Still being an active motorcycle rider at age 75 – I know, I know, I’m crazy! – it is quite disturbing to read nearly on a monthly basis about a motorcycle involved in an accident with a car in which the car driver is reported to have said, “I never saw him! He wasn’t there when I looked!” Yet the rider, if still capable of talking, often states, “The driver looked right at me before pulling out in front of me!”
I am convinced that looking without seeing is a very common human shortcoming. In my years as a flight instructor I have observed it hundreds of times. Take this recent example:
I was conducting annual recurrent flight training for a King Air operator’s group of four pilots. Although I never pull sneaky, unbriefed, surprises when conducting initial training, “all’s fair in love and war” during recurrent sessions. Trim runaway, inverter failure, pressurization failure, flap failure, GPS unit failure, engine gauge failures … are all common malfunctions I present.
As we departed the airport heading out to an Initial Approach Fix (IAF) for an LPV approach involving a course reversal, I pulled the circuit breaker for the right engine’s oil pressure gauge. We were climbing through about 500 feet above the airport when I did my dastardly deed, in a climb to 5,000 feet. Passing about 2,500 feet the pilot went through the After Takeoff flow pattern/checklist, including even running his righthand fingers down the stack of engine instruments, from top to bottom. “Looking good,” he commented. I bit my tongue. In fact, he did it again nearing our level off point, still not seeing that the right oil pressure was reading zero.
“Charlie!” I cried. “That’s twice now that you have missed the failure I’ve given you! Scan those engine gauges one more time. Slowly and carefully, this time. What is wrong?!” Finally, he noticed the lack of oil pressure. Poor fellow was very chagrinned.
This happens with distressing regularity as I have conducted flight training since 1968. It no longer surprises me in the least. There is a big difference between having an image from your eyes being received by your brain and yet that same image being totally recognized and understood: Looking versus Seeing. I think there are two leading reasons for this failure to observe what can be so readily apparent.
The first reason is going too fast, not taking sufficient time for the eyes to truly lock onto the item of interest and for the brain to process what the eyes see. “Expectation Bias” is the technical term that relates directly to this phenomenon. Your cerebral cortex thinks, “Since that instrument has read normally the last 500 times I’ve looked at it, can’t I expect it to read normal the 501st time, too?!”
This points at the second leading reason for looking without seeing. I call it a lack of “Judicious Suspicion.” Suspicion alone, without the modifying adjective judicious, can head one to a psychiatrist’s couch or a mental institution. Living in a constant state of concern and fear that “something is out to get me!” is a state of existence that no one seeks to abide. Yet judicious suspicion is a very healthy attitude, perhaps especially for pilots. It leads to thoughts like these:
“Just because there has never been another aircraft flying unannounced formation with me in my 8 o’clock position before I made my left turn, doesn’t mean there won’t be someone snuggled in there this time.” Or, “Just because I never got distracted on a preflight inspection before and left an oil dipstick loose instead of properly secured, doesn’t mean that I can assume it’s tight this time.” How about, “Just because the flaps have always extended to the Approach position whenever I moved the handle down to the first notch, doesn’t mean they will be this time.” And, “Just because there have always been ‘Three green, no red’ after I put the landing gear handle in the down position, doesn’t mean it will be so this time.” Get the idea?
We must all accept the sad fact that mechanical, electrical and hydraulic systems can fail, as well as the human species can make a mistake – at any time. Even the very best of pilots can, and do at times, make errors. The attitude of Judicious Suspicion plays an absolutely huge role in minimizing these errors in the first place and catching them before they lead to unnecessary danger in the second place!
I’ll let you in on a little humorous remark that I have made many, many times during training. As we taxied off the runway to head back for another lap around the pattern, I’d say, “I have some good news and some bad news. The good news is that you made a rather acceptable no flap landing. The bad news is that you didn’t know it was a no flap landing!”
Yes, many times after I had pulled the Flap Power circuit breaker in cruise, the failure of the flaps to extend to Approach – and to full Down later – has been completely missed. A few times, the pilot even remarked on the tendency of the airspeed to be a little fast. That should have triggered the Judicious Suspicion step of investigating why the airspeed was fast. Better yet, knowing that controls are not indicators, an ingrained procedure of the pilot with Judicious Suspicion is to never remove the hand from the control – in this case, the flap handle – until the indicator shows the proper flap position. Same with the gear handle … even more critical. Same with the Windshield Heat switch … less critical but important, nevertheless. Same with Engine Anti-Ice, same with Autofeather, and on and on and on …
Have you been taught this oh-so-easy technique? Never let go of a control until the indicator shows what did or did not happen? It makes me angry that many of you are hearing/reading this for the first time. Your past instructor(s) should have done a better job if this is a new technique for you.
I’ll tell you the story of perhaps the worst case of asleep-at-the-switch piloting I have ever personally observed. I was performing on-site ground and in-airplane flight training for a gentleman who was transitioning into a King Air B200. The airplane was to be used in a charter operation so the fellow was facing an FAA 135 PIC ride the day after we finished our training. This fellow was highly experienced in 135 ops, but most of that experience was a type of “bush” flying in piston-powered single and twin, non-pressurized airplanes.
Pressurization was a totally new topic for him so we hit it hard in ground school and tried to demonstrate its use in detail during the flight training. The significance of the Cabin Altitude/Differential Pressure gauge on the center subpanel received lots of attention, especially the importance of observing their readings in the After Takeoff checklist. No P, no pressurization taking place means a malfunction; an abnormality; something needs to be addressed.
