Article appeared in Flying Magazine December, 2014 by Martha King –
Maybe, someday, at the end of a flight I will be able to say, “My performance as a pilot was perfect on that flight. I didn’t make a single mistake.” So far I have never come close. My performance (and John’s) on a recent flight is a great example. It was time for us to fly just to keep current. We hadn’t been able to fly our old Falcon 10 for nearly a month. That’s a long time for us, because things move fast in that airplane and we get rusty pretty quickly.
So we decided on a flight from our San Diego home base at Montgomery Field to San Luis Obispo in central California. The Falcon 10 requires two pilots, so this would be a proficiency flight for both of us and a chance to hone our crew coordination. I would be captain on this leg and John would be co-pilot.
On the flight a series of little mistakes confirmed we indeed were rusty. During our cockpit checks we failed to notice that our pressurization system had somehow been turned off. John caught the failure to pressurize right after take-off. While dealing with the failure to pressurize, he was also handling ATC communications. When we were cleared to Flight Level 230 (23,000 feet), John put 13,000 feet in the altitude alerter instead because he didn’t want us to go any higher until he had the pressurization problem resolved. He quickly got the pressurization turned on.
Then, as I leveled off at 13,000, neither one of us could remember for sure what altitude we were actually assigned. John asked ATC to confirm our assigned altitude, and was told it was Flight Level 230. He put the assigned altitude in the alerter, and I immediately climbed to it. This wasn’t an altitude bust since we were cleared all the way up to Fight Level 230, and we only lingered briefly at 13,000. No harm, no foul, but still—it wasn’t perfect.
Next, we were cleared direct to a fix. Our standard procedure is for the captain to aim the airplane towards the fix immediately, while the copilot enters the fix in our flight plan on the GPS. We did all that, but then I forgot to select “nav” on the autopilot. When we saw the course deviation needle begin to move off to the side we caught the error and corrected it. Once again, no harm, no foul, but it wasn’t perfect.
On the other hand we didn’t mess everything up on the flight. San Luis Obispo had two approaches that we might use, so we briefed them both. Due to the low weather we expected the ILS, which would have us fly past the airport and then reverse course to intercept the final approach course. An improvement in the weather allowed ATC to assign us a non-precision GPS approach that let us fly directly to the airport from our present position.
This meant we were now high and fast with precious little time to get everything set up and get down and slowed down in time. We calculated our top of descent point, and the rate of descent we needed. As a result we made each fix at the proper altitude and at an appropriate speed, with John calling out the next altitude to descend to, and setting it into the alerter.
The best news is that we made a beautiful landing and the flight would have been judged perfect by passengers, who would have never known about the series of little mistakes leading up to the landing.
In spite of the good crew resource management we used on our descent, not trapping our earlier errors right off demonstrated a failure in our crew resource management. The idea behind a two-crew aircraft is to implement procedures that allow the other crewmember to catch errors. An example is when John set the altitude in the alerter. Under normal circumstances, I as the captain am supposed to verify that the altitude he set in is correct and announce that I am going to that altitude. With the pressurization problem I should have backed him up and made sure we remembered the assigned altitude. To our credit, John did quickly get the pressurization turned on and I flew the airplane well and without busting a clearance.
This illustrates that errors tend to cascade. The distraction caused by not having the pressurization turned on most likely resulted in both of us forgetting the assigned altitude. Those two errors probably rattled us enough to cause us to fail to set the autopilot to “nav”.
Our less-than-perfect performance did indeed verify we needed the currency, but it also might have shown that we were actually pretty good at catching and correcting mistakes before they became more serious problems.
Years ago we attended an aviation psychology symposium at The Ohio State University. One of the take-a-ways we got from the symposium is that experts make nearly as many mistakes as novices. Experts are just far better at catching and recovering from them. After all, experts become experts because they have made a lot of mistakes, and have gotten good at catching and recovering from them. If having made a lot of mistakes qualifies someone as an expert, then is it obvious that John and I qualify.
But not all mistakes are created equal. When pilots think about mistakes, they often think about skill mistakes—a bounced landing or failing to add right rudder on takeoff.
Other mistakes are procedural mistakes like the ones John and I made flying to San Luis Obispo—not catching that the pressurization had been turned off, forgetting our assigned altitude, and failing to select “nav” on the autopilot.
Although all mistakes are serious, the most serious mistakes are situational mistakes—putting yourself into a risky situation. The problem with situational risks is that they are often not intuitive. It takes knowledge to know that evaporating moisture and the associated cooling in virga creates a strong downdraft underneath, or that a ring of dust on the ground is a sign of a microburst and another strong downdraft. It also takes knowledge to know that flying in visible moisture at temperatures below freezing can result in an accumulation of hazardous ice on the aircraft.
Once, John and I took off on an IFR flight in a Cherokee 140 in the clouds from Twin Falls in Idaho. When we found ourselves really struggling to gain altitude, we returned to Twin Falls to try and figure out what the problem was. We discovered the airway we had selected was on the downwind side of a ridge and in a continuous downdraft. When we picked an airway on the upwind side of the ridge, we had no problem at all. This was a novice’s mistake, made because we simply didn’t have the knowledge and experience to consider the effect of a mountain ridge off to the side of our route on an IFR flight.
Novices are least equipped to catch situational mistakes, yet these are the type of mistakes that often have the most severe consequences. The reason we are given a knowledge test as pilots is so that we will learn the knowledge to be aware of risks and risky situations, and know how to mitigate them. Unfortunately, in the past the FAA’s knowledge tests have not focused well on the type of knowledge that will help pilots manage situational risks. There is hope for the future, however, because the new Airman Certification Standards (ACS), soon to be implemented by the FAA, will replace the Practical Test Standards (PTS). The ACS will provide standards for the knowledge a pilot is expected to know, and will also require pilots to demonstrate their ability to mitigate these kinds of risks.
I am still hoping that one day I can say I made that perfect, mistake-free flight. As time goes on it seems less and less likely. But the reality is, even if I do feel someday that I can say it, I will probably be deceiving myself. Which is both scary and dangerous. It is far worse to make an imperfect flight and think it was perfect, than to make an imperfect flight and know it was imperfect.
So maybe I can just console myself that my being aware of my mistakes is a sign of expertise. In fact, that’s my story and I’m sticking to it.