Pilot handling skills under threat, says Airbus
e28 driver
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I know quite a few First Officers who have never experienced an actual go around (in a public transport catagory aircraft) let alone a diversion. I do dread the day I have to use an alternate that I know nothing about on the minimum fuel we are 'encouraged' to fly with these days.
Do a Hover - it avoids G
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I have posted this elsewhere without response so I thought I would stick my neck out here because a huge number of words have been written recently regarding airline accidents that have involved pilot handling issues.
Many have blamed reduced crew experience and poor training standards driven by cost saving measures as the cause of these errors. Earlier generations of pilots have found some recent failures to control speed and attitude unbelievable, given the presence of two or more licensed pilots on the flight deck. Others have highlighted the loss of handling skills caused by the extensive use of automatics.
Both viewpoints predict a deteriorating future for safety unless we require better pilot training and experience levels and use automatics less.
May I suggest it helps to stand back and look at the full picture that is today’s airline scene and not argue from the particular towards the general, which I was brought up to believe shows lousy logic.
I do have suggestions to improve the situation for both standpoints but first may I explain where I come from, the better for you to understand my thoughts.
Logically every single airliner accident to date has been caused by human error.
There are no exceptions to this because only humans design, build, test, certificate, maintain and operate aircraft and airfields. Human errors or poor performance can clearly be involved in any of these areas. Some may ask what about lightning and birds? My reply is that we know the sky contains those and we choose to fly regardless. Thus aviation safety is about mitigating the effects of inevitable human errors or choices.
Human error can occur in the air and on the ground. The solution to mitigating the effects of errors made on the ground is to involve more people and time in checking and testing processes until the system is effectively free of the results of errors. Note, not free of errors but free of bad results that flow from the errors.
At this point some will doubtless be thinking I am ignoring costs and not in the real world because we will never have enough people and time on the ground. Please bear with me if you feel that because I first wish to establish the ideal system. Costs are a factor that cause us to compromise the design of our system for safe aviation but we should first establish the ideal.
The situation in the air is very different to that on the ground. The number of people that can be involved in detecting and countering human errors is small and limited, plus time available can be very short. Piloting an aircraft involves two very different functions - handling and operating. Handling is about controlling speed, height, attitude and direction of flight. Operating is about everything else from making decisions about ATC, weather, diversions, emergencies, what your company wants or expects, criminal behaviour and so on. The list is literally endless.
Handling errors (where I started at the beginning) tend to be the critical ones but are actually the easiest to eliminate in the long term. Therefore my first conclusion is that in the end all handling should be automatic because automatics do not make mistakes. They sometimes fail but the rate at which such failures occur (and matter) is purely a design spec issue involving redundancy levels. Please note I am not making a case for eliminating pilots only for automatic handing. Pilots are vital for the operation of aircraft but not for handling.
I formed this view back in the mid 1960s when as a safety pilot watching a BLEU trials Comet doing perfect automatic landings in a very strong crosswind, I had to say to the boffin crew that if the system dumped I did not have the skill to do that and would need to choose a different runway for landing.
Since that day I have been convinced that automatics could handle an aircraft better than me and the only issue was whether they could be made reliable enough for certification. As we know BEA was certificated to autoland its Trident passengers back in the 1970s. After 30 plus years of autolands with operators all over the world, has anybody ever heard of an accident during an autoland? What about manual landings over the same period?
In the long term I also believe that as automatics degrade in flight due to, say, loss of air-data input, they should not disengage and give control of handling back to the pilot. Rather they should keep themselves engaged and do what pilots are taught to do in that situation - hold attitude and power setting in this case - while telling the pilots what has happened.
In the short term we are stuck with what we have so what should happen now? Personally I do not think any of the accidents that have given rise to the current debate would have happened to airline pilots if those pilots were also current on small GA types and they routinely practised stalling and unusual positions.
Now costs. In the end the extent to which we deliberately compromise safety by driving down costs is properly down to the likes of the FAA and EASA. It is their job to provide an adequate level of protection for the fare-paying passengers. If they choose to allow two tired technicians to work on their own in the hangar at 0400 then that is their decision and we cannot expect all MROs to determine themselves that such standards are unacceptable.
Similarly if they choose to approve the licensing of pilots of limited meaningful handling currency then that is their shout. My own view is that while there are still aircraft out there that need pilots to handle them, either routinely or in emergency, then recent history shows we have cut costs just a little too far. However despite this an airliner seat is an amazingly safe place to be.
In the end extra safety costs exta money. However do we really believe that (all) current ticket prices could not stand a 10% hike providing that the money did go towards safety? This would be far from impossible to arrange – but that is another topic.
