Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me, Mercedes Ramirez Johnson. She’s a safety and Leadership Consultant but has an incredibly powerful story to share about her experience as a passenger on American 965. First and foremost, welcome to the show. Really excited to have you joining me today and blessed that you were able to walk away from that flight. Why don’t we start with a little bit of your personal story and that flight, American 965, what happened back in the 1990s?

First off, Eric, thank you so much for having me as a guest on your podcast. It’s a big honor to be here. And one thing that I can definitely say is the experiences that I’ve been through, hopefully, can help other people through their life and professional struggles that they endure. So, yeah, my story begins on December 20th, 1995. It happened to me be my 21st birthday. So, my parents and I were on our way to Cali, Colombia, to spend Christmas and New Year’s and celebrate my birthday. It was going to be the trip of a lifetime that they had been planning for years. And We lived in Kansas City, Missouri at the time, and so flying to Colombia was going to be pretty much a full day affair, but we were excited to be able to spend the holidays with our aunts and uncles and cousins and everybody. This was going to be the first time since my parents had left their homeland that they were going to be back for the Christmas holidays. It was really special for all of us, including all the passengers of American Flight 965. Most of the people on that flight were families who were just returning to go home for the holidays.

So, it was a very festive, happy atmosphere on that day.

I saw the review of the whole story of what happened. Definitely, it was a holiday moment. I heard the stories of people waiting to look at the beautiful lights for the holidays on approach. Tell me what happened, because this is a stunning series of events, a new airplane at the time, one of the most modern aircraft that existed, the 757. Nothing wrong with the flight itself, nothing wrong with the airplane itself, and yet on approach, everything went wrong.

Yes. As passengers, the vast majority of the flight was perfectly normal. My father at the time worked for another airline so we used to be able to fly for free on other airlines. So, my family and I were very comfortable with flying. If there was ever a little bit of turbulence, it was never something of concern to us because we used to fly so much. And as a passenger, I remember I took a nap on my father’s shoulder, and when I woke up, I woke up feeling a little bit of turbulence, but nothing out of control. It felt like we were flying through clouds. So, I wasn’t afraid. I wasn’t scared. And I thought, oh, that interrupted a perfectly good nap. Let me fall back asleep again. And as I was trying to close my eyes and fall back asleep again, that normal little bouncing through the cloud’s feeling turned into just an abrupt situation where we, as passengers, just felt that the pilot took the nose of that plane and just pulled it straight up into the air, where one moment we’re flying regularly, horizontally across the sky, and the next moment, panic just erupts because we just feel that we’re just barreling into the sky like we were on a rocket ship or something.

As you can imagine, as passengers, we’re not hearing any announcements as to why we’re flying straight up into the sky. We don’t know why this is happening. Of course. But we just… Just pandemonic. People, men, women, children, everyone screaming and crying and panicking because we’re not aviation experts, but as a passenger, you know when something feels wrong, and we knew something was terribly wrong at that moment. It was probably a matter of 10 to 15 seconds where we’re flying straight up into the air. I remember hearing all these screeching, grinding sounds on both sides of the wings as we were heading up into the air. I And my instinct was just to grab my father’s hand and close my eyes. When I was little, I was used to close my eyes when I was scared. So even though it was my 21st birthday, I went into a little girl mode because I thought, oh, my gosh, this is just terrifying. And so, I grabbed my dad’s hand, closed my eyes, and I was just focusing on my mom’s voice in the row in front of me because she was praying out loud. And so, I was trying to ignore all the screaming and the crying of everybody else around me.

And I was just trying to focus on her voice and focus on calming myself down by just listening to her. And my last memory was just hearing this loud, crashing, booming sound that came from behind me. And at that time, I didn’t realize what that sound was. I just remember how scary it sounded because not only did I hear it, I felt it. And I didn’t realize at that moment that that loud, booming sound was actually our plane hitting the side of a mountain, making contact with a mountain. We weren’t supposed to land on a mountain.

No, you’re not. Nowhere near a mountain.

It was fatal contact at that moment. After that, I just blacked out, and I don’t remember anything until I woke up in the wreckage the next morning. It was something that during those last 10 to 15 seconds, we all knew something was wrong, but never did I think, oh, my gosh, we’re going to crash. Oh, my gosh, we’re going to die. I kept on thinking, okay, just fix it. Just straight. I remember under my breath, I kept on saying, just straighten it out. Just straighten it out. Just thinking, okay, if the pilot’s accidentally hit a button, just straighten this thing out. It can’t be that hard. I’ve been on a million flights. Just straighten it out. I guess that’s the eternal optimist in me, but I never actually thought, oh, my gosh, we’re to die. I just kept on thinking, just fix this. Just straighten it out.

