“Knowledge is a commodity to be shared. For knowledge to pay dividends, it should not remain the monopoly of the selected few” ~ Moutasem Algharati
By: Ryan Van Haren
Tell me about the last time you had a perfect flight. Please, take your time, I’ll sit here and wait. Chances are you’ll have a tough time recalling one. Why? Because flying is the ultimate combination of art and science, neither of which can be perfected. Now ask yourself, how did great artists learn to be great, and how did the great scientists become great. The answer is that they studied and learned from those that came before them. They learned from their colleagues’ successes and failures.
How many of you have picked up the latest issue of FLYING Magazine and skipped right to the regular column called WHAT I LEARNED ABOUT FLYING FROM THAT? I don’t need to tell you because you already know that it is usually in the back quarter of the magazine and shares stories submitted by pilots recounting their most frightening and vulnerable moments in an airplane in hopes that others may also learn. This monthly column is basically the aviation equivalent of the centerfold spread whether you want to admit it or not. Now ask yourself two more questions. Why did you skip straight to the article where pilots tell all? and Would you have the courage to share your mistakes? Chances are you went straight for that article because it put you in the airplane experiencing what that pilot experienced, you were able to learn something about that pilot’s decision making process and you put the magazine down thinking, wow I’m never going to make that mistake!
As pilots we all strive to be safe, and to make good decisions. Good decisions are the result of experience and experience comes from having made mistakes or having learned from the mistakes of others. I recently read a book called The Pathless Way by Justin de Goutiere. This book was published in the 1960s and recounts the stories of a floatplane pilot working on the British Columbia coast. As I was reading in disbelief at some of the risks that were taken and tales that were told I took a moment and realized that at the time this book was published, “bush pilots” and “bush planes” had only really been a thing for twenty years. This pilot never had access to the resources that we enjoy today. No GPS, no Facebook Community to ask questions of or share experiences with, no Google, no satellite imagery or GFAs and certainly no safety management systems. He truly had to make his mistakes in order to learn and gain experience or glean what he could during limited face to face hangar flying with other pilots. I suppose that is what separates aviation pioneers from modern day pilots. Aviation pioneers had to learn the hard way while modern day pilots only have to learn the hard way if they are either unwilling to listen or unwilling to share their mistakes with others.
As pilots we all make mistakes. Let’s chalk it up to being more human than pilot. It is what we do with these mistakes that matter. In Commercial Aviation we have Safety Management Systems or SMS where pilots are required to self report safety concerns or errors be they minor or major. In Air Traffic Control the term used is Just Culture. It is a system where Air Traffic Controllers must self-report their errors. In both the SMS and Just Culture system reports are meant to be non-punitive unless gross negligence is involved. The idea being that by self-reporting, sharing mistakes and identifying the root cause others may learn and avoid making the same error.
The key here is to identify the cause and contributing factors of the mistake not to assign blame. When looking for a root cause one of the methods is the PETE model in which the following categories are examined:
P-erson
E-nvironment
T-echnology
E-xternal factors.
Why is it important to identify a cause rather than find a person to blame? If we want pilots to share their mistakes and lessons openly, the last thing we should be doing is starting a witch hunt or making them feel like they are being prosecuted for making a mistake. The very thing that differentiates a mistake from a malicious act is whether or not it was intentional. When a pilot or any human feels threatened or fears prosecution, they are more likely to cover up the mistake which can lead to much worse problems down the road, especially in aviation.
Case Study:
Tom arrives at the airport to take his flying club’s Cessna 152 out for a flight. His plan was to fly to a local airport for lunch. As he was pulling the aircraft out of the hangar his wife called. He finished pulling the aircraft out with the tow bar in one hand and his cell phone in the other. The conversation gets a bit heated and he paces around the aircraft a few times before getting in and starting the engine. The engine starts normally, all the gauges are green. He advances the throttle to begin taxiing and as the aircraft starts rolling, he hears a loud “PRANG!!” and sees the red handle of the aluminum towbar go airborne and land next to the hangars. Tom immediately shuts the aircraft down and inspects the propeller only to find that there is a small nick with a tiny fleck of red paint. What does Tom do?
The answer is quite simple right! Or is it?
It really depends on the culture at Tom’s flying club. If the culture is one that promotes learning and education and if Tom feels comfortable sharing his mistake, then he will report the prop-strike and educate his fellow club members about the dangers of using a cell phone while pre-flighting an aircraft. The other members might poke some good-natured fun at him, but everyone will have learned a valuable lesson. The odds of a repeat of this experience with anyone from the club is very low. Tom will report the damage, an AME will inspect it and chances are the aircraft will be returned to service.
