This is the Fifth in a series of posts that will provide, throughout the year, an improvement strategy that will cover the entire family of 9 Automation Airmanship® principles. This posting marks the half-way point for the year!
Nearly every contemporary aviation accident (and many similar accidents in other high-risk/high-reliability industries) have a causal component related to data entry error, or data evaluation error. It’s a real problem across so many aspects of our profession that in 2013 we called it out as a fundamental principle of contemporary airmanship.
Not a day passes—whether I am involved in cockpit duties or not—that I cannot find dozens of opportunities to either enter data myself or take advantage of data that others have entered into some form of digital system. Whether I am using data that I have entered (anything from a phone number entered into my smartphone to performance data entered into the aircraft FMS) or trusting data entered by another person, I am expecting nothing less than a one-hundred-percent likelihood that it is correct. A phone number entered in error might not lead to tragedy, but incorrect data entered into a complex system like the ones we encounter on the 21st-century flight deck can (and has). In either occurrence, there are similarities leading up to the error, even if the result is far different. Both of these preventable situations of modern life keep me fascinated with the natural conditions that surround this immensely important modern-day skill.
There is no shortage of examples that can be used to illustrate the perils of data entry error: we cover several of them in Automation Airmanship® (McGraw-Hill, 2013) in a chapter wholly devoted to what we have named the Third Principle: Data Entry. Almost at the same time that we were coming to our own conclusions, the Australian Transportation Safety Bureau (ATSB) began publishing their findings following a dramatic near-disaster involving a large, modern airliner. Since that study*, NASA has conducted its own related research†. Both studies are excellent—and can easily be located online—download one or both, and use them as the centerpiece of your flight department’s next safety meeting.
Getting back to my fascination with all kinds of knowledge about the use of automation in contemporary life (especially flying), I am constantly on the lookout for perspectives from outside of our industry as well as from inside aviation. In many cases, what I find outside of our profession helps explain complex problems that impact contemporary aviation. Automation Airmanship® briefly discusses how decision making at the highest levels of competitive chess can be used to model complex decisions in many high-risk/high reliability domains. In the June/July 2017 issue of Esquire magazine, Garry Kasparov (one of the game’s greatest champions who famously took on the Deep Blue computer) talks with journalist Maximillian Potter about confronting the cold, steady, and reliable modern computer with raw human brain power. It’s compelling how relevant his observations seem to be with operations on the contemporary flight deck:
“You cannot bluff a machine… With a machine—I don’t know what you call it, he, she, whatever—one inaccuracy means that’s it: You lose all the advantages you have been accumulating over fifty moves.” ††
So, do you want to avoid losing the advantage of all your previous moves during preflight because of one data entry error? What we are asking crew members to do in 2017 is to create a cockpit environment that fosters a 100% rate of correct data entry. Nothing less. Seriously. To do that, we could prescribe a steady ration of research analysis and industry studies to build a global cockpit crew force staunchly resistant to error; or we could suggest some fundamental steps that can be executed by every pilot on every flight leg that will approximate the same result—but with a lot less reading. Here’s that checklist:
- Locate FMS pages with ease, without awkward, aimless searching; maintain proficiency in inputting flight data through each input pathway available.
- Capture, question, and correct errors as soon as any possible discrepancy or potential error is recognized: “Stop the operation” if necessary to remedy the error.
- Cross-check flight critical data at a compliance rate of 100%.
- NO “secret typing”—all entries are made with the full knowledge and approval of supporting crew members.
- All displays are kept up to date, accurate, and consistent with crew briefings and SOPs for phase of flight.
- “Head-down” time is minimized by both pilots, and in no instance are both pilots simultaneously preoccupied with data entry or verification unless the aircraft is in stable level cruise or on the ground (stopped with the brake set).
If you or those that you fly with cannot or will not follow these tenets of the Third Principle: Data Entry, then you are more vulnerable to error (that could be catastrophic) than those who do.
Over the past weekend, I was operating a domestic afternoon leg—a routine single-departure that had few non-routine distractions. But during the climb-out, I found myself looking ahead to the descent, and while acting as Pilot Flying, I started paging through the FMS in anticipation of the arrival and approach. I had plenty of time to do that at cruise—and just as I was about make a menu selection on the FMS, I realized that I was violating SOP. It was a pure proficiency mistake; I stopped and regained my focus on the climb, and I debriefed the occurrence with my First Officer after shutdown at our destination. Again, I’m reminded of Kasparov’s words:
“I could make all sorts of mistakes in my daily life, but in chess it was always: Concentrate, work, stay on top of your game. Because we all get complacent. I call it, the ‘gravity of past success.’”
Think about it.
Until our next post, fly safe, and always, fly first.
*Hughes, K.L. & Godley, S.T. (2011). Take-off performance calculation and entry errors: A global perspective. (Research and Analysis Report AR-2009-052). Australian Transport Safety Bureau: Canberra.
†Berman, B.A, Dismukes, R.K. & Jobe, K.K. (2012). Performance Errors in Air Carrier Operations: Causes and Countermeasures. (NASA/TM-2012-216007). Ames Research Center: Moffet Field, California
††Garry Kasparov as interviewed by Maximillian Potter in Esquire Magazine, June-July 2017