After about 10 hours of flying, the initial training was complete but I stayed on to conduct additional training to get him set for his 135 checkride. Most of this was “under the hood,” practicing various instrument approaches, coupled with some engine failures and other system abnormalities. As we taxied back after one approach to depart for another, I secretly moved the Pressurization Control switch into the forward, Dump, position. I directed him to climb to 8,500 feet for some air work before executing the next approach. As we climbed, of course there was no ΔP, the cabin altitude was the same as our altitude, and the cabin rate-of-climb was matching the airplane’s. I asked him to repeat the After Takeoff checklist a second time, asking him to be particularly careful since something had been missed. Still the problem was not caught. I then pointed out the problem to him, again discussed the meaning of the “pressurization performance” gauges, showed him the mispositioned control switch, put it back in its normal, center “Press” position, and we continued the session, now with the cabin descending back to its proper altitude.
The next day I again failed the pressurization and again it went undetected until I discussed it with him.
The final day, the one before the checkride, the weather was severe clear, he was again under the hood, and again the pressurization was failed by me. We climbed out without any recognition of the problem on his part. It was maddening to me. Since my previous training and discussions had obviously failed to get the needed knowledge implanted, I gritted my teeth and vowed that he must discover the problem on his own. I had assigned 8,500 feet but now I amended the clearance and asked him to climb to 13,500. Passing about 7,000 feet he remarked that the cabin seemed louder than normal. I agreed with his observation and in a feeble attempt to instill some Judicious Suspicion I added, “Wonder why that is?!” My hint fell on deaf ears.
Passing 12,500 I was expecting the Cabin Altitude Warning annunciator to illuminate. That should get his attention! Guess what I found. The annunciator was inoperative! Add that to the squawk list we were creating. Damn! About this time, he again commented on the extra noise in the airplane – primarily due to the vent windows not being pressed out against their seals – and again I concurred and hinted that there must be a reason.
“He’s got to figure this out himself, this time!” I screamed to myself. I noticed a couple of chewing gum wrappers in the cup holders on the pedestal. “Let’s make the cockpit a little neater,” I said as I picked up the wrappers, opened my side’s vent window, and threw them out! No reaction whatsoever! That this action would be impossible with that vent window subject to over 250 pounds of force pushing it closed never registered with him in any way!
Screw it! I’m going to get him so high that he will notice some signs of hypoxia, so I asked him to keep climbing to 17,500 feet. This was so long ago that I believe all statutes of limitations have been met so I am admitting that I was now illegal since we passed 14,000 feet without oxygen masked donned. You can bet I was checking my cuticles regularly and if they started turning purple instead of their normal pink, oxygen masks would have been donned and my little experiment in learning would have been terminated. But, happy to say, we stayed pink for now.
“I know,” I thought. “I’ll give him some complicated amended clearance and maybe his onset of hypoxia will be noticeable as he struggles with the clearance.”
“Uh, King Air 12345, I have an amended clearance. Advise when ready to copy.” My student made sure the autopilot was flying as he desired, got out a pen from his shirt pocket, poised it above his kneeboard, and announced, “Ready to copy.” Then the pen blew up!
He calmly pulled a handkerchief out of his hip pocket, wiped up what ink he could find, and continued waiting for the clearance. At last, I broke.
“Come on, Elwood! (Not his real name.) Twice you told me the airplane was unusually noisy, I threw gum wrappers out the window, and now your frickin’ pen just blew up! What do these things have in common?! We’re not pressurized!”
As I said, this may have been the most severe, obvious, case of lack of Judicious Suspicion that I have personally ever witnessed. At least it was funny!
In case you’re wondering, he passed his FAA checkride the next day.
My colleague Dean Benedict has written in these pages about the variety of processes he has seen used by pilots when they pick up a King Air that has been in his shop for extensive maintenance, such as a Phase Inspection or two. If there is ever a time that exhibits the need for Judicious Suspicion, this is it! That pilots would do a cursory walkaround, enter the airplane, close the door, start the engines, and taxi immediately for takeoff with no run-up checks ever done is mind-boggling to me. Yes, I freely admit that routine runups are not high on my priority list. Why? Two reasons. First, King Airs do not have a history of finding system problems during these checks. Manual propeller feathering, autofeather, rudder boost, autopilot checks, TAWS tests, etc., usually come through with no discrepancies observed. Second, no one can guarantee that because a system correctly tested in the run-up area, it cannot fail during the very next takeoff. Judicious Suspicion leads us to realize that this is indeed possible … not likely, sure, but definitely possible.
But coming out of the shop with a high probability that some of these systems were examined, tweaked and adjusted?! And forgoing your own test of the systems?! To me, it is stunning in its lack of professionalism, in its disregard for the attitude of Judicious Suspicion.
Some readers may think that I am coming on too strong, emphasizing a technique or attitude that rarely produces positive benefits. I disagree. Friends, as pilots we operate in an environment that, as the famous poster of the Jenny in the tree says, “Is terribly unforgiving of any carelessness, incapacity, nor neglect.” We must diligently work to catch problems before they lead to nasty surprises … including the possibility of the death of ourselves and our passengers.
Y’all be careful out there. See … don’t just look!