In May 2021, a small plane crash in Tennessee killed weight-loss guru Gwen Shamblin Lara and her husband, actor Joe Lara, along with five others. Just recently, the National Transportation Safety Board (NTSB) issued its final report on the crash, stating that it most likely happened when Joe, who was piloting the plane, became disoriented in heavy clouds.
Personally, I believe the NTSB missed the mark when they cited “pilot error” as the cause of this crash. The heart of the case is laid out on the fifth page of their report. I found it interesting that one of the pilot’s flight instructors, William Lardent, told investigators the pilot “struggled when forced to rely on instruments in low visibility” and he “was a safe pilot but had trouble with multitasking and with situational awareness.”
Although the NTSB attributes the primary casual factor to pilot error and spatial disorientation, based on the flight instructor’s comments, I would point to the root cause of poor training and certification processes for allowing the pilot to have an instrument rating when he was not able to reliably fly in poor weather conditions. This is similar root cause that led to the death of Kobe Bryant when his helicopter pilot got into extremis when he went into the clouds in mountainous terrain north of Los Angeles and experienced vertigo and loss of spatial orientation.
In this mishap, I would point to spatial disorientation and uninformed skills as the two primary human errors, which can be thought of as symptoms of larger system weaknesses. Both point to inadequate training and oversight system-level structures that all complex, high-risk organizations need to have in place to ensure people working are qualified, trained, and proficient to do the jobs that are being asked to do by the organization.
James Reason, who many consider to be the father of modern human error and systems thinking, coined the term “blunt end–sharp end,” which refers to system-level influences on individual behavior that leaders need to design, monitor, and continuously improve. Culture is one of the strongest system-level influencers of individual behavior at the sharp end. In this tragic event, there seem to be cultural contributions that could be attributed to the FAA, aviation industry leadership, the flight school, or even the instructor in that they failed to provide adequate command or assignment in response to an emergent issue (based on the voiced concerns regarding the pilot’s struggles flying in instrument conditions).
It's unfortunate to see a completely unpreventable event led to the death of seven people. But similar events happen in healthcare when leaders don’t ensure their people are adequately trained or proficient, or fail to provide proper oversight, resources, or other people for staff to rely on until expertise is built over time. These are two critical roles of any HRO leader who works in a complex, high-risk environment that is unforgiving of failure.