The Bleeding Obvious

Mens sana in corpore sano

In the early years after the second world war, health researchers in Britain noticed a curious epidemic: people had begun dying of heart attacks in unprecedented numbers. Nobody knew why, and so a scientist in London named Jerry Morris set up a vast study to examine the heart-attack rates in people of different occupations – schoolteachers, postmen, transport workers and more.

“The very first results we got were from the London busmen,” says Morris.

“And there was a striking difference in the heart-attack rate. The drivers of these double-decker buses had substantially more, age for age, than the conductors.”

The data were so telling because drivers and conductors were men of much the same social class.

There was only one obvious difference between them. “The drivers were prototypically sedentary,” explains Morris, “and the conductors were unavoidably active. We spent many hours sitting on the buses watching the number of stairs they climbed.” The conductors ascended and descended 500 to 750 steps per working day. And they were half as likely as the drivers to drop dead of a sudden heart attack.

Today, almost everyone understands that physical exercise can help prevent heart disease, as well as cancer, diabetes, depression and much else besides. But on that day in 1949 when Morris looked at the bus data, he was the first person to see the link. He had inadvertently – “mainly luck!” – stumbled on a great truth about health: exercise helps you live longer.

Morris’s own mission of the late 1940s was heart disease. He spent “interminable hours” reading the postmortem folios of the London Hospital in the East End for 1907 to 1949. But he still couldn’t understand why heart attacks were increasing.

“We were in the fortunate situation,” he says, “that very ­little research had been done on it. It might be hard for you to imagine a time when heart attack wasn’t a major preoccupation of everybody.” Today, heart disease is the most common cause of death in western countries.

“The only hunch I had was that this might be related to occupation. It was commoner in men than women, it was commoner as middle age advanced, and there were some hints in the national statistics of mortality that it might be connected in some way to occupation.”

The busmen’s data were fascinating, and the sample size was thousands of men. But Morris didn’t treat it as proof of anything. In what he has called “one of the tensest moments of my professional life”, he had to wait for data to arrive for other occupations. Finally, he got the figures for postal workers. “It was strikingly similar!” he says. The postmen who delivered the mail by bike or on foot had fewer heart attacks than sedentary men who served behind counters or as telephonists and clerks. It was true: exercise prevented heart disease.

And yet Morris sat on his data for years. If there were flaws in his theory, he was determined to find them before anyone else could. “We set about destroying this observation,” he says. “We brought in outside people with no blood in their veins, no interest, to destroy it.” But they couldn’t. His paper (“Coronary heart-disease and physical activity of work”) finally appeared in The Lancet in 1953. His hypothesis, as he still called it, was greeted with general disbelief. What could exercise possibly have to do with heart attacks? True, there had always been a vague belief that exercise was good for the soul.

Even he had no idea how exactly the mechanism worked. Only after his paper appeared did the physiologist Henry Taylor sit him down for a solid day in a Washington hotel room and, in Morris’s words, “schoolboy-taught me the physiology of exercise”. Morris thinks the essential story is simple: “Exercise normalises the workings of the body.” Humans were meant to keep active.

With hindsight, his London bus drivers inhabited one of the first societies on earth where exercise was ceasing to be part of daily life. Technology was letting people grow slothful. Even in the 1950s, Morris foresaw that when poor countries developed, they would have the same problems. He remembers warning then: “Their time will come to develop these diseases, and not to make the mistakes that we made, eg a lack of exercise, eg smoking, eg our lousy diets. Of course, nobody paid any attention.”

**

Upon reading about the man that discovered exercise, it got Honestly Lay Bare thinking.

What is it that is plain for all to notice by no one can?

What is that the practitioners of internal audit, risk management and corporate governance are missing that will make eternal and fundamental sense of the world in which we ply our trade?

Honestly Lay Bare is going to start the ball rolling on this one.

Our nomination for the Bleeding Obvious That Has Yet to Be Found is something (well we would be more precise but by definition we cant because we actually wont know it until we see it) to do with the importance of communication within an organisation in improving its internal control culture.

We all seem to know that that is the case in the same way that we now accept that exercise is good for a healthy heart.

But we have no way of measuring it to prove it.

Indeed when it comes down to it – internal audit, risk management and corporate governance have little in the way of measurements to prove their hypotheses (and some would say, worth).

And therein perhaps lays our equivalent of riding a London bus observing the world.

What is the one measure that proves our worth?

And who amongst us will find it.

Post based in part on “The Man Who Invented Exercise”. The Financial Times by Simon Kuper. September 11, 2009

The Art of the Ditch

Education is an ornament in prosperity and a refuge in adversity

Here at Honestly Lay Bare central it is fair to say that we are inundated with examples of the worst execution of internal controls, risk management and corporate governance.

That is, paradoxically, good for us as it gives us a never ending stream of case studies to dissect and analyse.

But we don’t want to be just seen as the carcass finders of our profession.

So today we examine an event that had its first anniversary just under a week ago.

It is a case study of people and machinery responding exactly as one would hope it to react upon the occasion of an unfortunate event.

