trust organizations. Development and Learning in Organizations , 19-21. Retrieved from https://www.emerald.com/insight/content/doi/10.1108/14777281211225776/full/pdf Finlay, M. (2020, October 4). Tenerife Airport Disaster: How It Happened And What We Learned . Retrieved from Simple Flying: https://simpleflying.com/tenerife-disaster/ Flavin, S. (2020, October 5). Captive Resources . Retrieved from Captiveresources.com: https://www.captiveresources.com/insight/what-the-tenerife-disaster-can-teach-us- about-human-performance/#:~:text=The%20Importance%20of%20Standardizing %20Processes,hard%20to%20formalize%20these%20processes.

Gilbert, S. (2022, February 18). Tenerife Airport Disaster - The Lessons Learned . Retrieved from YouTube: https://www.youtube.com/watch?v=UkQ-dwF9158 Lencioni, P. (n.d.). The Five Behaviors . Retrieved from fivebehaviors.com: https://connect.fivebehaviors.com/become-a-partner/?utm_id=go_cmp- 17374076304_adg-145767963748_ad-664928925797_kwd-316195101330_dev-c_ext- _prd-_mca-_sig- Cj0KCQiA2KitBhCIARIsAPPMEhIILTYXxA9yEct_sepymoFz2GN1DtFqlrKHJAWq8JmaOrgiQJZ YPmcaAr3IEALw_wcB&utm_sourc MentourPilot. (2021, December 11). What Really Caused the Tenerife Airport Disaster? Retrieved from YouTube.com: https://youtu.be/2d9B9RN5quA?si=jD6GQAna8y9ytMai Pugliese, B. J., & Barton, B. K. (2023). Slicing Through the Layers of Pediatric Unintentional Injury With the Swiss Cheese Model: A Topical Review. Journal of Pediatric Psychology , 995- 1002. Wikipedia. (2014). Alexander and the Terrible, Horrible, No Good, Very Bad Day . Retrieved from Wikipedia.org: https://en.wikipedia.org/wiki/Alexander_and_the_Terrible,_Horrible,_No_Good,_Very_ Bad_Day_(film)

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