How and Why We Fail (Understanding Dumb Mistakes)!

http://aviationweek.com/bca/lessons-bedford-gulfstream-accident-part-2
N121JM wreckage, aerial photograph, from NTSB Accident Docket ERA14MA271

How many times have you mentally kicked yourself for doing something incredibly stupid? And upon reflection, you can’t even figure out *why* you performed this way?  This “all too human” process is fascinating and built into our human operating system. Examining and understanding the little daily goofs and lapses can improve your life, but more importantly, improve your aviation safety so the big, bad stuff can (hopefully) be avoided.

To unpack the psychological process at play here, we first need to understand that most of our activities in life are only semi-consciously decided and most often automatically enabled. Our human operating system copes with the daily overload of sensory data, decisions and actions by utilizing a series of scripts or schema largely out of sight and called “implicit.” This is how we can famously drive to our destination in a car and not remember anything about the trip (or that we intended to stop at the store). We can also type 180 words per minute but are usually unable to label the qwerty keys without tapping them out on a table. This “implicit knowledge” and associated “scripts and schema” are internal and and invisible. They also are not even filtered or examined by conscious oversight; operating in the shadows. (This “dual-process” brain theory was popularized in Daniel Kahneman’s book “Thinking Fast and Slow“). We continuously process and act in an automatic mode unless we have time and motivation to engage in effortful reflection. This natural optimizing has great survival value from efficiency, but in complex activities it fails to manage risk and can occasionally wreck airplanes.

Let’s examine a typically bad decision to drive home, despite being pretty buzzed, after a party. Imagine we arrive home just fine despite our incapacitation. Achieving this “success”, we experience a feeling of relief and accomplishment. Now consider the opposite example of having a totally sober designated driver taking us home but getting T-boned and injured. We have in the first case a bad decision resulted in a good outcome, but in the second case a good decision resulted in a bad outcome. And though decisions and outcomes actually stand alone, that is not how our human brain interprets these situations. The first decision is reinforced due to “success” and the second one discounted as “bad luck”. Letting this “implicit learning” into our subconscious as a standard of operation can have serious consequences for our future safety. Let’s see how our brains subconsciously “code” these experiences.

In the case where our decision was bad but the outcome positive, our “success” psychologically reinforces our decision with relief and a feeling of accomplishment; e.g. “that turned out OK.” Though defective, this decision and validating success delivers a warm buzz of dopamine that neurologically encodes in our brains as “acceptable”. Unless we consciously reflect later on this action, to critique and correct this mental coding, a habit can easily develop and become an implicitly learned bad procedure. Clearly luck was the primary operative factor in both cases, not skill. As humans, however, our “fast processor” tends to evaluate all decisions solely on the basis of the outcome rather than applying an objective standard or evaluating the quality of the decision. And once imported, an implicitly accepted standard of “only one drink” can easily slide to “only two drinks” in the same manner; and you see where this is ends up going. A more thoughtful approach, guided by objective reflection, (carefully decided) is the antidote to this implicit learning and the basis for “Standard Operating Procedures” in charter and airline flying. Implicit procedures are self-optimizing and haphazard and slide to the lowest level of acceptability based on luck. And we all, unfortunately, know pilots that fly in this manner.

An aviation example of this process at work might start with a successful outcome despite marginal weather; perhaps arriving into a Delta airspace safely under a 1200 ft ceiling (even though our personal minimums were “1500 for VFR in Delta”).  Unless we later reflect and critique this dubious “success” we now have an implicitly accepted “new normal”. Our optimizing human brain codes “that worked out OK” and this new standard becomes part of our pilot operating system, out of sight and never adjudicated by our “better pilot self”. Pretty soon we find ourselves with new and sketchy standards and we might not even know why or how this standard was established. These implicitly learned, automatic schema are imported “under the radar” and are accepted as operational–just like bad code embedded in computer program. And similarly, they may operate fine for a while until they fail suddenly and surprisingly. This neurological process is responsible for “normalizing deviance” that led to NASA’s safety issues with the Space Shuttle. On a “group think” level these same implicit procedures were working so we “go with it” (the only standard was “success”). Many of these errors are not big and obvious, but insidiously erode standards on every flight. And this is also how thousands of hours and increased experience can work against us by building complacency rather than excellence.

