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Human factors: Using good judgement


It seems there are lots of ways to get into trouble. A few ways we haven’t discussed yet are pressure, norms, lack of knowledge and lack of awareness. We often feel we are under pressure. We may feel pressure when things didn’t go according to plan and we are running late while en route to an important meeting.

When we are away, we may feel pressure if we are going to be late for work or for an important family function.

Pressure is like stress. It comes from our thoughts. We are under pressure only if we think there is pressure. If we are able to accept that we can do nothing about unforeseen circumstances and that there is nothing we can do about being late, a lot of the pressure we feel will disappear.

Good planning will allow us the time to perform what we have to do with time to spare. There are always variables like weather or mechanical delays which we can do nothing about. If we fret about the delays, pressure will build and we will make errors in judgment.

A C-182 pilot departed from Castlegar, B.C. for Vernon, B.C. close to nightfall and toward pilot- reported bad weather. He indicated to the FBO operator who informed him of the reported en route weather that he had to get home. About half way, he went into IMC. He climbed and called Vancouver Centre for assistance. Before the controller could respond, he watched the aircraft on radar descend into the mountains. When the aircraft was recovered months later, the crash was determined to likely be the result of a loss of control into a spiral dive.

Norms are unwritten rules and procedures that develop over time. Often norms develop when someone finds an easier or quicker way of doing a task. Others see it and copy it. It becomes a norm.

The problem with many norms is that although a shortcut or a different procedure may make a task easier or faster in the short term, we may not be aware of the long term consequences of our actions.

Some norms may be positive. Examples of positive norms would be; taking extra special care with the pre-flight inspection after maintenance has been performed on the aircraft or after someone else has flown it; or updating your ground position on a map regularly throughout a flight.

Negative norms could be things like only checking the weather if it is bad at the point of departure; only doing a preflight inspection if the aircraft has been sitting for a long time; not doing a weight and balance unless all of the seats are being filled; or checking the fuel for water immediately after refueling.

A C-172 pilot fueled the aircraft just before flight from a flying club fuel facility that was infrequently used and less frequently tested for contaminants.

He checked the aircraft fuel drains for water as he had been taught and loaded his wife and son aboard for their first flight with him as a licensed pilot and departed for a local sightseeing tour.

Forty-five minutes later, the engine sputtered and quit.

He turned back to the airport and was able to re-start the engine which continued to sputter and run rough until landing. He checked the fuel and discovered a significant amount of water in the tanks.

Checking for water at the fuel drains after refueling is a norm in the industry. We have forgotten that it takes up to forty-five minutes for water to settle out of fuel. If we are landing somewhere to refuel, we should fuel up, go for lunch and then check for water at the fuel drains. Lack of knowledge is no excuse for making errors or displaying poor judgment.

Lack of knowledge about en route weather is one of the main reasons for CFIT (controlled flight into terrain) accidents.

When we have made a thorough weather check and noted that weather may be marginal in a certain area, we are preparing ourselves mentally for diverting to another route or for turning around. It is usually when we are not prepared that we tend to push too far into marginal weather with often disastrous results.

A Piper PA 28-140 pilot flying from Vernon, B.C. to Abbotsford, B.C. encountered unexpected low cloud over the Coquihalla Highway. He thought it was just a local bit of low, thin stratus and tried to push through it. He went into IMC and climbed on a heading he hoped was keeping him in the valley.

Through 6,500 feet and between 7,500 foot high mountains he was able contact Vancouver Centre and shortly thereafter get radar vectors to Boundary Bay Airport where he was able to make a safe landing. Lack of knowledge about the correct frequency at a destination airport has resulted in several close calls over the years. Lack of knowledge about aircraft systems and emergency procedures have resulted in accidents.

Lack of awareness is not being aware of the consequences of our actions. A pilot making modifications to his own instrument panel may not be aware of how the modifications may affect the magnetic compass. Lear Aircraft was not aware of the long term consequences of installing the fire extinguisher behind the first officer’s seat. A long legged first officer will push the seat back and make it impossible to remove the fire extinguisher.

If we are not aware of how tired or distracted we are we will make mistakes or display poor judgment. If we are not aware of how stressed or pressured we feel, we may make mistakes or display poor judgment.

We are human and we will make mistakes. It is up to each of us to recognize when we are physically or mentally prone to make mistakes and then to either not fly or at least arrange the flight so that the least amount of judgment is called for.

• Dale Nielsen is an ex-Armed Forces pilot and aerial photography pilot. He lives in Abbotsford, B.C., and currently manages a small airline and teaches part-time for a local aviation/university program. Nielsen is also the author of seven flight training manuals published by Canuck West Holdings.