"Solving tomorrow's problems with yesterday's solutions"
For many of us, it seems we've done everything there is to do in our efforts to become safer pilots and run safety conscious flight departments. We've gone through the Safety Management System (SMS) process, we've achieved that highly coveted "Stage 3" audit, and we've even done a few renewals. We've accomplished everything our training vendor put in front of us and they are running out of ways to challenge us. The annual safety stand-down is becoming repetitive.
After all that, we have this nagging feeling that in our effort to make safety routine, it has become routine. We know that is a recipe for complacency, but what can we do about that? What's next?
I think there is a way going forward. Allow me the chance to elaborate.
Everything here is from the references shown below, with a few comments in an alternate color.
Photo: Captain Justin Serbent's high tech cockpit and low tech "whiz wheel."
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When I first heard this phrase I was immediately captivated. The obvious meaning is that we in aviation are stuck in the past, unwilling or unable to move forward. If we don't do something to completely ditch this thinking, we are in for some serious trouble. But wait, is that really true? Isn't there anything good from the past that we can (and should) take forward. You bet there is.
We are being paid to avoid hazard, but there are still many unexplored crevasses in our reservoir of knowledge. Our zeal for air transport is always soured when we so easily reflect on failures involving certain late comrades, who proved in the final analysis to be, like ourselves, only the tip of the arrow. We are obliged to recognize our possible epitaph — His end was abrupt."
— Ernest K. Gann
Fate is the Hunter
Photo: KC-135A Over-rotation Warning, T.O. 1KC-135A-1, p. 2-27
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I remember looking at this warning when I was in KC-135A copilot school thinking two things. First, what kind of idiots did they have flying these death traps who don't know enough to rotate to the correct pitch angle? Second, what kind of death trap airplane is this that a 2 to 3 degree error in rotation can leave the airplane unflyable?
Later that year I was at the controls of a maximum weight KC-135A when one of the engines blew up on me right at V1. (I write about that here: Know Your Limitations.) We were about twenty knots short of rotation speed with a thousand feet of pavement left. So I rotated ever so gingerly and found that the 8 to 9 degrees was indeed where the pitch needed to be.
From that point on, I started adding that to my takeoff briefing. "At rotation speed I will rotate to between 8 and 9 degrees."
"Don Lemon could have used that advice," Major Harry Butters said after hearing me say that. Harry started flying the KC-135A in 1965 and seemed to know the history behind every warning in the book. He explained that Captain Lemon was a KC-135A aircraft commander stationed at March Air Force Base, California who over-rotated his airplane on a takeoff at Minot Air Force Base, North Dakota. "The weather wasn't great but Don stalled the airplane and everybody on board was killed. The Air Force put in that warning to our flight manual the next year."
"Really?" I asked.
Harry pulled out his flight manual to the page where I knew the rotation warning appeared. Next to it was his handwritten note, "Capt D. Lemon, 17 Jan 1968."
"Son," Harry said, "Our flight manual is written in blood."
Sometimes we ignore history at our own peril.
To put it briefly, automation has made it more and more unlikely that ordinary airline pilots will ever have to face a raw crisis in flight—but also more and more unlikely that they will be able to cope with such a crisis if one arises."
Not too long ago pilots were simply accustomed to things going wrong, aircraft were simply more likely to misbehave. When you've had a few engine fires over the years, you tend to be better prepared for the next one. But our modern day aircraft are remarkably well behaved these days.
"What about modern 6-axis simulators?"
You can't learn to deal with panic and fear in a simulator, when you know you are going to walk away uninjured. But that brings up another issue. Many of our training vendors have become little more than diploma mills. If "SimuSafety, Inc." is getting a nice fat check for $100,000 (the list price of a G650 initial), how likely are they to fail you on your type ride? So too with recurrent. These schools have resorted to teaching just the minimum needed to pass a check ride, and little more.
As pilot experience levels (in terms of years, hours, and things experienced) decrease, the need for better training increases.
So let's look at Safety version 2.0. Why? Just remember life is hard. (Life is fatal, after all.) Aviation is hard too. If you don't think so, you need to get your mind right.
Most occupations in aviation are a lot like other intricate skills, like playing the violin, winning at chess, or becoming an all star football quarterback. You can suit up and do it, but if you want to do it at the highest level, you will need to do something special to obtain that extra "something." But how do you get there? How does one become an expert?
