Safety: Does attitude count for more than experience?
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I was replying to Wombats question about what would require a pull back on the stick instead of push forward.
http://ntsb.gov/Publictn/2010/AAR1001.pdf
He was awake at 03:10 and the accident happened at 22:16 and the previous 72 hours he seems to only have had 1 period in a bed. That night was the infamous first night on earlies which usually means that your not knackard enough to go to bed and sleep to give you 8 hours of kip. They don't go into what he had been working in the previous month but by the look of it he was constantly dealing with jet lag effect of shifting his sleeping patterns.
The accident happened on the third day of earlies which to be honest is the worst one for being knackard. The duty he did that day would not be allowed under the UK FTL's.
Personally I think it was a fatigue issue which caused a brain fart.
http://ntsb.gov/Publictn/2010/AAR1001.pdf
He was awake at 03:10 and the accident happened at 22:16 and the previous 72 hours he seems to only have had 1 period in a bed. That night was the infamous first night on earlies which usually means that your not knackard enough to go to bed and sleep to give you 8 hours of kip. They don't go into what he had been working in the previous month but by the look of it he was constantly dealing with jet lag effect of shifting his sleeping patterns.
The accident happened on the third day of earlies which to be honest is the worst one for being knackard. The duty he did that day would not be allowed under the UK FTL's.
Personally I think it was a fatigue issue which caused a brain fart.
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The more I fly, the more I find that my "little voice" is speaking to me. I guess it's the experience. Early on, though I never claimed it, I would have had the excuse that I was inexperienced. I no longer have that excuse available, so I work harder to not need it.
That said, I have noticed moments during flying when I can start to see the holes in the "swiss cheese" lining up. That little voice not only speaks, but it asks me: "could that minor thing that just happened be the first thing in a string of events, which will lead to an accident? Will I be writing about that in the accident report I may have to write? The more I have read accident reports, the more I recall the mention of something seemingly innocent, but definately an element at the beginning of a chain of events. Now I'm trying to spot it all the time - the first hole in the swiss cheese, which if aligned with the rest, will allow me to drop through to the accident. Prevent, prevent, prevent. I cannot afford an accident, it would just be too hard to explain!
People have taken a few too many of the aircraft I have flown, and made a (or a few) poor decisions, which resulted in their loss of life. Though very much less importantly, but memorable none the less, I ended up writing a report for the investigators about the aircraft, and what it did when I flew it, or tested it. This is not a good feeling. thought I have learned that it is hardly ever the plane, which caused the accident.
In every case, the accident could be shown to have a less than adequate attitude toward safety, as a major contributing element. Mostly, little experience was also a factor. For the one where experience was ample, it seems complacency was too....
So it's a blend of attitude and experience. In the best world, they both improve together...
That said, I have noticed moments during flying when I can start to see the holes in the "swiss cheese" lining up. That little voice not only speaks, but it asks me: "could that minor thing that just happened be the first thing in a string of events, which will lead to an accident? Will I be writing about that in the accident report I may have to write? The more I have read accident reports, the more I recall the mention of something seemingly innocent, but definately an element at the beginning of a chain of events. Now I'm trying to spot it all the time - the first hole in the swiss cheese, which if aligned with the rest, will allow me to drop through to the accident. Prevent, prevent, prevent. I cannot afford an accident, it would just be too hard to explain!
People have taken a few too many of the aircraft I have flown, and made a (or a few) poor decisions, which resulted in their loss of life. Though very much less importantly, but memorable none the less, I ended up writing a report for the investigators about the aircraft, and what it did when I flew it, or tested it. This is not a good feeling. thought I have learned that it is hardly ever the plane, which caused the accident.
In every case, the accident could be shown to have a less than adequate attitude toward safety, as a major contributing element. Mostly, little experience was also a factor. For the one where experience was ample, it seems complacency was too....
So it's a blend of attitude and experience. In the best world, they both improve together...
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Some thoughts to add to this interesting thread.
