Debrief: Errors of omission and commission: Remembering lessons learned

Debrief: Errors of omission and commission: Remembering lessons learned

Debrief: Errors of omission and commission: Remembering lessons learned

“A stood for altimeter. It told how high a man flew. B stood for boost. It told the power in the engines. C stood for compass. It told in which direction a man was proceeding. It was delightfully simple.” – Ernest K. Gann, Island in the Sky.

 

An error of omission is not doing something that we should have done like forgetting to put the gear down, not feathering a prop during an engine failure or neglecting to load an arrival/approach into the FMS. An error of commission is the mistake of doing something, but doing it wrong such as extending the gear but while too fast, feathering the wrong prop during an engine failure or loading the FMS with the wrong arrival/approach. Despite Ernie’s A-B-C, and ARROW, PAVE, CIGAR, GUMP, Identify, Verify, Feather and several dozen other memory mnemonics, litanies and checklists developed over the years, we continue to make errors of omission and commission. Most of our mistakes are small and of little consequence, but the potential for a serious blunder looms over us like the sword of Damocles. By reviewing significant events from our flights, a technique employed in the military (and the airlines and corporate), we can reduce both types of errors. This tool reinforces the good and helps us to avoid repeating the bad; it’s called a debrief.    

Doctorate Level Epiphany 

A fellow F-16 pilot sent me an article from BCA (Business and Commercial Aviation) magazine about military briefings and debriefings. The story focused on the methods and practices learned during Vietnam which led to the creation of the Navy and Air Force Fighter Weapon Schools. The BCA article reminded me of the tenacity we employed in learning from the events during each mission as fighter pilots. While flying the F-16 at Nellis AFB in Nevada, we were often tasked to support USAF Fighter Weapon School training sorties. Sometimes we acted as the air-to-air bad guys trying to shoot them down, and other times as the air-to-ground bad guys trying to drop bombs on their airfields, military machinery and other high-value assets – like their golf course. In both the air-to-air and air-to-ground scenarios, the Fighter Weapon School student’s mission was to intercept us and to shoot us down. During the doctorate-level briefings and debriefings for these missions (typically twice as long as the actual flight), we “operational” fighter pilots discovered the value and benefit of a best-of-the-best, detailed and critical debrief and we began to sit-in on the briefings even when not participating in the missions. I invite you to experience just such an epiphany.

Squirming Hatch Blower

Even though the piloting profession was in on the ground floor of using checklists, we continue to skip things accidentally (or intentionally if we think it’s already completed) and then we swear (often literally) that we will never make that mistake again. Many of us fly as PIC with no SIC so we can’t expect checklist assistance or a critique from the other pilot. Therefore, any criticism will have to come from a self-deprecating admission. 

To wit: I’ve been slow to retract the gear in the Duke during an oh-dark-thirty departure, forgotten the flaps on a missed approach, lowered the gear way too early during an approach in ice, worn work boots and landed with a brake pedal depressed (“Big Foot Flies Again,” T &T  May, 2018), failed to press the execute-approach button on the GPS/FMS, forgotten to move the fuel cross feed valves back to normal after a ground check, ran the wing of an MD80 into a deice truck (not my fault – see “Wintertime Blues,” T &T February, 2016), almost went into an inverted spin when I over-controlled a training spin in the T-37 and I recovered an F-16 from a computer-induced near deep-stall during a maintenance test flight (“Paper Airplanes,” T &T May, 2011). 

I’ve also left the door unlatched in a B36TC, hit the tail of a PA28 with a roll of toilet paper while in flight (“The Pilots Mom,” T &T  May, 2016), almost slid off an icy runway in a Cherokee 140, briefly caught a C-150 engine on fire during an over-primed start, got way too slow on a real, single-engine approach in the Duke – and these are just the ones that I’m willing to admit. Twenty-three thousand hours has given me plenty of time to make mistakes and to even repeat some of them. I’m certain that I wasn’t the first, nor will I be the last, to commit a squirming-hatch-blower faux pas. So, is there something more than self-deprecation that we intrepid aviators can use to defend ourselves from Ernie Gann’s probabilities of fate?

The Debrief Diary

I found her diary underneath a tree. And started reading about me… – “Diary” by Bread, 1972   

Debriefing a flight from start to finish allows us to examine and learn from the good, the bad and the ugly (Clint Eastwood, 1966). But after flying for several hours, it’s easy to forget what happened during the preflight, engine start, taxi, takeoff, cruise, descent, approach, go-around, taxi, parking, shut down, towing to the hangar (and in the words of Yul Brynner in “The King and I”) etcetera, etcetera, etcetera. Now imagine trying to remember all of that stuff after three or four legs, over three or four days in a row, month after month, year after year – for decades. We can’t remember it all so we should write it down as it occurs. As an F-16 instructor, check pilot and maintenance test pilot, I flew with a kneeboard and kept notes next to the mission profile to remind myself of what to discuss during the debrief. And at my carrier, I print a document showing the date, the to-from, and the takeoff and landing time of each leg over the span of the trip. I then record important events, questions and errors next to each leg of the trip. We can do something similar in our GA airplanes. 

In the Duke, I use a pre-printed flight planning form with room for the ATIS, copying a clearance, frequencies, logging time/fuel and the inevitable errors of omission and commission. We normally have some low-workload time during cruise to reflect and record issues. Once we reach TOC (top of climb) and have finished the cruise checklist, set the power, talked to the passengers and savored a crew meal, we can take out our pen and our debrief log (millennials and millennial wannabes can use the notepad icon on your phone or iPad) and list the errors we’ve made and questions that arose. During the descent, approach and taxi we need to make mental notes to be recorded similarly once at the FBO, hangar, hotel or office. If you have no anomalies or lessons to record then you either weren’t paying attention, were too embarrassed to admit them or you think that you’re the best pilot you ever saw. Here are a few things you may want to include in the debrief diary for those of us that aren’t Gordo Cooper:

  • Issues or events occurring with fueling, weight and balance, deicing or towing;
  • ATC clearances changes, surprises and issues;
  • Forgotten or improperly applied checklist steps;
  • Procedural confusion with air–craft systems including the FMS and autopilot;
  • Errors in navigation, altitude, the arrival procedure or the approach;
  • Ground movement issues including confusion, missed turns or near incursions;
  • Avionics, mechanical and weather problems. 

A thorough debrief is the best way to ensure hard experience is turned into lessons learned – especially if we review a list of our personal lessons from previous flights. For myself, I’ve begun transferring and compiling these recorded issues from each flight into a single source “There I Was” diary. A quick review of the compilation before a flight reminds me of previous issues, questions and errors. And not surprisingly, just the thought of the diary becoming longer with each flight is a motivator to be more diligent in procedural and checklist compliance so as to prevent adding yet another lesson-learned to the diary. I recommend you make it a practice to pull out your own record of the above debrief suggestions as part of your pre-flight routine.

A Regular Review 

It’s what you learn after you know it all that counts.  – John Wooden

Making an error of omission or commission is frustrating and you’re not the only one that does it. Despite memory mnemonics, litanies and checklists, we all make them. But we can combat the occasional sword of Damocles and Ernie’s assertion that we are hunted by fate, with a regular review of our debrief items. A several-hour, Fighter Weapons School, self-deprecation is certainly overkill, but we should at least conduct a regular review of our list of experiences to ensure that we remember. Millennials can record lessons with electronics; we geriatric, old-school types will use an ink pen. Either way, give it some thought. After all, no one wants to be a squirming hatch blower or find a bomb-crater on their golf course. Happy New Year my friends. 

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