July 1, 1999
MARK R. TWOMBLY
Looking back on 32 years of flying light airplanes, I have to admit that I've made plenty of mistakes. I don't mean mistakes such as not buying a new airplane 20 years ago when one could be bought for less than the cost of an Ivy League education. (It wasn't much of a decision back then because I could afford neither.) I'm referring to mistakes in pilot technique, procedures, and judgment. Stuff that I could not blame on another man, woman, or machine. These mistakes originated with me.
None resulted in bent metal or a violation of the Federal Aviation Regulations. They ranged from the mundane — forgetting to switch the transponder to altitude squawk before takeoff — to the very serious, turning 180 degrees opposite the desired course when transitioning from an instrument approach holding pattern to the next leg of the approach procedure.
I don't like to admit to any mistake I make as a pilot. But I believe there is value in facing up to mistakes and, more important, discussing them. After I've mentally beaten myself about the head for being such an idiot, I try to analyze, as dispassionately and objectively as possible, what I did wrong. One of the ways that I do this is to talk about the mistake to a few pilots whom I respect and trust. On occasion I've even written about something stupid I've done during a flight.
It's embarrassing to admit error, especially cockpit error. None of us wants to appear unskilled or guilty of lack of judgment. Of deeper concern is the fact that "pilot error" has potentially serious safety implications. If I make a mistake in grammar or punctuation or fact when I write a column and it sneaks into print, I'll be taken to task by sharp readers, but usually that's the end of it. If I make a mistake in the cockpit, it could result in an accident.
Actually, it's rare that a single error will result in an accident. Typically a chain of events, born of ill-advised decisions, precedes an accident-failure to top the tanks before departure, followed by inadequate flight planning to account for fuel consumption versus groundspeed, and the final lousy decision that seals the fate of the flight: deciding to press on to the destination airport despite knowing that the remaining fuel supply is critically low. Change any one of these poor decisions — let's call them mistakes — and you alter the outcome of the flight.
Each of us makes mistakes as pilots. We know that we're fallible; we realize it when we screw up; we don't like it; and we don't like to admit to it. But, having erred, we want to know why we did it and how to prevent it from happening again.
And that's why I talk about my errors in technique, procedure, or judgment. I believe it is instructive; it helps me to understand why I goofed. And even though it's embarrassing to do so, I may write about it because I think others can benefit from my experience.
It's why aviation magazines write about aircraft accidents and publish first-person accounts from pilots who have survived harrowing experiences. We learn from our mistakes and the mistakes of others.
In the professional pilot ranks, there is a growing movement to institutionalize the reporting of mistakes by flight crews. The motivation is the right one — to learn what mistakes are being made and under what circumstances, so that reasonable people can analyze the facts and discern why the mistakes occurred in the first place. Once you've identified the why, you can begin to clear a path to prevention.
The pros' understandable hesitation to embrace full disclosure of their mistakes is the fear that the information will be used against them, not so much by the FAA cops, but by their employers. There's a lot of talk about educating management on the value of encouraging flight crews to be open and honest about "unusual occurrences" because the information is crucial to understanding why they take place, and designing solutions.
One focus of this effort to collect and analyze mistakes is NASA's Aviation Safety Reporting System — ASRS. Traditionally, ASRS reports submitted by pilots describe errors such as altitude busts resulting in a loss of IFR separation standards. That and other ASRS "regulars" are piloting mistakes that conceivably could result in regulatory violations. But because the ASRS program does offer reporting pilots some protection from FAA enforcement actions, the reports tend to be of significant mistakes.
That's fine, but why not also use the ASRS medium to report minor mistakes, ones that don't necessarily constitute a violation, but that are examples of misunderstood concepts and misapplied procedures? Having a compendium and analysis of commonplace pilot mistakes and the circumstances surrounding those mistakes should lead to helpful remedial efforts. New pilots could be better trained, and existing pilots coached, to eliminate the potential for making those errors.
Using ASRS for formally reporting the slips and pitfalls in our performance is one important way that each of us should be talking about our piloting mistakes. We also should go to fellow pilots, instructors, and flight schools and discuss our shortcomings in the spirit of learning and improving.
Self-annointed super-pilots don't do well in an atmosphere of honesty and openness about occasional falls from perfection. The rest of us should find the air refreshing and restorative.
Safety and Education,
Pilot Training and Certification
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AOPA thanks our members for their continued support in protecting the freedom to fly.