20 Seconds
“In a decision making process, usually 20 seconds end up being not enough
time for an aviator or a crew”
Decision making in an ever
changing environment is at least a difficult task for anyone, decision making
in an aircraft cockpit gives a whole set of variables that sometimes
end up being too overwhelming to digest for any pilot or crew. Decision making
processes have been well studied, developed and implemented in every corner of
the world and have been among us from the beginning of time. Today you can easily punch the phrase in a search engine and anyone could get hundreds of different answers and techniques
even styles for one to implement and customize each need.
Some things have to be said about us
before we revise this topic by itself. One is the feeling of above average
performance we all feel we have at any point. And the other is the dynamic
environment playing a critical role as part of the equation.
Dunning-Kruger Effect
You are always
leaning in favor of your competence, you see yourself on a positive note. The
less you understand about a subject, the worse you do at assessing your
performance and the easier it is to feel an expert. If you continue to improve and add to your
craft it will be easier to be accurate at evaluating where you stand.
Attribution Effect
While evaluating a
person’s behavior you tend to jump to conclusions about its behavior blaming
the person and skipping the environment and then hold responsible the
individual. It is easier for our minds
to blame individuals than to evaluate the chance we have of being in the same
ship. It is easy to ignore the power of the situation. We take on this effect when we attribute
poverty to laziness for instance.
Why 20
Seconds?
Since the beginning of my career, I have always been puzzled by accident
investigations which bring up truth about fine aviators, well trained and
motivated and in good health, flying state of the art aircraft that end up
having to make life saving decisions in a matter of seconds. From the time things start to go south to the
time the voice recorder stops, we see some times as little as 20 seconds.
I will bring to you three accidents that picture this difficult corner
of decision making and try to learn as much as we can so we can better prepare
to coupe if at some point we are confronted with our own 20 seconds.
1st 20 second case:
TAM Airlines flight
3054 Congonhas, Brasil.
During landing at night on a wet
runway the A320 touched down and only one thrust lever (Left) was set to idle
and then reverse, leaving the other thrust lever (Right) in its flight position
which is usually fixed in the climb detent for this aircraft. The right engine due to a set logic
accelerated to climb thrust which was to match the thrust lever position. The aircraft departed the runway pushed by
the right engine and after leaving the runway crashed. No one survived. For thousands of flying hours these crew
members retarded both thrust levers to land. How can a pilot be overwhelmed
by aircraft design, technology and environmental factors that makes him make
such an important mistake, where is the answer, how can we cope?
2nd 20 second case:
TACA Airlines flight
390 Tegucigalpa, Honduras
During landing on a wet runway with
some tail wind, the aircraft touched down and full breaking was initiated at what
may be considered a couple of seconds late.
At some point during the landing roll the Pilot Monitoring called the
speed at which the thrust levers should be set to idle reverse and the Pilot Flying
took the thrust levers into idle reverse.
After a couple of seconds the aircraft departed the runway at about 50
knots crashing into a berm, one of the persons sustaining fatal injuries was
the captain. More often than not environmental factors
change the equation behind our backs. Transparent risks will not be evaluated
but will make a difference at some point.
3rd 20
second case:
Gulfstream 650
Flight Test Roswell, New Mexico
Taking Off from a 13000’ runway
during a heavy weight single engine performance test the aircraft was rotated
and soon after began rolling right which was the side of the idling
engine. The right wing contacted the
ground and even though the right engine was commanded to Takeoff thrust,
control was not recovered. The left
engine pushed the aircraft off the runway and after sliding on the ground a
fire ensued. Everyone on board sustained
fatal injuries. In less than a minute hundreds of ours of testing experience
were put to the test by technology and the environment. How can we avoid being set up to decide on
our lives and the lives of the persons we proudly transport on such short
notice?
As we see these accidents we tend to differ on the actions of the
persons and having enough time to think about the outcomes we all can come up
with better ways of accomplishing the tasks that ended up taking people’s
lives. Truth to be said if they gave us
all 20 seconds to decide on our lives as all this aviators did I’m positively
sure that most of us would fail to decide or decide erroneously. We are for the most part alike; parents, brides,
husbands, pilots, all experienced and knowledgeable, usually patient
and calm, capable of making good decisions in our dynamic environment.
