...checklists and human factors...breakaway thread

[SteveC]

The other book I haven't seen mentioned is "Basic Flight Physiology" by Richard O. Reinhard. I'm sure things are missed, but all in all it is a wonderful, relatively short (<300 pages), book that covers a white array of human physiological factors and how they effect flight.

Shameless self-promotion.

 

[Roger, Roger]

Re: Combinations of RPM & Manifold Pressure

You have to quantify where it is that you're trying to apply your theory here, because there are places where you simply can't. Example: military flying. There's nothing "macho" about washing out those that don't or can't measure up; it's simply a way of keeping them and possibly people flying along or with them alive. Pure and simple. There isn't a way to "change the task" so it becomes easier, because (especially for fighter aircraft or other tactical aircraft, helos included) the tasks are designed to insure that people are pushed to their limits and whether or not they cross the boundary of can hack it or can't hack it.

I don't know that that's necessarily the case-For example innovations like HOTAS, fly-by-wire, and FADEC have certainly made the task of flying a high-performance, complex, jet aircraft in a combat environment much easier and removed opportunities for pilots to make mistakes.

 

[MikeD]

Re: Combinations of RPM & Manifold Pressure

I don't know that that's necessarily the case-For example innovations like HOTAS, fly-by-wire, and FADEC have certainly made the task of flying a high-performance, complex, jet aircraft in a combat environment much easier and removed opportunities for pilots to make mistakes.

It's not just the mission employment basics, it's the unexpected situations where the basics still apply. If you have a guy who can't fly formation in day VFR, how can you expect him to fly it when he's IMC, flying off the wing of a tanker for 5 hours that he can't afford to lose contact with, or he's screwed? That's just one example. You don't bring the standards down to his level, he's meets them or he simply doesn't make it and washes out. It doesn't mean he's a bad person, he may just not have the hands or the SA or the coordination or the attention to detail.

Trust me, there's far more to military aviation and the reason things are the way they are with it, far beyond things like nifty innovations that reduce a little bit of workload. Remember, I've been doing this for a living. And the guy that had to sit on the tanker for 5 hours over the Atlantic at night, IMC, with nothing more than a KC-10s green navigation light to hold position with (couldn't even see the fuselage, and only momentary glimpses of the #3 engine), was me. There were 4 of us on that tanker, and the two guys on the other side were having a heck of a time with it. Plus, if I didn't fly formation correctly, there was another A-10 on my wing to my right, depending on me to not get us both lost by my losing the tanker in the WX.

 

[Orange Anchor]

Re: Combinations of RPM & Manifold Pressure

I don't know that that's necessarily the case-For example innovations like HOTAS, fly-by-wire, and FADEC have certainly made the task of flying a high-performance, complex, jet aircraft in a combat environment much easier and removed opportunities for pilots to make mistakes.

for every new innovation, there is the potential for a new error. And there is no consensus on the assertion that automation reduces workload. There is mostly agreement that it changes workload. But in many cases, it reduces workload where workload is already low and increases it where it is already high. An example is using an FMS to reprogram an approach. LOTS of keystrokes.

 

[Orange Anchor]

Re: Combinations of RPM & Manifold Pressure

You don't bring the standards down to his level, he's meets them or he simply doesn't make it and washes out. It doesn't mean he's a bad person, he may just not have the hands or the SA or the coordination or the attention to detail.

NEVER lower the standards. It just promotes failure.

In my 'conflict' we termed it forced maturation. You measured up or you were out. The risks of killing good guys was just too high to tolerate guys who couldn't do the basics.

 

[tgrayson]

Re: Combinations of RPM & Manifold Pressure

Pure and simple. There isn't a way to "change the task" so it becomes easier

Ah, yes, there is, and Sterns books deal to a large extent to military flying and the macho attitude that has led to accidents and failed missions. Human Factors and CRM have become a part of military aviation and they, in fact, have been some of the pioneers. And note that I said:

getting rid of those who can't measure up. While those things have a role,

so your assertion that I'm painting with a broad brush is inaccurate.

