HOW DO YOU DECIDE?

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©Jay Hopkins – All rights reserved

Originally published in Flying February, 1999

The corporate jet pilot was on the last leg of his LOFT (Line Oriented Flight Training) simulator session. Because a LOFT is supposed to closely simulate the challenges a corporate pilot normally encounters, the pilot had not been faced with the numerous malfunctions that usually plague a simulator session. He had served as copilot for his co-captain as they took off from Boston for the short hop down to La Guardia. As they were in the initial approach to their destination, their passenger had informed them that he had just received a call on the flight phone and he now needed to go to White Plains. They had gone through the hassle of changing destinations in the New York metropolitan area and were on final for White Plains when a wind shift necessitated changing runways.

After dropping off one passenger at White Plains, they had swapped seats and headed for Washington National with their remaining passenger. Now as they approached final the pilot thought about how easy this had been. There had been one minor problem with the environmental system and National was just above minimums, but other than that it had been a routine, almost boring flight. They joined the localizer and waited for the glide slope needle to come alive. A few more minutes and they would be on the ground. As the glide slope needle quivered and started down he asked the copilot to lower the landing gear. A few seconds later his copilot informed him that one main gear down and locked light was not illuminated and that the bulb tested ok. Suddenly his pulse quickened. He had to think fast. They were on final approach and if didn’t act quickly they would have to go around. Acting from memory he told the copilot to pull the landing gear circuit breaker and then activate the gear blow down lever.

As the copilot completed these steps, the pilot was astounded to see that the gear light was still not illuminated. In training the blow down procedure had always resulted in a green gear down and locked light, but now the bulb remained dark. Out of options and time, the pilot called the tower and initiated a missed approach. He also realized that he had painted himself into a corner. Once the blow down bottle is used, the gear can not be retracted until a mechanic bleeds the high pressure gas from the lines. Mentally he checked off all the options which were no longer available. He couldn’t cycle the gear to see if that would help. If the weather deteriorated below minimums, the distance he could fly to an alternate would be severely limited by the drag of the landing gear and the lower speed he would have to maintain.

The flight had a happy ending when the pilot touched down on the longer runways of Dulles International Airport a short time later, but his predicament illustrated the consequences of using the wrong decision making style for the situation. Each of us has a tendency towards one of two decision making styles. We call the people who make decisions very quickly “choicers”. Once these individuals have made a decision they usually stick with it and it can be very hard to get them to change their minds. In effect they are  “choiced out”. People who like to take a long time to assess the situation are called “expanders” because they like to keep expanding their options. They may seem to take forever to make up their minds, and will quickly change their decision if new information surfaces.

As with most personality styles, neither approach is right or wrong in and of itself. However, the proper decision making style has to be matched to the challenge facing the pilot. if a pilot uses the wrong decision making style for a given situation the results can be disastrous. There a quite a few situations in aviation that call for the choicing approach to decision making. If an engine fails on takeoff at low altitude, the pilot has to immediately assess where is the best place to land and take the appropriate action. Any hesitation or indecisiveness will lead to a reduction in options as the plane’s altitude steadily decreases until the problem is solved because there is not enough altitude remaining to land anywhere except straight ahead. A non-instrument rated pilot who finds himself in the clouds needs to immediately initiate a 180 degree turn or a climb/descent back to visual conditions. Every second of hesitation will lead the pilot further into the instrument conditions and make getting out safely that much harder.

A person who tends towards the expanding decision making style can have a hard time with these types of situations. Their hesitation to decide quickly can leave them frozen momentarily. Even after making the right decision, something may occur which leads them to vacillate until there just aren’t any more options. For example, if the engine quits just after takeoff, it is critical to immediately get the plane back on the ground, on the remaining runway if possible. A choicing type individual would likely make that decision without hesitation and stick with it. The expanding type personality might hesitate to consider other options such as checking the fuel selector and the mags. If the engine regains power momentarily, they are more likely to assume everything is ok and be tempted to continue with the takeoff. If the engine completely fails a few seconds later, the option of landing back on the runway may be gone.

Other situations call for the expanding style of decision making. If time is available we need to carefully consider all possible courses of action before making any decisions which may ultimately limit our options. The pilot in the simulator used a choicing type approach when he had time to consider his options. The lure of the runway and the anticipation that the blow down procedure would result in a down and locked indication led him to make a snap decision he later regretted. When the initial unsafe gear indication was noticed, there was plenty of time to deal with the situation. He could have declared a missed approach, asked for a holding pattern to sort things out, and then gone over what options were available with his copilot. They likely would have tried to cycle the gear and in any case would have retained the option to raise the gear if they needed to fly to a more distant alternate.

It is important to assess your own decision making style and then make sure your style doesn’t cause a problem in situations where it is not appropriate. If you typically make snap decisions and people say that it is impossible to get you to change your mind, you probably tend towards the choicing style. You will typically do well in situations calling for a snap decision but need to be careful that you don’t jump to a conclusion too quickly when there is time to carefully consider the available options. When appropriate you also need to stay open to other alternatives even after you have made your decision.

On the other hand, if you tend to have a hard time making decisions and always seem to need more information before you can decide, you probably use the expanding style. While you will do well in situations where there is plenty of time to consider the options, you need to make sure you don’t take too long to decide, especially when time is short. Try to prepare yourself to act quickly in situations that don’t afford the time for careful consideration. Be careful that you don’t vacillate in situations requiring a quick response. Once you have made a decision which will likely result in a safe termination of the flight, don’t let yourself be tempted into changing your mind, unless you have discovered a clearly superior alternative.

As pilots we can face a critical decision making situation at any moment of a flight. Some of these situations do not have easy answers. But whatever options are available, it is critical to match our decision making style to the time available—making an immediate decision when time is short, and pausing to consider the options when time is available to do so.

FATAL WEAKNESSES

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©Jay Hopkins – All rights reserved

Originally published in Flying October, 2006

Every airplane is a series of compromises. Various performance goals are defined, designs are made and systems are laid out, all the while keeping an eye on weight and cost. When the plane is actually produced, some decisions turn out great and others are cursed by pilots who fly that particular airplane. While most weaknesses are usually a minor inconvenience to the pilot, in some cases they can lead to a “perfect storm” of negative factors that can result in an accident.