Firstly, I think a key point is that the risks in flying are multiple and "diffuse". It's not as simple as factors being ranked or dominant (eg. the 'is attitude more important than experience' question). I haven't read the article Fuji mentions, but I guess a theme is that experience is far from being a sufficient condition for safety. The attitude topic is not new, it's been a major element of FAA training for years. See http://www.sportpilot.info/sp/Factors_Affecting_Decision_Making.pdf
Secondly, I would question the "cowboy" point IO made in one respect. Yes, some pilots are consistently cowboyish, and yes, some accident reports do read as, basically, "the guy was a cowboy". But I think it would be a mistake for anyone to think attitude was a fixed, inherent (or even genetic) trait, the sort of thing that can be screened for, and that as long as you aren't the "wrong type", you're fine. Personally, I think that, 95% of the time, I am as attitudinally inclined towards safety as anyone; just the sort of sensible, risk-averse, somewhat nerdy bloke you'd expect to be posting on a thread about safety. I guess I'd pass any psychometric safety test with flying colours. The really difficult thing about safety attitude is that it is very situational. You can always have the very best intentions, but the "pressure of the moment" has an incredible distorting effect on judgement. The "moments" I experience are in the last 30mins before a flight, even more than in-flight. I find it easy for some unanticipated set of circumstances to arise where my judgement ends up being different from what it might have been outside of that "moment". It's not even a conscious decision, along the lines of "ok, I'd rather not, but I am under this specific pressure, so I'll take the risk". It's just a sort of dominoes-toppling thing where, with hindsight, you realise you did something you shouldn't have, despite all the inherent attitudinal best intentions.
Thirdly, I think there's a trait in how GA pilots discuss safety which might be misleading to some. Safety discussions have a tendency to drift into statistically irrelevant minutiae. We like discussing interesting stuff and not banal and boring stuff. One example is glass-cockpit failure modes. I'm a member of a US pilot forum where a debate raged for hundreds of posts about the G1000, potential failures and the merits of different kinds of back-up instruments for IFR safety. People post on those threads with well-reasoned arguments that are laudably safety-motivated. The thing that never gets said (perhaps because it's so obvious to everyone except me, but I think it's mainly because we avoid sounding patronising) is "this is all very interesting, but you do realise that, as GA pilots, we are not (statistically) going to crash and burn because of some deeply technical combination of factors and events? It's (statistically) going to be a really banal bit of bad judgement or a really banal lapse".
The discussion of airline safety is interesting because airline accidents are almost exclusively the result of deep and complex interactions of human and technical factors. The deep, complex factors are almost meaningless for us GA pilots, who, per hour, are hundreds of times more likely to have a fatal accident than a professional 2 crew operation. The key lesson from airline safety for a GA pilot is not in how airline accidents happen, but in how they don't happen. They don't happen for 99% of the "banal" reasons GA accidents happen. Let me restate that those "banal" reasons are things that 'pyschologically' safe and 'non-cowboy' GA pilots do. I don't think that the airline safety record is driven primarily by technology like TCAS and EGPWS. Those technologies improve airline accident rates from one in a million to much better than one in a million. But the key differences between airline and GA safety are little to do with the amazing features of modern jets. They are as "banal" and "boring" as 2 crew, regularly trained, highly current and (I think most importantly) absolutely, unwaveringly, sticking to "Standard Operating Procedures".
For me, a good airline SOP example is one I remember seeing at Bournemouth on a fantastic CAVOK day. A Ryanair 737 was on the ILS at 5 or 6 miles. For some traffic reason, ATC had to tweak their normal approach clearance slightly. I don't remember the details, but it was trivial and blindingly obvious the crew could safely land this 737 on Bournemouth's long runway in these perfect conditions. But the crew called back and said politely, with no hint of exasperation, "sorry, on that basis, SOPs mean we have to go around" and so they did. On the surface of it, utterly pointless; costing the airline thousands and wasting 10 minutes of everyones' time, but it did make me think afterwards about how powerful the benefits of SOPs are, and how it’s both very obvious and very subtle. The power and subtlety comes from the airline profession accepting the “nuisance” of SOPs which might bring no material benefit in 999,999 out of a million times the SOPs over-ride a crews’ judgement. The safety benefit comes from that one in a million occasion when the crews’ judgement would be wrong. I’m not exaggerating the statistics, I think it is fair to think of airline safety in the one-in-millions range.
For a GA pilot, the lesson is simple. Don’t worry about how psychological testing might trap the inappropriate pilot. Don’t worry about the N1 spool-up needed to recover an airliner stall. Don’t worry about most of the regulatory and technical things we debate on forums. If you want to be safe, train regularly, stay current and, perhaps most of all, try and put yourself in an SOP environment. It’s difficult, because 100% airline-style SOPs would impact the cost and utility of GA to an intolerable extent. But the SOPs that would avoid most GA accidents aren’t that difficult; and they might prevent the really banal judgement lapses that can and will happen to any of us.