The decision making process can’t be set to be effective in 20 seconds,
no one can guarantee that we all would score 100 in this test. So we have to
avoid and make every effort within our reach to never be confronted with such a
small window of opportunity. All of our
actions have to be set to open that window as wide as we possibly can.
Where to start?
Attitude,
Structure, Knowledge, Proficiency.
Attitude:
It is true, every
instructor knows it is very easy to teach someone to fly, but it is really hard
to teach away a wrong attitude. It is
above all a discipline and a required and valuable asset. A proper attitude will open your window of
opportunity so the safety setup in your operation can come completely in view.
Structure,
The three types of
structure we can and should develop are: Management, Flight Ops and Flight.
Management should learn to look for risks by keeping the industry standards of evaluation, training
and development within the people in charge or related to flight
departments. You may be the only one in
charge and as such you are responsible for taking time to learn and evaluate
your flight operations or department at all times.
Flight Operations departments
should always have a watch full eye on risk, the ones which are part of our
operations and the ones which develop suddenly. Evaluating all operations and
learning from our and others mistakes has to be a way of life within the
operation. Evaluation and change have to
be part of our culture.
Flight structure comes
with SOP’s Standard Operating Procedures are to be developed, implemented and
followed. SOP’s are without any doubt
the most accessible way of elevating and maintaining a high level of safety in
our flights. Properly developed SOP’s
are invaluable safety tools.
Knowledge:
Yes knowledge, at all levels of the
organization, in this case knowledgeable aviators. The amount of information a pilot receives
comes basically from two sources. All of what he is capable and willing to
gather for himself and information brought to him by the organization. Much can be said about teaching and learning
which is outside the scope of this article but at least let’s put weight to the
transfer of information related to an operation first coming from the
outside.
Information in
regards to furthering the quality and quantity of knowledge a pilot possesses
has to be constant. A constant amount of
relevant information regarding aircraft and operations have to be set to flow
to him or her, reviewing different points of view and accepting critique and
opinions to flow back as to engage positively in an exchange of knowledge.
In regards to what
you can and are willing to gather for yourself I can only say that if you have
slowed or stopped due to the myriad of other things life throws at us. Take time for you and return to what you used
to do and enjoy so much before the kids, the mortgage, the cars, the second
mortgage, the economy, TV and the prices of goods. It always feels good, it never gets old,
planes are always beautiful machines and so is the feeling of wellness that
comes with knowing your stuff or reading a good article. Take the time.
Proficiency:
Aviation
departments big and small have training requirements usually to comply to
regulations, they are set up from a complying and an economic standpoint. After
those aspects have been taken care of usually we evaluate other aspects of the
training itself. Few are the ones which get training above
what’s required by regulation. Even
though this is an expensive topic, if you have in your organization the
possibility to increase the amount of exposure to training above the
requirement do so. Proficiency is
dependent on practice, there are things you cannot get away with by reading
about them, you can read many times a go-around maneuver but it takes a couple
of runs to get it perfect. If you have
been having months that come with few opportunities to practice, there may be an
honest reason to get a little more than what’s required.
Here we have seen three occasions
where the crews had a small window of opportunity to make a decision that would
have altered the outcome of their flight.
If any of us would have been there in the beginning of the last minute
before the Cockpit Voice Recorder stopped it is uncertain to say that we would
have done something differently. What we
can take from this is that sowing a good net that would prevent us from falling
into that position has to be the focus of a team. A team with the proper
attitude, working within a useful structure, composed of knowledgeable and
proficient members. There is opportunity in every corner to be better and
safer.
And above all care,
always care.
Luca Pineda
Luca Pineda
Written May, 2012
References,
1-NTSB, DCA011MA07
2-AAC El Salvador TACA
INTERNATIONAL AIRLINES FLIGHT 390
AIRBUS
A320-233 REGISTER No. EI-TAF
3- ACCIDENT INFORMATION TELEX FROM: Airbus
flight safety department Toulouse
SUBJECT: TAM Lineas Aereas flight JJ3054 accident in Sao Paulo, Brazil Our ref.: TAM JJ3054 AIT 4 dated August 02nd 2007
SUBJECT: TAM Lineas Aereas flight JJ3054 accident in Sao Paulo, Brazil Our ref.: TAM JJ3054 AIT 4 dated August 02nd 2007
4-Book, You are not
so smart Author: David McRaney- Dunning-Krueger and Attribution
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