ON SECOND THOUGHT
On Second Thought is a monthly, live-streamed aviation safety video series. Eachhour-long episode dissects real-world Human Factor Behaviors to identify why pilots continue to make harmful decisions that put themselves and passengers in harm’s way. And most important, this series offers practical personal develop solutions to improve one’s Aeronautical Decision Making skills.
PRESENTERS: JOLIE LUCAS & HARVEY MADISON
ON SECOND THOUGHT
WHEN ROUTINE BECOMES THE RISK
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Routine is one of aviation’s most underestimated threats.
The most dangerous flight is often the one flown a hundred times. The most dangerous maintenance task may be the one performed on autopilots. Controllers and line personnel face similar risks during familiar, repetitive operations.
This episode examines how familiarity breeds complacency across aviation roles, how shortcuts quietly erode margins, and how vigilant aviators keep routine work from becoming hazardous. For aviation maintenance technicians (AMTs), repetitive inspections, servicing, and installations can quietly normalize deviance if vigilance fades.
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Hello again, happy June, and welcome back to On Second Thought. I am Harvey Madison, instructional designer in the aviation industry.
SPEAKER_01And I'm Jolie Lucas. Tonight we're going to talk about something that every single person in aviation carries with them, whether they know it or not.
SPEAKER_03When routine becomes the risk.
SPEAKER_01So I wanted to talk a bit about the paper that we're drawing from tonight. As you know, all of our episodes are research-based and 100% human-focused. So for tonight, it's a peer review study out of Embry Riddle, and researchers, Frywald, Lensa Anderson, and Baker embedded themselves into a flight training organization that was experiencing a serious accident problem. And what they found out through them being embedded was directly relevant to every one of us listening tonight.
SPEAKER_03Yep, so let's get into it.
SPEAKER_01First things first, we need to thank our premier sponsor, Avemco. We simply love this company. They are so aligned with safety and also philanthropy in the general aviation community. Whether you're an owner, a renter, a CFI flying club, or term life insurance, please give Avemco a call because, as uh some of us know, you are speaking directly to an underwriter. If you tell them that on Second Thought sent you, you will be eligible for a discount.
SPEAKER_03Absolutely. And in fact, they even contributed some content that we're going to get to later tonight. And speaking of content, the content that you are watching tonight is eligible for FAA Wings credit. It is also eligible to AMTs, AMP credits, uh, and that includes IAs. Uh, what you need to do is complete a quiz after the program. You can go to our website and you'll see a menu over on the left side once you have clicked on to this particular episode. And one of the options that you have down there is earn wings credit. And that will take you to the quiz. Take the quiz, pass the quiz, and then it will tell you how to earn your continuing education credits for AMTs and Wings Credit for pilots.
SPEAKER_01Absolutely. And don't forget, for those of you that are watching, we do have our course resources segment, which is the second tab down. And in that, it will have all of our course notes for this episode, as well as all of the studies that we're going to be talking about tonight.
SPEAKER_03And there are quite a few of them tonight. We drew from uh a lot of a lot of different folks. And speaking of drawing from a lot of different folks, we want to draw from you, our audience, as well. So uh in order to participate, while you're on the menu page uh that we were just showing you, if you look down at the bottom right, there is an icon that looks like a little person. Click on that and you can join the conversation. You log in using guest, uh, enter your name, and that'll log you in, and then ask your questions, leave your comments, give us your Venmo numbers, you know, anything that like that that you want to do. That would be great. No? Okay.
SPEAKER_01Yeah, yeah, we should let everybody keep their hard-earned money. And as well, we will be asking you some questions during our broadcast. So we would love to have you comment there. If you have not already signed up for our newsletter, please do so. You can use the QR code that is on your screen. We try to make it very timely every month with things that are on our minds as educators and trying to give you just a perfect little snapshot into on second thought. As many of you know from being loyal viewers, uh, we are 100% focused on human factors. If you've got that uh brain in your head, then we want to talk to you, male, female, pilot, controller, mechanic, whatever. So we uh we just really feel like it's it's wonderful to focus solely on human factors. So again, no matter what population we are talking to tonight, we usually have controllers, pilots, non-pilot companions, and our maintainers. We're very happy that you're here tonight. All of the content that we will be discussing is equally appropriate across the different um the different, I guess, categories of folks that watch.
SPEAKER_03I believe the way that you put it that I like so much is if you've got that two to three pound gray meatloaf between your ears, then this program is absolutely for you. So, with that, let's get into it. When routine becomes the risk, so there's a particular kind of accident that doesn't fit the picture most people carry in their heads. It doesn't involve low-time pilots uh pushing the weather. Uh, maybe they shouldn't have been pushing it. It doesn't involve brand new uh mechanics uh torquing the wrong bolt or using the wrong torque value. And it doesn't involve a controller uh working their first solo shift on a busy sector. It involves an experienced individual, an experienced pilot on a route they've flown for years, on a flight that they start just like every other flight. Involves a senior AMT signing off an inspection they performed a thousand times, or a veteran controller working a familiar sector during a quiet shift on a normal afternoon.