 

[ppragman]

Re: Combinations of RPM & Manifold Pressure

Agreed. we have gone far afield of RPM and Manifold pressure. maybe we need to start another thread. ??

Flows with do-verify. Emergency stuff as read/do since the progression of steps is important.

Finally, most of us react properly to the horn/red light. The problem is the slowly evolving problem where the information is ambiguous. I can't remember where I read it but I like the quote which sums it up, "We are constantly moving from ambiguity to ambiguity." We seldom have all the info we need and the other side is when all hell breaks loose, there is a tsunami of info coming in that we have to wade through to find the relevant and useful bits.

I think there needs to be "memory items," which need to be instinctual. Then any complicated restart, or fire suppression, or other system needs to be read/do.

 

[MikeD]

Re: Combinations of RPM & Manifold Pressure

Ah, yes, there is, and Sterns books deal to a large extent to military flying and the macho attitude that has led to accidents and failed missions. Human Factors and CRM have become a part of military aviation and they, in fact, have been some of the pioneers. And note that I said:

so your assertion that I'm painting with a broad brush is inaccurate.

Your two statements above are contradictory. First you say macho attitude (which of course does exist with some people, but isn't the same as holding someone to a high standard), then you say it has a role. By equating the macho attitude with the concept of holding someone to a standard rather than lowering it to them, it comes off as incorrectly linking the two, whether you meant to or not.

Am well aware of GA and military safety and human factor issues. They're the same in many ways, different in others; as the two types of flying have different objectives entirely.

 

[tgrayson]

Re: Combinations of RPM & Manifold Pressure

Your two statements above are contradictory. First you say macho attitude (which of course does exist with some people, but isn't the same as holding someone to a high standard), then you say it has a role. By equating the macho attitude with the concept of holding someone to a standard rather than lowering it to them

We're talking about standards for two different things. It's one thing to be able to hold airspeed, altitude, fly an aerobatic maneuver, or hit your bombing target, and it's a whole other thing to not allow yourself to be distracted during a tight approach and stall/spin the airplane while trying to impress your girlfriend. In the latter case, the pilot had the skill to avoid the accident but wasn't using it, and it's not clear that a hot shot military pilot is any better than a private pilot at avoiding this sort of accident. The macho attitude that I'm referring to is the attitude that this sort of thing can be trained away by practicing physical skills, rather than acknowledging human failability and focus on the decision-making that led up the accident. The fact that many highly skilled pilots have crashed airplanes by making simple mistakes suggests that more skill isn't the cure.

 

[MikeD]

Re: Combinations of RPM & Manifold Pressure

We're talking about standards for two different things. It's one thing to be able to hold airspeed, altitude, fly an aerobatic maneuver, or hit your bombing target, and it's a whole other thing to not allow yourself to be distracted during a tight approach and stall/spin the airplane while trying to impress your girlfriend. In the latter case, the pilot had the skill to avoid the accident but wasn't using it, and it's not clear that a hot shot military pilot is any better than a private pilot at avoiding this sort of accident. The macho attitude that I'm referring to is the attitude that this sort of thing can be trained away by practicing physical skills, rather than acknowledging human failability and focus on the decision-making that led up the accident. The fact that many highly skilled pilots have crashed airplanes by making simple mistakes suggests that more skill isn't the cure.

Standards for one translate to the other, in many cases, regarding basics and how they apply forward; if we're referring to the same thing. Read my description of formation ops in above posts. That said, I do see where you're coming from where attitude now becomes a distrator regardless of experience or training, and that is a problem that can bite anyone, and has. If we're talking parallel conversations/subjects here, then my bad.

So far as highly skilled pilots crashing planes due to simple mistakes, it could be from any number of factors, but generally overconfidence in one's personal abilities is the unfortunate culprit and/or a macho attitude. Oftentimes though, said person may not normally be macho in their day to day life with flying; there have been more than a few normally-conscientious pilots who just up and do something dumb or stupid one day that they never would've done before, and buy the farm doing it. People that knew them are "shocked" to hear that they did it, they're normally "the safest pilot I know". Indeed, there is no training that can keep that from happening.