Many have blamed reduced crew experience and poor training standards driven by cost saving measures as the cause of these errors. Earlier generations of pilots have found some recent failures to control speed and attitude unbelievable, given the presence of two or more licensed pilots on the flight deck. Others have highlighted the loss of handling skills caused by the extensive use of automatics.
Both viewpoints predict a deteriorating future for safety unless we require better pilot training and experience levels and use automatics less.
May I suggest it helps to stand back and look at the full picture that is today’s airline scene and not argue from the particular towards the general, which I was brought up to believe shows lousy logic.
I do have suggestions to improve the situation for both standpoints but first may I explain where I come from, the better for you to understand my thoughts.
Logically every single airliner accident to date has been caused by human error.
There are no exceptions to this because only humans design, build, test, certificate, maintain and operate aircraft and airfields. Human errors or poor performance can clearly be involved in any of these areas. Some may ask what about lightning and birds? My reply is that we know the sky contains those and we choose to fly regardless. Thus aviation safety is about mitigating the effects of inevitable human errors or choices.
Human error can occur in the air and on the ground. The solution to mitigating the effects of errors made on the ground is to involve more people and time in checking and testing processes until the system is effectively free of the results of errors. Note, not free of errors but free of bad results that flow from the errors.
At this point some will doubtless be thinking I am ignoring costs and not in the real world because we will never have enough people and time on the ground. Please bear with me if you feel that because I first wish to establish the ideal system. Costs are a factor that cause us to compromise the design of our system for safe aviation but we should first establish the ideal.
The situation in the air is very different to that on the ground. The number of people that can be involved in detecting and countering human errors is small and limited, plus time available can be very short. Piloting an aircraft involves two very different functions - handling and operating. Handling is about controlling speed, height, attitude and direction of flight. Operating is about everything else from making decisions about ATC, weather, diversions, emergencies, what your company wants or expects, criminal behaviour and so on. The list is literally endless.
Handling errors (where I started at the beginning) tend to be the critical ones but are actually the easiest to eliminate in the long term. Therefore my first conclusion is that in the end all handling should be automatic because automatics do not make mistakes. They sometimes fail but the rate at which such failures occur (and matter) is purely a design spec issue involving redundancy levels. Please note I am not making a case for eliminating pilots only for automatic handing. Pilots are vital for the operation of aircraft but not for handling.
I formed this view back in the mid 1960s when as a safety pilot watching a BLEU trials Comet doing perfect automatic landings in a very strong crosswind, I had to say to the boffin crew that if the system dumped I did not have the skill to do that and would need to choose a different runway for landing.
Since that day I have been convinced that automatics could handle an aircraft better than me and the only issue was whether they could be made reliable enough for certification. As we know BEA was certificated to autoland its Trident passengers back in the 1970s. After 30 plus years of autolands with operators all over the world, has anybody ever heard of an accident during an autoland? What about manual landings over the same period?
In the long term I also believe that as automatics degrade in flight due to, say, loss of air-data input, they should not disengage and give control of handling back to the pilot. Rather they should keep themselves engaged and do what pilots are taught to do in that situation - hold attitude and power setting in this case - while telling the pilots what has happened.
In the short term we are stuck with what we have so what should happen now? Personally I do not think any of the accidents that have given rise to the current debate would have happened to airline pilots if those pilots were also current on small GA types and they routinely practised stalling and unusual positions.
Now costs. In the end the extent to which we deliberately compromise safety by driving down costs is properly down to the likes of the FAA and EASA. It is their job to provide an adequate level of protection for the fare-paying passengers. If they choose to allow two tired technicians to work on their own in the hangar at 0400 then that is their decision and we cannot expect all MROs to determine themselves that such standards are unacceptable.
Similarly if they choose to approve the licensing of pilots of limited meaningful handling currency then that is their shout. My own view is that while there are still aircraft out there that need pilots to handle them, either routinely or in emergency, then recent history shows we have cut costs just a little too far. However despite this an airliner seat is an amazingly safe place to be.
In the end extra safety costs exta money. However do we really believe that (all) current ticket prices could not stand a 10% hike providing that the money did go towards safety? This would be far from impossible to arrange – but that is another topic.
John, excellent. Another benefit of being able to hover – opportunity to view the situation, as you state, from the general, not the particular.
Basic training – yes, it's ‘general’; whereas FAA and EASA are becoming too particular, legalistic, and distant from the realities of modern operations and training requirements.
Basic training – yes, it's ‘general’; whereas FAA and EASA are becoming too particular, legalistic, and distant from the realities of modern operations and training requirements.
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John
Trouble is, if computers do all the handling, whose going to pay to learn to fly only to sit there bored while admiring the aircafts' autoflight?
You?
Not me!
Also, when it does roll over, how are you going to catch it if you never fly?