SPEAKER_01Absolutely. And the danger, the most dangerous flight is often the one that you have flown a hundred times. The most dangerous inspection might be one that you could do in the dark with your one hand tied behind your back. And the most dangerous shift might be the quietest one. Tonight we're gonna talk, we're going to talk about why this is true, not just as a saying or a slogan, but as a measurable fact based on research. And what it will show you is how your nervous system handles repetition. The research is unambiguous, and once you see it, you are going to see it everywhere. Okay, Madison, I usually ask you a question.
SPEAKER_03Yeah, I usually don't like it either.
SPEAKER_01No, you never know what I'm gonna ask. Okay, all right. So the last time that you flew commercially, did you listen to the flight attendant during the pre-flight briefing?
SPEAKER_03100%. Uh I do every time, and I even take the card out and and give it a quick glance. Absolutely. So, okay, so I did like your question this evening.
SPEAKER_01Yeah, so and most likely it was when you were coming back from us teaching pilot plus one at Oshkosh at the Pilot Proficiency Center. So now that I know that you listened to the flight attendant, even pulled out the card, followed along so that you knew what kind of airplane you were flying in. Sure. Can you tell me how many rows you were from the exit?
SPEAKER_03I'm back to not liking the question again. Um a few.
SPEAKER_01Right. We always do that we're gonna, they always say to count, it might be in front of you, it might be behind you, where the closest exit is. And we think we're paying attention, but we've heard it a million times. And so we end up forgetting. So I'm gonna kick it over to you here for the premise of tonight's episode.
SPEAKER_03Yeah, yeah, actually, that's that was a really good question. Um, so uh fits into our premise perfectly, which is it's worth sitting with the research that we're going to be doing tonight, but here's the premise first. Most safety messaging in our industry is uh it's oriented toward inexperience, and that makes sense. Um, you know, watch a low-time pilot, keep an eye on the new mechanic, uh monitor, the new controller who just got certified on a sector. Inexperience is a real risk factor. So it's a that's that's legit, but we've built training systems around managing that. There's a second category of risk that gets much less attention, and that's what we're going to talk about tonight because it's just as critical. It's a category that grows with experience instead of shrinking with it. It's risk that comes from doing the same thing so many times that your brain stops actually doing it or doing most of it. Your hands keep working, your eyes keep moving, you keep signing off on uh maintenance cards, but the attention, active, conscious, looking for something processing, that steps out of the room.
SPEAKER_01It exits the building.
SPEAKER_03Yeah.
SPEAKER_01And it isn't a moral failing, or you're not lazy, it's not careless. I see this in my practice constantly as a psychotherapist. People have been doing something so long they actually don't notice that they're doing it. And sometimes when I point that point whatever it is out, um, they have a hard time recognizing that they've been doing it because that's one of the hardest patterns by its very definition to have insight on.
SPEAKER_03Yep. And and that's what we're gonna show uh here is this is a documented property of the human nervous system. Sorry, you're born with it. Uh, it's been studied across multiple peer-reviewed disciplines for decades. Of course, that is one of the things that that we look for when when we're putting shows together. So you can always count on that.
SPEAKER_01Absolutely. And I think when we design this slide, I want to call everybody's attention to the bottom line of this slide, because uh what it says is familiarity is not the same as safety. And actually, you're going to see from some of the episodes that we will be talking about tonight, it's quite the opposite.
SPEAKER_03Yeah, and our job is right now to explain why, and then eventually we're gonna get to what we can do about it. So there is a word for all this, and the the that word is habituation. It's a specific term in cognitive neuroscience. It has a very precise definition, habituation. It's what happens when your nervous system is exposed to the same stimulus over and over. The response to that stimulus get stimulus gets smaller. Not because you've decided to ignore it. You haven't consciously done anything evil here or lazy. Uh, and it's not because you got bored, it happens because your nervous system, our nervous systems, are built to economize whenever they run across repeated low consequence inputs. And we'll get back to the low consequence part in a little while. So there's a foundational paper here by Thomson and Spencer. It goes way back to 1966. Um, it was uh published in Psychological Review, and that's a journal where actually most bedrock cognitive science uh is published. Uh, they laid out nine criteria that define habituation, and those criteria have been confirmed and refined over the decades since 1966 when uh this was put out. Uh so another researcher, Rankin, and their colleagues, updated this framework uh much more recently in 2009 and added a tenth criterion. None of this is contested science. Understand, it's one of the most replicated phenomena in all of behavioral neuroscience.
SPEAKER_01Absolutely. And three things about it matter for our audience tonight. First, it's automatic. You don't choose to habituate, you can't choose not to. It's not under our conscious control any more than your pupils dilating in low light is under your conscious control. Second of all, this is universal. Every nervous system on the planet that is complex enough to learn new things also habituates. It's been documented in sea slugs and rats, in humans, and every other population that was studied. So when we're talking about this happening to experienced controllers or experienced pilots, uh, we're not saying anything negative about them. We're we're trying to illuminate how your brain does work.
SPEAKER_03And third, uh, and this is a dangerous one, it's invisible, it operates beneath a level of conscious awareness. You don't feel yourself habituating, you don't notice your response getting smaller and smaller. From the inside, everything feels perfectly normal.
SPEAKER_01And that's the part that makes it operationally consequential. The moment you stop noticing the small things, you've also stopped noticing that you stop noticing.
