motzartmerv Posted April 11, 2012 Posted April 11, 2012 I have to say, I am pleased about the amount of discussion that has been generated from some recent events at temora and some other incidents which have popped up during these discussions. A common theme is " we should discuss these things so we can learn from them." Now, I agree with this idea in principle. Its a fundamental part of the aviation and indeed safety culture in all other industry's. But quite often the "learning value" is overlooked, or the story is lost in the telling. Another problem is this. One could quite easily argue that the benefits of reflection on past incidents and accidents were lost on a particular pilot who ends up having a problem anyway, even though he had heard of the issues before through others having the same problem or through other means. Regardless, its safe to say that a bloke that flys in the dark (for instance) has heard of the dangers before, but for some reason decided to do it anyway. Thats just an example of NOT learning from others mistakes. Generally speaking it could be said that a great deal of rule changes and paradim shifts in aviation have come about after an investigation into an accident has revealed hidden (or obvious dangers) and recommendations have been made which the 'industry' adopts as standards, and we move on. Safer, more informed and 'educated'. In a perfect world there would only ever be 1 weather related accident. 1 Human factor related accident. 1 CFIT accident. 1 disorientation accident after last light. etc, because, like we all say, we can all learn from the mistakes. Right?.. Well why are there countless accidents involving the same or similar circumstances? Now it may seem ludicrous and of course it is, to think the entire community would learn from the mistakes made and never have an issue because ALL the mistakes have been made and never again see the problem appear. The perfect world is a figment of the imagination. But why?.. Why do people seem to be having the same "sorts" of problems?.. I will attempt to answer this question as best I can. However, a disclaimer, I am no expert, I dont profess to hold all the answers, Im meerly offering my opinion. To understand WHY people cant seem to 'learn' from others mistakes, or indeed even there own, I think a good place to start is looking at the definition of learning itself. There a few different definitions getting around, but a common one is this. Learning" A change in behaviour brought about by gaining knowledge, experience or information." A CHANGE IN BEHAVIOUR. Think about that part of the definition for a moment. To learn something, we MUST (by definition) change.. If there is no CHANGE, then there has been no learning. A rat in a cage soons learns not to grab the cheese because its hooked to 12 volts and zapps the sh!t out of him. How do we know he has learned?.. Because he doesn't grab the cheese any more. His behaviour hase been changed through experience. He has LEARNED. Your instructors, the RAA, CASA etc all try to "teach" us the dangers involved in this hobby of ours. Sometimes those dangers are subtle, sometimes they smack you in the face, but if our 'behaviour' doesn't change, then we have failed to learn. We can answer all the questions in the Human factors exams, sit through the briefings and score 100% on the test. But does this mean we have "learned" about human factors and the dangers? Unless your behaviour is changed, then the answer is a big fat NO. You havnt learned diddly... So why dont we seem to be "learning". Why is our behaviour NOT changed by the storys we read or the incidents we witness. At our airfield recently, there was an horrific helicopter crash that took the lives of two people. Reflection and discussion on the accident (amongst witnesses) soon identified ways that this accident could have been avoided. The biggest "learney" bit was how important the use of checklists can be. Now one of my instructors admitted that he rarely uses them anymore when hes flying privately. In a briefing (about the accident) I indicated that perhaps it would be a good idea to take the practice back up. He claimed " I will do it if it makes you feel better, but I know the checklist off by heart". Little did he realise that on a flight just the day before this briefing (with he an I ) I noticed he forgot the control check just prior to takeoff. So apparently he DIDNT know the checklist, or, he forgot. Regardless the check wasnt done (by him). Now this was AFTER the accident, where we all clearly identified that a checklist would have no doubt saved them. Now he witnessed the accident, he was forced back by the flames as we tried to save them. He smelled the smells and heard the noises, but, FAILED TO LEARN from it initially.