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THE WAR ON ERROR
Humans lead in Bizjet accident causes - but it need not be so

According to the numbers- the past couple of years haven’t exactly been business aviation’s high point where safety is concerned. Landing accidents- runway overruns- in-flight misjudgments: All of these areas have seen an increase in accidents and- unfortunately- injuries and fatalities.

Why? Aren’t business aircraft typically the best equipped and best maintained of all general aviation’s 190-000-plus aircraft? Indeed- aren’t the typical crewmembers among the best trained in all of aviation? Score yourself points for both if you answered ‘Yes’ to the rhetorical questions.

Again: Why is this so? Why do the vast majority of business aviation accidents trace their causes back to the nuts holding the yokes?

Ultimately- because in the end those crewmembers are humans – and humans not only make mistakes- they learn to accept a certain degree of error as normal. Our ability to make mistakes- is recognized – correctly or incorrectly – as ‘only human’- a given that’s ‘just going to happen once in a while…’ even when our aircraft carry systems designed specifically to prevent some of those simpler ‘human errors’.

Consider the landing accident in which the flight crew touches down sans landing gear – despite the gear-warning horn blaring all the way to the ground. Or maybe the take-off accident that occurs because setting the flaps somehow slipped through the cracks of a two-pilot cockpit – despite another aural warning screaming 'FLAPS! FLAPS! FLAPS!' throughout the take-off roll. What about the crew which tries to stuff an airplane into a field too short for the approach speed or other conditions.

The reasons these mistakes occur and recur are as complex as both the machines we fly and the machines flying them – the human machine- that is.

The ‘human error dragon’
‘The War on Error’ is not a war we can win by turning more toward the two ‘Big Ts’ of modern business aviation: training and technology. In the words of safety authority Dr. Tony Kern- 'The challenge of human error will never be remedied by any traditional safety program.

'Personal error must be slowly untangled in a private battle within each individual. This is true because in high achievers- human error and personal weakness is secret and sacred ground.'

In other words- to win the War on Error at the root cause- each of us who flies- maintains or influences the operation of an aircraft must look within for some solutions. After all- we tend to rationalize our ability to make mistakes we already know how to avoid- leaning on the rubric that we’re only human.

Kern showed some examples of these surrender flags during his presentation to more than 400 business aviators during the Bombardier Safety Standdown 2005 last October. These flags manifest themselves in the following sentiments:

• 'People will always make mistakes- that’s a given'
• 'To err is human… it is easier to manage error than to prevent it'
• 'Humans are the weakest part of our safety system'

According to Kern- error happens- but it doesn’t have to happen nearly as often as it does. Airline data shows- more than 50 percent of errors involved some form of procedural non-compliance – that is- breaking with proven- approved procedures – including exceeding posted speeds or busting altitude limits; the failure to use a checklist or to complete the checklist fully; or some other form of corner cutting. Similar patterns also showed up in other areas of aviation.

Rule breaking seems- by the numbers- to be higher than the accident rates would suggest – an indication of how much we pilots can get away with… which only encourages more disciplinary breakdowns. So let’s look at some recommendations for winning the War on Error at the individual level.

Systems training needs discipline to work
‘Flight discipline’- as Kern defined it- is the ability and willpower to safely employ an aircraft within operational- regulatory- organizational and common sense guidelines- in the presence of temptation to do otherwise. Flight discipline- Kern told the pilots in the audience- is a 'tipping point' phenomenon. Maintaining personal discipline keeps all the systems for safe flight on line and operating.

The breakdown of personal discipline- however- breaks down any safety management system because it negates the protection provided by policy and procedures. Essentially- when discipline dissolves we can no longer assume that procedures will be followed.

Need an example? Well- look at any instrument approach plate and find the altitude minima for different phases of the approach. Now think about accidents you’ve heard about in which the pilot decided to 'go down and take a look' even in the face of reports of ceilings below the minimums. Maybe you- too- have been tempted to edge a little lower on approach to a familiar airport. You know the approach is clear of obstruction; you know the runway is far longer than needed and wide enough to allow some slight deviation off the centerline. There’s pressure to get into this airport; what harm can come from dropping to 150 feet when 200 is the lowest the approach allows before you’re supposed to declare the missed approach.

