‘To err is human, but to persevere in error is only the act of a fool’ – Marcus Cicero.
Phil Nasskau attended Bombardier’s Safety Standdown seminar and presents some of the key messages delivered as part of the ‘War on Error’ campaign.
Human error is something as a race we will never be able to avoid. But Bombardier, through its long-running Safety Standdown seminars, is trying to reduce the errors made by corporate pilots. Following the end of the EBACE show in Geneva a few weeks ago, the inaugural Safety Standdown Europe seminar was held in the Swiss city.
Pilot error is the highest cause of accidents. In the US from 2002 to 2005 there were 19 fatal accidents involving corporate jets, of which 78% were attributed to pilot/crew error by the NTSB. Broken down further, 50% of these accidents happened during the approach/landing phase.
The seminar’s key presenters focused on three different aspects that relate to flight safety. Dr Tony Kern covered professional airmanship; Dr Mark Rosekind fatigue countermeasures and Dr Jerome Berlin examined applied aviation psychology.
Developed
Kern explains that as the industry has developed with technology and changing customer demands, customer expectations have escalated. Before the 1970s, the differentiator of an airline could be speed, quality or cost, as customer expectation was low. This being attributed to a small resource base, but ‘performance’ was higher than the base and customer expectations.
By the ‘70s, customer expectations had increased, effectively an airline needed to chose two of the three factors. As the industry moved into the ‘90s, customer expectations were no longer expectations but demands for all three – speed, quality and acceptable cost. And overall expectations have increased dramatically as society has advanced.
Kern says the vast majority of mishaps occur with experienced crew members during routine phases due to human error. But what is even more frightening is the recently revealed trend - that the industry’s most experienced may be at the greatest risk.
“It is not our hands that get us in trouble, it’s our heads,” says Kern. Ultimately professional airmanship is dealing with two kinds of ‘trouble’ and the reactions that they produce. These reactions are either the ‘caveman path’ – fight or flight when the adrenaline and natural instincts kick in; or the ‘scholar path’ – where people have time to consider and plan their reactions.
Answers
But what is professional airmanship, and what is an expert pilot? From a survey of 400 pilots, more than 40 variations of answers defined an ‘expert pilot’. Most commonly pilots believe good judgement and situational awareness are the key factors. Perhaps the answer that gives the greatest insight is ‘I know it when I see it.’
According to Kern, the underlying principle of airmanship is a bedrock of principles: discipline, skill and proficiency. On top of these are the pillars of knowledge: self, team, aircraft, environment, political, regulatory, and physically, risk and mission. The pillars support situational awareness and this leads to judgement. Airmanship is all about judgement.
If most accidents are caused by human error, the focus should be on flight discipline. Kern defines this as the ability and willpower to employ an aircraft safely, within operational, regulatory, organisational, and common sense guidelines, in the presence of temptation to do otherwise.
Everyone has the ability to become a ‘rogue pilot’. Poor flight discipline is always the fault of the individual. It can result from one of several factors:
- Mission expectation – perception that the rules must be broken to get the job done.
- Ego and power – the belief that the violator has the skill and stature to set their own rules.
- Unlikely detection – the perception that the violation is unlikely to be detected by anyone in authority.
- Poor planning – lack of adequate planning time or depth resulting in ‘freestyling’ during execution.
- Leadership gap – leaders who personally practice or are known to condone procedural non-compliance.
- Unique event – an out-of-the ordinary situation such as an airshow or ‘special’ mission.
Sleep deprivation and fatigue play an important role in how we as humans operate, especially when we use technology. An example is the Exxon Valdez oil tanker running aground on a well-charted reef. The capitan retired to his cabin and left the third mate and an able seaman on the bridge. “Head to Alaska, then turn left… Missed the left!” says Dr Mark Rosekind. The accident investigation blamed fatigue for one of the worst oil spill disasters.
Sleep loss affects performance. Attention lapses increase by 500%; lethargy increases by 50%; vigilance decreases by 75% and microsleeps lasting from a few seconds to several minutes can occur. Two hours of sleep loss affects performance the same as drinking 1 litre of beer. Six hours of sleep loss is akin to drinking 2.6 litres of beer – for most people that would be considered drunk.
Sleeping
As part of a NASA sleep survey, 71% of US corporate pilots have admitted to sleeping on the flight deck – “the other 29% are liars!” says Rosekind. Sleeping in the cockpit isn’t attributed to laziness but to overall fatigue from a variety of factors. Modern society is a 24/7 environment, but the human body is not built to perform like that. Aging also plays a role in affecting sleep. Sleep becomes more fragmented with greater disruptions, deep sleeps are reduced and the brain cannot consolidate sleep.
Alcohol is something that is used by some to aid relaxation or for socialising. However, alcohol can reduce the ‘rapid eye movement sleep’ (where we dream) in the first half of the night and disturbs the sleep in the second half. As a result the quality and quantity of sleep is reduced. “If you’re going to get drunk, get drunk at dinner not afterwards.” says Rosekind.
Rosekind explains that although by cutting sleep the first day’s performance is enhanced because of the extra “time” in the day, by the second day performance is already dropping. On average, seven days at six hours sleep lowers performance by 17%, at five hours 43% and four hours 62%.
The underlying principle is that if you lose sleep everything you do will be impaired. It is very easy to develop a sleep deficit. On average the world loses 1.5hr. As a race this year we will lose roughly 2,321,894,629,470 hours of sleep. Sleep debt is something that will accumulate, and as that debt increases performance drops. The first step to clearing the debt is to make sure that there are two consecutive nights of 8hr.
Applied psychology is something that is constantly evolving. The culture of authority and control has evolved and can be broken into three separate areas. Ranked or institutional authority, the oldest and most formal type of authority, also absolves the bearer of personal responsibility; situational authority, where instead of authority being given it is taken; and finally personal authority.
Experiment
The Milgram experiment in 1961 looked to answer the question as to whether Eichmann, and his million accomplices in the Holocaust were just following orders? Could we call them accomplices?’ In brief, the experiment used a teacher (always the test subject), an actor playing the learner and the overseeing experimenter.
The subject was to adiminster electrical shocks to the learner for every mistake, increasing by 15volts after each mistake.
Starting at 15volts all the way up to 450v. Beneath the switches each is labelled as to what sort of an affect it will have the on the learner. At times the ‘teachers’ worried and questioned the experimenter. The experimenter would allow the ‘teacher’ to question the experiment four times before being stopped, or after administering the maximum 450v shock three times in succession.
The results of the experiment saw that 65% of participants administered the final 450v shock. None stopped before 300v. The result shows that provided we are absolved of responsibility at a personal level we are likely to proceed much further than we otherwise would. Similarly the left-seat of an aircraft holds the position of absolute responsibility.
As aviation technology has advanced the number of accidents caused by mechanical failure has dropped, and the accidents caused by pilot error have increased. According to Dr Berlin “nobody can lie like pilots, a pilot needs it to be simple. Pilots are brighter than the average person, they just don’t look it. They have a low tolerance for highly theoretical subjects”.
In a modern cockpit there is a need for the Captain to have high authority with high participation.
The First Officer needs to have a high level of assertiveness with a high level of respect. If any of these are missing it can lead to accidents or incidents. Ultimately a good Captain needs to have a high level of authority with a high self-confidence.
Source: Flight Daily News