(he has since started using them) Im not chipping him, im using this as an example. The behaviour wasn't CHANGED so nothing was learned. So back to my question. WHY.. WHY are we not learning? I think the answer is this. We are not learning because before we can learn, we must first UNLEARN. (Bare with me) I am sure that a high percentage of accidents involving non compliance and human factors, didnt happen the first time the pilot performed the risky act. So his behaviour was reinforced due to the fact that he probably got away with it. From the first time he gets away with it his behaviour is CHANGED (for the worse)...he has learned.. He has learned that he CAN fly through the cloud. He has LEARNED that he can fly after last light. He has LEARNED he can do a nice loop in a jabiru. He has LEARNED that you can fly around for more than half an hour without changing fuel tanks. Before we can learn from the mistakes of others we must FIRST UNLEARN what we know (or think we know). We must first identify in OURSELVS behaviour that has been changed, behaviour that is unsafe, and STOP doing it. This will require complete sekf honesty. No excuses. No "oh but i knew i could turn the lights on, or I knew the cloud wasnt very thick..Total self honesty. Identify the behaviour in YOURSELF that has changed for the worse, and fix it. UNLEARN it. Sigmund fraud was famous for (among other things) rasing the theory that : All men are driven by 2 fundamental desires.- SEX, and the desire to be great. Im not going to touch the first one, but the second fundamental desire is something that we ALL share to some degree or another. This brings me to my next point, and one I raised elsewhere. WE as an organization as a WHOLE have the power to stop almost ALL of these human factor related accidents. You, me, your instructor, the old guys sitting in the hangar, the engineers, the RAA, CASA. EVERYONE has this ability. We have the ability because we have the power of the second fundamental driving force behind all men. The desire to be great. We have the power because greatness is in the eye of the beholder. What is great?. What do we think of when we think of a GREAT pilot. In aerobatic circles, a great pilot may be someone who consistently flys flawless routines, wows crowds and wins competitions. Now if that same pilot takes off from your local airfield in a Jabiru and then performs a few loops and rolls for your enetrtainment, is he still a great pilot? Are you going to pat him on the back when he lands and say "wow man, that was sweet". While watching this display are you going to call your mates out of the hangar and say "come check this out, this guy is unreal".. OR Are you going to call your mates out and say, "have a look at this wanka" Greatness is in the eye of the beholder. If WE ALL change what we consider to be GREAT or good, then people will aspire for that greatness. They will, in their desire to be great, behave in a way that THEY think will be seen to be great or good. And that is where our power lies. Dont praise bad behaviour, ridicule it. Shun it. Applaud good behaviour. Nice cct there barry, very nice landing. Great use of the radio. Thanks for communicating well when I was inbound. Praise good airmenship TO EACH OTHER. It doesnt have to go to the pilot, but rather evryone else. Hey, did you see steve doing a walk around with a checklist? Yes, hes very pro, a good airman. Now after being exposed to this praise (about someone else) all that have heard you or been around you will aspire to have that praise thrown in their direction. They will LEARN what GREAT is. They will WANT you to talk about how safe they are because they have the same basic desires... The desire to be GREAT... This, in my view is culture... Its the raw, take home, usable culture that we ALL can have a direct effect on. Had this culture existed at YTEM on sunday afternoon then im SURE that in his desire to be great, Ian would have packed his trike up and drove the hours drive instead of taking off. His desire NOT to be ridiculed by his peers would have over ridden the desire to get home. Greatness is in the eye of the beholder.. We are ALL the beholders, we have the power to change what GREAT is. Lets change it. My 2 cents. 12
facthunter Posted April 11, 2012 Posted April 11, 2012 Peer group acceptance has a lot to do with it. many who do fool things are encouraged by the onlookers to do it. Pilots are often inclined to show how good they (think they) are. It's boring to just do the right thing. A GOOD pilot is someone who doesn't put an aeroplane into a situation where he/she has to be an exceptionally good (or lucky) pilot to get out of it. I know that I bore people by ratting on about safety, but I feel that something is needed. I have lost too many friends. This never happened when I was younger and it was usually something wrong with the plane, back then. Airmanship was taught, always. This generation doesn't just accept rules that easily either but the accidents are not with the young ones. I don't know what is wrong in absolute terms, but it must get back to the training, OR some of us have an attitude which just doesn't fit right with the art of SAFE flying. Nev 2
farri Posted April 11, 2012 Posted April 11, 2012 For me, no apology required! You kept my attention to the end! Frank.