It is fascinating to read through the Aviation Consumer’s Used Aircraft Guide (available individually or in a two volume set at www.used-aircraft-guide.com) to get the history of a design and see how various decisions turned out in real life based on comments by owners and pilots of that type aircraft. For example, when Piper introduced the PA-23 Apache in 1954, the only other models it offered were the tube and fabric Pacer, Tri-Pacer and Super Cub. Thus the all metal light twin was quite a step up, and there was nothing else like it at the time. As often happens, it was soon given bigger engines, and in 1960 it morphed into the more capable Aztec which was gradually refined until production ended in 1981 with the F model.

Pilots who fly the Apache or Aztec say that it is a very docile, easy to fly airplane that will carry a heavy load out of relatively short fields. On the down side, it uses lots of gas even though it is not particularly fast. One thing pilots complain about on pre-1976 models is a strong tendency to pitch up when the flaps are lowered. Piper came up with a way for pilots to adjust for this, recommending in a service letter that the pilot use small amounts of flaps to counter nose-heaviness in the pattern instead of using stabilator trim, and this seems to work well.

There is one other design feature on the PA-23 Apaches and Aztecs that normally would never cause a problem, but in certain circumstances can put a pilot in an extremely difficult situation. One of the advantages of a twin, and one of the reasons people are willing to pay the extra operating costs associated with two engines, is the fact that twins usually have two of everything—two generators, two vacuum pumps, and if there is a hydraulic system, two hydraulic pumps. However, that was not the case for the early Apaches, which came with only one of each.

Many Apaches have been upgraded by adding a second  alternator and vacuum pump, and the Aztecs came that way, but the single hydraulic pump on the left engine remained throughout the production of the PA-23, with an auxiliary hydraulic pump on the right engine finally offered as an option on the F model Aztec. I would guess that the original decision to go with one hydraulic pump had to do with weight and/or cost considerations, but for whatever reason, that design decision introduced a the potential for several situations that would be very difficult for a pilot to deal with.

Single engine performance on light twins is marginal at best. Even if the pilot does everything right—prop feathered on the failed engine, five degree bank toward the good engine, airspeed maintained at Vyse—the best that can be expected is a couple hundred feet per minute climb rate. If anything is not done just right, it may even be difficult to maintain level flight. It obviously requires excellent flying skills and lots of concentration to pull this off successfully, yet if the left engine fails on a Piper Apache or Aztec, the pilot is required to use a hand pump to get the landing gear or flaps up or down. There is also an emergency landing gear extension system using high pressure carbon dioxide as a backup if the hand pump doesn’t work.

The obvious weakness of this design was a significant factor in an accident that caused the death of a pilot and four passengers in an Aztec. They were approaching their destination when the pilot reported to ATC that he had “single engine problems here” and declared “Mayday, Mayday!” Five minutes later, after the controller had instructed the pilot to turn ten degrees to the left to intercept the localizer, the airplane make a hard left turn and the pilot reported he also had a vacuum failure but that he would be able to maintain heading.

Two minutes later the pilot reported intercepting the localizer and stated that he was “single engine and one propeller feathered.” The weather was not that bad, with a ceiling at 1,100’ AGL, five miles visibility, and a 12 knot wind right down the runway. The temperature was slightly below freezing, so aircraft performance should have been good. The NTSB report stated that the pilot held a commercial pilot certificate with airplane single-engine and multi-engine land and instrument airplane ratings. He also held a flight instructor certificate with an airplane single-engine land rating and advanced and instrument ground instructor ratings. He had close to 1000 hours total time, with over 300 hours in multi-engine airplanes, mostly in Aztecs. He also had logged eight hours of actual instrument time and six hours of simulated instrument time, including 20 approaches, during the previous six months. There seemed to be no reason that pilot should not have had a successful end to the flight, even with the failed engine.

Five minutes after intercepting the localizer, the pilot reported the runway in sight. It seemed like the crisis was over and the airplane would soon be safely on the ground, however a minute later he reported a “complete loss of hydraulics,” adding that he intended to circle to the left and hand pump the landing gear down. That was the last transmission from the pilot, and a few minutes later the resident of a home located south of the airport heard a loud noise, looked out the window, and saw the accident site in his side yard.

The NTSB report states that the airplane crashed nose first almost vertically as a result of “the pilot’s failure to maintain minimum control airspeed (Vmc), the resulting loss of aircraft control, and an inadvertent stall/spin. They also found that the pilot had succeeded in lowering the landing gear, but that the propeller on the failed left engine had not been feathered, and that there was ice present on the leading edges of the wings, stabilator, vertical stabilizer, and antennas.

Why couldn’t this pilot handle what should have been an unwelcome but not insurmountable problem on this flight? He certainly had enough training and experience. The conditions weren’t that bad. However, it is evident from the sudden turn at the beginning that he had his hands full flying the Aztec on one engine. It turns out he had not feathered the propeller as he believed he had, which probably removed what little climb capability the airplane had on one engine with five people on board. Fortunately he was headed downhill towards a landing in good weather. Unfortunately, it appears he forgot that with the loss of the left engine, he also lost his only hydraulic pump. He should have been carefully preparing to pump the gear down, or perhaps even use the emergency blow down system, at just the right moment on final as he intercepted the glideslope with the runway in sight. Instead, he was surprised to find that selecting gear down did not result in actually lowering the gear, and realized he had no hydraulic pressure.

While it would seem to be a good decision at that point to break off the approach and leave the pattern to handle the gear issue, it radically changed the situation. Instead of a descent at reduced power to a single-engine landing, he was now faced with trying to maintain altitude on one engine with the increased drag of the landing gear added to the unfeathered propeller, the effect of the ice that had accumulated descending through the clouds, as he turned towards the dead engine. Along with the distraction of pumping the gear down, it was more than he could handle.

In January and February of 2001 I wrote about the importance of “Knowing Your Airplane” and “Doing Your Homework” to learn all about the airplane you will be flying. Probably the most important homework you need to do on any airplane you fly is to discover its weaknesses and determine the best way to overcome those weaknesses. Often it will be as simple as knowing which way to trim as you extend or retract the flaps. Other airplanes require very careful study of the fuel system and a rigorous approach to tracking fuel burn. If it comes down to something like the single hydraulic pump on Apaches and Aztecs, you need to be fully aware of the tenuous nature of dealing with that kind of a failure, and have a carefully developed and practiced plan for surviving in case the worst actually happens. If you are tempted to cut corners, just remember that this kind of test is not graded on a curve, it is pass or fail only, with no makeup exams.