SPEAKER_03And that is the engine that drives everything else that we're going to be talking about now. So let's start by bringing this directly into the cockpit. We want to look at what US federal government data specifically says about the relationship between flight experience and accident risk. There are two public data sets that we need to look at. Um, incidentally, both of them are free and accessible uh out there on the internet, uh, and they're peer-reviewed. Um both are saying the same thing, the same uncomfortable thing. So the first is from David Hunter, uh 2002 technical report for the FAA Civil Aerospace Medical Institute. He built and validated a set of measurement scales uh for pilot risk perception and risk tolerance and tested them on a large sample of pilots, a very large sample of pilots. So that means that the data is going to be fairly reliable. What he found is that risk perception accuracy correlates with whether a pilot has been involved in hazardous events. Okay, keep that in mind. Flight hours by themselves do not. Hmm, okay, so a bunch of flight hours didn't really correlate. Um when he looked at experience pilots specifically, he found that experience correlated with higher scores on a measure of personal invulnerability. Ooh, that's one of the five hazardous attitudes. So those high hours actually kind of caused a little bit of a problem. The fly pilots who had flown the most felt safest, and the pilots who felt the surest were not the ones that the data showed were actually safer. That's a specific finding from the U.S. government study. This is not an anecdote. This this is this is studied data. FAA's own research arm documented this 23 years ago.
SPEAKER_01The second source that we're using, which you can see on the screen, is NASA's Aviation Safety Reporting System. As many of us know, it's a federal incident reporting where pilots, controllers, mechanics, uh, and dispatchers voluntarily report safety events. It's anonymous, no enforcement, just data. If any of you who are watching tonight have used the NASA report, could you, if you feel comfortable, could you please put it in the comments?
SPEAKER_03I mean, you can be anonymous, that's fine.
SPEAKER_01Yeah, that's fine. I'm just I I used it, I've used the system twice. And again, when you know that there's no there's no enforcement, that they're looking at data. With mine, one of mine was a bird strike, and the other one was um some wonky directions around Van Nuys uh busy airspace. So in 2017, NASA NASA published a callback issue specifically on complacency and with total FAA creativity. They named it no place for complacency. Their working definition is one that we want everyone to write down. Complacency is overconfidence from repeated experience on a specific activity. It's that cognitive state that we've been talking about all along. It has a name, it has a federal agency that is documenting it. And the agency notes that complacency is harder to recognize than fatigue because on the inside everything feels normal. Fatigue is something typically that we can assign an outward-facing symptom to it. The uh ASRS receives numerous reports where complacency is identified as a contributing factor. And the pattern crosses every role about that we uh care about tonight, whether you're pilot, controller, uh non-pilot companion, or our maintainers.
SPEAKER_03Absolutely. And and I I want to point out that word complacency, I mean, that right there has a negative connotation. But again, go back to a few minutes ago, excuse me, when we said, this isn't you being lazy, this isn't you being bored, this is us being human. So we take these two that are on the screen right now and put them together. Hunter says, 2002, experienced pilots feel personally invulnerable, but the feeling does not equate to safety. NASA says just a few years ago, just nine years ago, that this complacency is what makes that feeling dangerous and that it's harder to spot than fatigue because nothing inside the cockpit signals it. The line at the bottom, confidence is not the same as competence, is really, really important. Uh, it it's a paraphrase, basically, of 15 years of federal research. So in the next slide, we'll show you the driving research equivalent of that same finding. And we're also going to see where Avemco kind of showed their smarts as well. So we have the cockpit study. Now we want to widen the lens a little bit because the research on pilots and uh routine is it's a little thinner than you might hope. Uh, pilots have been studied to death on things like automation, uh, but on routine, not so much. Driving literature has done the heavy lifting, as in driving a car, and it transfers cleanly because the underlying mechanism is absolutely identical to what we're talking about that affects pilots and controllers and maintainers and humans, basically. So the headline study is by a couple of researchers named Yanko and Spalek. In 2013, they uh wrote something called the Accident Analysis uh uh or wrote in uh a uh uh document called Accident Analysis Prevention. The title is Route Familiarity, Breeds Inattention. Again, more creative titles there. Uh they ran three experiments. Uh in the first, drivers on familiar routes followed lead cars more closely and reacted more slowly to pedestrians stepping toward the road and to lead cars, the the cars in front of them breaking unexpectedly. In the second experiment, they controlled for following distance. Same speed, same gap, and the familiar drivers were still slower to react to both central and peripheral events, things happening out on the sides. So it wasn't that familiarity that made them. Follow too closely. Familiarity itself was slowing their perception and their response. And then the third experiment, this is an important one to remember. When the researchers told drivers to actively focus on the driving task, to pay attention, that's a theme in all of this year's episodes. When the researchers told drivers to actively focus on the driving task, the familiarity induced impairment disappeared. Suddenly, they were paying attention. They were safer. That means that impairment was not a permanent loss of skill. So there is a way out of this. It was an act of ongoing withdrawal of attention that could be reversed the moment the driver was prompted to pay attention.
SPEAKER_01And that is also the same mechanism that the FAA's Hunter report described, measured in a different population using a different methodology. Now look at the right side of this slide in front of you. This is our sponsor, Avemco. A Vemco published data that says exactly what the academic research is saying. Pilots with more than 2,500 total flight hours had a taxi accident rate of 13% higher, not lower, than experienced pilots. A Vemco's own analysts ascribed it to complacency-driven multitasking. Experienced pilots can oftentimes, when they're taxing in their home drome, they're doing five other things. Because the taxi, in a way, becomes so familiar that it doesn't really feel like it requires attention. Three independent sources, a 2002 FAA technical report, a 2013 driving experiment, and a 2013 insurance data set. All of them are measuring the same thing. The federal research is telling us what is real. The lab is telling us what is real. The actuarial data is telling us what it's real. And every one of us has felt it.