Bandit12 Posted April 11, 2012 Posted April 11, 2012 Freud's theories have plenty of shortcomings but what you mentioned about behaviour reinforcement (look up B.F. Skinner) is very relevant. If I do something, and something else that I perceive as positive happens as a result, I am more likely to do it again. Positive reinforcement - we have all had our ears bashed about by the media at times about using it for parenting. It certainly applies when it comes to pushing our boundaries and fueling our "it can't happen to me" attitude which I mentioned in another thread. Behaviour change is a very slow process that needs to be specifically targeted and needs a lot of persistance to make lasting change. For some people, a single traumatic event is plenty of reinforcement (tecnically positive punishment by vicarious learning, rather than reinforcement) and for others, constant reinforcers and punishers are needed.
sfGnome Posted April 11, 2012 Posted April 11, 2012 Thanks Motz. I really appreciated that post. Maybe it's this sort of discussion getting through to me, or maybe I already think this way, but I read a mate's story about his solo overnight bushwalk last weekend; all about all the places where he could have slipped over a cliff in the fog and how he ran out of water well short of the next creek, etc, etc, etc, and all I could think was "you crazy dope! Why are you boasting about being so foolhardy??" I wonder how many other people read it the same way I did, or alternatively how many though "Gee, isn't he brave..." 3
ayavner Posted April 11, 2012 Posted April 11, 2012 I think the desire to elevate the sport by passing on this sort of knowledge and wisdom is the very embodiment of Airmanship. Thanks Merv!
Guest Howard Hughes Posted April 12, 2012 Posted April 12, 2012 PS..Sorry for the long post... My eyes normally glaze over after a few lines of a long post, but thoroughly enjoyed every word of that! I have just two points. - Mostly I think men desire to be accepted among their peers, rather than great! This sometimes leads to risky behaviour in order to be accepted. - Secondly I have a theory that says everyone is allowed to make every mistake once. It is when we fail to learn from our mistakes, or make conscious decisions to go down the same path of a previous mistake when we have an attitude/learning problem. I can't remember who said it, but aviation is about getting yourself in situations where you think "I don't want to be here' and having the good sense not to get yourself in that position again!
facthunter Posted April 12, 2012 Posted April 12, 2012 I thought survival came very high on the list with Freud. In a primitive situation where you are going to be eaten by wild animals or fall off a cliff if you are not careful, the situation seems more obvious than it does with aviation, where one minute everything seems to be going well and then it all goes pear shaped for the unwary. There are enough unknown dangers in flying without taking KNOWN dangers into the air with you. Another one... There OLD pilots and there are BOLD pilots, but there are no OLD, BOLD pilots. ..............Nev
Guest davidh10 Posted April 12, 2012 Posted April 12, 2012 Attitude has a huge bearing on uptake of new information and an ability to re-evaluate one's own behaviour in light of the new information. The right attitude is partly a facet of the individual's personality and that part is very difficult to affect, however part of it can be attributed to the teaching / learning process and the environment in terms of other's attitudes (as expressed or demonstrated). That is the part that can be improved. Not of course forgetting that it isn't just schools from which we learn, but from everyone around us, all the time, if we are smart enough to sift the good oil from the chaff (to mix a metaphor). .. I have a theory that says everyone is allowed to make every mistake once. It is when we fail to learn from our mistakes, or make conscious decisions to go down the same path of a previous mistake when we have an attitude/learning problem.... We'd all be dead if that were true, but I know what you mean and agree with it. Perhaps restated: People shouldn't make the same mistake twice, but learn from it the first time. To paraphrase Motz, if a person makes the same mistake a second time it is evidence they did not learn. This should also encompass learning from the mistakes of others, so we don't make the fatal mistakes for which we know the causes. Unfortunately, some people's attitude makes them impervious to learning. Some improvement is better than none, but it is unlikey to achieve the overall goal. We only need to look at how OHS has changed the workplace in the last few years. The overall target is good, but we are now burdened with so many silly rules that are targeted at the lowest common denominator (both employers and employees), and the cost of goods and services has increased significantly because of such. At the same time there are still people who just don't grok personal safety. I have had to speak with several contractors over the last few months because they were operating power tools while wearing safety glasses on top of their heads. Another, last year where one person with appropriate PPE was using a hammer drill to drill masonry while an assistant with no PPE stood beside the drill to hold a piece of equipment against the wall, while the other drilled through its mounting holes!