DO YOUR HOMEWORK

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©Jay Hopkins – All rights reserved

Originally published in Flying February, 2001

Last month I provided examples which illustrated that many pilots lack even the most basic information about how their aircraft operates. While I am not advocating a return to the days when a DC-6 pilot needed to know the tail skid pressure or the thickness of the skin in each area of the airplane, before anyone flies an aircraft as pilot in command even for one flight, they need to have a good understanding of that aircraft’s systems, operating procedures and limitations.

There is no requirement in the FARs for a pilot to familiarize himself with an aircraft before a Part 91 flight. The only regulation which touches on this subject is 91.103, which requires the pilot in command to “become familiar with all available information concerning that flight.” However, the regulation goes on to specify only weather, fuel requirements and known traffic delays for “flights under IFR or a flight not in the vicinity of an airport.” It also mandates that the pilot consider runway length required. It does not mention systems or operational knowledge.

If you fly charter the picture changes drastically. Part 135 dedicates an entire subpart to training. There are training requirements for initial, transition, upgrade, differences and recurrent. Each pilot has to pass a written or oral exam every year for each type of aircraft flown. This test covers the aircraft powerplant, major components and systems, major appliances, performance and operating limitations, standard and emergency operating procedures, and the contents of the approved Aircraft Flight Manual or equivalent. The pilot also has to have a flight check every year in each type of aircraft flown, although one flight check covers all single engine aircraft.

Since the lives of general aviation pilots and their passengers are no less valuable than passengers on charter flights, it is important for pilots operating under Part 91 to acquire and maintain a similar knowledge and skill base. The obvious place to start is with the Pilot Operating Handbook (POH) or Aircraft Flight Manual (AFM). If you fly an older aircraft this may be nothing more than a small book covering the basics of the aircraft systems and performance. The original “Owner’s Handbook” which came with my 1967 Turbo Twin Comanche contains only 75 pages. It is not required to be in the aircraft and has no legal status. Weight and balance information is contained in a separate Aircraft Flight Manual, which has to be kept in the plane. The Twin Comanche AFM also covers all legally required limitations and has supplemental information on the autopilot.

How much effort you put into learning an aircraft depends on how much you think you will be flying that type of aircraft. Even if you are just going to do one flight you need to have a good handle on all the critical information available. Since many aircraft systems are similar in design, it should not be necessary to spend a lot of time to acquire the information necessary to safely operate an aircraft, but it does take a dedicated effort. Skim through the AFM or POH, looking for critical limitations and operating information that is out of the ordinary. At a bare minimum you should have a good understanding of the fuel, electrical, and hydraulic systems, and how the landing gear operates. Be sure to note anything out of the ordinary, or anything that you consider a weakness. For example, at least one type of twin engine airplane has only one hydraulic pump, which means if the engine with the hydraulic pump fails on takeoff or climb out, the landing gear would have to be pumped up by hand. This information could be critical in the case of an engine failure on takeoff. It is also important to run through a few weight and balance problems to get an idea how the plane can be loaded and how easy it is to get outside the envelope.

Once you have a basic idea of how things work, go out and sit in the cockpit. Skim through the book again, but this time actually touch the switches or levers involved in operating the various systems. Run through the normal checklists and then the abnormal and emergency procedures. Don’t just look at the emergency gear extension door, open it up, and extend or take the handle out. In fact, do as much as you can without actually operating the system. Move the fuel selector(s) to all positions. Be especially careful to find all controls located in hard to find places. For example, the alternate static source is often tucked up under the instrument panel.

This process sounds extensive but doesn’t have to take long. For a simple single engine airplane it can be accomplished in less than an hour. A complex single or twin may take a couple of hours. When you are done, you will still not be an expert on the aircraft, but when you activate the starter for your first flight, you will have the knowledge and skills to correctly respond to any reasonably anticipated event during that flight.

If you are going to be spending considerable time flying a particular type of aircraft, you will probably want to dig much deeper. There is a wealth of information available for anyone willing to spend a little time and effort to seek it out. Some excellent resources are:

USED AIRCRAFT GUIDE (Published by The Aviation Consumer)

This two volume set covers over 60 aircraft from the Aerospatiale Trinidad to the Globe/Tempco Swift. It has a short discussion on the history and performance of each model, along with information on any idiosyncracies and maintenance problems typically experienced. There is a Cost/Performance/Specifications Chart for every year the model was manufactured, and a Price Comparison with similar aircraft. Finally, there is a selection of comments from owners about what they like and don’t like about the aircraft.

AIR SAFETY FOUNDATION SAFETY REVIEWS

I put off ordering the Safety Review for the Twin Comanche, anticipating the usual collection of warmed over accident case studies. When I finally received mine, I was surprised and impressed by the wealth of information included:

  • An extensive history of the aircraft, including a separate description for each model produced.
  • A list of comparable aircraft used in the safety review.
  • A detailed statistical analysis of accidents covering such items as major causes, pilot related accidents, critical phases of flight, and systems involvement. The section is followed by a summary which explains what it all means in plain English and points out any weaknesses discovered in the analysis, especially when compared to similar aircraft.
  • A very detailed discussion of “well known trouble spots” (systems, airframe and operating) along with a listing of SDRs and ADs.
  • An extensive collection of actual accident reports organized by phase of flight or cause of the accident.
  • A complete Training Outline covering Specifications, a Written Exam, Ground Orientation, General Flight Operations, IFR Operations, Cross-Country Operations, and Flight Profiles for establishing target speeds and power settings.
  • Reprints of articles published on that model aircraft.
  • Information on any associations affiliated with that aircraft.

This is a wealth of information and anyone who wants to truly understand how to stay alive while getting the most out of a particular model needs to read this book. Safety Reviews are available for most of the popular Beechcraft, Cessna, Mooney and Piper models, and can be ordered from Sporty’s Pilot Shop (1-800-LIFTOFF).

ASSOCIATIONS AND TYPE CLUBS

Whatever type of aircraft you fly, there is a good chance that someone has put together an association to share information about that aircraft. The AOPA web site (http://www.aopa.org/) lists over 85 Associations and Type Clubs related to a manufacturer or even a specific model. From organizations serving all Cessna or Piper owners to a group for Short Wing Pipers or Straight Tail Cessnas, there seems to be something for everyone. I joined the International Comanche Society before I bought my Twin Comanche. They have provided an incredible amount of  information which I have used in the purchase, maintenance and operation of my plane. This information is available through a monthly magazine, The Comanche Flyer, other publications available through the society, individuals who make themselves available to other members for technical advice, and a forum on the Internet. There are also regional meetings with educational sessions, fly-ins, and an annual convention. I couldn’t imagine operating a 33 year old aircraft without the support provided by this group.