Especially as it will probably do so at the very moment you wish it wouldn't!
I think it would be better to do LESS autoflight and try to formalise some sort of hand flying recency. That way we could continue with the kit we have at the moment but with 'better' pilots!
Might have saved the THY and Colgan for starters.
Trouble is, if computers do all the handling, whose going to pay to learn to fly only to sit there bored while admiring the aircafts' autoflight?
You?
Not me!
Also, when it does roll over, how are you going to catch it if you never fly?
Especially as it will probably do so at the very moment you wish it wouldn't!
I think it would be better to do LESS autoflight and try to formalise some sort of hand flying recency. That way we could continue with the kit we have at the moment but with 'better' pilots!
Might have saved the THY and Colgan for starters.
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PJ2
You might understand that any post looking at medical situations and airline incidents makes my ears prick up.
Firstly diagnosis is a little different in medicine from that in an aircraft. Much medical effort is spent in getting to a diagnosis (and often many co-morbidities) but this does not interrupt the treatment of symptoms.
The concept of "preventable death" interests me deeply and I spend much of my working life probing this issue. I have certainly not found any definition of that term which stands up to scrutiny.
Preventable for how long? None of us live forever so there is going to be a spectrum of situations from a death which could have been postponed until other factors took over and resulted in death, to an incident where the situation was so hopeless that a small error which if avoided may have led to a few more minutes of life, with all the quality of life issues which accompany such events.
In theory, all air accidents are preventable, whereas all medical deaths are not. I'm not being flippant. Would a suicide be classed as a preventable death? Largely it is, but the motives of a potential suicide can be incredibly powerful and evasive to detection.
If an aircraft is given the necessary forces to stay airborne it will, whereas people sometimes just want to die, and will do so even if the biological processes are not sufficient to result in death.
I would like to categorically lay to rest (pun fully intended) the myth that doctors do not have any scrutiny over each and every case they deal with. They certainly do. If they did not, I would be out of work, and believe me my desk is piled high.
Certainly CRM is giving us in healthcare some very valuable lessons and I want to know more how it works, but there are some concepts which simply do not exist in even such a controlled envinronment as an operating room. The cohesive team cannot be fully defined in an OR as there are several teams involved, each with differing priorities which often clash. This may be a concept which captains may not appreciate as in an aircraft they are the final say whereas in an OR the surgeon certainly is not the captain of the OR.
MD
You might understand that any post looking at medical situations and airline incidents makes my ears prick up.
Firstly diagnosis is a little different in medicine from that in an aircraft. Much medical effort is spent in getting to a diagnosis (and often many co-morbidities) but this does not interrupt the treatment of symptoms.
The concept of "preventable death" interests me deeply and I spend much of my working life probing this issue. I have certainly not found any definition of that term which stands up to scrutiny.
Preventable for how long? None of us live forever so there is going to be a spectrum of situations from a death which could have been postponed until other factors took over and resulted in death, to an incident where the situation was so hopeless that a small error which if avoided may have led to a few more minutes of life, with all the quality of life issues which accompany such events.
In theory, all air accidents are preventable, whereas all medical deaths are not. I'm not being flippant. Would a suicide be classed as a preventable death? Largely it is, but the motives of a potential suicide can be incredibly powerful and evasive to detection.
If an aircraft is given the necessary forces to stay airborne it will, whereas people sometimes just want to die, and will do so even if the biological processes are not sufficient to result in death.
I would like to categorically lay to rest (pun fully intended) the myth that doctors do not have any scrutiny over each and every case they deal with. They certainly do. If they did not, I would be out of work, and believe me my desk is piled high.
Certainly CRM is giving us in healthcare some very valuable lessons and I want to know more how it works, but there are some concepts which simply do not exist in even such a controlled envinronment as an operating room. The cohesive team cannot be fully defined in an OR as there are several teams involved, each with differing priorities which often clash. This may be a concept which captains may not appreciate as in an aircraft they are the final say whereas in an OR the surgeon certainly is not the captain of the OR.
MD
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We ourselves
Interesting thread but I think blaming others (management, systems designers, FDM geeks) does us pilots no good. Competency is in our Realm; we are in the cockpit; no one else, and we owe it to ourselves, our passengers and our profession to ensure we are well practised and skilled in all aspects of the operation including hand flying. I think it is a question of what is appropriate at the time. Clearly, high workload approaches in busy terminals are not the best place to blow away the cobwebs on our handling skills but surely most of us can find suitable opportunities in quieter moments. Or perhaps it is easy to become a little lazy and put off a raw data approach until some other time...
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we are in the cockpit; no one else, and we owe it to ourselves, our passengers and our profession to ensure we are well practised and skilled in all aspects of the operation including hand flying.