 

[tgrayson]

Re: Combinations of RPM & Manifold Pressure

So far as highly skilled pilots crashing planes due to simple mistakes, it could be from any number of factors, but generally overconfidence in one's personal abilities is the unfortunate culprit

I think that's true almost by definition. Most of us are overconfident that we can drive down the street and talk on our cell phones safely. After we have the accident, we can pinpoint the cause in the decision making that caused us to think we have a greater ability to multitask than we really did. It takes a failure before we realize our limitations. I think it is a sign of wisdom to look at another's mistake and think, "That could have easily been me...what am I going to do to ensure that it never is?"

 

[MikeD]

Re: Combinations of RPM & Manifold Pressure

I think that's true almost by definition. Most of us are overconfident that we can drive down the street and talk on our cell phones safely. After we have the accident, we can pinpoint the cause in the decision making that caused us to think we have a greater ability to multitask than we really did. It takes a failure before we realize our limitations. I think it is a sign of wisdom to look at another's mistake and think, "That could have easily been me...what am I going to do to ensure that it never is?"

Agree. And thats the scary and sobering thing: nearly any accident could indeed be any one of us. Knowing that none of us are immune, does indeed breed wisdom. Especially when you see many pilots who use the "what an idiot, can't believe he did that, I'd NEVER do something that stupid" way of thinking; though Im not sure if that may be a coping mechanism of some kind due to not wanting to face vulnerability or mortality.

 

[Blackhawk]

Thanks for the posts on the checklist studies. I have always told students that the requirement is to use a checklist- what type of checklist they use is up to them. I provide them with one initially that conforms to a "flow" format so that items are done in a logical manner, but I give them the Word file as well and tell them to alter the checklist to fit their personality.
In standardized operations, such as 135/121/military, this is not the case. You must use the "company" checklist so their is standardization across a large pilot group. Sometimes we get it wrong- there have been a number of fatal and near fatal crashes where pilots thought they accomplished a task but did not. In some cases (such as the Spanair 5022 crash), automation also broke down and failed to detect the error.
I have personally come to the conclusion until I see something better that the checklist should be just that- a checklist, not a do list. Do a flow, then check the items. There are still errors at times- such as saying "three green" when they are not all green- but I try to train out these errors in the simulator.
On the military side I really saw a great deal of inertia toward change. In my National Guard unit we had a large number of airline pilots who had picked up techniques that we felt would improve safety in our military flying- such as flows. But the bureaucracy was adamantly against this change. Another habit that I faught in a Quixiotic manner was the tendancy of military pilots to "flail" in an emergency. I don't know how many people we killed in the Army because pilots were taught to react immediatly in certain emergencies. I almost had one pilot crash the aircraft in the desert at night during a simulated engien fire only a few miles from an airstrip because he had been taught to put the aircraft down no matter what in the case of an engine fire. The Army even lost an aircraft and its crew off the coast of Cyprus one night in just such a scenario- they shut off the wrong engine and flew into the water at 150 knots.
Good discussion.

 

[ppragman]

Thanks for the posts on the checklist studies. I have always told students that the requirement is to use a checklist- what type of checklist they use is up to them. I provide them with one initially that conforms to a "flow" format so that items are done in a logical manner, but I give them the Word file as well and tell them to alter the checklist to fit their personality.
In standardized operations, such as 135/121/military, this is not the case. You must use the "company" checklist so their is standardization across a large pilot group. Sometimes we get it wrong- there have been a number of fatal and near fatal crashes where pilots thought they accomplished a task but did not. In some cases (such as the Spanair 5022 crash), automation also broke down and failed to detect the error.
I have personally come to the conclusion until I see something better that the checklist should be just that- a checklist, not a do list. Do a flow, then check the items. There are still errors at times- such as saying "three green" when they are not all green- but I try to train out these errors in the simulator.
On the military side I really saw a great deal of inertia toward change. In my National Guard unit we had a large number of airline pilots who had picked up techniques that we felt would improve safety in our military flying- such as flows. But the bureaucracy was adamantly against this change. Another habit that I faught in a Quixiotic manner was the tendancy of military pilots to "flail" in an emergency. I don't know how many people we killed in the Army because pilots were taught to react immediatly in certain emergencies. I almost had one pilot crash the aircraft in the desert at night during a simulated engien fire only a few miles from an airstrip because he had been taught to put the aircraft down no matter what in the case of an engine fire. The Army even lost an aircraft and its crew off the coast of Cyprus one night in just such a scenario- they shut off the wrong engine and flew into the water at 150 knots.
Good discussion.