 

 

CLOSE ENCOUNTERS

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©Jay Hopkins – All rights reserved

Originally published in Flying March, 2001

My flight from Tucson to Ciudad Obregon was similar to other trips as a corporate pilot flying a Cessna 414 mostly in Mexico. The weather was beautiful and I had quickly cleared customs in Hermosillo. I had not encountered any other traffic the entire trip. On final and cleared to land at Ciudad Obregon, I was enjoying the smoothness of the late afternoon air. Because I speak Spanish, I was aware that one of the local Cessna 206s was on final for the crossing runway. I located the other plane and confirmed that I would land well before he did. Final checks complete, the big Cessna flared nicely and then touched down gently on the runway. I had just begun braking when I was shocked to see a 206 touching down on the crossing runway. Obviously I had been watching the wrong plane. As we approached a collision at the intersection we both had slowed sufficiently that we could each make a turn onto the other runway, thus avoiding each other. While this close encounter was due to controller error, this would not have helped those of us on the two aircraft if things had not turned out as well as they did.

There has been a growing awareness of the problem of runway incursions over the last year. The FAA formed a Runway Incursion Team to address the problem, and other significant players in the aviation industry have been trying to help make some headway in this area. The result—the headline on today’s USA Today reads “Close Calls On Rise.” After all that hard work the number of near-collisions on our country’s runways has increased by 31% over last year! Even if the increase is due to better reporting and record keeping, that does not alter the fact that we face a serious problem and all the current attention on this problem has not significantly reduced the number of incursions and near-collisions. General aviation accounts for over half of the runway incursions, and it is important to keep in mind that when an airliner and a small plane tangle, the small plane never wins.

Recently the FAA issued a Safety of Flight Bulletin for General Aviation (#FSGA00-06) on “Increased Surveillance and Testing of Surface Movements Operations.” In this bulletin, the FAA requires that all pilots being evaluated by an FAA Inspector or Designated Pilot Examiner be tested on safe airport surface movements. This means that if you go for any written exam or flight check you are supposed to be tested in this area. The FAA is also going to issue a new advisory circular on this subject, and is reviewing pilot/controller communications and other areas associated with this problem. The new runway incursion prevention and testing program includes ten “best practices” which can be organized into four major groups: Basic Knowledge, Preflight Planning, Taxi Clearance and Taxiing (before takeoff and after landing):

BASIC KNOWLEDGE

I think one reason many pilots may be weak in their basic knowledge of airport operations is that our attention during flight training is naturally focused on what happens in the air. The ground markings section of the AIM probably does not receive a lot of attention during flight training and even less thereafter. So whether you are a student pilot studying for your private license or an ATP rated airline pilot with years of experience, take some time to revisit Chapter Two, Section Three of the AIM which covers Airport Marking Aids and Signs. If it has been a while since you have been there you might be surprised at the amount of information it contains. There are twenty-eight pages with color illustrations covering taxiway and runway markings, holding position markings, and the six different kinds of signs used on airports. A review of this section is especially critical if you normally operate out of small uncontrolled airports and are planning a trip to a large airport. When you have Section Three of the AIM under control, turn to Chapter Four, Section Three and review Airport Operations. Pay particular attention to the paragraphs on Intersection Takeoffs, Land and Hold Short Operations, Communications, Taxiing, Taxi During Low Visibility and Exiting Runway After Landing.

PREFLIGHT PLANNING

As you prepare for a flight, keep in mind the potential risks associated with surface operations. Check the NOTAMs for any information on runway or taxiway closures, any construction areas or any changes in the CTAF frequency. If possible, review a map of the airport layout for both the departure and destination airports, and keep that map available for reference in the cockpit. This is not a problem for IFR pilots, as the airport diagram is included on the approach plate, but VFR pilots can find it difficult to access this information. One alternative is to purchase a commercial airport guide containing airport diagrams. The Air Safety Foundation is also working on this problem and is making airport diagrams available to all pilots on its web site. One advantage of this approach is that you can print the diagram out and then mark any construction areas or closed runways or taxiways on the diagram. If you have any questions about a complicated diagram or NOTAM, call the tower or other knowledgeable person and clarify what is going on before you get in the airplane. This is especially true at an uncontrolled field where you may not be able to get information on the radio.

TAXI CLEARANCE

Once you get your engine(s) started, give the process of getting and understanding your taxi clearance the attention it deserves. It is hard to concentrate if you are trying to do two things at once, so don’t start taxiing or try to accomplish other tasks while listening to your taxi clearance. I always use a kneeboard and write down at least the winds and the runway I am cleared to along with any crossing information. Don’t forget to read back any runway crossing or hold short instructions, and if there is even the slightest doubt in your mind about what you are supposed to do, ask for clarification. At an unfamiliar airport, simply state that you are “unfamiliar” and request progressive taxi instructions. The controller will guide you step by step all the way to the runway. At an uncontrolled field, if you are uncertain about where to go after starting your engine(s), you can often get advice on the CTAF frequency.

TAXIING

Before you get underway, turn on your rotating beacon and your strobe lights unless they will interfere with the night vision of other pilots in the vicinity. Focus on the job at hand and don’t allow yourself to be distracted by trying to accomplish your preflight checks while taxiing. The only items which need to be accomplished during taxi are to check the brakes as you start forward, monitor the gyro instruments and compass for proper operation during turns and perhaps accomplish a thrust reverser check in a jet. Everything else should be done before you start moving or after you get to the runup area. This allows you to concentrate on where you are going and increases your awareness of any aircraft or vehicles in your area. Whenever you approach a runway or taxiway, look carefully for any crossing or opposing traffic. At an uncontrolled field, broadcast your intention to cross a runway well before you actually enter the runway and check carefully in both directions before you cross.

As you approach the runup area, make sure that no part of the airplane extends past the hold short line. If the controller becomes aware that any part of your aircraft is extending past a hold line, he will stop operations on that runway until you are clear and may issue a violation. It is a good idea to park so that you can check the final approach one last time as you taxi onto the runway. If you have any question about a takeoff clearance, stop and confirm with the controller what was intended. Monitor the tower frequency closely and be alert for any indication another aircraft may have been cleared to take off or land on the same runway. Be particularly leery of “Position and Hold” clearances as they put you in a position where you are no longer able to see the final approach area. I always taxi forward very slowly and if I am still not cleared for takeoff as I approach the center of the runway I stop at an angle so I can still see the final approach path. Intersection takeoffs also provide an opportunity for error. In a recent accident at Sarasota-Bradenton Airport, the tower cleared a Cessna 172 for takeoff from the end of the runway. Another Cessna 172 was waiting to takeoff at an intersection 1,200 feet down the same runway. That pilot thought the transmission was for him and also taxied onto the runway. All four people on both aircraft were killed in the collision which followed.

