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CRM Series:  Error Management

by Darren Smith, CFII/MEI
General Aviation Human Factors, January, 2006

Navigation:  Fundamentals of CRM | Resolving Conflict | Workload Management Checklist Usage | Briefings & Callouts | Training CRM | Threats to Safety | Intro to TEM | Error ManagementIntegrating Threat & Error Management | TEM Countermeasures | FOTA | What are you doing over there? | New Captain Series

TEM Series:  Threats to Safety | Unsafe Acts | Intro to TEM | Error Management | Integrating TEM | Countermeasures

Flying with a new pilot is always interesting.  I immediately get a sense of pilot skill from informal conversation.  What I don't pick up in casual conversation is evident quickly because performance speaks for itself.  Most are accurately aware of their limitations and abilities and seek training to overcome those weaknesses.  As the Flight Instructor, it's very easy to sit in judgment of a pilot's skill when you're not the one doing the work.  From the student's perspective, being subjected to flight training or  flight checks causes anxiety and decreased performance.   All of our weaknesses as a pilot are exposed and excuses are never effective.  Since all pilot performance degrades under pressure, what remains for us is:  situational awareness and error management. 

Errors are defined as "actions or inactions by the flight crew that lead to deviations from intentions or expectations". Unmanaged or mismanaged errors will lead to an undesired aircraft state.  Errors in flight operations tend to reduce the margins of safety and increase the probability of an undesirable event.  Errors can be spontaneous (without apparent threat), the result of mismanaged threats, or part of an error chain.

Consider these levels of error management:
  1. Errors are not recognized or mitigated.
  2. Errors are recognized but skill to mitigate is lacking.
  3. Errors are recognized and eventually mitigated.
  4. Errors are recognized, managed, and mitigated in a timely manner.
  5. Errors are recognized, managed, and mitigated immediately.
Implications for Flight Instructors, Pilot Examiners:  Scoring anything below a 3 on a given maneuver is unsatisfactory for flight reviews, proficiency checks, and check rides.  Scoring 3 and higher requires the pilot to exhibit not only the logic and computational skills to detect an error, but also the motor skills to effect a change in the operating profile to resolve the error.  Achieving higher scores only requires time in aircraft type performing and learning maneuvers and accomplishing tasks. 

Pilots quickly understand that error management is about quickly:
  • Resisting or preventing error (Threat Management).
  • Resolving or mitigating error (Error Management).
  • Determining where you are and what comes next.
The effect of these actions is the consequence which can be scored as depicted above.  This requires situational awareness by knowing what's going on with and around the aircraft and how it is going to affect you in the immediate future.  It is the pilot not flying or the flight instructor's responsibility to monitor pilot performance (Pilot Monitoring) and challenge errors.  It's the pilot's responsibility to express doubt or uncertainty so that the PNF or flight instructor can effectively provide guidance for the proper resolution.

The errors that pilots make fall within five basic categories.  They are intentional non-compliance, procedural error, faulty communication, lack of proficiency/skill, and decision making.  Examples of non-compliance is failure to follow checklists, failure to follow guidance in the FAR/AIM, and failure to follow good safety practices.  An example of a procedural error is a mistake in the execution of checklists/procedures.  Examples of faulty communication include readback error and miscommunication with ATC.  Proficiency and skill errors relate to basic airmanship skills that are lacking.  Decision making skills improve when situational awareness is improved.