This is critical, I think the term, "immediate action items," or something like that is somewhat misleading, think then do is probably the best idea.

 

[Orange Anchor]

Re: Combinations of RPM & Manifold Pressure

I think there needs to be "memory items," which need to be instinctual. Then any complicated restart, or fire suppression, or other system needs to be read/do.

True but in jets there are VERY few things that need to be done immediately. Engine fire/failure. Nope. Explosive decompressions. Put the mask on and establish comm but other than that, nope? (seen too many missed items and the pax are going to pass out anyway).

Now, recips and t-props.. yes, there is a drag problem but even then there are few memory items that have to be done NOW. And from observation and from reading, many agree with the old axiom I had when I first went to USAF UPT.. STOP, THINK, COLLECT YOUR WITS.

 

[Orange Anchor]

Re: Combinations of RPM & Manifold Pressure

The fact that many highly skilled pilots have crashed airplanes by making simple mistakes suggests that more skill isn't the cure.

What is the answer? What does one do to prevent 'simple mistakes'?

 

[Orange Anchor]

But the bureaucracy was adamantly against this change. Another habit that I faught in a Quixiotic manner was the tendancy of military pilots to "flail" in an emergency. I don't know how many people we killed in the Army because pilots were taught to react immediatly in certain emergencies.

Don't know if it was true or not but it rang true.. When we were in UPT there was a report of a T-37 driver who punched out. Seems he had gotten himself into a spin and when he recovered, he was in a high speed dive. Being a bright guy he realized that his only option was a very hard pull-out which would over-G the airplane. Not wanting to do that (put excessive Gs on the airplane)..he punched out.

True or not it does demonstrate a thought pattern of trying to comply with various rules/laws that conflict. (FWIW, I love that story)

 

[tgrayson]

Re: Combinations of RPM & Manifold Pressure

What is the answer? What does one do to prevent 'simple mistakes'?

That's what the Human Factors discipline addresses. It may require a change in the task to reduce the likelihood of mistakes, or it may require a change in technology (stick shakers, pushers, GPWS, TCAS, etc) or a prohibition on certain error prone activities, such as circling approaches at night.

(Real world in most industries is that the mistake-maker just gets bitched at by the boss and the boss walks away thinking that he's taken care of the problem. )

 

[Blackhawk]

Don't know if it was true or not but it rang true.. When we were in UPT there was a report of a T-37 driver who punched out. Seems he had gotten himself into a spin and when he recovered, he was in a high speed dive. Being a bright guy he realized that his only option was a very hard pull-out which would over-G the airplane. Not wanting to do that (put excessive Gs on the airplane)..he punched out.

True or not it does demonstrate a thought pattern of trying to comply with various rules/laws that conflict. (FWIW, I love that story)

I ran into the inertia after this incident with the simulated engine fire. I realized more crew members were being killed by the emergency procedure than the actual emergency. I actually produced data that showed this- the Army had not lost a crew to an actual engine fire in flight in decades. Yet we had lost numerous crews because pilots over reacted to engine fires.
I could not convince anyone of authority to change the procedure and many even told me that the crew member I was training did the correct thing- even though the landing probably would not have been survivable.:dunno:

 

[Blackhawk]

Some general observations about checklists over the years in GA.
1. If they have multiple pages, they won't be used.
2. If they are bulky and put away, they won't be pulled out again.
3. If they are mounted in view of the pilot (say on a yoke clip), they are usually used.
4. I have not figured out the exact number, but if an in flight checklist item has more than about 6 individual tasks and is done in anything other than cruise, the items either won't be done or there is a higher likelihood the pilot will think they performed an item but did not.