Uncontrolled fields call for even greater vigilance in all directions as someone may decide to land downwind or on a crossing runway no matter what the “active” is. Broadcast your intention to takeoff and which runway you are using on the CTAF and listen carefully for any response. Then check the final approach path carefully as you begin to taxi onto the runway. Once you are lined up on the runway, check the approach path for any intersecting runways.

When you arrive at your destination, exercise the same vigilance and care during your approach, landing and while taxiing to the ramp. Listen to the ATIS or monitor the CTAF frequency to get the airport information as early as possible, and then use that information to plan your approach to the airport. Decide ahead of time which way to exit the runway and how to get to your parking place. Monitor the frequency and be alert for anyone landing or taking off on the same runway or an intersecting runway. After you land, make sure that you taxi completely past the hold line as you exit the runway, then stop and get your taxi clearance unless it has already been provided by the tower. At any time, if you have the slightest doubt about where you are or where you are supposed to be going, stop immediately. This is especially true when approaching any runway. Even if you think you are cleared across, it never hurts to call as you are approaching the intersection to make sure.

Ground operations may seem like an insignificant obstacle to getting in the air, but the close encounters, accidents and fatalities which occur every year prove otherwise. You may make a mistake or get confused, or someone else may not be clear on what they are supposed to do. There are a few pilots who will cut every corner to save a few seconds. Careful attention to the details while taxiing, taking off and landing will ensure that you make it safely into the air and back to the ramp at your destination.

BEING A GOOD INSTRUCTOR

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©Jay Hopkins – All rights reserved

Originally published in Flying October, 2001 

 “Not many of you should presume to be teachers, because you know that we who teach will be judged more strictly.” (James 3:1)

You can almost imagine the excitement. A friend reported that for years the young man had been reading books and magazines about flying, imagining the day that he could “break the surly bonds of earth” to soar free among the clouds. After working hard he managed to save enough money to get started. He called the local flight school and scheduled his first flight lesson. He probably didn’t sleep very well the night before the big day, his heart racing a little as he looked forward in eager anticipation to the adventure that awaited him. Finally it was time to head for the airport. He had driven this route many times before, but it was always just to stand at the fence by the end of the runway and watch the planes take off and land. Today he would be at the controls.

Soon he was walking out to the plane, his senses savoring all the new sensations of this moment. It was just an old Cessna 152 which had already spent over 9,000 hours introducing others to the joys of flight, but to him it was the most beautiful machine he had ever seen. It didn’t matter that the upholstery was worn, and he didn’t even notice the cracked plastic behind the seats. This was the vehicle which would allow him to experience for real what he had been dreaming about for years.

The preflight went by in a blur, and suddenly he found himself in the left seat turning the key to the start position. The instructor got the plane to the taxiway and then helped him taxi to the end of the runway. It was a little harder than he thought it would be, but he managed to keep the plane on the taxiway and soon was maintaining a fairly straight path to the runup pad. After the instructor helped him accomplish the runup and other preflight checks, he heard the magic words he had been waiting for, “cleared for takeoff.” The instructor told him to push the throttle all the way in and then helped on the controls as the plane accelerated down the runway. This was it! The plane was lifting from the runway! He was flying!

We don’t know exactly what happened on this flight, but a witness observed the end of the flight. The witness stated that “what attracted my attention was that I became increasingly aware the plane was in an extended dive. I could hear the engine running throughout the entire dive. I looked up and saw the plane in a dive, at an extremely sharp angle of descent, heading west. The plane continued down long past the time I thought it should have pulled up until finally it reached the tree-tops and disappeared from my view and I heard more of a muffled impact ‘thud’ than an actual explosive sound. I immediately looked at my watch and it was 2:11 p.m.”

So that was when the dream ended for both the student and the instructor, at 2:11 p.m. after a terrifying plunge with the engine and propeller of the plane that had served faithfully for so many years buried in about three to four feet of soft, water soaked clay loam and soil. What the new student had not known as he walked out to the plane in eager anticipation of the flight was that the instructor walking beside him was almost a babe in the cockpit himself. He had a total of only 307 hours flying time, and had only 77 hours of instruction experience. In fact, he had started working as a full time flight instructor less than 90 days before the accident. That alone would not be so bad, but the NTSB discovered that this inexperienced instructor liked to do spins with new students. The NTSB report quoted one former student who said the instructor had demonstrated two spins on his third flight. Another student reported the CFI demonstrated a spin on his second flight, entering the spin at between 3,000 and 3,500 feet and recovering within 500 feet. A student who had flown two instructional flights with another CFI said that on his first flight with the accident CFI he had demonstrated a spin and a wingover with the plane’s wings banked 90 degrees. Another student who reported having spins demonstrated on her first flight with the accident instructor said that he did not provide any ground instruction concerning spins and even after his “demonstration” she still had no idea how to recover from a spin.

In an ideal world every flight instructor would be a dedicated professional who took his or her job very seriously. Unfortunately, it is clear from this accident and the examples and accidents discussed in my last two articles (Instructor Roulette and Finding a Good Instructor) that this has never been the case and certainly is not true at this time. The fact is that pilots need to build time so they can apply to the airlines or other professional pilot jobs, and instructing is one of the few flying jobs open to low time pilots. So we are not only not restrictive in selecting people to be teachers of flying, we actually are running an instruction mill which churns large numbers of individuals through it with little regard for their skills as an instructor or even their motivation to be a good instructor.