Types of activities which enhance situational awareness:
  • Review clearance to determine adherence to it.  Anticipating time, airspace, heading, and altitude limits will give good error cues when non normal conditions exist.   I once gave a clearance to a private pilot rated student to descend to and maintain 1500 feet.  During his descent, I gave him various vectors to keep him occupied about every 300 feet.  As his descent progressed, I had to give him vectors to an open field because he went through his assigned altitude of 1500 feet and at 400 AGL I finally took control of the airplane and asked him to go visual and see what was going on.  When I asked him why we were so low to the ground, he had no answer as to how it happened.
  • Thoroughly brief your approach and conduct it as briefed. Review and rehearsing procedures builds skill and helps a pilot resist error.   Another private pilot rated student briefed a localizer approach to a non-towered airport to me.  When he arrived at his minimums of 600 feet AGL he leveled out and waited for the missed approach point.  I watched as the missed approach point came and went.  He continued three miles past the missed approach point unaware that the DME was now climbing again.  When he was on short final for a 30 story hotel, I asked him to go visual and land the aircraft.  He went below the minimums without an airport in sight and a hotel three miles in front of him.  When he was stabilized on the go-around, I asked him how it happened, he indicated he didn't know.
  • Be vigilant to situations which deteriorate rapidly and be able execute plan B.  Arriving at a cross country destination, I recommended to my private pilot rated student that he obtain the local weather from ATIS.  What should have come naturally was obtaining and analyzing the weather for the airport he planned to land at.  When he obtained the weather, direct crosswinds at 15 knots were present.  He did not correctly recognize that was near the maximum demonstrated crosswind capability of the aircraft and was likely to be beyond his skills.  Getting closer, I gave him a briefing on crosswind technique.  I gave a similar briefing when he turned downwind, again when he turned base, and again on 1 mile final.  Over the runway at 50 feet AGL in a 30 degree bank, my student asks, "What do I do?"  After I took control, landed, and shut down, I reviewed the better choices with him (such as a go-around).
  • Trap Procedural Errors. Follow checklists carefully, follow procedures and execute maneuvers properly, and know the pilot's operating handbook limitations and procedures.  By sticking to these golden rules, you'll trap the inevitable error that is part of human nature.
  • Manage workload.  Use the resources within the cockpit to effectively manage workload and prepare for threats to situational awareness.  Using automation in the cockpit such as GPS, radio altimeters, TCAS, as well as resources outside the cockpit such as FSS and ATC can help you prevent and resist errors.
  • Make stable approaches.  Executing a stabilized approach and descent keeps the pilot ahead of the aircraft to monitor non-normal conditions and become aware of error cues.
  • Ask questions:  what comes next?   what if?   Do you have taxi diagrams when you land? Are your radios preset when you are “in-range”?  Do you ensure you have weather before you land?  Do you have the fuel to get there?  What's the missed approach?  How do I do the next thing I gotta do?
  • Review and practice, obtain training, plan and prepare your reaction to a non-normal event so that it is not the first time you've ever done it.
  •  Know where you are & where other traffic is operating
A student once asked me, "How do things fall apart so quickly?"  The answer is as different as every pilot.  This list of threats to safe flight is from thousands of hours monitoring pilot errors and offering guidance to get them back on track.  Consider them red-flag events which may prevent you from safely executing the planned flight.
  • Failure to see the cues that an error is occurring.  Slowly drifting off heading, altitude, or airspeed leads to large deviations.  Why are you 100 feet below the assigned altitude and still trending downward at 500FPM? 
  • Failure to investigate the unusual or ambiguous cues.  Why is the engine running rough?
  • Failure to understand the risk of the behaviour.   Why are you 100 feet below minimums and continuing beyond the missed approach point?
  • Law of expectancy, failure to appreciate differences in the current situation.
  • Failure to react to changing conditions and prepare for the "way out" or the execution of a plan B. 
  • Jumping to inaccurate conclusions.
  • Get-there-itis.
  • Non-stable, rushed approaches & descents.
  • Lack of effective briefing.  (Departure, Take-off, or Approach Briefings)
  • Getting Behind the Aircraft: Allowing events or the situation to control your actions rather than the other way around.
  • Neglect of proper operating rules, flight & fuel planning, knowing all available information about your flight.
  • Failure to follow checklists, while the aircraft is stopped, and with your full focus.
  • Failure to divide attention between two tasks by avoiding fixation.
  • IFR operations:  descent below minimums and continuing beyond the missed approach point.
  • Environment of flight:  unfamiliar airport, unexpected weather, ATC, equipment malfunction.
  • Distractions: 
    - communication with ATC or passengers, 
    - busy work such as chart review, GPS programming, checklists
    - traffic alerts, looking for traffic instead of monitoring the flight parameters.
In the next article, I'll discuss the Undesired Aircraft State, it's implications, and a case study to help you integrate TEM into your flying. 

"If the Wright brothers were alive today Wilber would have to fire Orville to reduce costs."
—  Herb Kelleher, 1931-, founder Southwest Airlines, USA Today, June 8, 1994

Southwest's Cost-Cutting & Saving Strategies

1. Southwest's most effective strategy at cutting costs is its point-to-point short haul service.
2. First airline to sell directly to customers instead of through travel agents -- saving anywhere from 5-10 percent on cost
3. Kelleher chose not to use the airline computer reservation system that other airlines were using (and paying for)
4. Southwest designed as a "no-frills" airline offered no meal service
5. Southwest only uses Boeing 737s, meaning pilots and mechanics only need to be trained on this type of aircraft.
6. Southwest didn't enter a new market unless it was assured of a minimum of four daily flights there.
7. Use fuel contracts to hedge for the best price in a tough market
8. Allow employees to "be themselves"

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