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Old 04-09-2010, 18:30   #1
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Know Your Systems, Avoid Complacency, Break The Chain of Errors

I posted the following in another thread, so I apologize for the repetition, but it would help me to hear the collective wisdom of Forum members on these questions.

I have flown for over forty years in a variety of aircraft from simple tail draggers to sailplanes to jets. Three parts of pilot training have always jumped out at me: 1) knowing your systems; 2) avoiding complacency; and 3) breaking the “chain of errors.”

1) Many of us learn our systems through trial and error. Whenever I am on a new boat, I feel somewhat adrift (pun intended). It takes a pretty long time for me to feel comfortable. I go to Flight Safety at least once every year for a week and “relearn” an aircraft's systems. Airline pilots go to their training programs at least twice a year – for each model of plane that they fly! For my boat, sure I do some drills (man overboard, for example), but do I do enough? For myself, I can say “no;” I am too busy sailing – color me lazy. Can you think of practical ways to make the systems side of learning about and training on our boats easier and more effective? Perhaps picking a handful of critical scenarios and preparing a written plan for each would be a good exercise – then review them before each offshore trip?

2) For me, at least, there is a little warning bell that starts ringing as a situation becomes more tenuous. Of course, experience refines the trigger point of the warning bell, which is entirely appropriate. Sadly, experience can drift into complacency and tends to quiet the bell down, which is dangerous. Are there ways to amplify the noise level on the “warning bell?” For example, a physical action, such as raising a little red flag in your cockpit, whenever you are nervous about anything, might trigger more of a reaction, especially when we are tired. Maybe this is just too silly.

3) It is rarely, if ever, the first problem or error that kills you. Pilots are trained to break the “chain of errors.” When humans are highly stressed, adrenaline floods through our systems. While this is an important physical response, it also has some negative effects. For example, every pilot, who has been stressed in a flight simulator, can appreciate how fixated you can become on one input or task when the aircraft needs you to “scan” many. I personally have been so focused on a popped circuit breaker that I lost track of the attitude of the plane (e.g. I went upside down) and … the circuit breaker was non-critical! Scanning is drummed into pilots for just this reason. Checklists are used to break the chain of errors. Typically, there are memory items on every checklist that must be memorized, because sometimes you don’t have time to pick up the checklist. How do you break the chain of errors and broaden your scan when it hits the fan?

I am NOT for a second suggesting required training or licenses here, both of which I would personally dislike intensely. The point of my posting is to stimulate useful and practical ideas in these three areas.

Any thoughts?

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Old 04-09-2010, 19:08   #2
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I went sailing today, 20 knots, beatiful weather. Lost my mainsheet purchase, the block just broke off. While running the sheet through a padeye and wrapping it around the windward winch, hit something in the water that forced the rudder up. It's designed, on my boat, to surface when there's trouble. So I'm handicpapped, big time. Main is tenuous, rudder is up, making stearing almost impossible.

Boat is pitching all over the place, sails pounding. First reaction is to look around. For other boats, land, obstacles. All clear, no worries. Set sails, stand on rudder until it sinks to where it belongs, tie it off. Wound up with a great afternoon on the water and will visit the chandlery in the morning for new parts!

I'm not completely sure on the point of your post, but looking ahead and thinking ahead are very important on sailboats. And gravity is our friend on the water, not our adversary. It buys us time to look around and think. Not so much up in the air, I would think.

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Old 04-09-2010, 19:25   #3
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Originally Posted by Dragon701 View Post
[SIZE=3] Can you think of practical ways to make the systems side of learning about and training on our boats easier and more effective? /SIZE]
Systems that are simple and accessible are easier to understand, use, inspect, trouble shoot and fix than ones that are complex and inaccessible.
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Old 05-09-2010, 04:26   #4
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Originally Posted by Dragon701 View Post
1) knowing your systems; 2) avoiding complacency; and 3) breaking the “chain of errors.”

Seems like the key to making it work in airplanes is training and lots of research to develop the trainings. Here are the few thoughts I have on your ideas for boats. I am certainly no veteran of boating disasters, but I am very interested in the subject. My interest mostly comes from working as someone who does crisis management in a corporate environment. The exact same ideas apply in this situation, and we frequently benchmark the aviation industry for best practices.