I have a friend who was called in to explain why he was hand flying on departure above 15,000' after that sin triggered the company QAR.
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Barbie'sBoyFriend
I quite understand your points and naturally Turkeys don't like Christmas.
However I am not talking about how you and I might like airliners to be operated to suit us, but the safest way to operate them.
I am afraid the manually flown accident stats do not support letting pilots handle aircraft IF/PROVIDED/WHEN sufficiently reliable automatics can be engineered.
When the UK seriously set about developing autoland in the 60s the CAA said that for the system to be certificated (BTW nobody knew quite what sort of system it would turn out to be in those days) then it had to be an order of magnitude safer as a cause of fatal accidents than pilots at that time. This meant it was only allowed 1 fatal landing in every 10 million landings because pilots were scoring 1 in a million.
As I said in my post I have never heard of a fatal autoland since they started in the 70s but over that period of years there have been far too many manual landing accidents.
JF
I quite understand your points and naturally Turkeys don't like Christmas.
However I am not talking about how you and I might like airliners to be operated to suit us, but the safest way to operate them.
I am afraid the manually flown accident stats do not support letting pilots handle aircraft IF/PROVIDED/WHEN sufficiently reliable automatics can be engineered.
When the UK seriously set about developing autoland in the 60s the CAA said that for the system to be certificated (BTW nobody knew quite what sort of system it would turn out to be in those days) then it had to be an order of magnitude safer as a cause of fatal accidents than pilots at that time. This meant it was only allowed 1 fatal landing in every 10 million landings because pilots were scoring 1 in a million.
As I said in my post I have never heard of a fatal autoland since they started in the 70s but over that period of years there have been far too many manual landing accidents.
JF
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Then it boils down to this:
Let the autos do their thing. But you must provide training, in REAL airplanes/airliners of the type that the pilot is assigned to when the plane is empty of paying passengers (properly weighted with sand bags).
Pilots must retain manual skills and if we can't ''practice'' with passengers aboard, then we must practice at other times.
but of course this would cost money and might even be the cause of accidents,but we must be ready when the automatic stuff doesn't work or won't work right in the situation.
Pilots must retain manual skills and if we can't ''practice'' with passengers aboard, then we must practice at other times.
but of course this would cost money and might even be the cause of accidents,but we must be ready when the automatic stuff doesn't work or won't work right in the situation.
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John F
I see your point.
However, according to you, not only hand flying should be banned, but also manual landings.
Did they perform 10 million autolands to certify the system?
I don't trust the way safety assessment is done, regarding those "extremely unlikely" figures. How do they know? There is always something not taken into account that makes those probabilities more likely than they would like.
When so many variables tend to infinite, comparison is not very meaningful.
As for manual flight in general, you also have to take into account the probabilities of a catastrophic incident following a failure that leaves automation u/s. How much have they increased due to the lack of skill generated by overdependance in automation?
I guess you would defend NO GO any automation unserviceability in every MEL. But it can happen in flight, in a rainy and turbulent day.
I think that, given the magnitude of the probability figures that they are handling, autoflight is extremely safe, but overall safety will be increased if crews remain skilled by practising hand flying when conditions are OK.
What is the danger in hand flying for a while after take off? Do you think it is dangerous? Or that it is dangerous to disconnect AP FD from time to time to go down the ILS manually?
Isn't it dangerous that an airplane crashes because the total lack of handflying skils makes the crew unaware of an automation malfunctions?
Automation is better understood by pilots with good handflying skills. These will detect incorrect AP behaviour at the onset, instead of too late.
Honbestly I don't think that 10^-9 figures (calculated) should make us ban hand flying.
I also think that the AP makes better aproaches in bad weather that I can do myself.
I see your point.
However, according to you, not only hand flying should be banned, but also manual landings.
Did they perform 10 million autolands to certify the system?
I don't trust the way safety assessment is done, regarding those "extremely unlikely" figures. How do they know? There is always something not taken into account that makes those probabilities more likely than they would like.
When so many variables tend to infinite, comparison is not very meaningful.
As for manual flight in general, you also have to take into account the probabilities of a catastrophic incident following a failure that leaves automation u/s. How much have they increased due to the lack of skill generated by overdependance in automation?
I guess you would defend NO GO any automation unserviceability in every MEL. But it can happen in flight, in a rainy and turbulent day.
I think that, given the magnitude of the probability figures that they are handling, autoflight is extremely safe, but overall safety will be increased if crews remain skilled by practising hand flying when conditions are OK.
What is the danger in hand flying for a while after take off? Do you think it is dangerous? Or that it is dangerous to disconnect AP FD from time to time to go down the ILS manually?
Isn't it dangerous that an airplane crashes because the total lack of handflying skils makes the crew unaware of an automation malfunctions?