If Tom’s club has a culture of finger pointing, finding people to blame, looking for reasons to suspend one’s flying privileges or just a general atmosphere of distrust and aversion to learning then there is a very good chance that Tom, fearing repercussions and ostracization will find a rag, buff out the fleck of red paint and say nothing to the club in order to save face and keep his pride intact. Tom will push the plane back into the hangar and for the next nine months other members will fly it with no knowledge of the prop strike. When the aircraft goes in for annual the AME will find a small crack that has grown since the incident which had it been dressed immediately would have been no problem. Upon learning of the crack at the club the members find themselves in a feeding frenzy of distrust pointing fingers at one another trying to find a person to blame while Tom’s conscience weighs heavily in the back row.
Whether new or experienced, pilots have the opportunity to continuously learn from others as well as educate their peers by sharing their experiences and listening without judgement to the experiences of others. I took off in my aircraft this past June without my cowl being done up. The right half of my cowl departed the aircraft and went through my flap. It ended in a prompt landing and a rather large bill from the structures shop. That said, I can tell you using the PETE model exactly how it happened. I shared it openly and am still reminded by others constantly as they make jokes and poke harmless fun. I am glad that they make jokes because every joke made is a reminder to everyone to not make the same mistake that I did. Even highly experienced airline and military pilots are not immune to the odd screw up. About 10 years ago, an Air Canada flight came very close to landing in Vernon thinking that they were on final to Kelowna. Several years later, a military C17 heavy transport landed at a small general aviation airport in Florida next to the actual Air Force Base that they were meant to land at only to have to unload to be light enough to get back out. Mistakes Happen!
We are a community, we are human, and we make mistakes. By keeping our mistakes to ourselves or persecuting others for theirs we do our entire community of aviators a disservice. I challenge each and every person that reads this to take an opportunity to share a mistake that they have made with someone. The more we normalize sharing of errors and mistakes the more we can learn from one another and hopefully reduce the repetition of unfortunate events in the future.
Speaking of learning from mistakes, using the binder containing your journey log and aircraft documents as a temporary chock behind the main wheel isn’t a great idea. Don’t ask how I know!
Tell me about the last time you had a perfect flight. Please, take your time, I’ll sit here and wait. Chances are you’ll have a tough time recalling one. Why? Because flying is the ultimate combination of art and science, neither of which can be perfected. Now ask yourself, how did great artists learn to be great, and how did the great scientists become great. The answer is that they studied and learned from those that came before them. They learned from their colleagues’ successes and failures.
How many of you have picked up the latest issue of FLYING Magazine and skipped right to the regular column called WHAT I LEARNED ABOUT FLYING FROM THAT? I don’t need to tell you because you already know that it is usually in the back quarter of the magazine and shares stories submitted by pilots recounting their most frightening and vulnerable moments in an airplane in hopes that others may also learn. This monthly column is basically the aviation equivalent of the centerfold spread whether you want to admit it or not. Now ask yourself two more questions. Why did you skip straight to the article where pilots tell all? and Would you have the courage to share your mistakes? Chances are you went straight for that article because it put you in the airplane experiencing what that pilot experienced, you were able to learn something about that pilot’s decision making process and you put the magazine down thinking, wow I’m never going to make that mistake!
As pilots we all strive to be safe, and to make good decisions. Good decisions are the result of experience and experience comes from having made mistakes or having learned from the mistakes of others. I recently read a book called The Pathless Way by Justin de Goutiere. This book was published in the 1960s and recounts the stories of a floatplane pilot working on the British Columbia coast. As I was reading in disbelief at some of the risks that were taken and tales that were told I took a moment and realized that at the time this book was published, “bush pilots” and “bush planes” had only really been a thing for twenty years. This pilot never had access to the resources that we enjoy today. No GPS, no Facebook Community to ask questions of or share experiences with, no Google, no satellite imagery or GFAs and certainly no safety management systems. He truly had to make his mistakes in order to learn and gain experience or glean what he could during limited face to face hangar flying with other pilots. I suppose that is what separates aviation pioneers from modern day pilots. Aviation pioneers had to learn the hard way while modern day pilots only have to learn the hard way if they are either unwilling to listen or unwilling to share their mistakes with others.