Of course we are fortunate to have a significant number of professional instructors who have dedicated their lives to this profession. Because of the generally low pay and difficult working conditions, anyone who continues as an instructor for an extended period of time has to truly love this occupation and I would assume that most, if not all, of the career instructors can be expected to provide their students with the very highest quality flight instruction available. However, these individuals make up only a small portion of the large number of instructors necessary to meet the burgeoning demand for flight training. The lion’s share of the instructional load is carried by individuals who are passing through the instruction wicket on their way to a professional piloting job with an airline or corporation. I believe that there are probably three types of pilots in this group:

  • Those who really like instructing but still plan to seek other aviation employment due to pay or other considerations. There is not too much of a problem with this group. Anyone who likes what they are doing will usually take it seriously and work hard to do a good job even though they are looking forward to a different full time career in aviation.
  • Those who don’t particularly like instructing but are going to make the best of it until they move on. There can be a little more difficulty with this group, but there are still plenty of people doing work they don’t like who buckle down and do the best job they can while they are there.
  • Those who don’t take instructing seriously or even hate instructing and can’t wait to get out. It is difficult to imagine how someone who doesn’t take instructing seriously or hates instructing can ever be a good instructor.

So what makes a good instructor? Based on my own experience and the responses of Flying readers, here are some of the critical attributes:

HAVE A CURRICULUM

The first key to being a good instructor is to have a curriculum. This is not a problem in the Part 141 schools, which must have and use an FAA approved curriculum for each approved course of instruction. However Part 61 instruction is legally up to the instructor who is not required to do anything more than ensure the student has the required minimum knowledge and skills at the appropriate points in the instructional process. If you don’t have a curriculum there is no need to go to a lot of work to generate one, as samples are ready available or are included in various commercially available flight training products.

FOLLOW THE CURRICULUM

Even the best curriculum is no benefit if you don’t use it. Go over the curriculum with the student during the first lesson and then follow it as closely as possible depending on the weather and student capabilities.

INCREASE YOUR OWN KNOWLEDGE AND SKILLS

It is often said that the instructor rating is really a license to learn. It is especially important that new instructors don’t let the ticket in their pocket make them forget that that the time in their log book is minimal and they are still very low on the learning curve. Even experienced instructors should continue to study and practice. Keep in mind that sitting in the right seat you might not actually take the controls that often. It would be a good idea to occasionally do a practice flight with another instructor or by yourself.

BE CALM AND COMFORTABLE

Flight training is not boot camp, and the process of learning how to fly can be stressful enough without having an instructor who is tense. Never yell at or berate the student or do anything which might make the student tense or nervous. Instead, provide an honest assessment of the student’s performance in relation to your expectations based on their experience at that point.

CHALLENGE THE STUDENT

Being calm and comfortable does not mean that you don’t challenge the student to be the very best pilot they can be. Do not settle for sloppy performance and do not hesitate to let a student know when their performance is not acceptable. If it seems like the student isn’t trying or isn’t taking the lessons seriously, be sure to communicate this assessment in a professional manner which lets the student know you are disappointed and expect them to do better.

BE IN CHARGE

Even if your student is thirty years older than you and CEO of a corporation, you must remain in charge during the lesson and not be intimidated by your student’s age or station in life.

BRIEF/DEBRIEF

An airplane cockpit makes a lousy classroom. The student should have a clear understanding of what is going to happen each time they get in the airplane. The student also deserves a relaxed discussion of their performance after the flight. A ground school like the Cessna/King Private Pilot Course on CD Rom is an excellent resource which allows the student to prepare for the lesson without taking as much of the instructor’s time. It also comes with a complete curriculum.

DEMONSTRATE

To paraphrase, a demonstration is worth a thousand words. The instructor should always demonstrate the desired performance before expecting the student to perform. Don’t hesitate to demonstrate again if the student seems to be having problems getting the idea. This will also help keep your own skills sharp.

BE FUN AND CREATIVE

Even within the structure of a curriculum there is plenty of room for instructor creativity. Always be looking for new ways to get the point across to the student. Ask other instructors for their ideas.

FLY IN ACTUAL CONDITIONS

The real thing is much more meaningful than simulated practice. If it is possible to allow the student to experience the real thing without excessive risk, do it. This would include crosswind takeoffs and landings, short and soft field operations, and instrument conditions. Just make sure your skills are more than sufficient for the conditions you are about to fly in.

TAKE EXTRA TIME

The student should never feel like you are rushing off to the next lesson. Try to find opportunities to have a relaxed discussion with your students about flying in general.

SET A GOOD EXAMPLE

As an instructor, you are setting the foundation for what will possibly be a lifetime of flying in many different types of aircraft and varying conditions. What you do and what you say will make an impression that will literally last a lifetime. If you are at all lax in your approach to safety and professionalism, you may be signing a death warrant for your student sometime in the future.

BE HONEST

It is ok if your ultimate goal is the airlines and you should be honest with your students about this. It is also important to be honest about what you know or don’t know. Never give an answer if you are not sure it is right.

People are dying because of instructors who think instructing is a lark; instructors like the one in the accident described above who are doing stalls and spins and wingovers with new students just to get a thrill and show off. We will never know how many students have been scared away from aviation by this type of unprofessional behavior. We are not talking about poorly prepared meals or mixed up orders here, we are talking about people’s lives-both the student’s and the instructor’s. If you don’t have the discipline and can’t or won’t put in the effort it takes to be a good instructor, then do everyone a favor and find another way to build time.

 

ACCIDENT ZONE

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©Jay Hopkins – All rights reserved

Originally published in Flying March, 1993

Although it is often hard to assess the impact of fatigue on a pilot, there are two Learjet accidents in which it is fairly evident that fatigue played a significant role.  The first occurred in March, 1978.  A Lear 23 was on a medical evacuation flight from Phoenix, Arizona to Burbank, California.  The pilot, who was ATP rated with 2600 hours total time and 1680 hours in type, had been on duty for over 13 hours, and had flown almost 11 hours during the preceding 24 hours.  The weather at Burbank was 5000 feet overcast with 5 miles visibility in rain showers and the runway was wet.  In addition, the left outboard anti-skid valve was inoperative.

The landing was on the numbers, but the pilot failed to use full flaps and did not deploy the spoilers.  The aircraft hydroplaned, failing to stop on the runway.  It continued through a blast fence and the perimeter fence before coming to a stop.  The aircraft caught fire, but all occupants were successful in exiting the aircraft before the flames reached the cabin.

In May, 1980, inexperience and fatigue were a deadly combination for a Lear 23 charter crew on a ferry leg.  They had previously flown the aircraft from Richmond, Virginia to Louisville, Kentucky, where they picked-up six passengers and flew them to Gainesville, Florida.  The crew departed Gainesville at 1:52 am to return the aircraft to Richmond, arriving there at 3:11 am.  By that time the PIC, who was ATP rated with 2547 hours total time and 301 hours in type, had been on duty 20 hours.  The Lear was the only jet he had flown, and although he attended Lear ground school, he had not received any Learjet simulator training.