To successfully combat the implicit learning of questionable procedures, an “after flight critique and reflection” is essential for safety. Otherwise, our optimizing human brain is always at work creating implicit shortcuts–efficiency over safety. It is vital for future safety to always schedule a sacred time for personal analysis after every flight ; do it when you log the flight? This reflection process is essential to analyze what went right and wrong–and most importantly “why?” This is also the reason why written personal minimums (or professional SOPs) are necessary to keep a pilot honest and safe. Sliding standards, often implicitly learned, seem to always precede the crunch of aluminum.


Please “follow” our SAFE blog to receive notification of new articles. Write us a comment if you see a problem or want to contribute an article. We are always seeking more input on aviation improvements and flight safety. There are many highly qualified aviation educators out there! If you are not yet a SAFE member, please Join SAFE and support our mission of generating aviation excellence in teaching and flying. Our amazing member benefits alone make this commitment worthwhile and fun. Lastly, use our FREE SAFE Toolkit App to put pilot endorsements and experience requirements right on your smart phone and facilitate CFI+DPE teamwork. Working together we make safer pilots!

Educator Professionalism Creates Excellence in Aviation

It takes a Pro to make a Pro…

The tenets of professionalism apply to flight instructors regardless of whom we teach or the aircraft type. Instructor professionalism is the foundation for excellence and success. We read about it, and we talk about it. But what exactly is it, and how do we embody that crucial characteristic?

Characteristics of Professionalism

A business definition of professionalism is “meticulous adherence to undeviating courtesy, honesty, and responsibility in one’s dealings with customers and associates, plus a level of excellence that goes over and above the commercial considerations and legal requirements” (www.businessdictionary.com).

Professionalism is typically achieved only after extended training and preparation. This training usually requires significant self-study and practice and is typically accomplished with formal education. It brings to mind the seemingly endless hours of education, training, and practice one undergoes on the path to becoming a doctor. The path to becoming a flight instructor has similar requirements – not just in terms of formal academic study and training, but also in terms of what we might call “the unwritten requirements”. Let’s take a look at a few of them.

Skilled pilot

The aviation instructor must be an expert pilot, one who is knowledgeable, proficient, skillful, and safe. You should be very proficient on the equipment you use, especially avionics. Be alert for ways to improve your qualifications, your effectiveness, and the services you offer. Stay abreast of changes in regulations, practices, and procedures. Make a habit of referring to the current Aeronautical Information Manual (AIM), Airport/Facility Directory (A/FD), Sectional Charts, Handbooks, Manuals, and Practical Test Standards (PTS). You should also read aviation periodicals, browse the Internet, and attend meetings and seminars. And, of course we recommend that you have (and use) an account on www.FAASafety.gov.

Strong teacher

A flight instructor must have strong skills and abilities in two major areas. First, he or she must be a competent and qualified teacher, with all of the “soft skills” we attribute to teachers. These include communication skills, people skills, and patience. In order to understand the progress your students are making, you must understand the four levels of learning – Rote, Understanding, Application, and Correlation. To simplify my own comprehension of these principles, I reduced the concepts to concise, understandable definitions.

Practical psychologist

You need to understand anxiety and how to address it with a student. You must know that reactions to stress can be normal or abnormal, and be ready to act appropriately. You soon learn that obstacles to learning can be different for each student. You learn how to address impatience, worry, lack of interest, apathy, anxiety, discomfort, illness, and fatigue. You must work within your student’s other interests or enthusiasms. You must discover how to help the student with a multitude of troubles; you may even have to show your student how to handle fear. Also important is your understanding of the laws of learning. Your student’s progress will be enhanced if you remember that a student learns because of Readiness and Effect, but remembers because of Primacy, Exercise, Intensity, and Recency.

