This article is aimed at provoking a bit of thought in the readers mind as to what we can do, individually, but also in groups, teams and commercial flight departments, to leave a “safety footprint” for ourselves and others. By recalling a few common Human Factor Errors and thinking about them, we may spend a few minutes out of our busy lives to evaluate our own status and level of awareness. Maybe you can use some or all of it for your own flying. Refreshing on a few key items may help. If you think about them, you are already doing more than average and that is a good thing. As a guiding document you may wish to refer to the Dirty Dozen which is a listing of the 12 most common causes of human error, and subsequent failure developed by Mr. Gordon Dupont. While the basis of his initial effort was geared more towards the AMT (Aviation Maintenance Technician) his concepts and contributions to the industry have been widely accepted and recommended by the FAA, Transport Canada as well as EASA and apply equally to pilots and AMT’s.
“I have done this 1,000 times!”… As we gain experience in whatever we do, we tend to become more comfortable and relaxed in terms of our own standards. Just like a motorcycle driver is not realizing that he is just about to embark on a passing maneuver that is bound to fail, we may misjudge some minor detail that has tremendous impact on the outcome of our flight. We humans tend to categorize our reactions by putting certain triggers and responses and the experienced success or failure of the response into drawers within our brain. When we are triggered to make a decision, our brain automatically and very quickly determines which drawer to open. Experience can compensate for many shortfalls. The more we do something, the better we get at it, however, the better we get at something, the more prune we become, to making a quick mistake by simply ignoring the fact that not all situations are equal and not all reactions, solutions or measures apply exactly as we desire them to. Some say, it takes a certain amount of paranoia to effectively overcome complacency. Another, logical way to fight the effects of complacency is to keep moving the information that has been stored by continuing our education and thinking about our reactions ahead of an event. Just because something has worked well the last time does not mean that the same measure will yield the desired result this time. By staying open-minded and giving each situation or event the space and attention it demands we take a step towards avoiding complacency.
2. Lack of Knowledge:
“I did not know that this TFR was active”… Lack of knowledge is probably one of the most complex and dense areas of human error. We can have a lack of knowledge in regards to new regulations, technical details, new equipment installed in our aircraft, performance details, a new AD or service bulletin, airspace & procedure changes and much more. A lack of knowledge failure could probably best be described as having a large element of surprise hidden within. We find out after making an error that something in our system was not right. Every time we are asked a question we access stored information that could be outdated and obsolete or brand new. In order to create knowledge we need to reach for information. For many the simple way to reach for information is by asking questions. For others, the best way to gain knowledge is to read and research. Both methods come with potential downsides. The person we ask needs to have a solid understanding of how wrong information may affect us, down the road. If the information we have learned is incorrect we are just as well off as before. The gained knowledge is worthless. In turn if we read the integrity of the information must be assured. We could be reading the wrong document or overlook an annotation that specifies the area of applicability of the information. Only by asking and reading in a systematic way can we assure that what we are finding for answers is in fact substantiated. Using common sense can help in finding out if disbursed information is correct. Challenging an answer, or document, is sometimes needed to succeed.
3. Lack of Teamwork:
“I thought we are climbing to 2500…?” While this point may have only limited space in the single pilot environment we may, at any time ask a fellow pilot on his opinion or procedure to accomplish a certain task. When we look at multi crew cockpits, teamwork suddenly becomes much more important. In the single pilot environment we may consider the fuel truck driver, filling our fuel tanks, as a team member. On a seaplane base, the person who pushes you off the dock is an important part of your team. Whoever it is, who is engaged in the operation or movement of your aircraft or takes any active part in its movement must be part of a team. If a team is to be efficient and effective there must be common ground and a defined goal. Briefing and explaining what you wish to happen to your partner will leave space for questions and clarification before the action starts.
“Did I drain the fuel on the left wing or not?” …It is normal to lose track! We all do it, either in the office or on the phone. In many cases we find ourselves returning to a task after a short or long distraction and wonder where we left it off. For the passengers on a plane, occupying an aircraft who’s AMT was distracted during a repair or inspection, the one minute phone call or the 20 second small talk could turn deadly. For us as pilots, a distraction can have equal results, however we are subject to distractions all the time. Focusing on the task at hand requires us to do the simple, dirty things of flying first. “Fly The Plane” / “Look For Traffic” / “Keep The Ball Centered”… are just some of the things we may hear more or less frequently. When we watch other pilots fly, we have an awesome opportunity to gain a sneak peek at how they deal with distractions. A passenger pointing at his house in a turn, an ATC Controller rattling down a clearance or amended routing, a CFI dropping a pencil or a chart, or starting to chit chat just as we had to complete our pre- landing checklist or a talkative occupant can cause havoc to our ability to focus. Not answering the phone during a pre- flight inspection, not listing to last nights football results when getting ready to launch into the blue yonder… or keeping a sterile cockpit below a certain altitude can free up major resources in our brain and allow us to focus. It is never possible to remove all distractions. The only way to handle them is to continuously work on being aware of them and refining how much attention we pay to them.
“Someone got a toothpick”? … We are always fresh and relaxed when we fly our seaplanes. It’s fun! We have all spent time in cars or on airplanes and sooner or later we notice that everyone is asleep! It could have been a long flight, or not enough sleep the night before, or an oncoming cold. Whatever it may be, we may be physically or mentally fatigued and not even realize it. So could the guy or gal pumping JET A 1 into our Husky. Symptoms of fatigue are countless. Slow speech, slow eye movements, slow reaction times, delayed response, constantly doing the wrong thing first, or even physical weakness (trying to get up on the plane to fuel it) may be good indicators that we are dealing with someone who is, or are fatigued ourselves. Asking someone to look (y)our work over, and double-check, and paying attention to the symptoms of fatigue are the best prevention tools we have. Seeing someone walk around with an energy drink could be an indicator of dealing with someone who feels tired and is trying to squeeze a bit more performance out of him/ herself before taking a nap. Yes, there is a chance someone may just like the taste of Red Bull, but the chances of the person being tired or feeling exhausted are equally high. Ask a fellow pilots or share with him/her that you are tired and feeling exhausted. It may well mean the difference between a perfectly contempt copilot and a person who will keep us engaged and stay awake to keep us entertained on this upcoming 4 hour flight. Maybe its just better to take a power nap, sometimes a good nights sleep and a canceled flight are the best solution.
6.Lack of Resources:
“The sectional was sold out”… Missing people,equipment, documentation or time to complete a flight. Arrive a few minutes early and make sure everything is in order for the upcoming flight. By leaving ourselves an out, or a backup plan, in case we are missing anything that will help to complete the flight we have done a good first step. This could be as simple as finding out that the rental plane just recently had a new radio or GPS installed. Taxiing for takeoff is the worst possible time to try to figure out how to get a frequency changed or find out that frequencies for departure have changed.
To be continued…