It may be helpful to look at a few wrong answers before moving on to the right answers.
Before the days of Power Point, we could always identify the "expert" at any meeting in the Pentagon as the officer carrying the big stack of acetate slides. Now days, the same goes for any large meeting: it's the person behind the podium with the Power Point clicker. Of course, then and now, all of this is wrong.
The same holds true outside the office. Just because you wear the title "Chief Pilot," "Director of Operations," "Captain," or other such aviation title, does not make you an expert. You might be an expert, but the title didn't make you one. Just think of all the chief pilots you've known over the years that were completely clueless. Enough said about that.
[Ericsson, pp. 109-112]
There is an old saying that a pilot spends the first 10,000 hours learning, and the next 10,000 hours forgetting, so the pilot ends up at where he or she started. I've found that the impact of complacency hits pilots especially hard around 10,000 hours. So I would amend the old joke to say that a pilot's expertise tends to grow with hours until it doesn't. At that point, the pilot has to work even harder to remain sharp.
Photo: Tennis players (Tulane Public Relations)
If you put in a lot of tennis practice, you will probably improve. But unless you have good instructors or consistently play someone better than you, you are unlikely to get much better.
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[Ericsson, pp. 109-112]
I see this a lot. Pilots tend to improve their skills with practice to a point. There often comes a point where doing the same thing over and over again actually makes the pilot worse. Think of the simple task of flying an ILS approach. At first, it is incredibly difficult to keep the needles centered. But after a while, it becomes second nature. Then, after years of flying ILS approaches, it isn't as easy as it once was. Why? I think it is because keeping those needles exactly centered proves to be overkill. We accept a needle width of error. And then half a dot isn't so bad. (That's the ATP tolerance, after all.) We expect less of ourselves and that's what we get. There is, fortunately, a solution.
Photo: A radiologist examining tomography, (National Cancer Institute)
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[Ericsson, p. 141] A pattern of improvement [ . . . ] was seen in a study of radiologists interpreting mammograms. The radiologists improved considerably in their interpretations over the first three years they spent on the job, coming up with fewer and fewer false positives — that is, cases in which women did not have breast cancer but were called in for further screening — and then their rate of improvement slowed down sharply. Interestingly, this improvement over the first three years occurred only for radiologists who had not had fellowship training in radiology. Those doctors who had gone through a radiology fellowship did not have the same sort of learning curve but instead took only a few months on the job to reach the same skill level that the non fellowship radiologists took three years to develop.
Radiology is a field where feedback comes fairly quickly. These false positives can be identified on subsequent examinations and doctors learn from their mistakes. The doctors who attended fellowships had many opportunities to learn from their mistakes quickly. Those without the fellowships eventually learned, but it took longer.
Photo: Eddie's flight examiner days
A common compliment for many professionals is that he or she has incredibly high standards. But, even if that is true, these professionals rarely evaluate themselves by those standards. If, for example, you are evaluating a pilot's ability to keep those ILS needles centered on an approach to minimums, you can be brutally frank on the importance of doing just that. One needle width, after all, can be a few hundred feet off centerline. But when it is you flying the approach a needle width (or two) off center, the fact you spotted the runway and landed is proof you met those lofty standards of yours.
Okay, you say, you know that. But you always fly with another pilot in the other seat and you always end the flight with a post-flight critique. "How'd we do?" you ask. "Just another day at the office," your peer says. And that's the problem. Our peers are reluctant to give honest critique because (A) they are uncertain those critiques will be received well, and (B) they know they will be the ones being critiqued next time out.
But if we truly want to improve our skills (and retain the skills we have), honest critique is vital.
I've written extensively about the value of a good line observation program and the need to have an outsider look at how you are doing on a periodic basis. More about that: Line Operation Observations. The bottom line is that the check rides you get from your training vendor don't evaluate you on the line and the critiques you get from peers in your own flight department tend to be exercises in politeness. I encourage you to start or continue a good line observation program, but to broaden the audience. You need to include pilots outside your normal sphere. But more than that, you need to set them up to give you the best and most honest critiques possible.