You were literally feats away from probably having been able to straighten out if everything else had been done right. Although from what I gather, it wasn’t confirmed, but you weren’t necessarily that far away from that point. What if you share maybe some of the themes from the investigation? Because this one is a mind boggling one. When I was reviewing the incident, the series of mistakes, one after the other, things that should never happen on an airplane happened.

Right. I remember when I was still in the ICU, our family’s attorney I was in the ICU for nearly three months, recovering from all the injuries that I sustained from this crash. I was dealing with the grief of losing my parents because both my mom and my dad both instantly died upon impact of the plane hitting that mountain.

So sorry to hear that.

So aside from dealing with the grief of all that, I remember my parents’ attorney said, well, our main goal is for you to get better, but we’re going to be in talks with other passengers because there may be a lawsuit. And I thought, A lawsuit? It was an It’s nobody’s fault. It was an accident. As I was sitting there with five million different IVs in my neck and in my arms, and I wasn’t even thinking this lawsuit. Who thinks about these things when you’re in the middle of grief. But as the investigation unfolded, and of course, those things take years for the FAA and the NTSB to make their definitive conclusion decisions as to what caused the plane. But very early on, it was pretty evident that it was pilot error. It was human error. First, there was theories that the cartels had shot us down and that it was an on-purpose thing. All kinds of theories were running around in the hearts and the minds of different people. But once it became clear that it was indeed pilot error, it was very angering as someone who I’m just fortunate enough to have been able to survive it.

But for someone who lost their loved ones, my parents, I thought, oh, my gosh, this so easily could have been avoided. And not only that, but just even the pilots themselves lost their lives so needlessly, so uselessly. That’s where that bitterness really kicked in, because it was just a series of mistakes and oversights and omissions of things that should have been done, and verifications that should have been made, and navigational procedural steps that should have been taken that just did not happen. It didn’t happen because it wasn’t an issue because these were two brand new pilots. It didn’t happen because- No, 13,000 hours for the captain of flying. Especially, they are US-based. Different countries have different If you have pilots that are trained in other countries, the number of hours that they have to pass to become a pilot, you’re probably in the safest hands by flying with an American-based pilot. I don’t mean American Airlines, just a pilot in the US, the hundreds, if not thousands of hours that they have to prove in order to get their license. We were in the best hands. To my dying day, I will say that we were in the best hands.

These were two good men that just happened to have a really bad, bad day at work that day. It wasn’t because they intentionally crashed it, but it was really because of their lack of intention, their lack of mindfulness that just allowed this series of needless mistakes to happen.

There are some classic pieces that came out. We’ll go through some of the elements from the investigation. But there’s some classic elements where flight was delayed, there’s compounding issues where production pressure, this desire to arrive on time is an issue that happens in every industry. I would say aviation is one of the ones where they’ve done the best to manage it. But there’s still this desire to say, I need to land. There’s lots of references in the flight recording about the turnaround time, the rest time, and it’s right before the holidays. You’ve got multiple things that are creating an internal pressure. Tell me about some of the other elements that came out of the investigation because it’s, like you said, qualified, qualified people, lots of training, lots of oversight. Lots of phenomenal practices are in place, and yet simple mistakes that should have never happened occurred.

Right. I think I would say that the biggest mistake that caused this cascade of other mistakes was the fact that the pilots just entered in the wrong alphanumeric code into the navigational system. Not only did they enter in the wrong code, but then they didn’t cross verify to make sure, hey, did we enter in the wrong code? And so, everything they did from that point forward, they were making assumptions that they were headed in the right direction. But unfortunately, neither the captain nor the co-captain ever actually looked down to the navigational system to actually verify what coordinates had been entered. And neither the captain nor the co-captain ever looked down at the flight screen that would show them that we practically did a U-turn in the air, in mountainous terrain at night as our elevation is… We’re getting closer- Below the mountain range. Yeah, we’re getting closer to the ground because we were only about, I would say, 15, 20 minutes from landing. So, the landing gear sequence had already begun because as you get closer to the airport, you start slowing down and you start lowering your elevation. And so, they were basically flying at night with blindfolds on. 