Capable Coach

The best flight instructors use a syllabus, set achievable goals for their students, and use a well-designed lesson plan. You should personally prepare for each lesson, whether ground or flight, and personally prepare for each individual student. Not having an organized plan is, in fact, a plan…for failure. No two students are the same; they must be treated as individuals. You are the key to their success.

Positive role model

Consistently using a checklist is another mark of a professional. We all get excited or rushed at times and and the use of a checklist is the only way to ensure we don’t forget something. Students will follow the behavior you model, so do it right. A flight instructor must also have high standards of personal appearance, which means that you must be neat, clean, and dressed in a manner appropriate to the situation. Your personal habits must be acceptable. As a chief flight instructor, I once had a student request a different instructor because his instructor had an overwhelming body odor. I discovered that the instructor worked at a physically demanding job before reporting to the flight school. Moving his first lesson by an hour solved that problem. In addition to personal hygiene, you cannot be rude, thoughtless, or inattentive, and you cannot be profane or obscene.

Sincere

Professionals are true to themselves and to those they serve. Your sincerity of effort must be such that inadequacies are admitted, not hidden, and are corrected for the future. A Code of Ethics is a good reminder of the need for honesty, impartiality, fairness, and equity.

Inquisitive

True performance as a professional is based on study and research, and professionals are always searching for the “why.” Perhaps you can imagine the hard work required to produce a doctoral thesis. Becoming a flight instructor requires that same dedication to learning. Let’s look at an example from a private pilot syllabus for flight training. Let’s assume you are going to teach a student to perform turns-around-a-point. We all know this lesson begins in the classroom. To test understanding, you ask your student to place an “X” at the point on the circle where the bank angle is the greatest during the maneuver and then tell you why he chose that point. Assume the wind as shown and left-hand turns. Before you read on, place the “X” on the circle yourself. Many instructors place an “X” at the bottom of the circle; some place it half-way between the bottom and the direct left side point. Why are these not the correct answer? Remember, we are searching for the “why.” The key is to understand that the aircraft’s ground speed is the greatest at only one point. It is at this point that the wind will be pushing the aircraft away from the desired track at the greatest velocity.

Creative

You don’t have to be a mathematical genius to be a pilot or a flight instructor. While a flight test pilot and an aeronautical engineer may need higher math skills, the typical pilot, and flight instructor, gets by quite easily with the basic addition, subtraction, multiplication and division skills one learns in grade school. However, a professional flight instructor must have other qualities that could be defined as intellectual skills. These include the ability to reason logically and accurately, as well as the ability to make good decisions. Even though aviation has standard practices for normal and abnormal situations, we must also appreciate that some situations may require thinking outside the box.

You Touch the Future!

As Challenger astronaut Christa McAuliffe famously proclaimed, “I touch the future – I teach!” Whatever your eventual goals in aviation might be, never forget that being a flight instructor is a real job that has real – and lasting – impact. Make it count!

A wonderful article by Bryan Neville first published in FAA Safety Briefing. Click here for original pdf version.

Please “follow” our SAFE blog to receive notification of new articles. Write us a comment if you see a problem or want to contribute an article. We are always seeking more input on aviation improvements and flight safety. There are many highly qualified aviation educators out there! If you are not yet a SAFE member, please Join SAFE and support our mission of generating aviation excellence in teaching and flying. Our amazing member benefits alone make this commitment worthwhile and fun. Lastly, use our FREE SAFE Toolkit App to put pilot endorsements and experience requirements right on your smart phone and facilitate CFI+DPE teamwork. Working together we make safer pilots!

 

Giving Pilots “Sharp Tools”?

