Accidents & The Public Opine

“Human Error Cannot Be Ruled Out“…

Another ~ 150 body bags were filled with the remains of passengers of an Indian B737-800 that overshot a runway in supposedly good and calm weather. According to the news, all kinds of officials, representatives, ministers and others ‘in the know’  have been touched, the United States is sending NTSB professionals to the scene in trying to help put the pieces together on this most recent crash of Air India’s Flight IX- 812.

Accidents happen and will continue to happen. Its natural and can be expected in a system of worldwide mass passenger transport, which on average transports passengers for ridiculously low amounts of money. The non-flying public is extremely quick to judge, several self-declared experts usually jump on the wagon and make scary statements about the airlines, the alcohol level in the pilots blood, the shape and form of the runway, the weather, the general state of the fleet, the professionalism of the crew and so much else and if it will rain in their neck of the woods… However, when we (as pilots) read such comments we may feel as if the ‘idiocy carousel’  just got another heavy push for the worse. People seem to excel at their way of coming up with sometimes helpless stories as to what may have caused this last (or any other) aviation accident. We call it “Monday Morning Quarterbacking”.   The press throws the word “Human Error” around like warm chocolate cookies. That helps in selling sensational news but leaves the majority of readers under informed and moreover, it does nothing. When we take the word “Human Error” we find several meanings and associations:

• “Human Error/Reliability” is related to the field of human factors engineering, and refers to the of humans in fields such as manufacturing, transportation, the military, or medicine. …
• “Human Error” is a Swedish Punk Rock Band.
• “Human Error” is the twenty-fourth episode and season finale of the third season of House and the seventieth episode overall.
• “Human Error” is the stage name of Rafał Kuczynski (born 21 may 1982), a polish electronic musician, working mostly in the ambient music genre …

Here is a more logical explanation of Human Error & Reliability: http://en.wikipedia.org/wiki/Human_reliability. The point I am trying to make is that when we try to determine the reasons for an accident we need to make sure the non flying public understands the depth and complexity of the issues at hand when we talk about “human error”. What happened in India has caused quite some outrageous responses. Upon Colgan Air’s accident in Buffalo NY which killed 50+ people we had these same discussions with the same outrage. Every once in a while a Pilot is caught arriving for work with rest alcohol, or makes a mistake that is (by the general public) considered stupid. In Buffalo NY, once the press had picked up that the Captain had failed one or more Pilot Exams & Tests in the past we were extremely quick to pay political attention to an issue that has been bogging our industry into despair for decades. People started to gain a glimpse at the fact that being a pilot is no longer what it used to be in the not so distant past. We have, and will continue to have, Pilots who sleep on recliners, couches and sometimes a  futon, because they cannot afford hotels on their lousy salaries. We have and continue to have pilots who travel for hundreds of miles to fill a seat for less money than an average Star Bucks employee. We continue to have stressed pilots, under tremendous pressure. Idiotic schedules, idiotic rules or the fact that they will simply lose their job if they say no!, has a tremendous effect on the people in the pointy end of todays average airliner.

What can cause a Runway Overshoot accident?

• Aircraft to high or fast on approach (problem related to the human)
• Tailwind (selection of runway & compliance issue = problem related to the human)
• Malfunction of reverse thrust, brakes or spoilers (technical issue= ultimately related to the human)
• Miscommunication upon realization of the fact that something is wrong (related to crew & human)
• Lack of attention, situational awareness or a simple other, small mistake that is allowed to progress into a big issue (human)…

The lack of proper overrun space is not a cause for an accident like that. The fact that India does not have what we call the NTSB is not a cause. I’d go out on a limb and say the pilots where probably not drunk, drugged or otherwise impaired, did not suffer from a lack of intelligence or skill and where generally probably just as good or bad as you and me. Yet, the lack of proper overrun space greatly limits airport versatility and is cause for concern in quite a few airport management offices. When the issue comes up, and airports try to lengthen available space, the result is, usually and again the human who takes offense in the form of citizen groups who vehemently fight against airports and what they do. However we turn and twist it, when we look at accidents our first action should be to touch our own nose. It is the public, who wanted cheap flights. It is the public who called for and allowed the deregulation of the airline industry. It is the airlines human resources office, which hires and fires the pilots, and determines how many peanuts they get paid for what they do. It’s the laws, which allow them to do what they do, and it’s generally the law that prohibits them from doing things. I believe that we will unfortunately keep seeing such freaky accidents, which wipe out hundreds of lives and leave many thousands of families affected by grief and upset,  before we stop making the same mistakes over and over again.  I believe that our industry worldwide needs a heavy-handed “Integrity Check” and we need to re-evaluate our hiring practices for professional pilots and what we pay them. We also need to start looking at how we educate the non flying public in somewhat easy to understand terms as to what our issues are, currently. Maybe then, the press and John Doe will stop throwing the word “Human Error” around like a worthless, dry and tasteless cookie. Otherwise, I am afraid we will soon hear different comments of passengers when they enter the cabin while boarding. While many years ago, the public evaluated the shape and condition of the airplane (“Oh, I hope this airplane holds up, it’s so dirty!”) as a factor in determining if they are safe, we may soon hear “I hope the pilot does not make a human error!”. Well, the pilots can’t really make any other errors, so chances are, if there is a crash it’s going to be the result of a human error! Our goal must be to improve human reliability and hold people accountable for their decisions. Our goal must be to educate and learn as much as we can about why mistakes are made. The world cannot be free of mistakes, yet the only way to eliminate or reduce mistakes is by education, training and sound decision-making. I doubt we will see improvements as long as John Doe still flies across the country for $99.99………….

Think: Human Factors (1/2)

Thinking Human Factors:

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.

1. Complacency:

“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.

4. Distraction:

“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.

5. Fatigue:

“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…