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Errare Humanum Est

To Err is Human ...

By Sabrina Woods
Source: FAA Safety Briefing July/August 2017

This might come as a shock to you, dear reader, but someday, sometime — perhaps even within the next hour or so — you will make a mistake. Actually, this is highly likely because as humans, we make dozens of little mistakes daily. They are those innocuous little “oops” that rarely manifest into anything more than an irritant; that is if they even go noticed at all. Even Lucius Annaeus Seneca, the early first century Roman philosopher, is attributed with saying “Errare humanum est...” which means to err is human.

Still need convincing? Ok. When was the last time you burned your tongue diving (knowingly) into a hot piece of pizza or cup of coffee? When was the last time your glasses/cell phone/keys “took a walk” on you? And my personal favorite, when was the last time you walked purposefully into a room, only to find out you have no idea what that purpose was?

Now let’s get a little more substantial. Let’s talk about those mistakes that can rear up and really do you harm if not vigilant. When was the last time you ...

... Skipped a Full Weather Brief?

Because you were “only going to take ‘er up for an hour or so?” You might believe that a brief hop from here to there shouldn’t warrant more than a cursory glance at METARs (aviation routine weather reports), but I guarantee that Mother Nature can (and often will) have a very different take on your plans.

Managing the weather can often be the most difficult part of flying. Continued flight into instrument meteorological conditions (IMC) and encountering thunderstorms or wind shear remain firmly affixed in the top 10 causes of GA accidents. It is by far the most lethal, with more than 75 percent resulting in fatalities. This is a statistic the FAA and NTSB, as well as advocacy groups such as AOPA, EAA, the National Association of Flight Instructors (NAFI), and the Society of Aviation and Flight Educators (SAFE) are diligently working to bring down.

Long gone are the days when you had no other option but to call for an updated weather report. Today, up-to-date, accurate weather can be at your fingertips with any one of the great weather applications available out there. With a mere swipe, you can access the information needed to give you a complete mental picture of what to expect during all phases of your flight.

Even if you are flying in always-sunny Phoenix, Ariz., your safest bet is to start each and every flight with a full, standard weather briefing. Then set the app of your choice or the Adverse Condition Alerting Service (1800wxbrief.com) to give you timely, continuous updates throughout the duration of your trip. Last, always have a back-up plan for diverting ready to go just in case.

One more thing: cross-talk is a huge help in keeping the information stream flowing. The National Weather Service has a nifty pilot weather reports (PIREP) infographic (aviationweather.gov/airep) that can help with flight planning. Pilot reports that either support or cast doubt on the forecast can help your fellow aviators in making their own go/no-go decisions when planning their flights, so share the wealth!

... Didn’t Top Off?

Another common cause of GA mishaps is fuel mismanagement. This fact is rather appalling considering that of all the common reasons for mishap, this one is easily the most preventable.

filling up tank

One November day in 2015, the pilot of an amateur built aircraft failed to visually check his fuel level during the preflight inspection. At the time, he guesstimated his flight would only take about 1.5 hours and that he had more than 3 hours’ worth in the tanks. About 10 miles from his destination, the engine sputtered and died and he was forced to make an off-field landing. Post-accident investigation revealed only about a gallon of unusable fuel remained in the wing fuel tanks.

This pilot got lucky: he managed to walk away relatively unscathed. In a more tragic example, almost the entire Brazilian Chapecoense soccer team, as well as several support staff, were killed when, according to a preliminary report, their chartered Avro RJ85 ran out of fuel, and crashed in the Andes. Apparently, the pilot failed to include appropriate fuel stops in his flight planning.

Whether due to oversight, distraction, or miscalculation, these pilots took a gamble on getting to where they were going without physically checking or topping up the fuel. They both paid dearly for this mistake.

... “Multitasked?”

There is a reason this word is in quotes. It is because multitasking is a myth. Our brains simply aren’t designed to perfectly concentrate on more than one thing at a time. Before anyone protests too much, please note the emphasis here is on the words “at a time.” What most people think of as multitasking is really “task switching” between several different tasks in very short intervals. While experience and training definitely help to speed up a person’s ability to “task switch” efficiently, human beings are incapable of applying 100 percent of their concentration to more than one thing at a time. When we try to literally do everything at once, each task only gets a percentage of our full concentration. Said another way, this also means each task is getting shorted our full concentration. As Murphy often dictates, the thing getting the least attention typically has the biggest potential to bite us. So, while you are simultaneously receiving instructions from ATC, running the landing checklist, configuring your plane, and watching out for traffic in the area, you are really task switching from one aspect to another to accomplish everything.

