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Why Didn’t We Listen?

Article appeared in Flying Magazine February, 2014 by Martha King – Most pilots who have been flying for awhile know pilots who scare them. My husband, John, and I were two of those pilots. We were so wrapped up in using our airplane as a personal, fun, travelling machine that we wouldn’t let anything—inexperience, nighttime, bad weather, even a rough-running engine—get in our way. We had one close call after another until we had our inevitable accident.

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It’s not like well-meaning pilots didn’t try to counsel us—like the guy in Albuquerque who suggested to us that rather than taking off for a night trip over the mountains in a snowstorm, it might be wiser to wait until the morning. Or the multiple pilots, including John’s uncle, who felt we should have more time before we moved from our Cherokee to the higher-powered and complex Comanche, or that at least we should get some more time in it before we set off on a one-day trip from California to Indiana. In each case we not only ignored them, we were offended. What seemed to annoy us was that they told us what we were doing wasn’t “safe.” They even said that we were exercising poor “decision-making” and “judgment.”

The interesting thing is that these pilots were right. What we were doing, in fact, wasn’t wise. But why didn’t we listen? I think the answer is that as well-meaning as these pilots were, they didn’t use a vocabulary that would evoke a positive result from us.

For instance, even the word “safe,” which is of course is used by nearly everybody, didn’t get a good reaction from us. We had been following our pattern of behavior for some time and had not had an accident. We saw the interference from other people as disapproval and an attempt to stop us from doing what we wanted to do.

The problem with the word “safe” is that it is an absolute. According to Merriam-Webster, the word “safe” means “free from harm or risk.” Well, nothing in aviation is free from harm or risk. You can’t start an engine without risk, and you certainly can’t take off without risk. So our reaction was, if your goal is to be “safe” you can’t do anything. We considered talk about safety as being pompous and prissy. Talk about safety certainly didn’t get anywhere with us.

We were equally unaccepting of talk about “decision-making” and “judgment.” We were blessed with fine self-images, and considered ourselves successful business people. We weren’t willing to entertain any thought that we weren’t good at decision-making or didn’t have good judgment.

So what would have gotten a good response from us? I am not sure anything would have. But using a different vocabulary might have helped. If the people who were concerned about us had said something like, “There are risks in everything you do in aviation, but the key to consistently successful outcomes is managing those risks,” this might have resonated with us. We, like everyone else, knew we were taking risks. We just thought we could get away with them. We just weren’t good yet at identifying all the risks, assessing them, and coming up with a mitigation strategy.

The reason we weren’t good at risk management is that we hadn’t been taught to do it. The way we learned risk management is that, like many other pilots, we got our certificates and then went out and tried stuff. If we got away with something, we put that into the acceptable category. The more times we got away with it the more acceptable it became. In fact, we may have just been lucky.

On the other hand, if we tried something and scared ourselves we’d say, “Wow, we’ll never do that again,” and we’d place that on our growing list of things we’d decided we’d never do again. That’s what is known as learning by experience. But experience is a hard teacher. She gives the test first, and the lesson comes afterward. We were very fortunate to have survived the tests so far in order to get the lessons.

So how could we have been taught differently? Well, some schools and instructors are training pilots how to manage risks by incorporating a risk-management exercise in every pre-flight briefing. They set aside a little time with the learning pilot to have a discussion in which they together identify the potential risks of the up-coming flight. Some risks are obvious to a learning pilot, but some are not.

For example, if the lesson is to be ground reference maneuvers, an instructor might help the learning pilot identify the insidious and counter-intuitive risk of flying too fast while trying to maneuver around a point on the ground. The higher speed requires steeper bank angles to stay near the point, and the increased load factor increases the stall speed.

Once a risk is identified the instructor might help the learning pilot assess the probabilities and consequences of harm caused by the risk. In the case of high load factor while maneuvering, the instructor could point out that stall/spin accidents while maneuvering are the most common type of fatal accidents.

The instructor and learning pilot could then discuss mitigation strategies, including selecting a reasonable speed during the maneuvers and a maximum bank angle.

