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How common are mistakes made by professional airline pilots?

Mistakes are kind of a difficult thing to define and capture and correct. Most pilots make a lot of them, me included. We put some incorrect number into a display, go to the wrong radio frequency, say something in the incorrect format, misread a map or chart. It’s very easy to do.

Fortunately, the system is very, very robust and almost all the time, we notice it before it can become a safety issue. It takes a rather unique situation where lots of things align and the pilots get the wrong idea and follow it. The main issue is “confirmation bias” or the tendency of pilots to form a theory of what’s going on and accept information that supports it and disregard information that doesn’t. We are constantly reminded to be sure to test our assumption and working theory. It seems very reasonable and logical but it’s pretty hard to practice when you’re a little confused and a lot of information is being processed.

There are lots of mistakes and lots of way to combat them. I’m just going to take a small bite at a couple that I find interesting.

We sometimes have a person who sits in the jumpseat and watches us fly. They are not instructors or regulators but auditors. They list all the mistakes and corrections made during a flight and always seem to be writing and turning pages on their clipboards during the flight. They don’t grade us or give us feedback, they just quietly sit and write. It’s a little unnerving at first but after awhile, you forget they’re there.

These folks write down every time we put in the wrong frequency in a radio or turn our heading bugs improperly, even if we fix it a second later. They notice if we missed one of the landing lights or talk below 10,000 feet or miss a radio call. If we read back a clearance incorrectly and the controller corrects us, it’s noted. Just about anything that happens that isn’t perfect is noted. They also look for “non-standard” actions like using the wrong word for something. I’ve heard people say “gens” instead of “generators” on a checklist and that would be noted.

These are all studied and statistically analyzed to help the airline predict potential safety problems and to decide on the training emphasis in the next year. This is a serious attempt to prevent our usual way of improving our performance and safety using “tombstone engineering”. That is, waiting until we kill someone to look into what is wrong with our operation. The airline will be a lot better off by investing in continuous study than having an accident. They have had some success in finding issues but we’ll never know if they prevented an accident. I really appreciate that the big airlines share this information with their hated competitors. It must be very difficult for them to pay a lot for this information and give it away. The industry really collaborates on safety.

It turns out that bad habits creep into an operation without anyone noticing and becomes the “normal way we do it”. Since nobody studies these methods and thinks through the consequences, it can be a terrible threat. The auditors are there to capture our behavior and note anything that’s not “by the book”.

They call these “norms” and they’re little shortcuts we make that seem to be meaningless but could be a killer. In our 737 there are three hat clips. The captain always puts it on the top clip and the copilot on the lower left and anyone else on the right. It’s a norm that doesn’t matter. Some are more ominous. We can develop a non-standard phraseology that can lead to non-trivial misunderstandings which are hard to untangle under pressure (Think KLM, PAN AM accident in the Canary Islands). Using a non-standard procedure that seems to save time is often a source of problems. In my own life, I flew overwater 727s long ago and the procedure was for both pilots to laboriously enter latitude and longitude of each waypoint into the two navigation systems. But often, one pilot would enter the data and then cross-load it to the other nav system. It saved a lot of time. They justified this by having the other pilot check the entries. The problem is, that checking long lists of numbers isn’t nearly as thorough so mistakes would be made with potentially serious consequences. Luckily, a couple of flights had airplanes that made sharp turns on a straight planned course and it was discovered that numbers were entered incorrectly. It was an easy fix for the flights involved but it showed that it wasn’t a good procedure and it could have terrible consequences.

This looks a little like the Omega box but not quite.

These are the exciting hat clips on a 737!

There is another safety system called FOQA, it stands for Flight Operations Quality Assurance. The airline has access to a lot of data on how the flights are operated. I don’t know all the parameters but it’s a lot. I was sitting at the gate after a flight one day and writing up the flaps for sticking at an intermediate position on landing. I was trying to remember the details when a mechanic walked in and told me we selected flaps 25 at 1400 feet and at 210 knots indicated and 3 minutes from touchdown. I realized then that lying in the logbook wasn’t advisable.

