Friday, 24 February 2017

How do pilots stay disciplined in their use of knowledge?

One of the biggest challenges is knowledge re-use. How does the aviation industry address this challenge?

Image from wikimedia commons
I often refer to aviation as a successful example of knowledge management, with lessons captured from every accident and incident and provided to pilots in the form of checklists, or shared through site such as the Skybrary.

But how does the aviation industry address the issue of knowledge re-use? Why don't experienced pilots skip the checklist?

We know that this is a big challenge in other industries, and that experienced doctors, engineers, programmers and consultants often do not re-use knowledge, but rely instead on the knowledge they already have. How do you make sure that experienced airline pilots, with thousands of hours under their belt, stay disciplined and use the checklists, even after they have become routine?

  • Because if they skip it and it was not OK they can be fired and lose their license
  • In four years in an airline cockpit I only encountered 1 person who didn't respect checklists. Perhaps not coincidentally he did not make it through his probationary year and was fired 
  • Because if they skip it and it was not OK they could DIE
  • On commercial flights, key checklist items are forced by using a procedure call a "cross check". The one pilot must "challenge" another for those specific check list items. 
  • The cockpit consists of two people, one reading/actioning the checklist, the other one monitoring and checking/cross-checking. If you say: "Nah, no checklist today", your copilot is bound to say: "Sorry, but we have to!" 
  • The importance of a proper preflight is drilled into you by your primary instructor from day one in light aircraft, and that mentality carries through all the way up to heavy transport-category aircraft: You want to find any problems you can while you're on the ground, because if you take a problem into the air with you it's a decision you can quickly come to regret.
  • If you do it often enough, it becomes a habit. It then feels wrong to not run the checklist. 
  • You stay vigilant by having seen things go wrong.
  • Everyone expects everyone else to do the checklists properly and if you don't do it you will get called out. 
  • In an airline environment you will have recurrent checkrides every 6-12 months and captains will have line checks every year and proper checklist usage is among the most basic requirement to pass these checks.
  • Every year we sit through a day of crew resource management training and part of that day involves looking at past accidents and understanding what the first thing was that set the accident events in motion (pilot error!). These often serve as vivid examples of how bad things can get if you start ignoring the checklists (among other things) 
  • There are a few tricks that are used to stop you falling in to that "Yeah, everything will be fine" mindset and just skipping the checks 
    • Not doing the checks from memory, but actually doing them in reference to a physical check list. 
    • A prescribed order of checks, starting at a point on the aircraft and moving around methodically 
    • The fear of missing something, such as engine oil levels, which gets very serious once airborne. 
    • Once carrying passengers, especially nervous ones, they tend to feel safer when they've seen you PHYSICALLY checking the aircraft before flying it. 

We can see several factors at work here, including

  • a logical and emotional case for learning (we might die, our passengers might die, better to fix things on the ground, fear of missing something), 
  • peer pressure from the copilot (you will get called out) and passengers
  • you might lose your job if you skip it
  • an awareness of what might go wrong (looking at past accidents)
  • training (from day one, and every year)
  • audit (checkrides)
  • physical lists (not relying on memory)
  • logical lists (prescribed order of checks)
  • habit

Many of these can be transferred from the aviation sector into other sectors. You could imagine a company where the re-use of existing knowledge (in checklists or procedures or
other guidance) was mandatory, trained, supported, checked, believed-in (perhaps through regular analysis of failures), audited and habitual.

I agree this is a long way from where many of us are at the moment, but it is a vision for how one industry supports the re-use of knowledge.

To finish, here is a personal story from the Stack Exchange thread of how one person re-learned the importance of checklists
  •  In my case, I learned the discipline to use a checklist for every action on every flight the one time I decided not to use a checklist while taxiing from the fuel pump back to the parking ramp. It was winter, and a snowplow pulled up behind me, so I decided not to use the checklist in the interest of expediency (ha!). I primed the engine, checked the fuel valve, engaged the electrical system, keyed the starter, and the engine responded by firing up and then immediately dying. Repeat about a half-dozen times, at which point, I finally decided to use the checklist because something obviously wasn't right. Once again, primed the engine, checked the fuel valve, move the mixture to the rich posi-- Oh...I had left the mixture in the idle-cut-off position. Oops. I've used a checklist religiously ever since then ;)

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