A pilot who has gone through a similar risk-management exercise on every training flight stands a much higher chance of having a habit of practicing good risk management after they are out flying on their own. If John and I had been trained this way, and then been approached by a concerned pilot who used this same vocabulary with us, we most likely would have been much more accepting of their input.

So, based on John’s and my experience, I think we in the aviation community can do a far better job of thinking about risk and expressing ourselves. I suggest that we need to change our vocabulary, including banning the words “safe” and “safety”—for two reasons. First, when we use them we usually don’t mean them. And second, they don’t give us any guidance.

We say things like, “Safety is our number one priority.” If safety were our number one priority, we’d never fly. Or we say, “We will never compromise safety.” Getting into any moving vehicle, especially an airplane, is a compromise with safety. Absolute safety is unattainable. So when we say these things they cannot literally be true.

All of this clichéd talk about “safety” comes across as insincere hypocrisy. Plus, it is bad management, because we are setting unattainable goals. Telling someone to have a “safe” trip is a nice, courteous expression of good will, but it is lousy advice. It is literally impossible, and gives no advice that can be acted on. Better advice would be to suggest doing a good job of managing the risks of their flight.

Of course, the other two words that were used with us that I believe were not helpful were “judgment” and “decision-making.” Although they refer to components of risk management, I don’t think using these terms will be helpful with other pilots either.

The reason is that I believe these words will not be well received by the recipient, and are not likely to produce positive results. Aviation tends to attract competent, achieving individuals who naturally believe they already employ good judgment and decision-making. They are unlikely to pay heed to an (often younger) instructor who tells them they will teach them “judgment” and “decision-making.” Their reaction is more likely to be, “I don’t think so, kid.” Additionally, the term “decision-making” tends to imply that you get to a fork in the road and make a decision. I would like to see us be far more proactive than that, and anticipate that fork before we ever get there.

Well, you might say, if you don’t like the terms “safe,” “safety,” “judgment,” and “decision-making,” what can we say? I like focusing on “risk management” because it describes the process necessary to get good results. Risk management involves anticipating risks, assessing them, and developing an ongoing strategy for mitigating them. And that is exactly what we need to do to get better outcomes.

When we have converted the culture of our aviation community to focusing on risk management, pilots won’t have to gain their seasoning by putting themselves repeatedly at risk, and accumulating a long list of things they won’t ever do again—like John and I did.

26 Comments

  1. Reo Pratt

    I agree that the term “Risk Management” is better than “decision making” and other terms that have attempted to make aviation safety over the years. I would suggest that every pilot read and study what has been called “the shortest piece of FAA legislation every written” which is also the most effective piece of aviation legislation ever written. It is 14 CFR Part 5, the FAR passed in 2015 that required all FAR 121 airlines to develop a Safety Management System by 2018. While it applies only to 121 operators, the fundamental principles of risk management that it is intended to inculcate in an airline’s business model provide the CFI with perspective.

  2. Andrew Walker

    I have often wondered why we tell each other “Have a safe flight!” Or “Have a safe trip!” It always seemed like an empty pleasantry to me.. and now I know it is! Haha.. But nonetheless, great article on thinking about these words we throw around so much. And great way to challenge us into using different communication to help each other.. definitely something I want to incorporate.

    • William Blatter

      I couldn’t agree more with Martha’s position and have often viewed the declared obsession with ‘safety’ as an avocation-wide delusion. There is nothing ‘safe’ about getting into a tin can and flying it five miles above the earth. We fly because it is convenient, time-efficient and fun: that is, because it is useful and enjoyable (collectively, ‘utility’). Notice who didn’t make the cut – ‘safe’ and ‘economical’ (no one flies to save money, either).

      I would like to see not only the instructional paradigm (as argued by Martha), but also the operational paradigm as set forth in the FARs, modified to reflect and address this reality. While flying is a balance between utility and risk, the FARs often downplay or outright ignore the actual reason we fly (utility) as a significant operational consideration. For example, a quick but careful examination of online weather charts, notams and TFRs by a 500-hour pilot in a familiar aircraft to to a familiar airport within 50 miles of the home field on a VFR day is more than sufficient to acquire the information necessary to manage risk effectively. The regulatory mandate of a 20-minute standard briefing in this context whose only ‘benefit’ is to barrage the pilot with surplus information of no utility (NDB outages, MDA changes for VFR operations, etc.) compromises utility and wastes pilot resources with no appreciable risk management benefit. (How many lengthy briefings have led to daydreams?) The extent and content of a required briefing should be subject to limiting parameters in order to increase utility, foster risk management, and do away with this waste..