Here’s an example of how that data is used. Last year, all the 737 pilots got a safety memo which explained that the 737 fleet was doing fewer go arounds than all the other fleets by a significant margin. They went on to say that our fleet had about the same number of unstabilized approaches as the other fleets. (An unstabilized approach means that we don’t have the gear and flaps extended and the speed near Vref at 1000 feet. It means we are a behind the airplane.) So the memo went on to say that we should be doing more go arounds and that they were closely monitoring the fleet for compliance with FAA and company policy. They don’t use the data for a particular pilot unless it’s really an egregious issue. In that case, they get the Union involved and there is a procedure to take corrective action. The system is very good at detecting trends in our data and problems with how we’re operating and improves safety quite a lot.

That brings us to mistakes and how to manage them and make fewer of them.

I think I make about a hundred small mistakes on every flight. It’s important for me to have the right attitude about mistakes. I don’t punish myself but instead almost celebrate that I made an error and caught it. I try to do the same for the copilot. If she messed something up, I don’t ever criticise but make the observation that we both learned from it and now two people won’t do it again. It could happen to anybody. This may seem like I’m minimizing a possibly important problem but I’ve observed over the years that it’s the best way to proceed.

I learned very early in my airline career that moving on is a very, very important skill. I had a couple of bad simulator sessions where I made a silly mistake early in the session and because I couldn’t let it go, I got uptight and started making more and more mistakes and getting more and more agitated. I really presented myself as a poor pilot to the instructors. One took me aside and said I had, had, had to accept the error, tell myself I learned from it and move on with a clean conscience. He said that being a perfectionist is a weakness. He said I had to learn to work hard on accuracy and accept mistakes with ease. That’s why they pay for two people in the cockpit. People are not infallible. It’s not the mistake that’s important, it’s the recovery.

It was a very important message and I couldn’t change overnight but I did work on it and I’m better now, not perfect, but better. I still want to flog myself when I do something embarrassing in the simulator, I try to resist the urge.

That goes for the real airplane as well. I have flown with more than a few captains that would remember some mistake and bring it up over and over. It made me jumpy and emotional and a less effective pilot. In our cockpit today, I know that when a copilot makes it into a major airline, they are already experts and they wouldn’t be here if they didn’t demand a lot from themselves. If I jump down their throats, it won’t make anything better. I know they’re going to be hard enough on themselves so there’s no reason for me to pile on more pressure. Far better for me to observe the error, and maybe tell a story about an error I made that was more serious. I need them to perform at their best and they can’t be their best if they’re wallowing around in the past about something that’s no longer germain. I need them too much in the present.

I don’t want to minimize the importance of mistakes but they need to be put behind us in order to be good pilots in the present and future. There is going to be lots of time after the flight to ponder what happened and talk about it.

So we, as pilots, need to accept that we will be making mistakes on our next flight and think about how we’ll react when we do. We need to be vigilant and open minded and gentle with ourselves and our crew in order to prevent our performance from deteriorating because of them. It’s counterintuitive but we need to minimize our concern about our mistakes in order to make fewer of them.

Edit 1: I want to add here that if am able to accept mistakes without judgement and demonstrate that behavior to the crew, the crew will be more likely to speak up and tell me that something isn’t right or challenge me and make me justify a decision or my perception of our situation. If I can convince the crew that I accept my humanity and am not angered by mistakes, they’ll be willing to communicate clearly and even bluntly with me when they need to. I need them to do it because it makes the flight about 100 times safer!

Did I answer the original question?

Common mistakes? Lots of little things but usually not something really big. We are pretty well trained to keep the airplane upright and have a good idea of where we are and where the terrain is in relation. The errors are usually caught pretty quickly and corrected. As an industry and individuals, we study our errors and try to very hard to learn their lessons.

Sometimes, I get into a mood and write way too much. Thanks for slogging through all of this!


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