SPEAKER_03Yeah, whether we're willing to admit it or not. I have to admit it. Yeah, absolutely. I mean, 2,500 hours, somebody need you need to be watching this show so that so that somebody tells you, Jolie tells you, oh, hey, you need to pay attention because you're 13% more likely to have some sort of accident. Yeah, that's that's crazy.
SPEAKER_02Oh my god.
SPEAKER_03So the obvious question is how fast does this happen? You know, we we want to start building our situational awareness here now, right? Is this a thing that takes decades of experience? I mean, we just talked about 2,500 hours, or does this sneak up on you sooner than you'd think? Guess what? Another study. Charlton and Starkey at the University of Waikato. I really tried to get that pronunciation down in rehearsal, and I still couldn't get it. So perfect. Anyhow, John, don't cut that out. That was funny. University of Waikato published a study in the 2012 Australasian Road Safety Research, Policing and Education Conference proceedings titled Does Familiarity Breed Anattention? Why drivers crash on the roads they know best? Man, these creative titles are just killing me. The same research is described in their 2011 journal paper, but the this conference paper is freely available and we're kind of cheap. So, you know, I didn't pay the 65 bucks for the study, but this conference paper says exactly the same thing. So uh uh that's what's linked in our resources tonight. So they ran a longitudinal study, so a study over a long period of time, designed specifically to answer the question of how fast root uh routine inattention develops. They put participants in a driving simulator and had them drive the same route over and over for 12 weeks. Man, I really hope they paid those participants well. In the first few sessions, participants behaved like alert drivers. Workload felt normal and they reported actively engaging with the task.
SPEAKER_01But we all we always knew that there would be a butt. By the fifth and sixth sessions, the language they started to use to describe their own experience began to change. They started saying spontaneously and unprompted that they were driving without thinking about it or zoning out. And um one participant even said they put it on autopilot, even though it was in a car. These um again are not pilots that were talking, but these are drivers who are describing where their minds went and what they were doing while they were driving. By the seventh session, when the researchers started altering the road, they changed the environment, they changed buildings and altered the traffic signals and signs, the drivers failed to notice. The scene had changed, their eyes were on the road, but they did not notice.
SPEAKER_03Wow. Buildings are missing, and they're just like and they're missing that they're missing. So six weeks. There, there's your answer, folks. Six weeks. That's the timeline. After six weeks of routine repetition of the same drive, that sounded redundant. Expert drivers had developed measurable inattentional blindness. Ooh, that's a cool phrase. Inattentional blindness. They were missing things that were physically right in front of them. And then in a follow-up study, young Mackenzie, Davies, and Crundell in 2018 took this out of the simulator and put it on the real roads with a professional driving instructor. Don't worry. So an expert. Uh, they used eye tracking glasses and uh put this expert through 28 repetitions of an 18-kilometer route. The instructor knew he was being observed. He knew what he was being observed for. And yet, the findings show that the time spent looking ahead decreased significantly with familiarity and attention to driving irrelevant stimuli increased significantly across multiple road types with an expert who knew he was being watched. Didn't matter.
SPEAKER_01And now we got to translate that to what we are doing. How many times have we flown the same departure procedure out of our home airport? Uh, maybe you've done the same inspection as a maintainer a hundred different times on the same type of aircraft. And how many overnight shifts has a controller worked in the same sector at the same airport? The number is large, and the research is telling us long before you get to that number, your nervous system has started treating the work that you're doing as background.
SPEAKER_03Okay, one more piece of research before we start getting into our specific roles uh and applying what we've talked about to us. Um so this study was published in May of this year. Seven uh our uh May of May of last year, so 13 months ago. Uh it was in cognitive effective behavioral neuroscience. The lead author is Tanya Endrass of TU Dresden, uh German. Uh, so it's gonna be very precise. Sorry. Stereotyping, that's gonna be a whole other episode, I think. Anyway, what they did was actually very simple. They taught participants a 12-step motor sequence using their fingers on a keyboard. So over two days, the participants practiced a sequence enough that it became automatic. And then the researchers started introducing variations at random intervals, they would omit one of the 12 steps. The question was when the sequence changes, can the participant adapt? Or does the trained response, the habit, fire anyway? And the result on the normal sequence is what you would expect from any practice study. Faster, more accurate, more training produced, more competence, and that's how learning is supposed to work.
SPEAKER_01But the result on the change sequence is the one that should worry every single one of us. Errors went up, and this is the critical part. Errors went up more with training and experience. The more the participants had practiced the routine, the harder it became for them to deviate when deviation is what was required. That's the experimental analogy that every case any of us has seen where a senior person executed a step that wasn't appropriate for the current situation, because it's the step they always execute. One thing I will say that I say to clients is that when you argue with reality, reality always wins. So when something has changed, whether you're paying attention to it or not, uh you you need to know that the that mother nature or the engine or the environment is gonna win every time.