      Another example of a regulation disconnected from risk management reality is the requirement of the venerable wet compass. In the era of GPS and ADS-B, does such antiquated equipment have any utility at all? Would its removal not actually be consistent with risk management by eliminating a useless distraction? (When was the last time you had yours spun?)

      I am hopeful that Martha’s sensible change in focus regarding instruction can be transmuted to actual flight operations..

      • Lou Toth

        Hi William,
        I agree on the ‘Saturation Method Brief’ as being counter productive for a short local flight or flight lessons. I also agree with the non-utility of the ‘Wet Compass’ and is why my experimental does not have one (Not Required). But I do have a more accurate flux valve feeding my iEFIS, an iPad and phone backup with Foreflight, and a GNSS fed compass on my phone to ‘mitigate risk’ in case the primary and backup battery, or the iEFIS were to fail…..Of course one could just look out the window….. D’0h?

  3. James M Barnes

    As a Forestry Airtanker Pilot for more than 30 years I have had several close calls. Almost all of them were because of faulty risk management or loss of situational awareness which is also a vital part of risk management. In the later part of my career I instructed tanker pilot trainees on actual fires. My greatest strength as an Instructor was that I had somehow survived all the mistakes caused by bad judgment and rogue pilot behavior so that I could recognize and correct that bad behavior right at the beginning of tanker training. Fostering a good attitude about mitigating risk right from the beginning of the preflight became my highest priority. Screening students according to their willingness to accept their responsibility to perform a risk management inventory by briefing and debriefing before and after every flight was essential to them succeeding in training and becoming a responsible and effective Airtanker Pilot.

  4. Christopher Dale Bleakney

    I too have had an accident in an airplane. I am not proud of it and, although it was my fault, I had some help along the way. How could I have prevented the accident; better risk management. In addition to SAFE or IMSAFE, I used a simple algorithm. 4 scenarios are involved in every flight: day/night, IFR/VFR, Mountains or Water/Flat Land, and Single Engine/Multi-Engine. When I had my first accident, I had accepted the risk of the worst of all 4. I was night, IFR, SE, Mountains and lost an engine. I was very fortunate to have my passengers and me survive with very minor injuries. At first I changed and I said I would accept 3 of the 4, now I only accept 2 of the 4. If anyone reads this and wants to provide feedback, I will welcome it.

  5. John A Bartholomew

    This is my second time renewing by FIRC and enjoying your course. I can give you a for real life risk management scenario. My late wife was in surgery for infection. The bottle on the gurney was CO2 and not oxygen so she went into an arrhythmia and later coma and died 4 days later. I didn’t sue and they put me on this board to improve procedures. The Institute of Aviation Research in Wichita, Kansas came up with the idea to use checklist to reduce risk. If you look you will find 2 books have been written about use of checklist in the hospital and most hospitals are using checklist today. This happened in 2011 and our efforts didn’t do much for my situation but maybe somebody has survived some surgery with this information.

  6. David Bloomquist

    Great article, ESPECIALLY since it was written during the Ice-Age! (ok, but 6+ years is a long time ago – time does fly and i think “time” is 100% safe – unless a black hole appears). Anyway, I am in the Coast Guard Aux Air and since we are fanatical about “risk” I wonder if I can share your article with the group?

    Thanks in advance

  7. Mary Ann Serian

    I work as an anesthetist and as you might imagine, having an anesthetic is full of risk and the term risk management is very familiar to me. I am happy to see this terminology used in aviation as well because a safe flight is full of risk management. Bravo Martha

  8. Ed Kennedy

    Great article. Jimmy Doolittle called it “Calculated Risk.” My airline uses an RRM (Risk Reduction Model) decision loop. Very effective.