The copilot had a commercial license with an instrument rating and 905 hours total time but only 10 hours in type.  He was a part-time employee of the company and had worked a full time job before reporting for the flight, for a total duty time of 18 hours.  He also had attended the Learjet ground school, but had no other jet training.  His ten hours in the Lear were acquired on air taxi flights.  The copilot was flying the aircraft on the approach into Richmond.

Although it was a clear night with calm winds, witnesses reported that the aircraft crossed the threshold “a bit high,” the wings started to rock, and the engine noise was heard to increase as the aircraft rolled inverted and crashed adjacent to the runway.  Both pilots were killed.  The crew may have been distracted by the approach lights.  They had made two calls on short final requesting that the sequenced flashing approach lights be turned down.  The controller did so when the aircraft was approximately 1/2 mile from the runway.

Pilots are known for their “can do” attitude.  Our job often consists of long hours, as we start early to get people to their meetings and work late to bring them home.  Even when the day gets long and the flight time adds up we are hesitant to say anything because we know there are hundreds of pilots ready to take our job if we can’t handle it.  Besides, in many of the jobs which involve long hours, the pilots are in the process of building time so they can apply for a better position.  Thus, a lot of hours in one day puts them that much closer to their goal.

Every day we start out with a certain amount of “stuff” with which to meet the demands of the day.  Over the course of the day, as fatigue and hunger take their toll, our “stuff” is diminished.  At the same time, the demands of the flight vary.  Often the greatest demands occur at the end of the day when we may have to accomplish a night instrument approach in deteriorating weather.  Thus the greatest demands on our ability as a pilot occur just when our ability to meet those demands has reached its lowest point.

When stress, fatigue and high workload have reduced our capabilities to less than the demands of the situation, we have entered the Accident Zone.  An accident is not inevitable, but we are riding the ragged edge of our abilities, and any additional demands on us may be the straw that breaks the camel’s back.  In the first accident, the weather would not be considered bad, so the pilot likely was not overly concerned about the landing.  In his fatigue he neglected two items which are critical in a landing on a wet runway.  First, he didn’t use full flaps, so his final approach speed was higher, increasing the likelihood of hydroplaning.  Also, he neglected to activate the spoilers, which would have killed the lift and increased the weight on the wheels, helping to overcome any tendency to hydroplane.  With one anti-skid valve inoperative, it was critical that the pilot take every precaution to avoid hydroplaning, but in his fatigue he had entered the Accident Zone and failed to accomplish two steps that would have helped.

The second accident illustrates the point that pilots often start a flight at the end of the day, after accomplishing other duties or possibly after working a full day at another job.  So instead of a full bag of “stuff” to meet the demands of the flight, they are already seriously depleted, increasing the likelihood of entering the Accident Zone.  On top of the fatigue, in this case we have a relatively inexperienced pilot letting a pilot with almost no experience make the landing in a jet aircraft that is known for its ability to bite on short final if the pilot lets things get away from him.

How can you tell when a combination of fatigue and high workload are putting you into the Accident Zone?  Usually this situation is accompanied by feelings of uncertainty, indecision, or discomfort.  You may recognize you are having a hard time maintaining normal performance levels, as evidenced by lower standards and increased errors.  Often this situation is accompanied by tunnel vision and fixation, resulting in a poor scan.  One of the best clues is communication problems, especially difficulty talking.

Once you realize you are nearing or in the Accident Zone, you can either reduce the workload or increase your capability to handle that workload.  Unfortunately, at that point it’s a little late to deal with fatigue.  It’s better to realize ahead of time that you need a break.  If you are flying for a living, it is important to get your company’s support for realistic and firm flight time and duty day restrictions, using examples like the accidents referenced above to support your case.  It is also common, especially at night, to go long periods without food.  Hunger and low blood sugar can compound your fatigue and put you on the verge of incapacitation, so at least make sure you have some good, high protein snacks available.

If there’s not much we can do to increase our capability to handle the workload in an Accident Zone, we’re going to have to reduce that workload.  One of the best ways to do this is to expand the time available to deal with the workload.  In other words, SLOW DOWN!  I have been amazed in the Lear and Westwind simulators at how reluctant pilots are to slow down.  Typically, I would get them in a situation where they were working on one or two system problems.  Then I would clear them to the VOR, which was only a short distance away, give them holding instructions and tell them to expect the VOR approach, circle to land.

That’s a load for anyone to accomplish, but they would be headed for the VOR at the maximum allowed 250 knots below 10,000 feet, scrambling like crazy to handle the emergency, figure out the holding pattern, complete the descent checklist, and prepare for the approach and circling maneuver.  As they began to exhibit some of the symptoms of the Accident Zone, such as making errors and difficulty communicating, I would casually ask them if they were in a hurry to get to the VOR so they could maybe get one extra turn in the holding pattern?  I would then suggest that thrust levers work in both directions and they might consider slowing down now to their holding speed, which would give them the extra time they needed to figure things out.

I would also suggest that they prioritize what they had to do.  Typically a crew would try to do everything at once: resolve the system problem; plan the holding pattern entry; and plan and brief the approach and how they were going to circle to land.  The result was that they didn’t do anything well.  While it is important to stay ahead of the aircraft as far as the big picture is concerned, detailed planning too far in advance typically is wasted and distracts from accomplishing the task at hand.

In this example, the most important consideration is to correctly enter the holding pattern.  Once that is done, even one turn around the holding pattern will allow four minutes to cleanup system problems, complete checklists, and brief for the approach.  If you’re not done when the approach clearance is received, tell ATC and give them an estimate of how much longer you will need.  Most crews were amazed to find that when they prioritized the tasks facing them, they actually had time to spare and did a much better job besides.

For anyone flying single pilot, it is even more important to be alert to fatigue and workload and to avoid getting into an Accident Zone.  The single pilot has no one to share the workload with, and it is much harder to notice the Accident Zone symptoms in yourself than in someone else.  Even though most aircraft that are flown single pilot are quite a bit slower than aircraft requiring two or more pilots, because of the increased workload it is still important to slow down.

Web Based Error Prevention Training

IT ONLY TAKES A SECOND

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A heart breaking story this week reminds us of how easy it is to make a simple mistake that changes our lives forever. Former astronaut Alan Poindexter was killed when his adult son collided with him on a personal water craft (PWC). Poindexter and one son were sitting still on one PWC when the other son “came barreling into them.”

