In a recent post I talked about the linkage between golf and process. My contention was that good golf is process based to the point where measuring the appropriate item and focusing on improving the process around that item can reap dividends.
Now I want to expand on that by giving an example where this is not appropriate
Flying.
Last year I got my Private Pilot's Licence and I now spend as much time as I can afford in the 'wild blue yonder' learning as much as I can about the plane, navigation, Air Traffic Control, circuits, VP propellers etc. etc.
It struck me recently that flying is very much process based and usually it is when processes fail that aircraft accidents occur.
Let me give you an example: Most Controlled Flight Into Terrain (CFIT - basically a plane hitting a hill, mountain or rising ground) is a result of several factors: Tiredness, lack of concentration, spatial disorientation, flight into poor weather, lack of communication, wrong pressure settings on the altimeter and poor flight planning. Basically all of these can be solved through an appropriate process.
Tiredness: Business Rule"Don't fly on less than 8 hours sleep"
Lack of concentration: Process step "Follow appropriate check lists when operating"
Spatial Disorientation: Process Step "Follow Instrument readins to remove disorientation"
Flight into poor weather : Decision "Is weather bad? If yes then turn back or land immediately"
Lack of Communication : Process Step "Always contact ATC and keep them informed" plus 'Read back all clearances and permissions"
Wrong presure settings on Altimeter : Business Rule "Review Altimeter setting regularly and confirm setting with ATC"
This is, actually, a rather flippant approach to what is a very complex matter.
Flying is controlled by processes. Check lists, standards, licenses, ratings, reviews, evaluations etc. All of these things apply to pilots worldwide - from folks like me who have less than 100 hours experience on a single-engined plane right through to the guys with thousands of hours flying 747's across the globe. We are all subject to the same standards when it comes to flying.
All of these standards boil down to one thing: The correct way to operate a flying machine. In other words the
process of flying. Every plane has a Pilots Operating Handbook (POH). The POH mandates performance envelopes for just about every factor regarding the plane itself: How much fuel it can carry, how much fuel it uses at what speed, how fast it can climb, how high it can climb, what is the best speed to glide the plane in at if there is an engine failure, what's the fastest speed this plane can fly without damaging the structural integrity. In the process world these parameters are either business rules or decision criteria.
Likewise, a pilot has a set of criteria to govern how he flies: Is he approved to fly this type of plane? If he is, can he fly in bad weather, or at night? Can he fly a plane with more than one engine? Can he fly a plane where the cockpit is primarily computer screens rather than the traditional dials?
Even before getting into the plane the pilot has a list of items that need to be carried out - the pre-flight checklist: How much fuel is in the tanks? Has the engine compartment been visually checked for oil leaks? Is the oil level in the engine between acceptable limits? Are the flying surfaces free to move? Is there damage on the leading edges? Do the wheel supports have sufficient travel in them? Are the pitot tubes blocked? Are all the radio aerials attached correctly. Do the flaps extend fully? Does the fuel pump work? Do the radio's work?
The list extends once the pilot gets into the cockpit: Are the dials functioning correctly? Are the circuit breakers set appropriately? Is the compass deviation card present and up to date? etc. etc. etc
Even when talking on the radio there is a set protocol to be followed (In fact you can't use a radio without having passed a specific exam and been granted a Radio Telephony Operators certificate).
All of these things work together to reduce the possibility of misunderstandings, omissions, errors and issues.
But of course problems still occur. So why is that?
Mainly, because there are human factors involved. A large proportion of aircraft accidents have an element of human error as the attribute. The worlds worst air crash (Which occurred between two 747's on the runway in Tenerife in 1974) was caused by a pilot hearing what he wanted to hear on a radio and not what was actually said. This was because he wanted to hear a take-off clearance rather than a delay. A delay would put the crew passed their flight window and result in them not getting back home that evening. He heard a take-off clearance and went, unaware that another 747 was taxying up the runway at that point. The two planes collided in fog resulting in 583 fatalities. At it's basic level this was a process failure because the pilot did not read back the correct clearance and this resulted in a communication error.
Let's come back to earth (so to speak) and talk about something a lot less drastic, but still as dangerous: Carb Icing. Without going into too much detail, propeller planes that are not fuel injected have a carburetor. The carb feeds high pressure air into the engine to allow it to work. however the mere fact that it is high pressure (it is forced into the engine through a constriction rather like putting your finger over part of the end of a hosepipe) means that certain physical forces come into play regarding temperature. The long and the short of it that under the right conditions (i.e when you have lots of moisture in the air and cold air in the carb - or example when you reduce engine power), a large lump of ice can form in your carb and stop your engine. Not what you want! To combat this, engines have a carb heater which can be turned on to remove the ice blocks. They generally work like a treat. However they can't be left on too long as they reduce the efficiency of the engine. Therefore there are key moments when you can add carb heat to be most effective.
The process says you add carb heat when reducing power on a warm day. The process says you add carb heat when making final checks for landing (although you don't keep it on). What the process doesn't say is that you add carb heat during taxying over wet grass on a cold day. However this is another occasion when ice can form.
So is the process wrong? No.
The '
rule' attached to the process says that carb heat should be applied 'whenever conditions for carb icing are present'. Training should indicate that any occasion which would allow moist air to enter the carb under conditions where the temperature is low should warrant carb heating. The problem is that the conditions for carb heating are not always known and understood.
Believe or not carb ice can form in an engine when the outside temperature is 20 degrees celcius. It can also form very quickly so action needs to be taken ASAP. I learned to fly in Florida with very high ambient temperatures, but was still taught to add carb heat at the appropriate time.
All this could lead us to think that even if the process works correctly there are always circumstances where things can fail. This is, of course, absolutely true. What happens when all the process and procedure is followed and there is a technical issue with the carb heater? Answer: The engine will probably starve through lack of oxygen, stop working and you will be forced to follow a different procedure that of an emergency landing.
"But isn't flying a skill rather than a process": I would maintain (in a similar way to my golf analogy of recently) that the skill comes in the application of the process to the best ends. Good pilots are those who have technically applied the process to a finite degree of skill. The guys who know exactly the correct approach path to bring a plane down at it's POH operating speed and bleed the airspeed off until it stalls right onto the ground without a bump or a jump. These are the guys who are following the process in exactly the right way. The pilots who drop the plane from a height after realising they are going to overshoot the runway, slam the wheels onto the tarmac, bounce (or 'porpoise') three or four times down the runway and then wear the brakes down trying to stop before reaching the end are the ones who haven't followed the process correctly.
Being a good pilot actually means being a skillful process follower!
For more about me check out my "About Me' pageAll information is Copyright (C) G Comerford
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