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Fingerprints - Part OneFingerprints - Part One

Growing up in my house, I always thought it was just my mom who had a thing about dirty hands but not so.  

Way back in 1686, Marcello Malpighi, an Italian anatomy professor and also apparently quite a neat freak, seems to be the first guy who complained about the curious ridges, spirals and loop marks left by his students’ greasy hands on his nice clean desk. It wasn’t for another century, in 1788, that a German anatomist Johann Mayer figured out how fingerprint impressions were formed by the skin ridges at the end of our digits and still another 100 years, in 1880, that Henry Faulds published his studies that fingerprints are unique and everybody has a different pattern.  Although it’s taken 200 years to figure out that we all have different fingerprints, modern psychologists have taken only a few years to recognize another unique fingerprint that we all have, our own unique and personal fingerprints of errors.

Recent neuroscience studies clearly show that our brains are imprinted with individual patterns of decision-making processes and this is what leads us to make the choices we make every day.   Knowing the right thing to do and actually making the decision to do that, choosing the correct option from all the knowledge we trained and stored in our heads is a critical aspect of our safety as pilots in the air as well as everything we deal with throughout the day right here on the ground.

Another big part of safe flying and decision making is understanding the difference between our decisions, based on knowledge stored during ground school and flight training, and the judgment and wisdom to make the right choice from those knowledge options.  How we make those choices is exactly our personal fingerprint of decision-making and error.  There’s an old saying that knowledge is knowing a tomato is a fruit, but wisdom is not putting one in your fruit salad.  Trying to figure out how to get well-trained smart people to choose the right option from among a bunch of stored knowledge has been a recent focus in adult learning and decision-making training.  P.G. Schrader and Kimberly Lawless wrote an interesting article on a model of adult learning they call the “KABO” theory, which stands for knowledge, attitude, behavior and outcomes.  It’s a newer iteration of Bloom’s taxonomy of adult learning that defines a set of three skills used to classify educational learning objectives into levels of complexity and specificity.  Schrader and Lawless build on these older models because research has shown that our knowledge, instruction and training alone are incomplete methods for influencing safe decision choices.  They have shown that neither knowledge nor attitudes are necessarily strong predictors of behavior alone, so training methods that influence our behavior directed at selecting safe options is just as important as the rote knowledge we have stored in our heads.

These studies all lead to the same conclusion: just cramming knowledge into pilots’ heads is often too narrow a training strategy. They also show that the traditional training methods of focusing only on academic or knowledge-based development are not enough to keep us safe for our aviation careers. This is where the KABO model has come in suggesting that a third arm of pilot training needs to be designed that adds attitude and behavior skills (the “A” and “B”) to the usual ground school memorizing and stick and rudder drills.  

We can cite any number of recent major airline disasters as examples of how well-trained, experienced and very knowledgeable pilots crashed their airplanes based on making a bad choice from among a bunch of options.  Think back to Air France flight 447 that was an Airbus A330 flying from Rio de Janeiro in Brazil to Paris on June 1, 2009.  The weather conditions were bad over the ITCZ (Intertropical Convergence Zone) along the equator but were totally known, expected and normal for early summer at that time of year.  There was a broad band of thunderstorms along the flight’s planned route with an area of mesoscale convective activity extending all the way up to 50,000 feet above the Atlantic Ocean. AF447 was one of 13 aircraft in a long conga line on the same route from South America to Europe that night.   All the other planes picked their way through a break in the weather to the east of their original planned route of flight.  Why the AF447 pilots chose not to deviate but instead go right through the worst area of the storm we will never know, but the result was ice, frozen pitot tubes, loss of control after a stall, and the plane fell 35,000 feet into the ocean, killing all 228 passengers and crew on board.  AF447 was a tragic result of a really bad choice.  This is only one example, but the trend indicating decision-making errors are a major cause of aviation accidents is confirmed by FAA accident analysis reports of part 121 and 135 carriers showing that wrong choices are the underlying cause in 45-50% of fatal aviation accidents. It’s certainly not that high-time, well-trained pilots don’t know what the right thing to do is; they just made a bad choice. 

We all know we make mistakes.  We also know that we hide those from the outside world, and often even from ourselves, deep in our heads in some secret and sacred place.   It’s not hard to understand that identifying our unique error fingerprint patterns takes a lot of effort.  But it’s worth it because identifying our own error tendencies is a crucial first step in avoiding them.  It’s just not possible to improve your performance and minimize errors at anything, least of all the complex skills required in aviation, without recognizing your own individual error tendencies.  Next month we’ll talk about several recommendations that safety experts make in order to understand and identify your own personal error trends.  This will train your own mind and improve your “A’s and B’s,” your attitudes and behaviors to insure safer flights.

Kenneth Stahl, MD, FACS

Kenneth Stahl, MD, FACS is an expert in adapting principles of aviation safety to the healthcare industry for patient safety. He also writes and teaches pilot safety principles and error avoidance. He is triple board-certified in cardiac surgery, trauma surgery, surgical critical care and general surgery and holds an active ATP certification and a 20-year member of the AOPA. Dr. Stahl practices surgery full-time and is Healthcare Division President for Convergent Performance, an industry leader in teamwork, checklist and accountability training and consulting. He can be reached at [email protected]

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