SPEAKER_03Absolutely right. And of course, I I I grimaced, you know, uh when I heard you say that just because training is my profession. Uh educating and and instructing uh is what I do and I believe in. And so when it said that with an increase in training, that habituation got you know made it even more difficult to uh uh break the pattern to not do what you've been conditioned literally to do. You know, that that's that's a tough one to swallow. But it also tells me, well, that should be part of good training is throwing in curveballs so that you're always paying attention. So a pilot who flips a switch for muscle memory, because a checklist always has that step there, except for today, in this configuration, that step isn't supposed to be there. The AMT who reaches for the torque value, they've used a thousand times, except this revision of the maintenance manual changed it, and they didn't read the card or the controller who gives standard clearance for that intersection, except today's traffic picture isn't standard. That's the kind of thing that we're talking about.
SPEAKER_01And remember, this isn't because people are lazy, they aren't cognitive lapses, they're documented capture errors, a term Donald Norman coined way back in 1981, when I think Michael Jackson's thriller album came out. That's another aside, where we will where well-practice response takes control when a similar but different response was actually required.
SPEAKER_03Woohoo! I shouldn't have done that. Anyway, this is how habituation becomes operational error. Routine doesn't just dull attention to the rare event, it actively interferes with our ability to adapt when a situation changes. The more routine, the stronger the interference, which brings us to the practical question. You are on that flight for the hundred dollar hamburger you've gotten every weekend for 10 years. You are doing uh a hundred-hour maintenance uh uh on uh the on a skyhawk for the flight school you work for. You are bringing the same fleet of training aircraft into your airspace again for the umteenth zillient time. What do you do about it?
SPEAKER_01Well, every every um episode that we offer here has what to do about it um built into it. But I would like to take an aside, and if you can write in the comments where your favorite place to get your $100 hamburger would be, I would, I will love to look at those.
SPEAKER_03That's a nice little aside. That's a good palate cleanser, right there. Literally, $100 hamburger. So, you know, good palette cleanser. I like that. So, um, from personal habituation to shop-wide normal. Habituation is the engine inside one person's nervous system, but it doesn't operate in isolation. When everyone in a shop or on a sector or at a flight school is habituating to the same deviations, the deviations get reinforced socially and the standard quietly moves. And we had a whole episode about that. There are two pieces of organizational research that have become canonical in aviation safety culture, and we touched on them again back in episode five with the uh uh Frywald paper on Embry Riddle campuses. They're worth naming directly because they explain how individual habituation scales up into systemic risk. So the first is Diane Vaughn's work on the challenger disaster published in 1996, 10 years after that disaster happened. Vaughn coined the phrase normalization of deviance. Boy, have we all heard that one. And her definition is the one to remember a deviation from proper procedure is repeated, and there's no catastrophe that results from it. And the absence of catastrophe is read by everyone involved as evidence that this deviation is fine, it's acceptable. And then the next deviation happens, and again, there's no catastrophe. Well, eventually the deviation stops even registering consciously for anyone. It's not a deviation at all, it's simply how we do things, it becomes standard operating procedure.
SPEAKER_01And that's the definition of habituation. Um, and it's operating in this case on the social fabric of the team. If you remember from episode two, I believe it was, we talked about how energy in the cab, in the airplane, in the mechanics bay is socially contagious. And so this is one of those habituation is one of those things that does go across the fabric of your team. The mechanism is identical. Again, the repeated exposure, plus no negative consequences. Um, and so the response keeps getting attenuated, and um, it's the team's collected ability to see the deviation, they don't see it as deviant. Uh a psychiatrist that I like to watch was talking, uh Daniel Eymon was talking about uh talking to your three-year-old, your two or three-year-old about a temper tantrum. And what he says is that parents should say this if you have a temper tantrum to get your way, the answer is going to be no every time. And if you question that, just go ahead and test me. Because you need to say no every time. You need that negative reinforcement every time. And so uh in family systems, we see this, obviously, with my toddler reference, but it's any group that's been together for a long time where there might be a policy, nobody really does the policy, we kind of laugh at the policy, and uh then we stop seeing the policy, and that's where the danger really begins.
SPEAKER_03And something else that just struck me as you were describing all of that is even sometimes when you're in a social system like that and you do kind of notice it, you still have a little bit of I'm not gonna say anything because I don't want to rock the boat. Rock the boat. I'm telling I'm telling myself that as much as any of you. So absolutely.
SPEAKER_01Well, and we we did cover that, I believe, in episode three, where we need to ask clarifying questions. So if we're seeing something uh that uh the there's a policy, I read it in the manual, and then we're not doing it. We have to slow the process down and ask clarifying questions. It's very difficult to do, but it's what needs to be done.
SPEAKER_03Absolutely, absolutely. Amen. And you just have a whole program, just repeat that over and over. Actually, no, then it would become habituated and we would wouldn't pay attention anyway. So, okay, so there's a second piece. Uh, a guy named Scott Snook wrote uh friendly fire back in 2000. He studied the uh uh there were some Blackhawk helicopters uh in the Middle East that got shot down by F-15s, oops, in the no-fly zone uh over Iraq. Um his term uh that that Scott Snook came up with is practical drift. The mechanism is slightly different from what we just talked about with Vaughn. For Snook, that drift happens because local actors are continue uh are continuously adjusting their behavior to fit perceived current task demands. And those adjustments accumulate. So over time, the written procedure and the actual work drift apart, they uncouple. The procedure says one thing, but the shop does something completely different. Both have been doing it that way for so long, no one remembers that there was ever a difference.