It is a case study that is worthy of repeating throughout the ages.

It is the art of the ditch.

**

Not long after takeoff from LaGuardia last January 15, as the Charlotte-bound US Airways flight was climbing out smoothly over the Bronx on a northerly heading, something hit the airplane.

Something that seemed big.

There was a loud noise and a collective gasp from the passengers. Some of them had seen something like a flash of brown going into the engines. The airplane began to wiggle a little and decelerate. The flight attendants were still strapped in their seats not near any windows, but they guessed what had happened. There was a smell of something burning. It had become completely quiet. There was no word from the cockpit.

A woman would text her husband, "My flight is crashing."

The airplane was not crashing, but it was definitely headed down.

At about 2,500 feet it had collided with a flock of Canada geese flying southwest; geese are not uncommon in the New York area, their ancient migratory routes passing over it. At least five birds had hit the plane, three or more going into and virtually destroying both engines. The copilot, Jeffrey Skiles, had been at the controls, and he and the pilot, Chesley Sullenberger, had suddenly seen, at the same time, the flock of geese slightly above and ahead.

"Birds!" Sullenberger cried just before they hit.

"Whoa!" Skiles said.

They were fortunate that a bird—Canada geese are large—hadn't crashed directly into the windshield, but the engines were already banging and winding down. Fire was coming from both of them, flames from one and fireballs from the other.

Briefly, for some fifteen seconds, Sullenberger tried to restart the engines and also, more or less instinctively since it was not part of the procedure, he started an auxiliary power unit in the tail to maintain electrical power. His pulse rate must have been high, but he said calmly, "My aircraft," and took over the controls.

Sullenberger was almost fifty-eight years old, an experienced and steady captain who had been flying since he was sixteen. He had learned to fly in high school in Denison, Texas, from a grass field and had gone on to the Air Force Academy and the beginnings of a career as a fighter pilot, during which he had flown a Vietnam-era fighter, the F-4 Phantom.

He had never, in his long flying career, had an engine failure. It was hardly surprising since jet engines are simple in design and extremely reliable although subject to damage if anything reasonably substantial comes into the intake. He called New York Approach and said, "We lost thrust in both engines. We're turning back towards LaGuardia."

As Sullenberger began a turn to the left to return to the field, Skiles began working on the checklist of air restarting procedures. They had slowed to a recommended gliding speed. In the cabin no one knew what was happening, although knowledgeable passengers could see that they were turning back and had some idea of the situation.

Sullenberger had been quickly offered Runway 13 to land on at LaGuardia. He was just descending through 1,900 feet, and the field was still out of sight to the left. He was a precise, mature pilot. At this already crucial point he had two tasks and just one decision. The tasks were, first, to get one or both engines restarted. If he was successful, that would solve things. If not, or in any case, he had to land the airplane someplace. The question was: where? Runway 13 was seven thousand feet long. In a case like this, you might prefer ten thousand feet, but of equal importance was that the water of Flushing Bay came right to the threshold of the runway, there was no overrun or stretch of grass if you hit short. So it would have to work out almost perfectly.

It was too risky. He called and said, regarding the offer of the runway, "We're unable. We may end up in the Hudson."

Sullenberger, in his Airbus A320, continued with Skiles to try to restart the engines, and amid unnecessary and irrelevant voice alarms going off in the cockpit, continued talking to the controller. Teterboro, an airport off to the right in New Jersey and no closer than LaGuardia, was briefly considered, but, like Newark, rejected. The decision had really been made. The best choice was the Hudson.

Ditching is best done with power.

The general assumption is that the airplane will be going down in the ocean somewhere, perhaps in a bay. With its landing gear up and at close to normal touchdown speed, the airplane is flown parallel to any waves and between them, and the aft section is the first to come into contact with the water. There have been only a few airliner ditchings and apparently only one without power, in Java, just seven years before Sullenberger's. That plane also ditched into a river (and one person, a flight attendant, died).

The need for power is obvious: the pilot wants to be in complete control of the descent, holding it off just above a stall and allowing the tail to touch and then smoothly setting the rest of the fuselage down like a boat launched at more than a hundred miles an hour.

Sullenberger's first announcement to the cabin, when the die had been cast and they were going to end up in the river, was "This is the captain. Brace for impact."

Although three and a half minutes, the time that elapsed between hitting the geese and landing in the river, seems leisurely enough—a man can run close to a mile in that length of time—the pair in the cockpit were too occupied to explain, even in the briefest terms, what was going on.

The order came as a surprise to nearly everyone. One man said out loud, "What does that mean?" Soon enough he figured it out.... The most astute passengers had known for a while that they were descending over the Hudson, and would not be returning to LaGuardia, but some had held out hope that they were headed for Newark instead. Now they knew that the airplane was going to crash into the river.

The flight attendants did not know it, because...they had no eye-level windows while seated in their positions, and were expected to rely on instructions from the cockpit.... They therefore reacted purely by rote, chanting, "Brace! Brace! Heads down! Stay down!" with no idea of how high they were, where they were, or what was going on.

