Murphy’s (real) law seems to be that we often succeed despite poor procedures and sloppy execution. A painful failure would result in learning; ouch! Instead, every “lucky success” actually reinforces and “normalizes” questionable procedures and activities. Online stupidity provides an additional catalog of “leveraged luck.” Just because some wild act worked once (for one person in a rehearsed environment) does not mean it is a good idea or solid procedure for us (please watch those “fail” videos too).
Humans are “learning machines” and we input everything despite our best intentions to “unsee” some content. Our continuous input requires analysis and filtering or bad habits can easily get embedded in our operating system – coded as “useful/acceptable.” These usually lie dormant, like viruses, to surprise us at the worst times e.g. “what was I thinking?” Reflective analysis is the proper antidote; a skill every pilot must learn and practice for safety. The military version of this same process is an after-action report.
Challenge and adventure are what makes flying so addictive. Pilots are very practical, straight ahead, hard chargers, and enjoy overcoming obstacles. Aviation requires positive, time-critical decisions in a real-world, high-stakes environment. However, learning and growing the pilot and educator toolkit of resources safely requires reflection. This process involves making a quiet, thoughtful time for a review and analysis. Reflection has to happen soon after every active flight and is the heart of improvement and positive change. Reflection requires asking questions of ourselves: “How and why did this action work?” “Was our success (or failings) a result of skill or luck?” “Am I normalizing some non-standard procedure that just happened to work (luck)? It is a huge (but very human) mistake to validate procedures based on results alone. Just because something worked (for us or for others) is not a reason to accept and use a procedure.
Because the flight environment is time-critical and always in motion, pilots often function on the level of embedded, automatic “scripts.” These stored routines come from prior hours of hard training and review. When facing unique and rapid challenges, a pilot often has to punt, choosing the “less bad,” reflexive actions guided by previous experience but with no clear script. (A previous blog covered “satisficing,” which is the heart of aeronautical decision-making) Careful after-action analysis of these actions that occurred “in the moment” builds the master pilot and educator.
This contrast of “regular day, plain vanilla” missions vs “off the wall challenges” is profiled in Gary Kline’s excellent book “Streetlights and Shadows.” Dr. Klein argues for a precise script – think checklist/SOP – when the situation is predictable (Streetlight) and inspired and flexibility when “all bets are off” and no rulebook applies (Shadows). The latter would be the Sioux City DC-10 or the Miracle on the Hudson response; they never wrote a checklist for these situations. The key to safety is defining these different worlds and applying the correct formula. “Going cowboy” is inappropriate to meet the demands of an ordinary day where checklists and procedures are the proper guidance.
Reflection is the antidote to “normalizing” or “regulatory drift.” Celebrating mere success might create permission to lower or reform performance standards or adopt new procedures. This process was the cause of both of NASA’s shuttle accidents where a deviation from protocol was accepted as “normal procedure” due to the lack of any immediate negative consequences (they got “lucky”). In these cases, when the luck ran out we experience the shock and surprise from of our inadvertent violation of proper safety standards (“what were we thinking?”)
After every flight spend a moment and review your actions. Did they meet standard SOPs and regulatory standards. Were the successes of tthe flight from skill – or from luck? The debrief every CFI does with pilots-in-training is this same reflective analysis. And this process should become a habit for every pilot when they achieve certification. To make master pilots, every CFI must encourage and embed this habit into every new pilot. After every flight ask yourself; “Was our success a result of skill and knowledge correctly applied or was I lucky?” and adjust accordingly. Fly safely out there (and often). Live longer and fly more.
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The “other” way of describing this is the tried and true “normalization of deviation”. One gets away with the deviation from standardized actions, e.g. skipping checklist items, and nothing happens. And nothing happens and nothing happens until you die. I do check rides for a volunteer organization and I absolutely demand that the check list be followed or the examinee fails the ride. Usually before we even get in the airplane. Rigid? Yup. I don’t want to have to stand before a board to explain why the pilot I just signed off is dead.