SPEAKER_01And both Vaughn and Snook are describing what happens when individual habituation goes unchecked at the team level. Every habituated individual contributes to the habituated team, and the habituated team produces a drift in standards, and by the time anybody notices it, that they don't, it looks like normal to them. And I want to challenge you all to say habituated in a sentence three times.
SPEAKER_03I I haven't been able to do it correctly once, so no. Okay, so uh Bedford 2014, uh Gulf Stream 4 crashed because the gus lock was engaged. There had been 174 prior flights, it turned out, they found post-mortem, uh, where the crew hadn't run the checklist. This isn't a story about just one bad day. It a crew had habituated to skipping the checklist, and that had been reinforced by an organization that was not insisting on running the checklist until the day the procedure they had been ignoring would have saved their lives.
SPEAKER_01And that's why this matters habituation in the cockpit shop or cab. You know, it's the seed of the normalization of deviance. And um we just I guess what I one thing I wanted to say before we move forward is that I'm keenly aware that it's very difficult for us to have insight into ourselves and our actions, specifically when they are unconscious or just below the surface. And so I just applaud you all for being here, for being willing to look at yourself and the things that you will be could be doing on an autopilot sort of basis. And uh so I just wanted from as a therapist, I just wanted to give you kudos for being willing to look at your behavior honestly with new eyes, and then make the changes that you need to make.
SPEAKER_03Absolutely. Uh, and I second that, and I tell you, this program would not be uh eligible for Wings Credit or AMT continue education credit or an EVMCo discount with it without the value that it provides, and the fact that you're here getting that value matters. So before we get role specific countries. Measures. We want to ask everybody listening to do something real quick while this slide is up. And I'm gonna take you by surprise a little bit so that you can't quickly change your mind. Okay, pick the one, the one flight, the one inspection, the one shift. We all have just spent 45 minutes talking about the research, pretty in depth. So the answer should be sitting close to the surface. Whatever just came to mind, that's the answer. Don't edit it, don't talk about it, don't say it out loud to yourself. For the pilots, it's probably the flight you have made so many times that the briefing has become a formality. Maybe it's a trip from your home airport to a familiar practice area. That's what it is for me. Uh maybe it's the commute up to the same fishing strip every summer. Maybe it's the run from the FBO over to the maintenance bay. Uh whatever it is, that flight is the one your nervous system has stopped fully processing. Whether you believe it right now or not, it is. For our maintainers, it's probably the inspection you could do in your sleep with your hand tied behind your back, like Jolie said. The 100-hour on the airframe you've worked on more than any other. Pre-departure check on a type you've signed off a thousand times, a recurring item on a recurring card. They all just kind of blend together. For controllers, it's probably the sector that runs the same way every shift. Busy or not, the familiar arrival float, a familiar time of day, an overnight that almost always plays out the same way.
SPEAKER_01Absolutely. Whatever you just named, that's where the research showed you tonight that it's operating most strongly on your work. The Hunter report that we spoke of gives you a sense of personal invulnerability on the flight that is higher than the data supports. So I kind of go back sometimes to the fact that 70% of drivers think they're above average. That Yanko and Smalik research that we were talking about would predict that your reaction times on that route are measurably slower than on an unfamiliar route. Charlton and Starkey would also predict that you have already missed the environmental changes that you didn't notice were missing. From my perspective, as a therapist in private practice, this matters because just naming the one thing where you are habituated, where it just seems like you are just you know which where you're going to be handed off to which sector next. It's important that we name the thing. And in a way, the naming of it, the saying it out loud is what helps us to make sure that that pattern that we have habituated is not running us. The pattern that you name out loud is the one that we can start to change. And that's true for patterns, like I said in my clinical practice with folks. And it's true about what we're talking about tonight. One thing I did want to add is that when I got my instrument rating in the Los Angeles basin, very busy airspace, had to learn to talk fast, try to think even faster. I was really, really on my P's and Q's. I was very alert, I didn't take anything for granted. And I and I and Mike Jess, my flight instructor, said something like right after your check ride, you're probably the most safe instrument pilot out there. And it's because I hadn't habituated to the same departure out of Santa Maria that I fly, you know, every other trip. So sorry to interject that, but I think it's important to know that sometimes our students or our our folks that are getting additional search certifications and ratings, they're safer than those of us who've flown in the like I've flown in the LA basin a lot. And so yeah.
SPEAKER_03Absolutely. No, that's a great point. And that's why if you get a new rating, uh, you know, the FAA restarts the clock on uh uh uh flight reviews and thing things of that nature. Absolutely. Um so again, the the bottom line on this slide is the bottom line of this slide. Naming the routine is the first countermeasure, period. Everything that follows in the next three slides builds on whatever the thing is that you just named.
SPEAKER_01That's right. So we're gonna give you what to do about it now.
