“What were they thinking?” (In most senses of the word, they weren’t!) If you read accident reports, you have often encountered seemingly smart pilots facing an obvious threat they “never saw.” How does this happen? There is a simple explanation and it is a process common to all of us – and totally “natural” (beware)!
Risk hides in the familiar 
because our human perception defaults to “autopilot” by necessity to save mental effort in the majority of daily life; “human screensaver mode.” Our incoming data flow is filtered first by our senses and again at the cognitive level to be manageable and useful. Our primary perception filters the environment (very rapidly) for “threats” and once that is satisfied, we largely “stereotype our world” and automatically transform it into patterns we have learned from experience. This is a sad commentary on appreciation and “living to the fullest” but a surprising 90% of our daily activities are only barely at the level of awareness. Common daily activities are largely relegated to automatic processing. These stone-age systems often miss subtle “technological threats” – it was designed for more obvious saber-tooth tigers ready to eat us!
“We construct an expected world because we can’t handle the complexity of the present one, and then process information that fits the expected world, and find reasons to exclude the information that might contradict it. Unexpected and unlikely interactions are ignored when we make our construction.” Charles Perrow; “Normal Accidents“
As an example of the world’s complexity and our amazing automatic processor, watch how many discrete pieces of information are presented in this Teslla film capturing the “simple” act of driving. As humans, our amazing human brains handle all these activities rapidly and automatically below the level of consciousness. Think of how many processes we employ in a “normal” day or when flying.
We all know that some people have a continuously higher level of awareness and we ourselves vary in awareness based on mission, distraction and fatigue. The key to success in efficiently handling life and its challenges is twofold. First, we need to apply the correct level of awareness appropriate to every situation – and also consciously turn up awareness during potentially threatening or demanding situations. The second coping mechanism is embedding accurate, automatic scripts for common high-
danger situations so they deploy automatically (reflexively) in cases of surprise or startle. The first skill is “situational awareness” and the second requires “skill and emergency training.” In flying, this “reserve capacity” requires lots of accurate and repetitive “overlearning” until reactions become easily accessible and “totally natural.” Without this essential “reserve skill capacity” we have no margin of safety when “Plan A” goes to pieces.
Take the example of driving in “automatic mode” when a child runs out into traffic and surprises us. Hopefully, our reactions are available appropriate, and immediate (trained/embedded/reflexive). We apply the brakes or swerve before we even know what happened. Immediate action like this is too quick for our thoughtful/critical mind to engage and react. In retrospect, you are often surprised at the accuracy and speed of the reaction. Most sports and high-stakes activities operate almost entirely at this level of “over-training.”
In these “surprise situations,” the heart rate also picks up and we are suddenly aware and alive, critically processing. Too much excitement in this direction brings us to the “startle” (a common failure mode). Continuous awareness at the higher level is exhausting (and inappropriate) so our awareness soon degrades back into “automatic.”If however, the thoughtful brain overrides this saying “we are in a schoolyard, we better stay alert” (situational awareness) we maintain the higher level of threat processing. This parallel processing has been on board since we were hunting sabertooth lions on the savannah, but the unique threats of technology can be subtle and overwhelm this amazing system – it is just a needle above the redline?
Psychologists call these two united brain modes a “dual-processor system.” The workhorse, automatically running everything from breathing to digestion and driving, is called “System One” by Nobel scientist Daniel Kahneman (Thinking Fast and Slow) and handles all routine daily activities. And yes, we do pilot a lot in this mode, it is faster and energy-efficient. During critical, time-challenged events the automatic scripts we embed during training enable immediate and appropriate pilot action.” System two” (Kahneman) is the aware and analytical mode of thought, actively scanning for threats and also projecting possible outcomes (and potentially changing the plan). “System two” is slower and deliberate and requires more time and energy so we continuously default to less expensive “system one.” The essence of safety is consciously engaging “system two” during critical phases of flight and maintaining “situational awareness.” (A similar formulation of X and C systems: Daniel Lieberman: “What Zomies Can’t Do“)
Teaching situational awareness requires providing “continuous surprises” to shake up the “comfortable world.” As soon as a “pilot-in-training” is comfortable with an operation, a good educator is “changing the world” and preventing complacency. Hide a plastic snake in the “lightening holes” of the wing before pre-flight; are they “really looking?” By nature, we all miss “really seeing” because we think we know what is there; the human condition!
