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My 2 Cents Worth - Breaking the Error Chain

By Randy Mains

“This is stupid!”

What wonderful words to break the error chain.  I’ve certainly said it when I’ve been flying.  Like in bad weather when scud running, or doing anything in the air where I figured I probably shouldn’t be there.  “This is stupid,” can potentially be one of those simple, but brilliant, ideas designed to let you, the pilot, know it’s time to call it quits, go home, and thus prevent really scaring yourself and possibly having an accident.

I came across the ‘This is Stupid’ idea quite serendipitously.  I was speaking on the phone to Lieutenant Commander Dan Leary, Aviation Engineering Officer, Coast Guard Air Station, Astoria, Oregon.  He had inquired about the possibility that I come to his base to give my six-hour symposium on Crew Resource Management to 50 members of his team. 

Our phone conversation drifted onto the subject of the brilliantly simple idea of the Enroute Decision Point (EDP) a tool developed by members of the National EMS Pilots Association as a simple, but effective way to save lives.  It’s brilliant because of its simplicity, and easy enough for any pilot to remember signaling it’s time for him or her to abort the mission and get to a safer place. 

To refresh your memory about the EDP, if due to deteriorating weather you reduce your airspeed to 30 knots less than cruising speed, or if at night you are forced down to an altitude of 500’ above the highest obstacle in your flight path, or 300’ during the day, it’s like hitting the decision altitude on an instrument approach.  You must make a decision to either land, turn around, or if equipped and you are comfortable doing so, climb and request IFR handling.  BUT YOU DO NOT CONTINUE!  

Dan told me over the phone, “We’ve come up with something similar to the EDP.  We’ve discovered that when someone in the crew suddenly says, ‘This is stupid,’ we know it’s time to turn around and go home.”  Dan and I agreed it’s much like an EDP, but this tool relies on a gut feeling based on experience and comfort level, two very valid safety markers.  Fantastic!  By using either the EDP or the “This is stupid” tool, you have effectively broken a vital link in what could be building into a deadly error chain, and by doing so and resolving it, you very likely averted having an accident.

Let me review with you the 11 elements in an error chain. If you identify these clues early on, you will go a long way to avoid, trap, or mitigate the further building of links, thus breaking the error chain that could ultimately lead to you, and those with you, having a bad day.

1.    Ambiguity:  Any time two or more independent sources of information do not agree, for example, an attitude indicator showing a right bank, but no corresponding change in heading on the compass or heading indicator.

2.    Fixation or Preoccupation: The focus of attention on any one item or event to the exclusion of all others.  Accept this truism:  We humans are not good at multi-tasking.  Our brain is a single processor able to do only one thing well.  Think of a diversion of attention as a red flag.

3.    Confusion:  A sense of uncertainty, anxiety or bafflement about a particular situation.

4.    No One Flying the Aircraft:  Remember - Aviate, Navigate, Communicate.  Many accidents have occurred solely because a pilot did not make flying the aircraft his or her top priority.

5.    No One Looking Out of the Window.  Self-explanatory.

6.    Use of Undocumented Procedure:  The use of a procedure that is not prescribed in approved flight manuals or checklists in order to deal with abnormal or emergency conditions.

7.    Violating Limitations or Minimum Operating Standards:  Intent to violate or actual violation of defined minimum operating conditions or specifications as prescribed by regulations, flight operations manuals or directives.

8.    Unresolved Discrepancies:  Failure to resolve conflicts of opinion, information, or changes in conditions.

9.    Failure to Meet Targets:  Failure of the flight crew to attain and / or maintain identified targets such as ETAs, airspeeds, approach minima, altitudes and headings.

10.    Departure from Standard Operating Procedures:  Intent to depart or inadvertent departure from prescribed standard operating procedures.  Well-defined SOPs are the result of a synergistic approach to problem solving with the influence of time removed.  In short, they are designed to keep you and those around you safe.  Violating an SOP usually puts you at risk.

11.    Incomplete Communications:  Incomplete communications are the result of withheld information, ideas, opinions, suggestions or questions.  It’s also failure to seek resolution of misunderstandings, confusion or disagreements.

The presence of one or more of these eleven clues could be an indication that a link in an error chain might be forming and that appropriate caution should be applied to avoid, trap or mitigate it from happening.  This requires your constant vigilance.  Always be on the lookout for a link in the error chain that could be forming.

Aviation research over the years has uncovered that there are a minimum of four links to an error chain, with the average being seven contributing to an accident.  The ability to recognize the presence of a link provides a pilot with a powerful tool to better manage risks associated with flight.   

I suggest adding the “This is stupid” tool to your safety toolbox along with the EDP tool.  You can either say it out loud or perhaps just think it. Either way if it ever filters into your consciousness, by acknowledging that what you are doing is stupid, consider it a mental micro-switch tripping in your head, telling you it’s time to stop whatever it is you’re doing and follow the procedures as if you’ve reached the Enroute Decision Point.  It is now time to land, turn around, or request IFR handling.  But one thing is certain:  DO NOT CONTINUE.

Safe flying!
 

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