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Unsafe Acts

by Darren Smith, CFII/MEI
General Aviation Human Factors, September, 2011
CFIDarren Newsletter, September 27, 2011
Navigation:  Fundamentals of CRM | Resolving Conflict | Workload Management | Checklist Usage | Briefings & Callouts | Training CRM | Unsafe Acts | Intro to TEMError Management | Integrating Threat & Error Management | TEM Countermeasures | FOTA | What are you doing over there? | New Captain Series | CRM Series | Professionalism

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

If I were to tell you, “You’re about to do something unsafe," you would probably disagree with me.  But the reality is we all commit unsafe acts everyday.”  After much protest, you might discover that you are actually committing some unintentional unsafe acts.  Consider this scenario...

You’ve had a hard day at work, you figure you’ll go to the airport and do some traffic patterns to relax and do something enjoyable.  On your first turn to downwind, you forget to look before turning.  You think to yourself, “my gosh, my flight instructor drilled this into me.”   And this starts the accident chain.  The distraction of a difficult work day, the stress you’ve built up over the last few weeks, trouble with family… all of these are deposits in the unsafe acts bank account.    It’s all very inadvertent, but it’s still going to distract you.  It can manifest itself as failure to look before changing lanes, or the rolling stop at an intersection, or even as pilot error.  After all we’re only human.

Some pilots like to believe that they can compartmentalize the stressors and shut them off when they go flying.  They couldn’t be more wrong. 

James Reason, in his 1990 book Human Error, describes an unsafe act as “an error or a violation committed in the presence of a potential hazard.”   Violations are defined as “a deliberate deviation from standard operating procedures, FARs or rules.” Violations are sometimes caused by hazardous attitudes — “I know this is wrong, but I am going to do it anyway!” Violations are a topic for another article, so lets get back to our discussion about errors.

Errors can be thought of in two ways:
  1. Our action didn’t turn out the way we planned for.
  2. Our action goes exactly as planned, but it was the wrong action. 
The first kind of error—things didn’t turn out as planned has two possible causes:
  1. The error that was made was observable, in other words, it was a slip.  You saw it, and others did too.  An example is pulling the red mixture knob full out when you meant to pull back the throttle on a Cessna.   Another example would be busting an altitude because you were distracted by an indicator light.
  2. A lapse on the other hand was a memory failure.  Others would not necessarily notice that you’ve made the error.  An example is forgetting to put the carb heat on when pulling the Cessna throttle down below 1500RPM.  Another example is flying past your destination airport because you were so preoccupied with personal family problems.
The second kind of error, where things went exactly as planned but it was the wrong thing to do is called a mistake.   An example is planning for a normal takeoff without considering density altitude.  Assuming the takeoff doesn’t end in disaster (i.e. you were successful), then it would be a mistake not to properly assess factors affecting takeoff, like density altitude.  

Errors in aviation have the potential to harm ourselves and our passengers.  Violations have an equal or higher chance of causing harm, but are more preventable than errors.  There is no professional field that is immune to these concerns — medicine, power generation, law, and aviation all have high potential of harming others because of error. 

Silly mistakes, errors in judgment, or poorly justified decisions are a human condition.  The challenge in avoiding this human failing is to predict when the chances are high that errors, unsafe acts, and violations could occur.  This is underpinning of “Threat & Error Management” that we’ll talk about in the next few articles in the TEM series. 

Pilots are not necessarily willing to admit their shortcomings, especially when it comes to making errors.  There is almost a self-hypnosis that pilots sometimes experience — the myth of infallibility.  Over time, this myth has been in decline as pilots have come to an understanding that an attitude of perfection is ineffective and irrational. 

How can we cope with those who are slow to adopt a “Threat & Error Management” approach?  Our regulatory agencies have taken the approach of punishing those who make errors or violations.  Over time, these agencies have come to the understanding that the errors are still occurring in spite of punishment.    As such, our industry has tried to educate itself on countermeasures relating to errors and violations. 

In conclusion, Threat & Error Management goes a long way in helping pilots identify situations which are prone to cause errors or violations.  If we can manage the precursors, we might be able to prevent errors, even those which are the most sneaky — lapses which may not be detectable.
Next: Introduction to Threat & Error Management>>

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