And air traffic control kept on asking them to verify when they make it to certain waypoints. And instead of actually looking at the navigational system to actually answer those questions, they just kept on powering through. I don’t want to go as far as to say that they were ignoring air traffic controls questions, but they definitely weren’t answering them in a truthful like, okay, this is exactly where we missed that waypoint, but this is where we are now because they had no idea where they were. It’s evident in the recording. Only once in my life have, I actually put on my headphones and listened to the Blackbox recording. But just with talking with you a little bit earlier, I think I might listen to it again because I haven’t listened to it since 1996, so many moons ago. But when the only reason they knew something was wrong was because that ground proximity warning alarm started to go off in the cockpit. It came up. Yeah, and that alarm tells a pilot that you’re coming in hot. You’re basically coming in too close to the ground at too fast of a speed and you need to pull up.

As you’re listening to this black box recording, you can hear the automated robotic voice telling the pilots to pull up. As this alarm is going off, they are telling each back and forth, Why the bleep is this thing going off? Where the bleep are we? What the bleep is going on? Because that’s when they finally looked at their instrumentation and realized, Holy crap, we’ve gone off- Nowhere nearby. Yeah, we’ve gone off like 130 miles in the wrong direction. And that’s what somehow, we missed the first mountain range because our elevation was still slightly higher, but we ran out of luck once we hit the other, literally hit the other mountain range. And it wasn’t until that alarm went off that they had any idea that anything was wrong.

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When you look at that or we listened to the flight recording, because I had a chance to review it just before we spoke, complete situational awareness was completely lost. There’s a where they turned. The one you should be aware because as you said, you at night, you’re in between two valleys, in between three mountain ranges, essentially. They somehow ended up, instead of being in the mountain range, they should be in the valley, they should be, and they were in the one right next to it. Because they had turned 180 degrees, almost, sorry, 90 degrees to the left, almost, with the wrong instructions, which you would have felt the plane turn, rather than say, okay, are we in the right place? They continue and I essentially assumed that they had a direct landing. Now, the contributing factor is that I was listening to the radar for the ground was disabled, so it wasn’t working, so the airport had no visibility to where they were. There seems to be some signs where air traffic control was confused as to what they were hearing, but everybody had lost situational awareness based on at least the recording and some of the readings I had.

Right. Unfortunately, the cartels in retaliation to the government had destroyed a lot of those different radar towers leading to the airport. And so, communication between air traffic control and the pilots on approach to Cali, Colombia was always very, very pivotal, very important, because basically air traffic control is blind, and the pilots are relatively blind. They must rely on their instrumentation. But unfortunately for this flight, they chose not to. And so when it all boils down to it, after, I think it was about a five or six year investigation that the FAA conducted with the NTSB, both organizations ruled that for whatever reason, these pilots disregarded or just forgot or just did not complete 64% of the standard operating procedures from the time they pulled out of the gate in Miami until the moment we hit the side of that mountain. That doesn’t even include all the things that should have happened upon descent and approach and landing and taxiing and pulling to the gate. That doesn’t even include all the stuff that didn’t happen because we just didn’t make it to that point. Just from leaving Miami to the time we hit that mountain, for whatever reason, they only ended up doing 36% of all the standard checklists and verifications that they were supposed to have done.

If you think on any given day when anyone’s job is safety-focused, can you imagine going out in the field or going out on the line and only doing 36% of what you’re supposed to do? I mean, it seems insane. But these pilots weren’t insane. They just weren’t paying attention. Unfortunately for us, out here in the real world, we’re all guilty of losing situational awareness. We’re all guilty of mind wandering, where you could be in the middle of a task, but you’re thinking about the game that you watched last night, or you’re thinking about the last thing that your kids said as they were storming out the house on their way to school that morning. Our minds wander so much- Absolutely. That it’s up to us to get ourselves back to maintain that situational awareness, especially when our own health and safety and the health and safety of people around us is on the line. I think sometimes we can get so well experienced and so good at our jobs that we sometimes forget how tremendous of an impact our actions, or our inactions have.

I think this is the part is This is in an industry where there is very clear understanding that it’s very unforgiving environment to be operating in. This is the industry that has done the most from a safety standpoint, because if you look at there’s still somebody in America that dies, I think it’s every 96 minutes in a workplace injury. But if you look at aviation, it’s come a long way since the ’60s in a fairly nascent industry with only, I think, three fatalities on US oil in the last 15 years. So significant improvement. But you’ve got rigor, you’ve got consistency, you’ve got standard operating procedures, you’ve got checklist, it’s trained, it’s retrained and validated, and yet you can have drift. Exactly.  