If you know of a nearby flight department that seems to do everything right, or at least seems to have its act together in ways that perhaps yours does not, you might consider a high level sit-down of ideas. It could be between chief pilots, or safety officer, or just like-minded pilots who strive for improvement. Two pilots involved with each flight department's standardization program would be ideal.
An exchange of audits between flight departments is ideal, because you can learn when giving as well as receiving an audit. But such an exchange isn't always possible. Some flight departments, for example, operate under strict non-disclosure agreements. But that doesn't preclude you from getting a useful audit. If you know of a pilot who you respect, or even a contract pilot who seems to always have a good idea at the right time, you may have an ideal candidate. See: Line Observation Pilots for what to look for in a line observation pilot.
The LOO is not a check ride and the observed pilots' careers are not at risk. The LOO is an opportunity to see how well the pilots are doing in the eyes of another pilot. The better the qualifications of the observing pilot, the better the feedback is likely to be. The primary purpose of the LOO is to catch complacency before it becomes a problem.
The purpose of the Line Operation Observation is to:
Everyone involved needs to understand that because the audit is taking place in a flight department doing a job and the line observation on a "live" trip, that the audit and line observations cannot interrupt the business of the flight department.
You will need your company's permission and will need to convince them that the audit will improve the safety of your flight department without encouraging the idea that you need improving because you are unsafe. A few thoughts:
Everyone in your operation should be briefed well in advance about the purpose and conduct of the audit and line observation. They should understand that the intent is to improve the operation, that nobody's job (or pay) is at risk, and that the execution of the job at hand takes priority over the audit or line observation.
If the auditor has previous flight evaluation experience, you need only emphasize the need to remain "in the background" and the role is to observe, not to evaluate. With or without this experience, the auditor needs to understand your organization's desired outcomes:
See: Line Observation Pilot Training for a few ideas on how to train a line observation pilot.
You should customize the audit and line observations to meet your specific needs, to accommodate company restrictions, and then adjust to any time constraints you or the auditor may have.
The debrief should be informal and may be limited to just the department head or selected members of the flight department, at the discretion of the department head. The auditor should cover everything seen, good and bad, as well as any suggestions. The person(s) receiving the debrief should make clear at the outset that they are interested in learning from the exercise and that the auditor's opinions will be appreciated and acted on if appropriate. Once the debrief is complete, it is up to the flight department's leadership to decide what comes next. I think these recommendations should be considered for the SMS process.
The following examples come from my current and a previous flight department, over a span of fifteen years. The first wasn't an audit at all, merely a meeting of minds between flight department heads. The next two were solicited feedback from individual pilots. The last example was a formal audit and line observation.
The director of aviation for a large (six aircraft, sixty people) Falcon operation asked me to visit prior to their conversion to an all-Gulfstream fleet. I provided what help I could regarding pilot flight operations and training, as well as maintenance best practices. But, in return, I learned about techniques they were using that were superior to our own. I brought back with me better ways to ensure oxygen compliance and tool inventory control.
We have always encouraged our contract pilots to provide honest feedback about everything they see. This tends to work slowly at first, since few contract pilots are willing to "bite the hand." But after a while, when they see how cheerfully we give and receive critiques amongst our full time crews, they start to open up. One such pilot noted that we were not recording engine cycles correctly. (We didn't record missed approaches as engine cycles, in accordance with Gulfstream rules.) We researched the suggestion and found our contract pilot was 100% correct.
Another contract pilot appreciated our strict adherence to "Challenge-Do-Verify" checklist discipline but noticed that after we had become comfortable with him, we tended to accelerate the pace of the checklist to the point he was no longer able to keep up. (So his ability to verify was compromised.) We stressed among our crews that checklist pacing required more patience. Specifically, we had to allow the "challenge" before the "do" to keep things safe. That was five years ago and we seemed to have stuck with this more patient approach to checklist accomplishment.
Our line observation pilot was struck by the fact the two pilots he observed were using three senses (aural, visual, tactile) for many crew coordination chores. Altitude changes, are announced by the PM while pointing to the altitude select knob and seeing the altitude select window. The PM then repeats the altitude while pointing to the altitude shown in the pilot's flight display. (There are many other examples.) The chief pilot didn't know about this technique and, as it turned out, only the two pilots flying the line observation were using the technique. (The other six pilots were not.) This encouraged the chief pilot to encourage the other pilots to adopt the technique.