ayavner Posted April 12, 2012 Posted April 12, 2012 Seems we (as people) are good at the Letter of the Law, but not so much the Spirit?
naremman Posted April 12, 2012 Posted April 12, 2012 It ain't short Motz, but anybody who has taken the trouble to read such a well thought out espistle would surely have picked up many grains of wisdom Any apology for its lengtth is completely unessessary. The title to his thread brought a wry smile to my face. A while ago, as a testosterone charged 20 year old, I was about to embark on my aerobatic training with John Douglas, the then CFI of the Royal Aero Club of WA. John enquired why I wanted to learn aerobatics? I responded to the effect that I owned an aerobatic aircraft, I was keen to experience aerobatics, and was looking to improve my overall flying skills. "Just remember, far too many aerobatic pilots have died less than a mile from their girlfriend's house" was the salient rejoiner. Whilst my late first wife was happy to have me doing aeros over my airstrip, both my late mother and second wife were firmly of the opinion in they not only did not wish to observe the activities, they did not want to hear them either!! Most of my aeros locally have been conducted 10 miles from home, downwind. 1
motzartmerv Posted April 12, 2012 Author Posted April 12, 2012 My eyes normally glaze over after a few lines of a long post, but thoroughly enjoyed every word of that! - Mostly I think men desire to be accepted among their peers, rather than great! This sometimes leads to risky behaviour in order to be accepted. yea howard, im with you, but even that can be broken down to one of the basic driving forces that freud talks about. perhaps both, depending on the ...uhhuumm,... attractiveness of those peers..:) Im so glad to see a few of you have understood where I was coming from ( i knew id loose a few due to the length) but I was concerned I wouldnt be able to articulate my views. I think that some of Nevs comments in this and other threads are very telling. Fot those who don't know, Nev is probably one of the most experienced guys getting around today (for sucha young fella) He spoke of the early days and how rare accidents involving human factors or pilot error were. Mostly it was some sort of mechanical problem. So logic should dictate that as our technology has improved, fatalities should be less common due to more reliable technologies and manufacturing techniques. But clearly there has been a reversal. We are actually crashing more per hour of flying then we did in the good old days. This fact alone indicates we have a huge problem somewhere. Im sure the reasons are not clear cut and simple, but I can think of a few casual factors that may be at play. * Reliance on technology * Faster, busier lifestyles promoting get there itis * False security in "safer aeroplanes" * Airmanship being a 'concept' rather than an engrained, inseparable part of aviation, at ALL levels. * Last but not least, culture. Sorry to harp on, but I believe the safety culture is and has been on a downturn for some time. This is evident in some recent events in the governing bodies 'decision' making. For instance, some time ago the whole idea of hiuman factors as a subject rared its ugly head, and guys that had been flying for decades, suddenly had to hit the books (as did the rest of us) and study up on this human factors thing. Most of them, when talking about it, would say "they use to call this airmanship back when I was flying". It seems somewhere along the line airmanship stopped forming THE underlying principle in flight training and operations. Not some seperate part that could be studied and passed, but part of the fabric of aviation itself. They used to fly Passengers around the world, through thick and thin, day and night, in aircraft that by todays standards had all the technology of a digital watch. Without GPS, without INS, without VOR's etc. But it was still a safe, viable means of transport for one major reason.. The pilots were AIRMEN. There was no such thing as human factors because AIRMANSHIP meant, pilot.. It meant aviate. Just have a look at the connie parked at wollongong. Its roof has a dome where the navigator would use a sextant ( i presume) to get star fixes and plot position and course. ARE YOU KIDDING ME???... This was an airliner.. Thats how it was done, and done with huge success. These days we have autopilots crashing airliners in swamps while the crew change a lightbulb. Further, recently CASA identified a problem with the standards of pilots obtaining a CPL. So they started a campaign (still ongoing) whereby they would alomst ensure that every instructor cantidate would fail his/her first test. That was their way of improving standards. A nice Idea, make the instructors better, and then we will have better pilots. But no addressing the culture. No grass roots take home methods for improving the safety culture. They try, but I am yet to see many changes in this regard. Failing the instructors on their first hit out did not improve them, just made them perform better