As pilots we all make mistakes. Let’s chalk it up to being more human than pilot. It is what we do with these mistakes that matter. In Commercial Aviation we have Safety Management Systems or SMS where pilots are required to self report safety concerns or errors be they minor or major. In Air Traffic Control the term used is Just Culture. It is a system where Air Traffic Controllers must self-report their errors. In both the SMS and Just Culture system reports are meant to be non-punitive unless gross negligence is involved. The idea being that by self-reporting, sharing mistakes and identifying the root cause others may learn and avoid making the same error.
The key here is to identify the cause and contributing factors of the mistake not to assign blame. When looking for a root cause one of the methods is the PETE model in which the following categories are examined:
P-erson
E-nvironment
T-echnology
E-xternal factors.
Why is it important to identify a cause rather than find a person to blame? If we want pilots to share their mistakes and lessons openly, the last thing we should be doing is starting a witch hunt or making them feel like they are being prosecuted for making a mistake. The very thing that differentiates a mistake from a malicious act is whether or not it was intentional. When a pilot or any human feels threatened or fears prosecution, they are more likely to cover up the mistake which can lead to much worse problems down the road, especially in aviation.
Case Study:
Tom arrives at the airport to take his flying club’s Cessna 152 out for a flight. His plan was to fly to a local airport for lunch. As he was pulling the aircraft out of the hangar his wife called. He finished pulling the aircraft out with the tow bar in one hand and his cell phone in the other. The conversation gets a bit heated and he paces around the aircraft a few times before getting in and starting the engine. The engine starts normally, all the gauges are green. He advances the throttle to begin taxiing and as the aircraft starts rolling, he hears a loud “PRANG!!” and sees the red handle of the aluminum towbar go airborne and land next to the hangars. Tom immediately shuts the aircraft down and inspects the propeller only to find that there is a small nick with a tiny fleck of red paint. What does Tom do?
The answer is quite simple right! Or is it?
It really depends on the culture at Tom’s flying club. If the culture is one that promotes learning and education and if Tom feels comfortable sharing his mistake, then he will report the prop-strike and educate his fellow club members about the dangers of using a cell phone while pre-flighting an aircraft. The other members might poke some good-natured fun at him, but everyone will have learned a valuable lesson. The odds of a repeat of this experience with anyone from the club is very low. Tom will report the damage, an AME will inspect it and chances are the aircraft will be returned to service.
If Tom’s club has a culture of finger pointing, finding people to blame, looking for reasons to suspend one’s flying privileges or just a general atmosphere of distrust and aversion to learning then there is a very good chance that Tom, fearing repercussions and ostracization will find a rag, buff out the fleck of red paint and say nothing to the club in order to save face and keep his pride intact. Tom will push the plane back into the hangar and for the next nine months other members will fly it with no knowledge of the prop strike. When the aircraft goes in for annual the AME will find a small crack that has grown since the incident which had it been dressed immediately would have been no problem. Upon learning of the crack at the club the members find themselves in a feeding frenzy of distrust pointing fingers at one another trying to find a person to blame while Tom’s conscience weighs heavily in the back row.
Whether new or experienced, pilots have the opportunity to continuously learn from others as well as educate their peers by sharing their experiences and listening without judgement to the experiences of others. I took off in my aircraft this past June without my cowl being done up. The right half of my cowl departed the aircraft and went through my flap. It ended in a prompt landing and a rather large bill from the structures shop. That said, I can tell you using the PETE model exactly how it happened. I shared it openly and am still reminded by others constantly as they make jokes and poke harmless fun. I am glad that they make jokes because every joke made is a reminder to everyone to not make the same mistake that I did. Even highly experienced airline and military pilots are not immune to the odd screw up. About 10 years ago, an Air Canada flight came very close to landing in Vernon thinking that they were on final to Kelowna. Several years later, a military C17 heavy transport landed at a small general aviation airport in Florida next to the actual Air Force Base that they were meant to land at only to have to unload to be light enough to get back out. Mistakes Happen!
We are a community, we are human, and we make mistakes. By keeping our mistakes to ourselves or persecuting others for theirs we do our entire community of aviators a disservice. I challenge each and every person that reads this to take an opportunity to share a mistake that they have made with someone. The more we normalize sharing of errors and mistakes the more we can learn from one another and hopefully reduce the repetition of unfortunate events in the future.
Speaking of learning from mistakes, using the binder containing your journey log and aircraft documents as a temporary chock behind the main wheel isn’t a great idea. Don’t ask how I know!
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