A man in the back had the poise and presence of mind to call out, "Exit row people, get ready!" A woman mid-plane with a baby boy on her lap did not know what to do. The man next to her asked if he could brace her son for her, and she passed the child to him, and he did.

In the cockpit the ground warning alarm had begun, an automatic voice repeating that the plane was too low. Sullenberger called for the flaps on the wings to be extended in order to slow the plane for impact. At two hundred feet he began breaking his glide and ballooned a little. They were at 150 knots—about 180 miles an hour.

He lowered the nose slightly and then, pulling back on the stick in the last few seconds before touching down, his airspeed spent, remarked coolly to Skiles, "Got any ideas?"

"Actually not," Skiles said.

They touched the water at an optimum angle, nose slightly high, 120 knots. The left engine tore away, the plane's belly ripped open toward the rear, and the aircraft skimmed to a stop. There was such heavy spray that the passengers near the windows thought they had gone entirely underwater.

The evacuation of the plane was all one could hope for.

Water entered quickly. There was an eighty-five-year-old woman who needed a walker, plus several children aboard. In the rear, the floor had buckled and a beam had broken through. There was more water there; it rose to almost chest-high before everyone was out. The flight had been sold out—only one empty seat.

The flight attendants, three women all in their fifties, were exemplary.

Doreen Welsh, the oldest, in the rear, had the greatest difficulties and was seriously injured. People tried to swim in the river, some slipped into the water and were pulled back, all ended up standing on the wings, some waist deep in water, or in the inflated slides and rafts.

Sullenberger and Skiles had all along been moving through the cabin assisting and handing out life vests. In the end Sullenberger went through the deep water in the cabin one last time to make certain no one was left. The water was bone-chillingly cold, but within five minutes the first of the rescue boats was at the plane.

There had been no casualties. All survived.

Chesley Sullenberger and his entire crew had performed admirably. The event was so spectacular, in full view of Manhattan and the New Jersey side of the Hudson, and it ended so happily that the public embraced it.

It seemed a miracle.

A "miracle."

On examination it seems more like a bit of luck and a job perfectly done.

Airline crashes normally produce so many fatalities that this was an unexpectedly nice outcome.

Whether the computerized characteristics of the A320 were an important element in that outcome seems uncertain.

Experts gives the airplane credit for smoothing out the slight ballooning in the last moments and easing it in the optimum position onto the water as Sullenberger held the stick full back, but given Sullenberger's abilities and good judgment, along with the weather and other circumstances, it seems likely that he would have accomplished the same thing in a Boeing, and that no autopilot or computer we can conceive of could have handled the emergency half as well.

**
Post based in part on The Art of the Ditch by James Salter. The New York Review of Books. January 14, 2010.

Risk Profiling's Moment of Truth

Assumptions are the mother of all stuff ups.

In our first blog for the new decade we pause to consider the ramifications for risk management borne out of two events that occurred within hours of each other on Christmas Eve / Christmas Day 2009.

The circumstances surrounding the events call into question a key element of risk management - the practice of risk profiling.

It is difficult to establish the history of risk profiling other than to say that it is likely to have been around (if not in a formalised state) for as long as people have tried to manage risk.

The concept of risk profiling is based on the assumption that one can predict future risks or better understand existing risks by examining or analysing information, trends or data points.

Risk management as a discipline has long used risk profiling as a tool in the understanding of the - not suprisingly - profile of risk that is to be managed.

**

We don't need to rewrite the many thousands of newspaper articles that have been written about the two instances that we refer to.

Firstly, the failed Christmas Day attempted bombing of the Northwest Airlines flight and its 278 passengers by a Nigerian man, Umar Farouk Abdulmutallab.

Secondly, the assault on Pope Benedict on Christmas Eve by Susanna Maiolo.

In both instances there were glaring indicators that both persons were of high risk and would be possibly dangerous in the circumstances that they ultimately found themselves in.

With regards to the Northwest incident, the alleged attempted bomber's father had warned authorities of his son's likely intentions.

With regards to the Papal incident, in 2008 - at the same Mass - the lady had attempted to jump over the security barriers (wearing near identical clothes to the ones that she wore in 2009).

Risk profiling should have prevented both instances.

Is it not reasonable to expect that Maiolo may have been stopped somewhere before she was in the physical presence of one of the highest profile people in the world? This was a person that had previously attempted to breach the security of the Pope - yet she was allowed to be within striking distance again.

Is it not reasonable to expect that the attempted bomber may have been stopped before he got on a plane and put so many lifes in jeoporady.

Undoubtedly official investigations will be - and have been - launched to ensure that such instances do not happen again.

One does wonder, however, as to what the practitioners of risk profiling have to say about the instances.

Why is it that we only hear about risk profiling when it works.

When it fails there is but silence.

For Honestly Lay Bare - that equation of truimphant success against silent failures is not the foundation upon which risk management should be basing its long term future.

The moment is upon risk profiling to prove its worth.

Honestly Lay Bare doubts that it can.