Many people have watched people zooming around on PWCs and thought, “That looks like fun – I think I will try it.” It also looks very easy, and PWCs are available for rent with no training or instruction other than how to make it go and how to turn. However, PWCs are powerful, fast vehicles that can cause a lot of damage in a collision.

Let’s look at some of the common ways people are injured or killed while using PWCs:

Horsing Around

A 16 year old girl on a PWC was killed in the ocean off Cyprus when she collided with a PWC operated by her boy friend.

A man was killed and his passenger injured when they were hit broadside by a PWC driven by one of the victim’s friends.

Losing Control

A college football player who was four days away from playing in the Orange Bowl was seriously injured when his PWC collided with another one operated by a teammate as they crossed a wave. It took four months for him to recover to the point that he was ready to play again.

An 11 year old boy was seriously injured when he was trapped between a PWC and a partially collapsed dock. A man was approaching the dock on a PWC at about 5 mph to drop off a friend’s daughter when a wave suddenly pushed the PWC into the dock. Three other people were injured.

Knocked Out

A man operating a PWC apparently hit his head on the handlebars, was knocked unconscious and drowned.

Falling Off

A teenager was killed when he fell off a PWC and was struck by another PWC driven by a friend.

Didn’t See Swimmer

A woman was seriously injured after a PWC operator failed to see her and struck her in an area of a lake not reserved for swimming.

In the hands of an experienced operator, PWCs can be safely used for recreation, racing, towing surfers, or rescues. If inexperienced people who rent a PWC for the first time were content to just cruise around on it, it would also be pretty safe. However, after a few minutes the excitement of operating a PWC wears off and people start doing other more risky things like trying to splash other boaters or people on docks, or heading right at someone and then swerving at the last second.

There are PWC experts with years of experience who can safely do those kinds of things, but someone who is new to PWCs doesn’t have the training and experience to handle rough conditions or make split second decisions like trying to swerve at the last second.

We almost lost two of our children in just such an accident. Several of our adult children were out playing on PWCs. Todd headed right for Candice, intending to swerve at the last second and spray her with water. He waited too long to turn and collided with her, punching a hole in her PWC. Fortunately neither was seriously injured, but the PWC sank and they had to pay for it, so it was an expensive lesson in error prevention.

In the Smart People/Dumb Things course you will learn to recognize the Traps involved in operating a PWC, and you will be taught how to use the Tools of Error Prevention to carefully assess the risks involved. Once you have learned about the Traps and Tools™ of Error Prevention, you can access an extend version of this article in the subscription only area of our website. This article will detail which Traps to watch out for when operating a PWC, and how to best use the Tools to correctly assess those risks and set reasonable limits that will adequately mitigate the risk. Best of all, it only takes a couple of minutes to make sure you can have a fun day and then go home with no injuries or fatalities.

 

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HONEY – WE LEFT OUR KID!

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Recent headlines screamed about the “PM’s Parenting Blunder” when British Prime Minister David Cameron and his wife Samantha left their eight year old daughter Nancy in a local pub. There was much discussion in England about whether the Prime Minister was a fit parent. However, when you learn the details of what happened, it turns out it was a classic error prevention situation. Cameron and his family had arrived at a local pub in two cars on a Sunday afternoon to visit with friends and their children. Nancy went to the bathroom just as everyone was preparing to leave. Cameron thought Nancy was with his wife in the other car, and Samantha thought Nancy was with Cameron. The distraught parents discovered Nancy was missing when they arrived home and had returned to the pub to get her only 15 minutes after they left.

While some people are judging whether Cameron is a fit parent, I can easily identify with what happened because I have experienced almost the exact same situation both as the kid and as the parent:

How I Got Left Behind

When we were children our family used to go to Humarock Beach south of Boston every summer to get together with our grandparents and cousins. On one trip we stopped at a restaurant for lunch about 30 minutes from the beach. As we were getting ready to leave I went to the bathroom and came out to see both cars pulling out of the parking lot. I ran after them screaming as loud as I could but they didn’t see or hear me. To make matters even worse, there was great prestige to be the first kid on the beach, and that year I was over two hours later than the other kids!

How We Left Our Son Behind

Our family was visiting with friends when we all decided to go out for ice cream. The children piled into the two cars. We didn’t realize that our son Jesse was playing by himself in an upstairs bedroom and wasn’t aware we were leaving. As soon as we arrived we realized Jesse wasn’t there and rushed back to discover he still was not aware we had left.

Common Factors

Each of these examples involved a gathering of two or more families with children from the various families playing as the adults talked. In each case there were two cars, and in the hubbub of leaving, one child was off by themselves in the bathroom or bedroom. There are several Error Prevention Tools in our e-Learning course that could help to avoid this situation. These Tools help us to recognize an error likely situation and to focus and take stock even in the midst of distractions and confusion.

Other Examples

That is unfortunately not the only time I have left one of my kids behind. A very different set of circumstances led me to leave our daughter Jaime at church. Each Sunday after the service I would typically stay at church for an adult discussion group while my wife Donna would take the kids home. This particular Sunday Jaime said she wanted to stay with me. When we arrived at the discussion group, someone asked if Jaime would like to go play with some other children, which is what she did. Once again I was at the discussion group by myself as I usually was. An hour later when we left, my mind was focused on the various errands I needed to run, so I didn’t remember that Jaime was there. When Jaime was the last kid left, someone called Donna and she drove over to the church to pick her up. Then as I was returning home after completing my errands, Donna sprayed water on Jaime’s face to make it look like she was sweating. Jaime went out the back door and up the street a little ways as I was coming in the garage. As I came in Donna casually asked, “Where’s Jaime?” You can imagine the panic I felt when I realized I had left her at church hours ago. I jumped into the car and was even more distraught to see little Jaime walking down the sidewalk as if she had walked all the way from church by herself.

I’m Not Alone

In a similar situation that could have had a much worse outcome, a couple with an infant managed several businesses. They followed a schedule each day in which they would alternate taking care of their child. One day they had to change the schedule and the mother had the baby during a part of the day the child was not usually with her. She was late and in a hurry as she arrived at her next appointment, quickly locked the car and ran into the office, totally forgetting she had her baby with her. Fortunately someone noticed the child in the car and informed the mother before the baby died from heat exhaustion.

Common Factors

In both of these stories, the common factor was the change from normal. Anytime we have an established way of doing something, any change leads to an error likely situation. Once we understand this we can be alert for these situations and use the appropriate Tools of Error Prevention to avoid or deal with the potentially adverse outcome.

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