It Hurts When I Do That

Why ask "why"? 

Because the outcome of everything I do is a result of why I do it.

The great comedian Henny Youngman provides the best rationale for avoiding negative consequences.  If it’s going to hurt, don’t do it.

There just seems to be a pernicious lack of connection between today's airline pilot and his modern aircraft.  Often at cruise and sometimes even during climbs and descents the flying pilot is involved in various activities other than supervising the aircraft's vertical and horizontal flight path.  Some say that the most acute problem for airline pilots is a loss of stick and rudder skills.  I believe the bigger problems are more that of disengagement and distraction particularly when the autopilot is being controlling the aircraft. 

Lately, the aviation community has also targeted the area of "monitoring skills" as one that needs improvement.  This was the fundamental problem that allowed the crew of an airliner to over fly its destination. The crew failed to monitor because they were mentally (and physically by the automation) disengaged from the airplane.  Ineffective monitoring skills may have contributed to some recent approach and landing incidents.

A big reason for these areas of concern is a mental disconnect between the pilot and the airplane. It takes discipline and motivation to remain mentally connected to the airplane when physically detached by the use of automation.  Piloting has evolved from flying the aircraft to manipulating the automation. Once it's been programmed, the pilot is unintentionally or unconsciously giving the automation the responsibility for managing the aircraft. The problem is that the pilot always has authority over the aircraft and the automation and therefore cannot delegate responsibility for either.  A pilot may delegate a task to another pilot or the automation, but never the authority or responsibility for its outcome.

A classic example of this was demonstrated recently on approach to LAX.  The crew was cleared for a visual approach to 24R.  They were on a heading to intercept final just outside the marker.  The autopilot was on with the approach mode armed. Since the intercept was about 40 degrees and only about 7 miles from the runway, the autopilot captured the localizer late and went through final about 1 dot as it turned to capture the localizer.  So here they were with CAVU weather and flying a visual approach and the aircraft overshoots final.  Who was flying the airplane or was it flying itself.  I guess that "program the automation and see what happens" was the plan.

Whereas the genesis of a pilot’s mental disengagement is the physical disconnection with the airplane, the root of complacency and intentional non-compliance is a disconnect with why we, as pilots, do what we do!  With respect to flight crews, the term intentional non-compliance has been used to describe a range of behaviors.  Here I am using the term to refer to a mostly unmanaged disconnect by a disengaged or distracted pilot.  I am not talking about the rogue or defiant pilot.  Defiant behavior is an entirely different discussion.   

These problems all start with the motivation behind why pilots, particularly Captains, do what they do or do not do.  From choosing a runway to programming the automation to running a checklist, the motivation or reason why pilots do what they do and when they do it is critical to their ownership and the quality of the result.  A pilot is much more likely to be complacent or intentionally non-compliant depending on how they answer the following question, "Why do I respect a particular procedure, regulation or limitation?"

1.    "Because they said so."  "Don't ask why, just comply."

2.    "Because I am managing a threat." It will promote safe operations by managing a threat or trap an error.

How a flight operation wants their pilots to answer that question, "Why do I respect a particular procedure, regulation or limitation?" will determine the philosophy and mission of their department as well as the entire operation. Is the answer procedural compliance or threat management?

If it is the first, their mission will be to teach and evaluate standard operating procedure SOP.  If it is the second, their mission will be to teach and evaluate threat and error management TEM.  The primary objective must be one or the other it cannot be both. 

Procedural compliance can be and is an effective strategy for managing a threat, but if it is the only strategy, anything less than 100% compliance is unacceptable.  However, it is also unachievable.  This was the motivation for the work published in 1997 by Drs. Merritt & Helmreich at UT and others in the area of error management (the 5th generation of CRM).  Humans have never been and will never be 100% compliant even when they know and understand the rationale.  "To err is human......" is not a recent quote, but it has taken aviation a long time to accept it.  However in 2013, it is still not a universal mindset.  The medical community has been even slower to embrace and manage rather than criticize and hide their errors. 

Those flight operations that primarily target procedural compliance usually emphasize standards over training.  They put their emphasis and resources toward directing their pilots in what to do (procedural compliance) without necessarily establishing the rationale (threat management) for the procedure. Some connections between a procedure and a threat are obvious, but data shows many are not.  The movement to make cross verification of automation selections a procedure has only been partly successful because many crews see compliance, not threat/error management, as the objective.

