The Gimli Glider had a crash landing on a small former Royal Candian Air Force Base in Gimli, Manitoba, hence where it got the nickname.
It was not just one thing that resulted in the aircraft having to make an impromptu stop in the middle of Canada, but a number of mistakes over time that cumulatively resulted in gravity overcoming the flying metal bird.
First was a unit conversion error, on July 22nd 1983 the Air Canada Boeing 767 had its routine checks. An engineer found that the fuel-quantity indication system (FQIS) was faulty. That meant that they would have to manually do a dipstick reading for one of the channels.
Captain Weir was told about this and converted the dipstick reading from centimetres to litres to kilograms. It all checked out and so they flew to Montreal.
At Montreal, Weir passed on the captaincy to Bob Pearson. Weir told Pearson about the FQIS and Pearson decided to take on enough fuel to make it to Edmonton. At the same time, an engineer was in the cockpit and enabled the defective channel and performed an FQIS self-test. He left the channel enabled after the failed self-test. Pearsons went back into the cockpit and found the FQIS blank, as expected.
Pearson did a dipstick reading and converted it as Weir did before but he converted it to pounds/litre as per the Air Canada refuelers slip, which they use for all aircraft in the fleet except the all-metric 767 which needs to go kilograms/litre.
The plane got to Ottawa without a problem and then another dipstick measure was taken in pounds/litre and it appeared that the plane had enough fuel so no more fuel was loaded.
While flying over Red Lake, Ontario, the fuel-pressure warning went off in the cockpit. Assuming a fuel pump had failed the pilots turned off the alarm because the engine could be fueled with gravity while flying level.
Seconds later the left engine failed, then the right engine,
The plane was never meant to fly without all engines, it had an electronic flight instrument system which needed power from the engines to operate.
And so they were going down.
Seven Errors
Malcolm Gladwell talks in his book Outliers that “the typical plane crash involves seven consecutive human errors.”
As flight Air Canada 143 shows, it is not one thing that ruined your project.
It also highlights that at multiple points along the way the error could have been second-guessed and corrected.
There was no fatal decision, just a bunch of smaller decisions along the way.
Circle Back and Be Clear
At the start of the project, you want to be clear on what success looks like. What information do you know, and what your assumptions are.
Periodically, you want to go back and assess them. Do we know any new information? Are the things we thought we knew still correct? Are there any new assumptions?
If there are any changes to what you know or assume, then you will need to look at what success is and update that.
Continuing to work towards a goal that is no longer valuable because it is what you started trying to do is wasting everyone’s time and corrodes trust in leadership.
Being clear that the team has learnt more, updated plans and now recognising their efforts with new information demonstrates that you can learn and grow and that your team should follow.
Luke McMeeken-Ruscoe 