SPEAKER_03Okay, so let's get practical. We're gonna do this uh the same way we did in episode five with role-specific action items, uh, because the routine that's putting an AMT at risk is different than the routine that's putting a pilot at risk or a controller. So the countermeasures are different too, and you're all getting your own individual uh uh interventions here. So for the GA pilot, five things. Number one, speak the routine out loud. The flights that feel the most routine are the flights where you stop verbalizing what you used to verbalize as a student. Get the verbal call-outs back, altitudes, headings, clearances, saying it out loud forces. Get this a different cognitive process than just thinking it silently. It really makes you pay better attention. And that process is much more habituation resistant. Ha! I got that out without stumbling, Jolie. It's absolutely free and you can start it on your very next flight. Number two, very the familiar. Okay, change the environment so that you're less likely to habituate. Yanko and Spaleck's third experiment showed that the moment a driver is prompted to engage, the impairment of habituation disappears. You can prompt yourself, pick one thing, a different scan pattern, a different depth to go into in your briefing, a different fuel calculation method. I mean, back it up, you know, with your normal one also, but you know, try it a different way too. Apply it to every flight that you have made a hundred times. The variation itself is a great countermeasure.
SPEAKER_01And number three is gonna seem counterintuitive. It is hand fly the familiar leg. No. I know most pilots, when they're tired, they're like, I'm gonna let auto handle this one. But the research would say that you've got it backwards. The familiar leg is the one that you are most likely to have a risk for habituation because the autopilot doesn't keep you engaged, uh, it lets you stop being engaged. So hand fly the part of the familiar leg deliberately and take the cognitive load back. Number four, pre-flight, as if it was the first time you've ever pre-flighted your plane. The walk around on the plane uh that we fly the most, I flow my Maggie for over 20 years. Um, I try to tell myself every time, new eyes, new eyes, what do you see? Change the direction in which you're looking and treat it like a check ride in a way. And again, introducing that attention is going to help us to break the habituation and to see things more clearly.
SPEAKER_03Absolutely. And in fact, Julie, I also want to point out something that you got me doing. Uh, you're a very good influence. Post-flight inspection of your airplane and debrief yourself on how the flight went as well. Write something down in the logbook, just very, very briefly, your own personal, not your official logbook, like we said a couple of uh episodes ago. Okay, finally, number five, name the familiarity out loud. So before you start the engine, say to yourself, I've done this a hundred times before. Okay, normally when somebody says, Oh, I've done this a hundred times before, what they're trying to say is, eh, no problem, I've done this a hundred times before. Now, when you hear yourself say that, and you need to say it before your next uh flight that you've taken a hundred times, it needs to be the warning flare that you just shot into the sky, going, ooh, oh, I've done this a hundred times before. Okay. So now for the AMT audience, the Harper and Bliss study uh we'll reference in the research, briefed um uh surveyed certified mechanics working for major US air carriers. 77% of them identified complacency as a cause of maintenance errors sometimes or at the level of sometimes or greater. Okay. Um when researchers interviewed those mechanics one-on-one. Oh boy, uh, the mechanics described the mechanism itself, the repetitive, simple nature of the work drove the complacency. Repetitive, simple, familiar. These are all conditions habituation feeds on. So, five things for AMTs. Read the card every time. We're talking to mechanics tonight who have done some of these inspections more times than they can count, which is probably almost all of you watching right now. The Endrus study we just looked at says exactly that. This is when the error is going to happen. Um, the card on the bench is the simplest, cheapest defense available.
SPEAKER_01And number two, build that forced pause before you sign off on an inspection. Physically remove yourself from the work for a couple of minutes. Find a different vantage point. Uh early on in our episodes, we talked about two brains are better than one. If you're able to get somebody else to look at your work with you, uh, they might be seeing things that you don't see because of habituation. And number three, um, which I kind of joined with number two, but have a second set of eyes, have another tech there, and make sure that um even though if you've done this this maintenance 40 times, that um that you are actually seeing your current work and my current cat, Lorelei.
SPEAKER_03Absolutely. Okay, number four, speak the torque, or in other words, say the value that you think you know out loud. Hear yourself say it. When you say something out loud, a different part of your brain is actually hearing what you're saying. I know it's kind of weird, but humans are weird. So um you're you're saying this because it produces the exact cognitive state in which a missed defect, the defect being the wrong number, maybe, uh uh is going to pop up in your head, and that's gonna help you catch it. And then number five, treat the thought, I've seen this a thousand times or a hundred times or yada yada yada, as a warning flare. Okay, this one is the same as it was for pilots. Now, for our controllers, there was a Euro control study by Sonja Straussberger, lots of Germans here, published in 2006, ran a simulator in the field uh and measured uh the state of monotony in controllers. It indicated uh physiological deactivation, um, increased subjective uh kind of feelings of sleepiness, behavioral impairment, uh, took longer to resolve conflicts uh when something unexpected happened. This isn't automation, okay? That was our other episode. We were very, very clear to uh when we were building this to make sure this was not an overlap of automation. Um, that it this was a nervous system, this was being human. Sorry. So, for air traffic controllers, number one, quiet does not equal easy. And I I'm just gonna I'm gonna go straight to the example that I've always noticed. If you go into a restaurant when things are busy, you're gonna get pretty decent food, and your server is going to get to you as quickly as they possibly can. It might take a little while, but it's going to be fast attentive service. You go into a restaurant when things are slow, the food's not going to be as good. They're going to forget about you. When you ask and say, Hey, did you forget about me? They'll go, Oh, yeah, oh my goodness, I'm so sorry. I completely forgot. Same thing.