Under such pressure- you may not remember you need to adjust the altimeter differently or forget about the margin of error of your instruments. It’s happened too often; the pilot lets the airplane drop a little lower- then a little lower still- until the airplane impacts the ground unexpectedly because the pilot never established visual contact with the ground.

Sure- in the abstract- the pilot knew it was the wrong thing to do – but did it anyway because- well- he was only human. And ‘was’ implies just what it’s supposed to – the pilot was a live- breathing- thinking human before the approach. Now he’s a deceased pilot whose break in discipline becomes part of the NTSB’s probable cause finding.

Mind over matter
According to Kern- one simple tool for recognizing the onset of a breakdown in discipline involves recognizing intent. Poor discipline can occur in many forms- Kern told the Safety Standdown pilots. But it must involve intent.

An unauthorized procedural break or shortcut like the scenario described above is but one example of intent leading to a break in disciplined flying.

Another is an intentional act of recklessness – like a pilot buzzing a sports event in a crowded stadium- or flying under a bridge across a river. Some discipline breakdowns may be blatant – as in: 'I’m so good I can do it without getting caught.' This pilot willfully breaks with the rules because of ego.

Some are driven by the situation – a little like the scenario above – so we’re going down below minimums 'just this once.' If the pilot gets away with it- without damaging the aircraft- the deviation can be more easily justified the next time.

In other cases- the pilot simply feels there’s a ‘better’ way to do something that should be allowable – even when it’s not.

Such breaks may even be routine – as in- something ‘everybody’ does- ‘everybody’ knows its being done- so it’s OK- even though ‘everybody’ knows it’s wrong. All of these justifications go unnoticed- by and large- when the pilot survives making the mistakes.

But when the pilot’s actions lead to an accident- well- then the world learns that ‘pilot error’ brought down another aircraft – and many other pilots will read of the disciplinary folly and wonder why the late- not-so-great aviator would ever do something so obviously outside the rules- regs and procedures for that fatal flight.

Eliminating error depends on discipline
Kern suggested something of a personal checklist as a tool for reducing personal errors. He also suggested some points that show how maintaining discipline can become a positive habit.

For example- procedures and discipline are liberating- not restricting. Deciding to stick with approved procedures can actually free the pilot to say- 'No- it’s violation of procedures to try to force the approach and I’m not going to violate procedures.'

Maintaining the discipline to stick with procedures and approved practices can improve a pilot’s intuitive actions to the point that the pilot instantly sees a break in discipline because it breaks from the usual patterns of proper procedures.

Sticking with the book- if you will- also can help eliminate the surprise factor that deviations can spawn. Sticking with the known- correct methods avoids exposure to the risks of doing things with unknown outcomes.

However- any sets of rules- procedures- or checklists are only as good as the user’s strength of will. And will power can be a powerful ally that turns into habit. Habit- Kern maintained- is its own tool- a tool that can help a pilot avoid mistakes – or help a pilot fly down the glidepath to disaster- depending on how habits are developed and whether the pilot pays attention to those habits.

If the pilot develops sound habits built on following procedures- the pilot need only stick with those tried-and-true habits and will avoid trouble. Ignore those good habits and the potential for peril grows.

In the end- though- the best weapon a pilot has in an individual war on error exists between the ears – the human brain. Listening to that little voice nagging about knowing better may seem a little weak kneed to some- but ignore that voice at your own risk. We seldom read about pilots who did everything right but still suffered a sad end to a flight.

With nearly 78 percent of all business aviation accidents found to stem from pilot error- business aircraft pilots can stand to think a little harder before doing something they know better than to try.

Stick to your guns- follow the procedures – and save the defiance of throwing out the rulebook for those rare times when the rulebook is already in shreds because of mechanical malfunctions. That’s when all that discipline can actually help our creative thinking – and give us the potential to save the day instead of ending it.

Fly safe – think first and don’t do what you know better than to try.


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