S.A.F.E. is presenting “The Improbable Turn” this Thursday at 8PM with Rod Machado and Russ Still. Please sign-up here; we even have a Lightspeed Zulu 3 headset to give away to FAA registered pilots (WINGS)! At the heart of the issue is the poor unfortunate pilot in a suddenly quiet plane in the air on takeoff (and his CFI responsible for providing guidance and solutions). So if this turns out to be you, what’s the “best” answer; and if you are a CFI, do we convey the simplest, safest advice or potentially risk more danger with the “sharper tool” of a turn back maneuver requiring greater judgement and skill?

This title comes from my childhood experience growing up in a family of feral brothers and friends always playing in the extensive woods around our home. My father was criticized by a neighborhood “helicopter mom” for letting his young son have a pocket knife (this was hunting and fishing, not “in the hood”). My mother’s defense was “if his father gave it to him, he also taught him how to use it safely” As CFIs, do we teach pilots the “least common denominator solution”? or can we risk “sharp tools” and teach judgment with the inevitable danger of misuse? I think every pilot (and CFI) has to decide this question for themselves, but we certainly want to carefully examine all available options.

So let’s freeze our airplane and pilot at that “point of decision” when our engine coughs and goes silent on takeoff; CRAP, THIS IS BAD! Imagine yourself in this situation. These failures are usually powerplant (89%) and statistically catastrophic, though often avoidable (fuel mismanagement 38.8%).  So step one is more careful preparation before advancing the throttle on takeoff to eliminate ever having to choose a solution in the air. Step two is being contantly vigilant on every takeoff so we are ready if we have to suddently “do that pilot stuff”.

Once in this “awkward agl,” power failure situation, only one thing is certain; we will be on the ground in about a minute-either as a falling object or in a successful outcome. Comparing straight ahead with turning back is statistically difficult since successful turn-backs are seldom recorded. What we *do* know is that only 4.8% of emergency off-field landings are fatal and in 83% there are “little or no injuries.” (from the excellent Rod Machado emergency programs). Straight ahead at best glide with slight turns is a remarkably good solution. It is also important to remember at this point of decision “the insurance company owns the plane” and your primary goal is to save yourself, your passengers and minimize any threat to people on the ground. Another solid fact is that if you attempt a turn-back and screw it up, this loss of control will almost certainly be a fatal stall/spin ending.

But pilots *do* regularly complete this tricky emergency maneuver and turn back successfully; that is what we will discuss this Thursday. Glider pilots are required to perform this maneuver on every checkride. My previous 135 training in the PC-12 required a turn around to be demonstrated ever 6 months our regular ATP checkride. What would I personally do at this “point of decision” and what should I teach this as a CFI? (my personal score is currently 2 and 2 in 48 years of flying) The successful execution entirely depends on altitude, preparation, proficiency and the context of wind and geometry for each unique runway situation. If you have *not* carefully evaluated and prebriefed this maneuver and also practiced it at altitude, absolutely land straight ahead with slight turns to a hopeful landing. In the 135 flying world, standard operating procedures requires that before every takeoff  we precisely brief all our options; straight ahead and turnback altitude. This includes who will fly, when and which way to turn back; also who works the radios and where to land. (At most urban airfields there are also few open areas.)

Join us Thursday, there is lots more to discuss, but on every takeoff please do your homework and make your decision *before* takeoff. Also always exercise extreme vigilance as you advance that throttle for takeoff. We know this is a statistically a very dangerous time (24% of fatal accidents). Though flying is fun we also have the huge responsibility of managing risks.


Please “follow” our SAFE blog to receive notification of new articles. Write us a comment if you see a problem or want to contribute an article. We are always seeking more input on aviation improvements and flight safety. There are many highly qualified aviation educators out there! If you are not yet a SAFE member, please Join SAFE and support our mission of generating aviation excellence in teaching and flying. Our amazing member benefits alone make this commitment worthwhile and fun. Lastly, use our FREE SAFE Toolkit App to put pilot endorsements and experience requirements right on your smart phone and facilitate CFI+DPE teamwork. Working together we make safer pilots!