By contrast, the flight operations whose objective is threat management emphasize rationale (threat management) in conjunction with procedure use evaluations to monitor the quality of the training process (effective threat management skills) rather than simple procedural compliance of the pilot.     Just as programming the automation does not relieve the pilot of responsibility for the outcome, publishing procedure does not satisfy the responsibility of flight operations leadership.

The adoption of a threat management based flight operation is a bold move. It takes belief, resources and commitment.  It requires flight operations management to give up some control and trust that the training they have delivered has prepared their pilots to make effective decisions in a dynamic environment.  Effective decision-making is the crucial difference in a safe operation.  The lessons learned from LOSA (Line Operational Safety Audit) support this.  From THREAT AND ERROR MANAGEMENT:DATA FROM LINE OPERATIONAL SAFETY AUDITS, Klinect, Wilhelm, and Helmreich summarized in part:

"Intentional noncompliance errors were the most frequently committed and also the least consequential.  Proficiency and operational decision errors were the most difficult for flightcrews to manage."

"The most common errors committed were associated with automation and checklists.  The majority of these errors were not typical slips, but a failure to cross-verify settings or incorrect usage."

Some flight operations have opted to retain the old paradigm of writing extensive policy and procedure and teaching their pilots to depend on compliance as their decision-making strategy.  Absolutely, procedural compliance is crucial to safe operations, however, as the sole basis for decision-making, this path has its limitations.  Procedure cannot provide an answer for every situation. I am reminded of the saying; "reality is more interesting than fiction because it is not limited by what someone can imagine." 

There is an interesting similarity between the relationship of pilots and their automation and the relationship of some flight ops management and their pilots.  The pilots program the automation and expect a certain result they same way managements issue procedure and expect a certain result.  Neither the pilots nor the managers would characterize the relationship that way, but it is often the reality.  Automation and procedure are tools that when used effectively promote safe operations.  When manipulations of the automation or blind procedural compliance become the objective the outcome is often in doubt.  

Let's Try Looking At The Forest Instead Of The Trees

I have really struggled this week to organize my thoughts on the Asiana 777 tragedy at SFO last Saturday.  Sadness with the loss of life of course, was my first reaction.  I was awed at the scenes from amateur video showing the evacuation where lives were saved as well as lost.  I am frustrated that once again, experienced professional airmen with the best intentions were unable to prevent this accident.

The NTSB team that is investigating this accident will determine the factors, the set of threats if you will, that led to this fatal, hull loss.  They ultimately will determine the probable cause and contributing factors.  We do know that the aircraft was in an undesired state from which the crew could not or did not recover, but that is just the starting point.

It has been said that there are three crucial points in the evolution of an accident.  They are the point at which an accident becomes possible, the point when an accident becomes probable and then the point where an accident is inevitable.  Avoidance or recovery by the crew is possible, but becomes increasingly more difficult until the third point is reached. 

The analysis of approach and landing accidents resulting in a runway excursion has shown that unstable approaches are a major contributing factor.  In a majority of these accidents, absence of a go around or missed approach was the point at which probable became inevitable.

It is far too early in the investigation of Asiana 214 to discuss or speculate what factors, i.e. threats and errors, contributed to the accident.  It is certainly appropriate, however, to discuss the psychological factors that go into the critical decision to execute or not execute a go around.

The psychology of a go around is a profound and complex topic.  It would appear to be very simple, particularly in light of the fact that most operators and regulators have very clear procedural guidance on the continuation of an unstable approach.  Why then, do the statistics show that only a small number of unstable approaches by scheduled carriers result in a go around?  FOQA (Flight Ops Quality Assurance) recorders, LOSA (Line Operational Safety Audit) observers as well as anecdotal data all confirm the same paradigm.  Airline pilots fly very few (far less than 5%) approaches that would be classified as unstable.  However, of that small number of unstable approaches, very few go-arounds are performed.  It is this conundrum that defines the psychology of a go around.

Why is the continuation of an unstable approach to a landing such a common occurrence?  The same pilots who land out of an unstable approach would never consider continuing below a decision altitude on an instrument approach.  Years ago one would occasionally come across a “cowboy pilot” that would duck under, but I haven’t heard of that in many years.  Why do pilots treat the bottom line or decision altitude on an instrument approach differently than the stabilized bottom line, usually 500’ AGL, on a visual approach?  Is it because we have not “given ourselves emotional permission” to go around?  Is it just a matter of ego or saving face? Is it the same mental process that allows drivers to be ok with talking on a mobile phone because they have “gotten away” with it in the past?  Is it because pilots see their immediate and specific goal as landing vs. the general objective of maintaining a safe operation?  Is it because the crew does not think a go around is necessary at that point to remain safe?