Automation is better understood by pilots with good handflying skills. These will detect incorrect AP behaviour at the onset, instead of too late.
Honbestly I don't think that 10^-9 figures (calculated) should make us ban hand flying.
I also think that the AP makes better aproaches in bad weather that I can do myself.
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As I said in my post I have never heard of a fatal autoland since they started in the 70s but over that period of years there have been far too many manual landing accidents.
Any autoland that went wrong, at any phase, had the pilot who intevened to rectify. Thank god, because there must have been many, myself having interrupted three of them.
It's almost like the protections covering me at times, happened once as well, I have to admit.
We're a good complement, but no one ever drew a statistic about that fact.
To me your claims about "automatics forever" are somewhat preposterous.
We need the good pilots more than ever.
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Chaps
In defence of my case I did say (I was shouting as well!) IF/WHEN/PROVIDED sufficiently reliable automatics are available.
I did not say they were there already.
Wings used to fall off, flutter used to happen to airliners in the cruise (Electra - twice) but we gradually improved things so that those things (and others) were beaten. In my view the LONG term future is that we will be able to make automatics that are more reliable than us.
When people consider what good human performance achieves (as pilots in this case) there is a natural tendency to forget the bad results from similar humans when they make mistakes.
Fifty years ago airline passengers wanted to try any aircraft that offered faster and higher now they want cheaper and no departure delays (most passengers take safety as a given).
Meanwhile as I suggested in my first post it does seem cost reduction has dragged down (handling) training a little too far and it does seem that various authorities have realised this may be the case.
JF
In defence of my case I did say (I was shouting as well!) IF/WHEN/PROVIDED sufficiently reliable automatics are available.
I did not say they were there already.
Wings used to fall off, flutter used to happen to airliners in the cruise (Electra - twice) but we gradually improved things so that those things (and others) were beaten. In my view the LONG term future is that we will be able to make automatics that are more reliable than us.
When people consider what good human performance achieves (as pilots in this case) there is a natural tendency to forget the bad results from similar humans when they make mistakes.
Fifty years ago airline passengers wanted to try any aircraft that offered faster and higher now they want cheaper and no departure delays (most passengers take safety as a given).
Meanwhile as I suggested in my first post it does seem cost reduction has dragged down (handling) training a little too far and it does seem that various authorities have realised this may be the case.
JF
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John
I see what you mean. The autos that WILL be invented etc. etc.
What about 'at the moment'. Now?
I'm sure your well thought through thoughts are correct but we have a 'handling' problem NOW!
The latest copy of Flight is citing 'pilot handling' as opposed to pilot error in a large (was it 31%) fraction of recent fatal accidents.
What do you think?
Practice more at hand flying or use the autos more?
Personally, I keep my hand flying skills as sharp as I can although I'm in no way obsessive about it (prolly 5-10 mins each sector).
I find it very easy and if I can get a shot at a visual I'll usually go for it.
Maybe I'm a hazard to Flight Safety!
I see what you mean. The autos that WILL be invented etc. etc.
What about 'at the moment'. Now?
I'm sure your well thought through thoughts are correct but we have a 'handling' problem NOW!
The latest copy of Flight is citing 'pilot handling' as opposed to pilot error in a large (was it 31%) fraction of recent fatal accidents.
What do you think?
Practice more at hand flying or use the autos more?
Personally, I keep my hand flying skills as sharp as I can although I'm in no way obsessive about it (prolly 5-10 mins each sector).
I find it very easy and if I can get a shot at a visual I'll usually go for it.
Maybe I'm a hazard to Flight Safety!
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BBf
You a hazard to flight safety? I very much doubt that. You are one of those who think about what is going on around them which in my view is what safety is about.
Re the term Pilot Error that you mention it is a simple notion that is often literally true - the trouble is the term ignores what caused or contributed to the error. Which is why its use properly gets up so many people's noses.
Sometimes, in handling cases, the pilot error takes the form of insufficient skill for that day's task which we know is not at all the same thing as forgetting to set the flaps before takeoff. Skill issues take us straight back to training and qualifications to obtain and maintain a licence. Which I believe is what the current debate is all about.
JF
You a hazard to flight safety? I very much doubt that. You are one of those who think about what is going on around them which in my view is what safety is about.
Re the term Pilot Error that you mention it is a simple notion that is often literally true - the trouble is the term ignores what caused or contributed to the error. Which is why its use properly gets up so many people's noses.
Sometimes, in handling cases, the pilot error takes the form of insufficient skill for that day's task which we know is not at all the same thing as forgetting to set the flaps before takeoff. Skill issues take us straight back to training and qualifications to obtain and maintain a licence. Which I believe is what the current debate is all about.