  9. Bob Kilmer

    I have been instructing since 1964 and it is easy to get tired of the same old thing. Thank you
    for your course that can make things new again. I want to train my students the best I can and
    being current sure helps! “THANKS”

  10. Dennis

    I have been flying since 1965but spend my working day in Risk Management worls as a director of safety where I see too many accidents every day!. Your comments are causing me to rethink how I talk about safety, judgment, etc.

  11. Dave B

    Hello Martha,

    Thank you to you and John for a FIRC that’s well thought out and for a safety message that is well timed.

  12. LOU

    Hi John and Martha,

    I am presently taking your FIRC, just read your article and you are absolutely correct. I emphasize to my students that we have 100% risks in flying, so I make it my goal to eliminate or reduce the risks before during and after all of our flights.
    Gota get back to your online course.

    Thanks
    Lou DiVentura CFI
    http://www.CFILOU.INFO

  13. Mike

    Dear John and Martha,

    I am back! In 1986 I started my Private Pilot training with you sitting an a cold hangar watching your courses after high school.

    Now, as a 10,000+ hour pilot and Check Airman with an Air Carrier I am back with you to refresh my CFI knowledge and continue to aspire to be the best.

    Half way through the first lesson I am excited that I have decided to continue my training with you as the program is excellent!

    I will see you soon for the helicopter course.

    Thank you,

    Mike

    • Pilot One

      Thank you for the kind words and comments. We are so very grateful you continue to choose King Schools.

  14. Joe

    Wow! Well written article Martha. We have been spewing the “safety” rhetoric without real thought. Awesome clarification, my teaching ability has just improved.

  15. Gary

    Very nice article, Martha. I always take my FIRC with you!

    When I instructed full time back “when”. I always taught Risk Management even though it was not required back then.

    I would start Risk Awareness in the first lesson with the gunfight at the OK Corral scenario from the biography of Wyatt Earp.

    “We all had our guns out. Billy Clanton had his pointed straight at my heart and I had mine pointed straight at Frank Mclaury, who I felt was the best shot and most dangerous man in the group. We all fired at once.”

    As pilots we face multiple risks at any given time and must effectively identify and prioritize them as calmly as an experienced gunfighter.

  16. Austin Crumley

    As I renew my CFI for the first time and prepare for teaching new CFI applicants the FOIs and best practices of instruction, I appreciate your perspective. I am also the lead instructor at my school, so I also must manage, and positively influence, junior instructors as well as all our students.

    I think you’ve hit on a great approach to the safety topic. People want to know the “so what” of every theoretical topic we discuss in our training, and safety is no different. Given your advice, I will use that approach to give my students a practical, “so what” approach to recognizing and managing risk.

  17. Dave Hook

    You’re spot-on, Martha! I look back on my flying training in the 1970’s–taught and evaluated by very good and competent instructors of the time–and am amazed that I haven’t yet bought the farm. The risk management culture in general aviation has evolved over time, but needs to be seen as an ever-evolving culture. Keeping our student’s out of aviation’s Darwin Awards is our responsibility as instructors.

  18. Richard Onysko

    When I was at Embry Riddle, one of the professors defined the word safety as meaning “the freedom from unacceptable risk”. It made sense to me at the time and I remembered it. That’s how I’ve been defining it to students since then. Presently, I’m an instructor at FlightSafety in San Antonio teaching the CE650. Our local POI can renew our certificates based on duties and responsibilities, but I haven’t taken a real FIRC in awhile and I thought I’d try your course! Very nice!

    • Pete Sachs

      Same here,my POI would sign me off as well.
      I used King the last time as I didn’t want to bother her.
      Learned a lot of stuff that I forgot or just couldn’t remember.
      Doing it again this year before I go in for my company LOFT

      • Reo Pratt

        Excellent thoughts on what safety really means, and a suggested path for the GA community. I spent three years teaching SMS – Safety Management Systems – to the leadership of FAR 121 airlines and large 135 operators. I suggest that every flight instructor’s understanding of risk management could be enhanced by a study of 14 CFR part 5. Although it’s applicable only to 121 airlines, it efficiently and compactly codifies risk management.

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