I am not a psychologist and I struggle to completely resolve these questions in my own mind.  I could not begin to answer them for anyone else or the pilot population as a whole.  I wonder what would be the effect of making a go around the default termination of a visual approach like that of an approach in instrument conditions.  We are always emotionally prepared as well as mentally committed to a missed approach in low visibility.  Why can’t we be as prepared and committed to a go around on a visual approach?

Accident investigation data has shown that policy and procedure alone are not adequate to address this perplexing issue.  The data has also shown that non-compliance is seldom an overt act, but rather the result of some distraction or other operational threat. In fact, sometimes the rigid or compulsive pursuit of procedural compliance becomes the distraction.  It’s the classic case of getting lost in the forest because of all the trees.  The points where an accident or incident progresses from possible to probable to inevitable are not objective, but rather exist subjectively in the mindset of the crew. 

Are we, individually and collectively, prepared and committed to execute an unnecessary go around to avoid the point where probable becomes inevitable?  

The Power of Influence

In a recent episode of the Big Bang Theory, Bob Newhart makes a guest appearance as an elderly scientist/TV personality.   His character hosted a children’s science show that Sheldon, Jim Parsons, and Leonard, Johnny Galecki, obsessively watched as young boys.  When Professor Proton, Bob Newhart, laments his legacy, Sheldon and Leonard give him credit for inspiring them to become ground-breaking physicists.   Sheldon tells Prof. Proton, “A generation of scientists are standing on your shoulders.”  I am sure I’m not the only one who sees the irony that the relationship being acted out by Prof. Proton, Sheldon and Leonard is one that took place in real life between Newhart, Parsons and Galecki.  Bob Newhart is a legend.  He has been the inspiration for many famous comedians and ensemble actors.  His TV shows have helped define the standard by which all sitcoms are judged.  The Big Bang Theory is now just as popular as Newhart’s shows for the same impeccable comedic timing and the humorous relationships of quirky characters.  Life imitating art imitating life.

How do we know what influence we may have overs, whether they be in the next generation or our own?  The answer is, “We don’t.”  But that is just the point.  Since we do not know, we must act as if we do.  When we are given an opportunity to influence others we must exercise that responsibility deliberately and with a purpose.  This is especially true in the area of our chosen profession.

A professional is one who is accepted as very skilled or expert at a given activity.  Usually those professionals who are recognized among their peers as having influence are not in leadership roles.  Their influence comes from how they perform at their job.  Airline Captains have a very influential role in their profession. Because of the unique interface of man and machine, the airline Captain must have effective skills handling the crew as well as the aircraft.  When they are in command, Captains set a tone on the flight deck that will establish the relationship they will have with their crew.    How the Captain handles the aircraft will establish his or her performance expectations.   The Captain who builds effective relationships as well as demonstrates strong airmanship skills is the one who has influence.

To have influence is one of the greatest honors that can be given a professional.

Hours of Boredom........

This is my 50^th post on Flying The Backside.  That’s not much of an accomplishment for a real writer, but for a pilot like me it is quite a milestone.

In its brief few years the blog has evolved, but the objective hasn’t changed.  From the outset I wanted to initiate a dialog among aviation professionals.  I hoped that my statements, questions and opinions would lead readers to make comments both in agreement and opposition.  I endeavored to have an online facilitation of topics relevant to human factors in aviation.

I would like to thank everyone who has spent their valuable time reading and considering my thoughts.  Also, special gratitude goes to those who felt comfortable making comments.

The origins of this quote cannot be verified, but it is well known and often used to described aviation.  “Hours and hours of boredom punctuated by moments of sheer terror.”  Moments of “sheer terror” might be hyperbole, but it makes the point.  Because during the moments of “sheer terror” it is difficult for aircrews to immediately react with effective plans unless those scenarios have been considered in advance.  Checklists and procedural guidance can help, but the most effective technique crews can use is to consider these emergency and non-normal scenarios in advance.  For the same reasons recurrent training events are more suited to practicing and reinforcing potential strategies than an opportunity to begin considering these events.

My hope is still that Flying The Backside would initiate discussions involving the human factors that influence aviation safety.  As a community we have a vast amount of knowledge and experience.  Informally sharing this information and related topics can only have a positive effect on aviation safety.

Thank you and I look forward to your thoughts and insights.