SPEAKER_01And number two, read back what you hear, not what you expect. Um, a familiar call sign on the same frequency that you always use is actually the moment in which your ears stop hearing. Uh, in episode four, as we've been speaking of, we did talk about communication research. And so I'd encourage you to take that course and watch that seminar and take the quiz if you had if you've missed episode four. And number three, take active rest breaks. A lot of us think, oh, I've got my 15, 20 minute break, I'm just gonna go veg on the couch. But research shows that passively sitting during breaks does not help uh in terms of your brain function, your ability to combat habituation. So if you got a chance, um go on a walk, or if nobody's around, turn on your music and shake your groove thing a little bit.
SPEAKER_03There you go. Uh number four, uh, if it's quiet or if you feel like you're you have the blinders on, uh you need to have a deliberate conscious scan. So once an hour, look at something you haven't looked at in 15 minutes. And then finally, name that pattern. When today looks like yesterday, looks like the day before, looks like last week. Say it out loud. Okay, you don't want the other controllers making fun of you. Say it like this, but say it out loud.
SPEAKER_01Yeah. And that's usually enough to get you back to active attention. Um, we're gonna focus a little bit on um uh the tenerife accident.
SPEAKER_03Yeah. Um well, we're doing excuse me, not the tenerife. Yeah, it was episode four. There goes Mike. Okay, well, I do mention it, though, actually. So uh we we're anchoring the episode in a real accident, the same way that we did uh episode four on Tenerife. It's it's the Gulf Stream Four crash with the gust luck. Uh it the aircraft was was a corporate Gulf Stream 4, experienced crew, professional aviators. They'd flown this exact airplane a whole bunch in the past. Uh they accelerated down the runway, couldn't pull back. Uh, and uh people died. Actually, I think everybody on board uh passed away, unfortunately. Uh the NTSB in their investigation, their accident report established something extraordinary. Flight data recorder. This is how they knew that they had skipped it 174 times before. They the NTSB went back, looked at the flight data recorder, and showed on 174 prior takeoffs a crew had performed in this airplane. They had not performed a complete flight control check on any of them. So the probable cause uh was flight, uh, the flight crew members' habitual non-compliance with the checklists. Seven people died.
SPEAKER_01It's so sad. And you know, we want to be careful here because we're not condemning the crew, um, and we're not above them, but the mechanism that killed everybody on board is the mechanism that we are focusing on to tonight. And and again, we're we're trying to help save lives and and also uh get us to think to have a bigger thought process, to be able to think about myself in space and use some of these um, you know, some of these tricks and techniques that we've been speaking of.
SPEAKER_03Absolutely. Um, and so the way we want to close before Jolie wraps up uh and uh and we have the program notes is the same way that we closed last month. One action item per roll, pick the one that's yours and start tomorrow. GA Pilot, so take a good look at the screen. For GA pilot, before you start an engine on your next flight, say out loud to yourself, I've done this a hundred times. If you just say it out loud, it makes a big difference. Um, it costs you three seconds.
SPEAKER_01Yeah. And for our AMTs and maintainers out there, on your next inspection that you could do in your sleep, really read the lines on the card, pay attention, use it as a checklist, get a new set of eyes to help you with your work. And for our ATC folks, you know, it's that quiet error in the familiar, excuse me, quiet hour in a familiar sector that that really could bite you. And so you want to make sure that um you are calling it out loud, like this is quiet, and um it might be dangerous to stay quiet.
SPEAKER_03So, a reminder for everyone listening episode six, this episode, like all of our episodes, qualifies for FAA Wings credit. Log your participation at FAA safety.gov so you get credit for being here tonight. AMT participants, this episode also qualifies for AMP continuing education credit. The instructions for claiming it are on our website at onsecondthought.me. And for anyone who wants to go deeper than where we have gone tonight, uh, you can simply go to our website and take a look at the research brief uh that we have. There's a whole bunch of documentation uh in this particular episode, which is good stuff uh to take a look at.
SPEAKER_01Absolutely. And so um the takeaway tonight, in one line, again, is the is the quote that's on the bottom of the slide. The dangerous flight is not the unfamiliar one. The dangerous one is the one that you could uh do in your sleep. So up next, July 8th, is our episode that will be on right before we all get ready to put KOSH in our flight plans, and it will be what safer decision makers have in common.
SPEAKER_03Vemco really likes you.
SPEAKER_01Well, the feeling is mutual again. If you tell them uh that you saw on Second Thought Live, then you are eligible for a discount.
SPEAKER_03And once again, you can earn FAA wings and AMP credits. Uh simply go take the quiz on our website uh after the program, which is now, uh, and uh you could get uh those uh those credits that you are looking for. And just a quick reminder of where to find uh that, if you go to our website, click on an episode, you'll see all of those menu options listed over there on the left. And about halfway down, you will see earn wings credit. That is gonna take you to the quiz. And once you pass the quiz, uh you're gonna be able to uh submit for your wings credit. I love our last line. Together we can help pilots pause, reflect, and choose safety on second thought. But you know what? That also goes for AMTs and right seat companions and controllers and anyone with that two to three pounds of gray meatloaf between their ears. I'm sorry, Jolie. That's your line.
SPEAKER_01And remember to fly safe. Come and see us uh next month.
SPEAKER_03So long, everyone.
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