Yes. And the pilots are evaluated for their health and their vision and mandatory age requirements. I mean, there’s so many things that are worked in to try to keep this as safe as possible, that it’s almost like you almost have to go out of your way to not be safe in that environment. And we’ll never, sadly, we’ll never be able to get into the minds of these pilots as to why they inadvertently allowed this to happen. But as ugly as it sounds, they did allow this situation to escalate beyond control.

I think the flip is also, to your As I said before, we all do these things. We all do careless things. This is the environment where there is a lot of constraints, checks, balances to make sure this doesn’t happen. But then when you say 64% was disregarded, in my mind, I’m thinking, this could happen anywhere else. In some cases, even if I think about utility workers, mind workers, the standard operating procedures, most of them are not detailed like they are in It can. And it’s very easy to get distracted.

Sometimes those workers are working as lone wolves. In this situation, there was two pilots in there. So it makes you wonder, Okay, I can understand maybe one of the pilots is completely disorganized that day and just doesn’t have his or her mind on the job. But what about the other person? What was it about the culture there or about the open lines or lack of open lines of communication? Did that other pilot even pick up on any of these things that were being disregarded, or were they also completely oblivious to what was going on? I mean, there’s just so many questions.

Yeah, because listening to the fight recording was mind-naming because the number… I just listened to the back to the tail end of it. But the number of things that you would expect, having been in a flight deck many times, have We listened to many other recordings, the number of things that were not happening that you would expect to happen and the amount of questioning attitude that’s drilled in in the aviation space, which is unfortunately not drilled in in so many other industries of saying, Hey, what just happened? What could go wrong here? We just drifted to the left. What could go wrong, assuming our plan is still good?

Right. It was almost like they were colorblind to the red flags that they themselves were creating, and they were just barreling through, whether it be to make up for lost time or whether it be because they were tired. We will never know. But regardless, the outcome is still the same. They unfortunately lost their lives, and then 160 other people lost their lives as well. Their families must live without loss, and everybody else’s family has to live without loss. No one in their right mind would ever accuse these pilots of being willfully negligent or willfully… Neither of them had a death wish that day. They were just two good people who just had a horrible, horrible day that day at work. And we’ll never know why but that’s why I’m so passionate about what I do is because if pilots can do this, where they’re constantly being asked to verify what they’re doing while they’re doing it, if a pilot can do that, what about someone who is working in a mine? What about someone who is an electrical worker or a plumber or someone at a plant? If this can happen to a pilot, it can happen to anybody in any industry.

I would say even probably more likely to happen.

Oh, absolutely.

Yeah. Because there’s less checks and balances than what you see normally in aviation and training and so forth. That’s why this This one is really an interesting one to just explore. I like what you’re trying to do, which is share. It’s not about those pilots. It’s about the learning for others and to see that if it can happen in this industry, it could happen anywhere else. Situational awareness can impact any of us. I think we can all admit that we’ve been at some point where we weren’t fully situationally aware. Where we make an assumption, and we assume the rest works. I’ve worked with some utilities where a team has a really good plan, something doesn’t go to the plan, and then the others are saying, Let’s go. But luckily, one of them says, hold on, we had a plan, it didn’t work. Let’s not keep going because we may have missed something else, which is what I would have expected here, say, well, we made one mistake that was apparent, or two, or three, or four. Any one of them should have said, what else is wrong with our assumption?

Where was voice of reason on that day. That’s just two people who literally have someone in their ear. They literally are listening to air traffic control, and they are constantly being asked these questions. If they can do it, if it could happen to them, it could happen to anyone.

The other part that strikes me is the comfort to speak up. There were really only three people in conversations at that point in time that knew anything that was going on, the two pilots and the air traffic control. And any one of them, and I think this can happen in any industry, I see this day in and out, far worse than other industries, because at least in aviation, there’s things like CRM that are trying to get people to feel comfortable speaking up. But how often do we see something, and we don’t say something? Any one of the three probably could have said something and say, hey, something feels off.

