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Hic Sunt Dracones

My son likes to collect old maps made by ancient mariners long before they knew much about the landmasses of our planet. In the sepia tones of antique artists there are some guesses of “continents” drawn as best they could from scant knowledge acquired during sailing expeditions.

But still there are some big holes, and where the land ends and the seas end – sort of the end of their world – there’s just a bunch of squiggly lines and vast open areas labeled “Hic Sunt Dracones.” I’ll admit I had to look this one up since my Latin is pretty stale years after my high school days. I found out that it means “here, there be dragons.” This was the “terra incognito” – unknown land – of our ancestors and they “knew” there was nothing good there, only unknown but definitely painful disasters.

Old-time mariners who dared to sail beyond their known world fighting dragons and facing dangers is an apt analogy to pilots accepting the unknown risks of flying around outside our own safety box that we worked on last month. We’ve spent the last few articles talking about personal safety standards, our “little voice“ to enforce them, and constructing that safety box defined by your own fitness to fly, the airplane flight envelope, the weather and fuel consumption, and load. If you don’t heed your “little voice” and find your “normalcy creeping“ allowing you to wander into your own “terra incognito,” you’ll find the same sorts of things the ancient mariners did, nothing but dangers and unknowns. Since this is such an important idea for us in the GA world it’s worth drilling down into it with a finer granularity based on the principles we worked on in the last few articles.

As I’ve said before, the borders of the box and your own willingness to stray outside it define your personal risk tolerance and safety standards. The difference between ancient times and our modern world is that we can apply millennia of science, information, and knowledge to shaping our safety box. Depending on which side of that box you wander out from determines the types of risks you bring on yourself. Creeping outside is not due to ignorance or malice, it’s just a failure to pay attention to your own advice, risk tolerance, and flight planning. I can think of at least six dragons you’re going to have to slay out there to end up with safe flight. Perhaps you folks can come up with more; I’d love to hear back from you, so to get the conversation started here’s my list:

(1) you instantly become a test pilot for your airplane by getting outside the established safe operating parameters;

(2) you test your own “frog boiling” heat tolerance;

(3) you challenge your body’s physiological tolerances for rest, 02 demands and problem-solving skills;

(4) you defy basic CRM and the stored SA packed into “that little voice”;

(5) you defeat your own flight planning by introducing unaccounted for and unplanned for circumstances, and;

(6) very importantly, you establish a continuously lower personal safety standard.

Staying inside your safety boundaries requires putting all the information we’ve outlined together with one other important skill, good information management. You can’t maximize safe use of all available information and resources without knowing how to prioritize it and handle it. The next question is how to do that.

Modern informatics geeks have a concept in their world called “Johari’s window” of information management and the link here has a great diagram that’s easy to follow. The name comes from the developers, psychologists Joseph Luft and Harry Ingham, who constructed the model and combined their first names for the label. It’s an excellent conceptual model for pilots and it not only applies while we’re in the air but to all sorts of things we do here on the ground. The model is a box matrix (yeah, sorry, another box) combining four categories of information. There is a box of the best kind of information that is open and known to you and everyone else. The second box is your blind spot of information not known to you but known to others (ATC, passengers, and crew like the flight engineer on the Portland UA flight). Next there is a silo of hidden information that you know but don’t share so nobody else knows, and the last box is the dangerous “terra incognito” pile of information that is unknown to everyone. For sure, this is the box where dragons lurk waiting for an opportunity to inflict their special brand of harm on our passengers, our plans, and us.

The key to using the matrix model for mission safety is to understand how to identify information in each box and move it around out of the hidden silos into the open where you and everyone else know it so it can be accessed and acted on. To optimize your information management, you need to know which dragons inhabit your world, inside and outside the safety box (weather, fatigue, fuel) and using the model gives you super situational awareness combined with optimum crew resource management to handle all of it. But your information has a short life span and has to be continuously updated as circumstances change. Make sure everyone on your team knows the latest update of everything you know and that you know everything they know – then discuss what each one will do when the dragons rear their ugly heads.

Failing to keep your SA current and drifting right up to the edge of your safety box or even outside the borders happens occasionally. Sometimes it’s due to circumstances out of our control. The real dangers are two-fold: the first one is going out there intentionally, that’s avoidable, but the second one also should be avoidable but not always; that’s being out there and not knowing it. Johari’s model doesn’t help with the first danger, which we covered in the “Little Voice” article, but it sure helps us with the second risk of just not knowing you’re out there. By understanding how to move all your SA and available flight information into that first box of the model, into the open space where everyone knows it, we can prevent drifting blindly where only dragons lurk. The ways to do this vary a little for each of us but the basics don’t change. We need to continuously question our own assumptions, reevaluate and update our SA, practice solid communication and single pilot or crew resource management skills, and demand of ourselves absolute adherence to our own little voice of caution reinforcing our safety standards. The value of good information management and knowing where dragons live offers us time and “mental bandwidth” to deal with any sudden unknowns and imponderables that pop up in flight like the examples in the last few weeks: sudden loss of power, fire, or emergency exit from the airplane.

Part of good information management and proactive thinking is to never forget that there is at least one other critical piece of information that you don’t know yet and haven’t planned for. So give yourself extra time to deal with known and yet-to-be-known factors by shifting routine tasks and steps of a procedure to less time intensive phases of flight. A good practice is entering your descent, approach and landing runway data into the FMS while still in the more leisure time of the cruise. In doing this and moving as many tasks to open phases of flight as possible, you have a cushion of time and mental acuity to handle the dragon fire if it jumps up at you; like a sudden wind shift when the tower hands you a different runway. It’s a great safety net that can prevent surprises from turning into disasters. If you don’t do it, you’ll get scorched. The takeaway from all this is the critical flight safety skill and integral part of your safety mindset to be able to account for all the variables and information in all four boxes of Johari’s Window and have a pre-planned script for as much as you can well in advance of when it will be needed. There are enough unknowns and imponderables in our lives and flight missions; don’t add more by flying blinding to the edges of “terra incognito.”

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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