PS. A good overview of this whole subject is available here:
http://rgl.faa.gov/Regulatory_and_Gu...Chap%201-3.pdf
Firstly, I think a key point is that the risks in flying are multiple and "diffuse". It's not as simple as factors being ranked or dominant (eg. the 'is attitude more important than experience' question). I haven't read the article Fuji mentions, but I guess a theme is that experience is far from being a sufficient condition for safety. The attitude topic is not new, it's been a major element of FAA training for years. See http://www.sportpilot.info/sp/Factors_Affecting_Decision_Making.pdf
Secondly, I would question the "cowboy" point IO made in one respect. Yes, some pilots are consistently cowboyish, and yes, some accident reports do read as, basically, "the guy was a cowboy". But I think it would be a mistake for anyone to think attitude was a fixed, inherent (or even genetic) trait, the sort of thing that can be screened for, and that as long as you aren't the "wrong type", you're fine. Personally, I think that, 95% of the time, I am as attitudinally inclined towards safety as anyone; just the sort of sensible, risk-averse, somewhat nerdy bloke you'd expect to be posting on a thread about safety. I guess I'd pass any psychometric safety test with flying colours. The really difficult thing about safety attitude is that it is very situational. You can always have the very best intentions, but the "pressure of the moment" has an incredible distorting effect on judgement. The "moments" I experience are in the last 30mins before a flight, even more than in-flight. I find it easy for some unanticipated set of circumstances to arise where my judgement ends up being different from what it might have been outside of that "moment". It's not even a conscious decision, along the lines of "ok, I'd rather not, but I am under this specific pressure, so I'll take the risk". It's just a sort of dominoes-toppling thing where, with hindsight, you realise you did something you shouldn't have, despite all the inherent attitudinal best intentions.
Thirdly, I think there's a trait in how GA pilots discuss safety which might be misleading to some. Safety discussions have a tendency to drift into statistically irrelevant minutiae. We like discussing interesting stuff and not banal and boring stuff. One example is glass-cockpit failure modes. I'm a member of a US pilot forum where a debate raged for hundreds of posts about the G1000, potential failures and the merits of different kinds of back-up instruments for IFR safety. People post on those threads with well-reasoned arguments that are laudably safety-motivated. The thing that never gets said (perhaps because it's so obvious to everyone except me, but I think it's mainly because we avoid sounding patronising) is "this is all very interesting, but you do realise that, as GA pilots, we are not (statistically) going to crash and burn because of some deeply technical combination of factors and events? It's (statistically) going to be a really banal bit of bad judgement or a really banal lapse".
The discussion of airline safety is interesting because airline accidents are almost exclusively the result of deep and complex interactions of human and technical factors. The deep, complex factors are almost meaningless for us GA pilots, who, per hour, are hundreds of times more likely to have a fatal accident than a professional 2 crew operation. The key lesson from airline safety for a GA pilot is not in how airline accidents happen, but in how they don't happen. They don't happen for 99% of the "banal" reasons GA accidents happen. Let me restate that those "banal" reasons are things that 'pyschologically' safe and 'non-cowboy' GA pilots do. I don't think that the airline safety record is driven primarily by technology like TCAS and EGPWS. Those technologies improve airline accident rates from one in a million to much better than one in a million. But the key differences between airline and GA safety are little to do with the amazing features of modern jets. They are as "banal" and "boring" as 2 crew, regularly trained, highly current and (I think most importantly) absolutely, unwaveringly, sticking to "Standard Operating Procedures".
For me, a good airline SOP example is one I remember seeing at Bournemouth on a fantastic CAVOK day. A Ryanair 737 was on the ILS at 5 or 6 miles. For some traffic reason, ATC had to tweak their normal approach clearance slightly. I don't remember the details, but it was trivial and blindingly obvious the crew could safely land this 737 on Bournemouth's long runway in these perfect conditions. But the crew called back and said politely, with no hint of exasperation, "sorry, on that basis, SOPs mean we have to go around" and so they did. On the surface of it, utterly pointless; costing the airline thousands and wasting 10 minutes of everyones' time, but it did make me think afterwards about how powerful the benefits of SOPs are, and how it’s both very obvious and very subtle. The power and subtlety comes from the airline profession accepting the “nuisance” of SOPs which might bring no material benefit in 999,999 out of a million times the SOPs over-ride a crews’ judgement. The safety benefit comes from that one in a million occasion when the crews’ judgement would be wrong. I’m not exaggerating the statistics, I think it is fair to think of airline safety in the one-in-millions range.
For a GA pilot, the lesson is simple. Don’t worry about how psychological testing might trap the inappropriate pilot. Don’t worry about the N1 spool-up needed to recover an airliner stall. Don’t worry about most of the regulatory and technical things we debate on forums. If you want to be safe, train regularly, stay current and, perhaps most of all, try and put yourself in an SOP environment. It’s difficult, because 100% airline-style SOPs would impact the cost and utility of GA to an intolerable extent. But the SOPs that would avoid most GA accidents aren’t that difficult; and they might prevent the really banal judgement lapses that can and will happen to any of us.
PS. A good overview of this whole subject is available here:
http://rgl.faa.gov/Regulatory_and_Gu...Chap%201-3.pdf
Last edited by 421C; 5th Jun 2010 at 16:03.
