1987, Northwest Airlines Flight 255, MD-82, Crashes After Takeoff in Detroit, Killing 156 People.

Happy Friday!

On this day, August 16, 1987, Northwest Airlines Flight 255, a McDonnell Douglas MD-82, crashed after takeoff in Detroit, Michigan, killing 154 of the 155 on board, plus two people on the ground. This tragedy underscores the need for proper procedures and a robust safety culture in high-stakes environments. Flight 255 was scheduled to fly from Detroit Metropolitan Wayne County Airport to Phoenix, Arizona, with a stopover in Santa Ana, California. The aircraft began its takeoff roll at 20:45 local time, but shortly after becoming airborne, the plane rolled from side to side, struck a light pole and the roof of a car rental building. It then crashed onto Middlebelt Road and burst into flames, coming to rest against a railroad overpass. The National Transportation Safety Board (NTSB) investigation revealed that the flight crew had failed to extend the aircraft’s flaps and slats for takeoff, which are crucial for providing the necessary lift during this phase of flight. The investigation also found that the cockpit voice recorder captured sounds consistent with the takeoff warning system, which should have alerted the crew to the improper configuration. This crucial evidence was obtained from the aircraft’s ‘black box’, which records flight data and cockpit conversations, highlighting its importance in understanding and learning from aviation incidents. However, for reasons that remain unclear, the crew either did not hear or chose to ignore these warnings. This disaster led to significant changes in airline safety procedures and pilot training, emphasising the importance of adhering to checklists and responding appropriately to warning systems.

Change Leadership Lessons: As change leaders, we must view failures and near misses as opportunities for learning and improvement. Conducting thorough evaluations and implementing lessons learned are crucial for preventing future incidents. It is essential that leaders of change enforce rigorous procedures by implementing and strictly adhering to checklists and standard operating protocols, as even experienced professionals can make critical errors when deviating from these established guidelines. They cultivate a safety-first culture, fostering an environment where every team member feels responsible for upholding safety standards and is empowered to voice concerns without fear of reprisal. Change leaders guard against complacency, ensuring their organisations implement continuous training and role rotation, keeping teams engaged and alert to prevent the onset of potentially dangerous routines. They know it is crucial to balance technology with human judgement; while technological safeguards are vital, team members must be trained to understand, respect, and appropriately respond to these systems. Leaders of change establish formal processes for analysing implementation failings to ensure that lessons learned are widely disseminated and integrated into future change and transformation initiatives. Apply Change Lessons Learned or Repeat Failure.

“Effective change leadership demands rigorous procedures, a safety-first culture, vigilance against complacency, balanced technology use, and continuous learning from both successes and failures”  

Application - Avoiding the Charade of Change: Just as the airline industry implemented rigorous checklists and warning systems post-incident, organisations should establish formal ‘change checklists’ and feedback mechanisms to ensure critical steps aren't overlooked during organisational change. To prevent the charade of change and ensure lasting organisational improvement, leaders must prioritise continuous learning and the retention of lessons learned. Without proper documentation and knowledge transfer, valuable insights can be lost, hindering future efforts and leading to repeated mistakes. Effective change closure involves documenting benefits, capturing lessons learned, and completing knowledge transfer, thereby preventing knowledge drain and supporting continuous improvement. Change leaders should foster a culture that values reflection and learning from both successes and failures. By assessing past initiatives, organisations can identify effective strategies and avoid repeating ineffective practices, reducing risks like resistance amplification and cultural misalignment. To combat the loss of institutional knowledge, especially with leadership turnover, change sponsors must ensure comprehensive documentation and accessible knowledge management systems. This approach ensures valuable insights are preserved for future initiatives, moving beyond the charade of change to create a foundation for genuine, sustainable transformation. This practice enhances change management capabilities and fosters organisational agility and resilience in the face of ongoing challenges and opportunities. 

Final Thoughts: As we reflect on the lessons from Flight 255, consider: How can your organisation create a ‘black box’ for change initiatives? What systems can you implement to capture, analyse, and apply lessons learned from both successful and failed changes?

Further Reading: Change Management Charade - Leadership of Change Volume 8

Have a fantastic weekend with the ones you love and care for, enjoy some fresh air, exercise, eat, drink and be happy.

Peter consults, speaks, and writes on the Leadership of Change^®. He advises CEOs on how to prepare and align their corporate leadership teams to successfully lead their organisation's change.

For further reading please visit our websites: https://www.a2b.consulting  https://www.peterfgallagher.com Amazon.com: Peter F Gallagher: Books, Biography, Blog, Audiobooks, Kindle

Leadership of Change® Body of Knowledge Volumes: Change Management Body of Knowledge (CMBoK) Books: Volumes 1, 2, 3, 4, 5, 6, 7, A, B, & C available on both Amazon and Google Play:

~ Leadership of Change® Volume 1 - Change Management Fables

~ Leadership of Change® Volume 2 - Change Management Pocket Guide

~ Leadership of Change® Volume 3 - Change Management Handbook

~ Leadership of Change® Volume 4 - Change Management Leadership

~ Leadership of Change® Volume 5 - Change Management Adoption

~ Leadership of Change® Volume 6 - Change Management Behaviour

~ Leadership of Change® Volume 7 - Change Management Sponsorship

~ Leadership of Change® Volume A - Change Management Gamification - Leadership

~ Leadership of Change® Volume B - Change Management Gamification - Adoption

Coming Summer 2024: 

Change Management Charade - Leadership of Change Volume 8

By Peter F Gallagher

Keywords: Business Strategy, Change Management, Leadership