During cruise flight (on a good day) events are often non-threatening and it is easy to lapse into complacency and fatigue. It is absolutely essential for safety to consciously power-up “system two” and scan for threats periodically (see “Code Yellow“). If both the plane and the brain are on autopilot, we are “cruising on luck.” I personally try to run through all the gauges and indicators and review the flight progress – expectations vs. actual – after every radio check-in. A SA scan every 5-10 minutes helps avoid being blindsided by slow or subtle changes that can ruin your day. As the night or the flight get longer, more active interventions are necessary to combat fatigue.
But it would be wrong to paint the slower, analytical, “system two” mode as always the hero. The reflexive “heuristics” of “system one” are the heart of all excellent athletic (and aviation) performance. This is how the batter hits the fastball or the aerobatic pilot performs their unlimited freestyle. This appropriate/automatic “reflexive” mode is required for the fluid and immediate actions in time-critical situations. This is why we train so hard to embed “muscle memory” into the implicit memory of “reflexive system one.” (And this is what you are testing when you pull the throttle on your student).
The thoughtful and analytical “system two” 
is not always the desired mode of operation. We all have had situations where we “over-think” an operation and ruin the fluid/automatic flow of a procedure. “Inappropriate analytical intervention” is also the root cause of the common phenomenon we call “choking” in any performance activity. Though exclusive dominance of either system at the wrong time can ruin effectiveness, the “90% automatic” statistic almost ensures that the most common failure mode is when the “threat radar” of “system two” is not engaged. We do not perceive and are “asleep” at the switch!
I am currently doing FAA-required retraining for a very current 20K hour pilot who landed without clearance at a Charlie-level airport. How does this happen? What was he thinking? (he wasn’t). This guy was way “too comfortable” (complacent) during this critical phase of flight. What if an airliner was cleared onto the runway while he was floating down final (in “auto-mode”)? Risk hides in the familiar and it takes a disciplined pilot to switch modes correctly and force proper vigilance.
It is the job of a good CFI to provide appropriate “surprises” once their pilot-in-training is getting “comfortable,” both to “sell” the idea of vigilance and also test the embedded emergency scripts. Remember, both creativity and restraint are essential here or your student will become like a dog with a shock collar – always on the edge of panic. As an example of creativity, consider a partial power loss (not on the test but more realistic). This failure mode engages both the requirement for immediate action items but also requires thoughtful/analytical brain functions. “Creative surprises” are even more essential for rusty rated pilots.
Technology and high-workload environments provide unique threats and surprises that our stone age brain circuits were never optimized to handle. Get a good CFI and surprise yourself regularly (until you “expect” the surprises) In charter flying, we go suffer (train) every six months. Fly safely out there (and often)!
Join SAFE and get great benefits. You get 1/3 off ForeFlight and your membership supports our mission of increasing aviation safety by promoting excellence in education. Our FREE SAFE Toolkit App puts required pilot endorsements and experience requirements right on your smartphone and facilitates CFI+DPE teamwork. Our CFI insurance was developed by SAFE specifically for CFIs (and is the best value in the business).
And then there is the related issue of “normalization of deviance”. We get away with doing something risky so often that we no longer perceive the risk. The initial occurrence may be due to error or ignorance. Regardless, it leads us into doing something repeatedly with no awareness of the real risk involved and then exhibit surprise when it eventually bites us.
Yes, “normalizing” is the dark side of “human adaptation!” We can adapt to any weird situation and it becomes “just another day” – usually to our peril: https://safeblog.org/2016/03/11/the-dark-side-of-adaptation-normalizing/
Excellent article David, reinforcing the idea that risk, stress, fear and mitigation are far more complex than we realize. For more on the subject I recommend “Deep Survival” by Lawrence Gonzales.
Thanks Ken. Gonzales is epic, many subtle threats have BIG results; we live in a “predicted world!”
This is, in my opinion, another one of DStG’s must read pieces! Superb!
Thank you so much Matt!