JF
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BBf
I don't know because I suspect the answer is not a 'one size fits all' and must depend on the individual pilot, their aircraft type, their employer and the other pilot in the cockpit.
I'm just glad that I reached retirement without one of my many handling errors/problems being irrecoverable or resulting in a prang.
JF
I don't know because I suspect the answer is not a 'one size fits all' and must depend on the individual pilot, their aircraft type, their employer and the other pilot in the cockpit.
I'm just glad that I reached retirement without one of my many handling errors/problems being irrecoverable or resulting in a prang.
JF
MD;
Thanks for your again-thoughtful comments MD. A lot has been written on how aviation's CRM process "should" assist medicine and as I was writing I was considering and perhaps recognizing the differences and where the model might break down given their vastly different tasks, responsibilities and processes. Down in the details of design and execution of effective approaches, CRM is not be a panacea nor is an OR QAR!
What drove CRM in the very beginning was the unpleasant-at-the-time recognition brought about by several prescient observers whose names we know causing shifting of points of view that contrary to the socially-accepted views of the time", (called myths when we no longer believe such points of view), the captain didn't know everything and actually made "the occasional mistake" and that if others didn't speak up, the captain could (and did) kill everyone.
While such authority-figures "occured" in a society where top-down "command and control" was a characteristic of a post-war economic and social structure much was learned about how this structure and an unquestioned allegiance to authority alone could threaten end-goals such as preserving life, property, wealth and even 'a way of life', etc.
"What, not Who" slowly became the focus of change, that being the first signs of what was later recognized and labeled as "human factors".
Such development was neither natural nor easy for as late as the late 20th century, man (and his works) was still viewed philosophically as "perfect" or the "pinnacle of perfection", even in the face of major events showing quite the contrary. Philosophically, man's encounter with himself and the encounter with such events which showed not all was within man's control, expressed itself in the notions of existentialism.
I will stop there before those remaining drift off to sleep, but there are clear and definitive connections between what most would reasonably consider esoteric and largely irrelevant philosophical world views and such practical and seemingly "obvious" safety processes as we are discussing. In truth, it's philosophy all the way down...
To complete the point, the authority of the captain, though never undermined or denied, began to be viewed differently. I can recall my first CRM course very well because there were a lot of older captains made angry by the thought that "speaking up" was in fact challenging the captain's ultimate authority. Of course, nothing of the sort was intended and that view gradually "retired".
CRM is neither a way of "being polite or respectful" nor is CRM a challenge to the authority of the commander who is always legally responsible, but is instead a way of raising concerns or handling an abnormality (but not necessarily an emergency, which has its own procedures). Everyone has the authority and responsibility to speak up; sometimes the final outcome is a group decision and sometimes the captain makes the decision which may even be contrary to the results of CRM discussion. The key understanding in CRM is in expressing concerns, not flying the aircraft by committee.
It is impossible to state how many lives such an altered view has saved but the accident rate, which plummeted from the mid-60's on, is partial evidence that it worked. Of course, technical, mechanical and computerized solutions to aviation's primary accident causes of the time contributed heavily to the trend.
It is my impression that this view (changing authority gradients and the legitimacy of intervention) is extending itself into the OR and that's partially why, along with other observations, I made the comments I did.
I sense too that patients are embracing such a view. For my parents in the 40's, 50's and even 60's, the medical profession could do no wrong, "the Doctor" was never questioned, and one never sought second opinions for fear of offending or undermining confidence. Part of this is living in small communities of course. That is no longer the case, interestingly I think, because such a response is largely informal as society's views of authority changed, as described.
These are very black-and-white statements I know and I would expect that they offer only metaphorical "grains of truth" rather than definitive prescriptions for "the way things are/should be". I think that is the nature of John Farley's excellent contributions, which suggest and point rather than prescribe, as I read him anyway.
Your reassurance in your comments accomplish their purpose, thanks. - PJ2
I would like to categorically lay to rest (pun fully intended) the myth that doctors do not have any scrutiny over each and every case they deal with. They certainly do. If they did not, I would be out of work, and believe me my desk is piled high.
What drove CRM in the very beginning was the unpleasant-at-the-time recognition brought about by several prescient observers whose names we know causing shifting of points of view that contrary to the socially-accepted views of the time", (called myths when we no longer believe such points of view), the captain didn't know everything and actually made "the occasional mistake" and that if others didn't speak up, the captain could (and did) kill everyone.
While such authority-figures "occured" in a society where top-down "command and control" was a characteristic of a post-war economic and social structure much was learned about how this structure and an unquestioned allegiance to authority alone could threaten end-goals such as preserving life, property, wealth and even 'a way of life', etc.
"What, not Who" slowly became the focus of change, that being the first signs of what was later recognized and labeled as "human factors".