Psychology Professor Anders Ericsson coins the term "purposeful practice" to differentiate it from what he calls what most of us do, something he calls "naive practice." The former is a way to really ramp up our level of expertise, the latter is just going through the motions. Purposeful practice has the following characteristics:
[Ericsson, pp. 15-17]
In an ideal world, we would apply these principles to our regular recurrent training, but we aren't in an ideal world. We have regulatory requirements (61.58, etc.) to take care of. But there is a path to achieving purposeful recurrents.
You know how it goes. You finish the last of the legal training requirements and the simulator instructor says, "anything else?" This is fine if you have an answer for something that can only be done in the simulator that has a meaningful impact on how you conduct yourself as a pilot. But more often than not, the instructor might have a suggestion of his own. Based on the number of all-engine-out instances in aircraft I've flown over the years, I think the usual answer of "let's try a deadstick landing" to be a waste of time. But there are better answers. Here are four examples for a start:
I've had instructors tell me they don't have time for these, even after I noted they had very elaborate setups for simple maneuvers that wasted simulator time my company was paying for. I can imagine teaching the same simulator profile over and over again can be boring and instructors want to do something different. I don't care. The purpose of the recurrent is to hone my skills, not to amuse the instructor. Over the years we learned to identify one or two things to add to our training request. We never send pilots to recurrent without at least one or two of these special requests. This puts the stress on the instructor to fit it all in. And somehow they always do.
When you are new to an aircraft, it is vitally important to follow up initial training with some operational time and a good recurrent session. In fact, you should probably have several recurrent trainings. As it turns out, most FlightSafety full-service contracts are good for two years and that should be good enough for one initial followed by three recurrents. Now what? The usual answer is to renew and get four more recurrents. That might be the right answer, depending on the pilot and the aircraft. But if you are at the point where it is all getting stale and it seems you are teaching the instructor more than the other way around, it might be time to break up the routine. You might consider terminating the recurring contract for one year, and then at the six month point throwing in something different. You may find that the something different is actually cheaper and you will end up a better pilot. Your company will have saved some training dollars. And, on top of all that, you will have a renewed interest at your next recurrent after your recurrent contract is renewed.
Here is an example from a few years ago. We had three pilots each with a full service contract that cost us $60,000 per year per pilot, with a two-year term. We sent each pilot to recurrent every six months, as our company policy requires this. After doing this for two contracts spanning four years, our pilots were becoming bored. So we ended the contracts after each pilot's fourth recurrent of the expiring contract. We then allow each pilot to pick an upset recovery training flight school for the next training event. The most expensive was $30,000. For the following training event, we renewed the full service contract. Each pilot learned upset recovery in a high performance airplane, the company saved $30,000 per pilot, and each pilot felt more motivated at the next simulator recurrent. For more about upset recovery, see: Unusual Attitudes Recovery.
If you have been flying the same aircraft for ten years or so, the repetitive recurrents can lead to complacency. You should consider upset training, certainly. But you might also consider glider training, tailwheel training, or even helicopter training as ways to improve your stick and rudder skills and motivation.
Safety 2.0 doesn't mean discarding Safety 1.0. We need to fully embrace the lessons of the past and, in many cases, rediscover those lessons that many think technology has solved (but hasn't). But we should add effective critiques to our arsenal of weapons against complacency. We should look for opportunities for outside audits and line observations for critiques we would not have received under regulatory requirements. We should emphasize recurrent training that sharpens us in ways that are pertinent to everyday flight operations. Taken as a whole, these steps will make us better pilots (while improving our resumes) and prevent complacency. And, as a side benefit to those of us running flight departments, it keeps pilots fully engaged and perhaps less likely to jump ship for a bigger pay check, newer type rating, or more exciting challenges.
Ericsson, Anders, Pool, Robert, Peak: Secrets From the New Science of Expertise, Mariner Books, New York, 2017.
Gann, Ernest K., Fate is the Hunter: A Pilot's Memoir, 1961, Simon & Schuster, New York
Langewiesche, William, Should Airplanes Be Flying Themselves, Vanity Fair, October 2014.
Technical Order 1C-135(K)A-1, KC-135A Flight Manual, USAF Series, 10 August 1975
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