The limitation is in our working memory. We use our senses to pick up information we need to make decisions. Anything we don’t think is necessary, we dump. What is left over is combined with long-term memory (experience) in order to make decisions. Because we aren’t receiving all of the information we need when we attempt to multitask, the quality of the information we do have to make decisions is degraded. This is how “distraction” and its equally evil fraternal twin “fixation,” are born.

This magazine has discussed both of these hazards many times, but just as a quick refresher, distraction is anything that draws a person’s attention away from the task at hand. The more a person attempts to multitask, the more likely he or she will become distracted by any one of the tasks.

The opposite effect is fixation. That occurs when a person only concentrates on one task despite information indicating something else might need attention too. One situation that fits both of these scenarios is when flying with other people, particularly non-pilots. While wanting to engage with your passengers is only normal, never forget your number one task is to aviate. A gentle conversation about key, silent cockpit moments prior to even stepping out to the aircraft will go a long way in ensuring your passengers don’t inadvertently become a detriment to safety.

... Skipped a Checklist?

Quite often, particularly when we become comfortable with something, we have a tendency to take doing that thing for granted. We think: “nothing has ever gone wrong before, so why would it now?” I once wrote a short article about complacency (https://go.usa.gov/x5kwq) confessing how I totally messed up a batch of chocolate chip cookies because I got cocky and decided to skip looking at the recipe card. Long story short; nasty, hard, pale little coal cookies. While there wasn’t a whole lot of harm done in the total annihilation of what otherwise would have been a tasty snack, in the aviation world complacency and failure to use the tools provided to you (e.g., checklists) can result in mishap or worse.

Industry safety databases are full of mishaps that could have been prevented if the participants had stuck to the checklist. In aviation, perhaps none is more glaring than the May 31, 2014 crash of a Gulfstream IV that took the lives of seven people. The aircraft failed to get airborne because the pilots simply forgot to disengage the gust locks. The post-accident investigation revealed the pilots failed to run a single checklist between engine start and take-off. Sadly, this omission appeared to be a bit of a habit for them.

The bottom line? Complacency is a killer and checklists were written for a reason.

checklist

... Rushed a Preflight?

Similarly, rushing or bypassing a preflight is just a really bad idea. The preflight is literally that last line of defense before taking to the skies. It is your chance to ensure your bird is up to the task, and it is a chance for that previously unknown little anomaly to finally catch your attention.

Forgoing the preflight can result in anything from forgetting to release the tie-down (an embarrassing, but likely non-injurious situation) to failing to discover contaminates in the fuel. The latter is by far the most common overlooked item in a preflight and can result in power loss or complete engine failure.

Rushing a preflight is often a symptom of a dreaded ailment variously known as get-there-itis, hurry-up syndrome, or pressing. A quick review of 125 Aviation Safety Reporting System (ASRS) mishaps that fell into these categories indicated the majority (63 percent) could trace the point of error back to something missed in the preflight.

... Flew Under the Weather?

I’ve already mentioned paying respect to the actual weather, so that isn’t what I mean here. We super-motivated, driven, eager human beings have this pesky tendency to “push through” and stiff-upper-lip-it when it comes to not feeling well and getting the job done despite it. You may not realize it, but your overall health is directly connected to your mental faculties and decision-making ability. Meaning, when you aren’t feeling your best, your ability to safely and efficiently execute a task (like piloting an aircraft) is also diminished. Take heed because cruising around at 1,600 feet AGL is no place to suddenly have your body completely rebel and shut down on you.

Now About That Quote

To be clear, the entirety of Seneca’s famous quote is errrare humanum est, sed in errare perseverare diabolicum. It means “to err is human, but to persist in error is
diabolical.” What he meant was that while we are all human and therefore prone to making mistakes, consistently making the same mistakes over and over again is folly, and downright dangerous. Ensuring all of our little mistakes don’t manifest to anything more than a burnt mouth and misplaced iPhone takes diligence and a real understanding of our own limitations.

Sabrina Woods is a guest writer for FAA Safety Briefing. She is a human factors scientist with the FAA’s Air Traffic Organization. She spent 12 years as an aircraft maintenance officer and an aviation mishap investigator in the Air Force.