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Sunday, September 1, 2013

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.