Such development was neither natural nor easy for as late as the late 20th century, man (and his works) was still viewed philosophically as "perfect" or the "pinnacle of perfection", even in the face of major events showing quite the contrary. Philosophically, man's encounter with himself and the encounter with such events which showed not all was within man's control, expressed itself in the notions of existentialism.
I will stop there before those remaining drift off to sleep, but there are clear and definitive connections between what most would reasonably consider esoteric and largely irrelevant philosophical world views and such practical and seemingly "obvious" safety processes as we are discussing. In truth, it's philosophy all the way down...
To complete the point, the authority of the captain, though never undermined or denied, began to be viewed differently. I can recall my first CRM course very well because there were a lot of older captains made angry by the thought that "speaking up" was in fact challenging the captain's ultimate authority. Of course, nothing of the sort was intended and that view gradually "retired".
CRM is neither a way of "being polite or respectful" nor is CRM a challenge to the authority of the commander who is always legally responsible, but is instead a way of raising concerns or handling an abnormality (but not necessarily an emergency, which has its own procedures). Everyone has the authority and responsibility to speak up; sometimes the final outcome is a group decision and sometimes the captain makes the decision which may even be contrary to the results of CRM discussion. The key understanding in CRM is in expressing concerns, not flying the aircraft by committee.
It is impossible to state how many lives such an altered view has saved but the accident rate, which plummeted from the mid-60's on, is partial evidence that it worked. Of course, technical, mechanical and computerized solutions to aviation's primary accident causes of the time contributed heavily to the trend.
It is my impression that this view (changing authority gradients and the legitimacy of intervention) is extending itself into the OR and that's partially why, along with other observations, I made the comments I did.
I sense too that patients are embracing such a view. For my parents in the 40's, 50's and even 60's, the medical profession could do no wrong, "the Doctor" was never questioned, and one never sought second opinions for fear of offending or undermining confidence. Part of this is living in small communities of course. That is no longer the case, interestingly I think, because such a response is largely informal as society's views of authority changed, as described.
These are very black-and-white statements I know and I would expect that they offer only metaphorical "grains of truth" rather than definitive prescriptions for "the way things are/should be". I think that is the nature of John Farley's excellent contributions, which suggest and point rather than prescribe, as I read him anyway.
Your reassurance in your comments accomplish their purpose, thanks. - PJ2
Hand fly more or .....Autos more..............or something else?
Engineers have done a fantastic job with todays machines, which is why we are at such historical lows in accident rates (the famous "10 to the minus 9"). Our job now as pilots is to understand and apply to the fullest extent the benefits of automation. A luddite mentality will get us nowhere, and I speak as one who grew up in military flying where manual flying was the order of the day, be it at night doing 500 knots at low level over the sea , or at Mach 2 at 50,000 ft. We thought nothing of it, because that was the way it was.
You want to practice manual flying now? Your company should have you doing it on recurrent sim training (raw data approaches; repeated if necessary till proficient to acceptable standards; Can't hack it in the sim? then maybe time to retire, or go down to the local flying club and rent some time on a C172 or better still, a Pitts Special).
But to subject your paying customers to extended periods of maybe not-quite-up-to-par manual flying practice in the typical airspace that we operate in these days while at the same time perhaps overloading the PM and degrading his monitoring activities? I don't think so somehow.
I have said it many times before- if you or your family were riding down the back, what would you want the guys up front to be doing? I would suggest you would be looking for the smoothest, safest ride possible, not some chap trying to prove he is still up to the" manual fly at all cost"job; ( it would be great if we could always own up to the old adage-"the older I get, the better I was".). We often criticise the youngsters coming into the profession, but I have found that they generally do a pretty good job, given their inexperience; it all depends on standard of training received. As for we old timers, I always tell them that we need watching as well!
Automation will generally guarantee to perform as advertised (if properly instructed and monitored by our good selves) 100% of the time; Unfortunately we humans cannot provide any such guarantee.
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PJ2
As always a valuable post from you. I value the posts and posters on this site as it has been extremely beneficial to my professional development.
I have been thinking about much of your post today and done a little research.
Both the airline industry and healthcare share a mutual background in the military. Many doctors and nurses have military backgrounds ( as I do myself) so the concept of decisive action and command and control was innate. Some of the military concepts were beneficial, some detrimental, but as we in the UK remain at war the relationship to the military remains strong. The wild card in healthcare is the religious background with nursing. Hardly a week goes by without the Nursing Times commenting on the vocation (or calling) versus the professional attitude.