And I think that’s what’s so important about companies Company culture and safety culture is that it does not matter where you are on the org chart, whether you have a title of a manager or supervisor or not. If something feels off, if your gut feeling is kicking in, that is the Lord’s way of trying to protect you. And normally, our gut is usually right. And for us to dismiss those gut feelings, we are doing ourselves and our coworkers and the communities we serve and the clients we serve a major disservice. And we just start disregarding our own gut feelings. And if we’re jaded to the point where those gut feelings aren’t even kicking in, then I can’t help you there. But normally, if people are taking, quote, unquote, harmless shortcuts or doing things their own little way, like, well, yeah, that’s how you’re training We need to do that, but let me tell you how we actually do it. I ask my clients this question all the time, who do you think is more of a liability? The worker who’s been at it for 15, 20 years, who has a ton of experience and who is willfully doing things their own way?

Or is it the worker who is brand new, fresh out of training, who may make mistakes just based on lack of experience or lack of knowledge. In my assessment, I would think it’s the worker who’s been there for a long time, who is just willfully just going on their own little way instead of sticking to standard operating procedures and sticking to doing the work the way it should be done. Because all those rules, all those procedures, those are written in blood. They’re there for a reason. They’re not there to make your job harder or to frustrate you or to annoy you. They’re there to protect you. If people can remember that and keep that in the back of their mind as the foundation of how they make their decisions moving forward, people just need to remember that. For some reason, it’s just so easy to forget, which is why business is always good for me because I’m constantly going into different companies to just remind people of these procedures are there for a reason, and it’s to protect you. 

I would say it’s not even willful disregard. Too often, it’s even just drift where We get comfortable. We’ve cut a corner, or something worked. There was no consequence. Like you said, in aviation, the rules were built, were done in blood. There were some crashes. The industry learns more than any other industries, I would argue, in terms of anything that could go wrong, your misses, et cetera. There’s a lot of rules for a reason, but many of those rules won’t have an impact 99% of the time, 99.9% of the impact. You don’t need them. Every industry is the same. But that one time where you do need it, there’s a reason it was designed there. 

I think sometimes we get a false sense of security. So many of our processes are done in that Swiss cheese model where if something goes wrong, maybe we have something else built behind it to help mitigate that. But sometimes that can give us a false sense of security and comfort. That’s where the danger really lies, is having that… Competence is a great thing in your personal life but Having confidence in your ability. Confidence can sometimes turn into inadvertent arrogance, and we can’t allow that anywhere. When it comes to work, we can’t allow arrogance to take the place of confidence. We need workers who are confident in what they do in their ability, but we also need workers who have the humility to follow the rules, to have the humility to speak up or take direction when needed, and to do what’s best for everybody, not just personally. Well, I want to get off work here soon, or lunchtime’s coming up, so let’s go ahead and power through this. No, that’s not what’s best for… That may be what’s best for you because you have an amazing sandwich waiting for you in the break room.

But what’s best for the team is for us to do this and to do it the right way. Just having that open line of communication without fear of retaliation is very, very important.

I think that’s an important point because a lot of these themes, like overconfidence, these are biases that all humans have. As we’re successful, we keep saying, okay, we’re good at this. We can do it. And analogy often uses people speeding on the interstate. You know there’s a rule, there’s a reason for that rule. But when I ask any room who has never sped, there’s usually nobody who raises their hand because we accept that five miles an hour faster is okay, maybe 10, whatever the difference, and we start getting comfortable with it because we’ve handled things well most of the time. And most of the time, there is no impact, but maybe one time there will be.

We sometimes get numb to the risks we submit ourselves to. It’s not just a sign of the times. I think it just comes with being at a job or in an industry for so long that you just grow numb to the huge impact everything that you do has on everybody around.

Mercedes, thank you so much for sharing your story, the incident, but also bringing it to the reality that this can happen to anyone. If somebody wants to get in touch with you, what’s the best way for them to do that?

The best way, they can just find me on my website, mercedesromeriusjohnson.com. I’m on all the social media platforms as well, but usually the best way is just to contact me through my website, and I would just love to talk to them about safety.

Excellent. Well, thank you very much for joining the show. It’s a miracle you survived because I think there’s literally, was it five people that walked away from that plane?

Out of 164 that were on board, including the crew and the pilots, only four of us survived.

Only four.

I am very, very blessed to be able to talk to you today and to be here alive still today.

Yes. And being able to share the learnings when I want. So, thank you so much for joining me.

Thank you, Eric. Thank you for having me.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at execsafetycoach.com. Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.