1) Knowing your systems is still totally doable, just requires a little discipline. A combination of reading, diy, collecting suitable spares/reference materials, and studying the systems seems to go along way. Two things I see mentioned over and over by veterans are: keep it simple and have redundant systems. Redundancy (and suitable spares) greatly increases the cost of these systems, but think how much a modern aircraft costs. I was on one flight where they did not let us leave because the backup AC unit was failing. Personally I think there is too much safety in modern commercial air travel, but some of that attitude could go a long way in boats. If you have redundancy in each key system and verify each is in regular working order on a regular basis, I think you would be going far above and beyond in this category.

2) Avoiding complacency. One of the greatest ideas I have come across in this space is "Vigor's Black Box Theory". It is a very useful way to think about complacency. Every time I am out sailing and I think about it for a second, I make a deposit into the box. This also goes for things like checklists and maintenance schedules. For each critical system, check the primary and backup on a regular basis. Learn to do things a second way, such as steering with sails, docking under sail, replacing the hardware on your boat with knots and rope. All of these deposits into the black box are you insurance against complacency.

3) Breaking the chain of errors is pretty much a matter of training your mind to operate a certain way. I think training in this area in aeronautics is all you need for boating, or any other endeavor. The key is teaching the mind not to adopt tunnel vision and learning how most tragedies are caused by a chain. The only thing that might be different on boats is to also make sure you do not rush into something that makes a bad situation worse. For example a flogging sail in high winds can be extremely troubling, but rushing forward to subdue it can be fatal. One of the great things about boats, is that almost nothing ever happens fast. Provided you are properly prepared, not much ever happens that you cannot take a little time to think about first. Stopping to think through the ramifications of your actions is one great way to break the chain.
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Old 05-09-2010, 04:55   #5
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Originally Posted by RainDog View Post
... Personally I think there is too much safety in modern commercial air travel ...

... One of the greatest ideas I have come across in this space is "Vigor's Black Box Theory". It is a very useful way to think about complacency. Every time I am out sailing and I think about it for a second, I make a deposit into the box ...
Interesting & useful observations, but you may want to rethink your wording on item 1.

Good Old Boat: Vigor's Black Box Theory by John Vigor
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"If you didn't have the time or money to do it right in the first place, when will you get the time/$ to fix it?"

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Old 05-09-2010, 05:07   #6
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I am wondering about the psychological factors that affect performance on a boat.

Drew13440 makes are great point that “looking ahead and thinking ahead are very important on the water.” I could not agree more. Is this a skill or just innate in the person? If it is a skill, can it be taught or is experience the only way to learn it?

While “systems that are simple” as nautical62 suggests seems sensible to me, it has limits. As time goes on, complexity is naturally increasing – lead line to depth sounder; oars to engines; sextant to GPS; canvas to Dacron etc, etc. While I have many years of experience with a sextant, I would not want to give up the utility of a GPS at this point (I still carry a sextant for fun and backup though). So … the boat that I built from a bare hull in the 1970s and sailed around the world was much simpler than the one that I sailed recently for a year through Central America. And … I would not really want to go back.

Nautical62 also mentions “accessibility” which is a terrific point. Boats especially, with their inevitable nooks and crannies, can be “anti-accessible.” Some of my favorite ideas are:

a) remote filters (of course, it adds complexity),
b) extra length in wiring looms so connections on the back of electronics/instruments can be easily inspected,
c) avoiding placing one part under or behind another (happens all the time), and
d) wing nuts (where appropriate).

What are some of yours?

At some level, not “knowing our systems” comes from not taking the time to study them. We can’t all be electronics technicians. But … it seems to me that one practical approach is to have really good drawings and the best troubleshooting instructions that we can find. Many manufacturers provide woefully inadequate troubleshooting advice with their equipment.

Complacency seems like a hazard in any job. It is the bane of safety programs in companies, yet some companies in similar industries have injury rates that are 1/10th of others in their industry – how? I have never seen it happen without a major and sustained effort. One common step is to have a “safety briefing” before each shift. One of my favorite tools is the video camera. Take a simple video of some critical maneuver on your boat then review it to see what you can learn. It might have two effects. First, you learn. Second, it might make you less complacent.

RainDog, your comment that very few things REQUIRE an immediate response is terrific. The “memory items,” that are used on aircraft checklists, are the things that have to happen immediately. Stopping and thinking after your “memory” items would go a long way to helping.

Thanks for the comments folks!

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