With reference to lives saved, In the last 5 years the most important development in both cancer care and other life threatening conditions has not been a new drug or scanner but the low key development of a MDT - a MultiDisciplinary Team. Its a clinical review of a case where everyone with an interest in that case has an equal input. This means that specialist nurses, radiologists, pathologists and surgeons meet to discuss and mutually agree the best path for the patient. Inititally this was viewed with much suspicion and was expected to degenerate into an argument with the surgeon taking the final say as he wields the knife. It depended on the focus as the patient first, ego second, as I imagine that a safe landing is more important than a captain's ego. As the teams matured, they produced coherent and pragmatic treatment plans, with magnificent results. We cannot match the French in cancer survival rates but part of that is the way we keep statistics and partly because the French have a far superior screening programme.
Ive used much of the terminology from aviation in improvement programmes for healthcare. MEL is one. Having the staff define what they absolutely need prior to an OR case was a very big step forward. Go\no go decisions was also very important. I can cite many examples of where a junior and inexperienced member of staff halted a procedure early (ie before it went pear shaped) because the go\no go decisions had been outlined.
Your comment about questioning medical opinion made me smile. It is largely a welcome development as it involves the patient in their own decisions for treatment. The thorn in the side is the media. They get so much wrong its astounding. Take MRSA - the superbug. Its widely described in the media as a hospital acquired infection (HAI). The facts are that if you swabbed the nostrils of every passenger on a 100 seat aircraft 20-30 would have MRSA bacteria positive. The reasons why we all dont get ill are complex but some facts about HAI is that a person turns up at hospital not well and we do tests and detect MRSA infection. They most probably acquired the infection in the community but as we discovered the cause, the hospital gets the statistic for MRSA infection.
I had an entertaining discussion with a surgeon today and the subject of airline\healthcare parallels came up. The discussion involved a very insightful comment from her - an aircraft takes off in a definable condition. A patient may turn up at hospital in a desperate state, and requires definitive and urgent attention. The surgeon described this situation in aviation terms as a pilot materialising in the captain's seat with an aircraft in severe difficulty and on its way to crash unless interventions were made. The surgeon has a PPL by the way.
PJ2 and others.. thanks for the posts. We have much to share.
As always a valuable post from you. I value the posts and posters on this site as it has been extremely beneficial to my professional development.
I have been thinking about much of your post today and done a little research.
Both the airline industry and healthcare share a mutual background in the military. Many doctors and nurses have military backgrounds ( as I do myself) so the concept of decisive action and command and control was innate. Some of the military concepts were beneficial, some detrimental, but as we in the UK remain at war the relationship to the military remains strong. The wild card in healthcare is the religious background with nursing. Hardly a week goes by without the Nursing Times commenting on the vocation (or calling) versus the professional attitude.
With reference to lives saved, In the last 5 years the most important development in both cancer care and other life threatening conditions has not been a new drug or scanner but the low key development of a MDT - a MultiDisciplinary Team. Its a clinical review of a case where everyone with an interest in that case has an equal input. This means that specialist nurses, radiologists, pathologists and surgeons meet to discuss and mutually agree the best path for the patient. Inititally this was viewed with much suspicion and was expected to degenerate into an argument with the surgeon taking the final say as he wields the knife. It depended on the focus as the patient first, ego second, as I imagine that a safe landing is more important than a captain's ego. As the teams matured, they produced coherent and pragmatic treatment plans, with magnificent results. We cannot match the French in cancer survival rates but part of that is the way we keep statistics and partly because the French have a far superior screening programme.
Ive used much of the terminology from aviation in improvement programmes for healthcare. MEL is one. Having the staff define what they absolutely need prior to an OR case was a very big step forward. Go\no go decisions was also very important. I can cite many examples of where a junior and inexperienced member of staff halted a procedure early (ie before it went pear shaped) because the go\no go decisions had been outlined.
Your comment about questioning medical opinion made me smile. It is largely a welcome development as it involves the patient in their own decisions for treatment. The thorn in the side is the media. They get so much wrong its astounding. Take MRSA - the superbug. Its widely described in the media as a hospital acquired infection (HAI). The facts are that if you swabbed the nostrils of every passenger on a 100 seat aircraft 20-30 would have MRSA bacteria positive. The reasons why we all dont get ill are complex but some facts about HAI is that a person turns up at hospital not well and we do tests and detect MRSA infection. They most probably acquired the infection in the community but as we discovered the cause, the hospital gets the statistic for MRSA infection.
I had an entertaining discussion with a surgeon today and the subject of airline\healthcare parallels came up. The discussion involved a very insightful comment from her - an aircraft takes off in a definable condition. A patient may turn up at hospital in a desperate state, and requires definitive and urgent attention. The surgeon described this situation in aviation terms as a pilot materialising in the captain's seat with an aircraft in severe difficulty and on its way to crash unless interventions were made. The surgeon has a PPL by the way.
PJ2 and others.. thanks for the posts. We have much to share.