during the test the next time round. And anyway, most have their eyes on the big shiney jets and aren't interested in producing good quality, safe AIRMEN to share the skies with them in the future. A point I like to make with Instructors is this. When a student rocks up for a flying lesson, the lesson doesnt start when they sit down for the briefing, or they walk around the aeroplane, or they sit in the plane and start up.. The lesson started well before then. At the initial contact. The moment they walk in, ring you up or whatever. The entire time a student is in your presence or at the airfield, they are learning. They are learning so so much and dont even realise it. The way aN instructor conducts himself, speaks, interacts with other pilots, other aircraft is ALL part of the learning. Students are like sponges, obsorbing everything they see, hear touch smell and taste (bad coffee is a must).. Sure we must teach them about aerodynamics etc, but the airmanship, aviator part is all encompassing. A quick example. I often tell a story, about my second ever solo. A flight where I stupidly flew low over a friends house.. So low infact that i almost hit a SWER line in his back yard. Stupid, dumb, impulsive act that could have...no...SHOULD have killed me. Now there are two ways I could tell this story. 1. Back when I was learning they made us tough. My second solo was out in the training area, I buzzed me mates place, almost hit a wire, but I was lucky and she was all sweet. OR 2. Back when I was learning, My second solo was in the training area. being a young impulsive pilot, whod always dreamed of becoming a pilot and now had a plane in my hands, I buzzed a mates place to show off my new found skills. It was a quick, stupid decision that almost took my life. There were unseen dangers, let alone the fact I had ZERO training in low flying. I almost hit a wire which would have certainly killed me. When i saw the wire the next day and realized how close id come to it, I felt the colour drain from my face. I had been within a foot of death. It was then i realized that if I was to survive aviation, I would have to do it by the book. no ifs, no buts. So thats the same story, told two different ways. Just an example of what im talking about.. Of one ways that airmenship is either encouraged and taught as part of the fabric of EVRYTHING we do...Or ignored, bypassed, taught as a sperate subject or a concept. All pilots have one thing in common...They love to talk about flying. Its during these conversations, airmenship can shine through, or dissolve. Like I keep saying, ridicule bad behaviour, praise good behaviour, in all your conversations, in all your dealings with other pilots...Eventually, that desire to be great (accepted by our peers) will bubble to the surface. cheers 2
turboplanner Posted April 12, 2012 Posted April 12, 2012 Motz, that's all about behaviour (known in the aviation industry as airmanship) When we were cleaning up the fatalities in speedway racing we started with the obvious - posts protruding above the safety fence which took people's heads off, then concrete safety fences of sufficient height to retain the car, then catch fences to stop the spectator fatalities, then a host of car specifications like roll cages, safety nets, neck brakes, fireproof overalls and so on and still we had a small fatality rate. When we started to focus on driver behaviour this dried up to a fraction of what's happening in aviation today. A couple of decades ago we had another outbreak of fatalities, all in one class, and after the dust had settled it became obvious that the standards of stewards had progressively slackened, driver testosterone had taken over, and behaviour had become progressively worse. In one video I examined over and over and over, I realised that the car of the driver being killed was sideways to the track, but was accelerating so fast...sideways...that he slammed into the back of the car ahead of him, still sideways. Of course it then became obvious that the guy following him on the track had killed him by deliberately slamming into him and holding the throttle wide open until the next crash, with the car ahead, did the job. What caused me to focus on the culture of bad behaviour however, was that after 30 or 40 viewings I noticed a very deliberate sideways lunge in the background, and there was a guy slamming the side of his car into another. It took a bit of very savage and repeated argument, but the stewards were retrained/replaced and there have been no fatalities or serious injuries in that class since. Appealing to the drivers would have been a waste of time; it was only when officials started laying down the law and backing it up with suspensions that behaviour changed. RAA has the ability to solve the current issues by doing exactly the same thing. 1
Tomo Posted April 12, 2012 Posted April 12, 2012 Being responsible and the consequences if not, is being squashed a lot these days I believe. It all starts at the beginning...
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