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The Little Things

Last month we left off talking about how there’s too much information, TMI, in our world and how that informational deluge makes it hard to focus on the really important details of our immediate task.

In spite of all the noise around us that we need to filter out, we still need to concentrate on the essential details, all of those “little things,” to solve the next piece of our safety puzzle. The greater the risk of whatever you’re doing, the more attention you have to pay to the details in order to have safe outcomes. I’ve made no secret in these pages about my fascination with Sir (Dr.) Arthur Conan Doyle’s character Sherlock Holmes, who said it best in his famous story “A Case of Identity.” Discussing how he solved the mystery with his buddy Dr. Watson, Holmes said, “It has long been an axiom of mine that the little things are infinitely the most important.”

Spotting someone who’s not paying attention to “the little things” usually isn’t too hard. A while back I was driving south on the Golden Gate Bridge from Sausalito over to San Francisco. As much as I wanted to get out to the middle lanes where traffic was moving better, I was stuck all the way over in the right lane behind a line of slow cars. Just to make things even better, the guy in front of me, who was the slowest in the lane, had his right blinker light on the whole way over the bridge. I kept wondering if there was an exit coming up in the middle of the bridge that he was going to take. As far as I know the next town west of the San Francisco Bay is Honolulu; it’s a long, tough trip in a car and with the price of fuel these days, you’d run up a hefty gas bill. Going slow with your blinker light on for miles is not the best sign of someone paying attention to the details of their driving. Since I ride around town mostly on my motorcycle I’m always pretty careful around cars with turn signals on. I never know if they really intend to cut into my lane or if their heads aren’t in the game and they’re just not paying attention to the continuous flashing light and the blinky-blink sound in their car. It matters. A while back in this space I talked about driving skills as a metric of pilot safety, and this kind of lack of attention to driving details is a perfect example. It fits right in with other recent topics we’ve also spent a lot of time on in these pages such as focus, distraction, and attention.

Another thing about riding around on a motorcycle is you get to look right into the windows of the cars around you, and these days it’s pretty unusual to see a driver who is not on their cell phone or driving head down sending text messages. That habit would certainly make you oblivious to the blinker light going on for miles. Whether you’re here on terra firma or up in the sky, there are serious consequences for performing high-level skills and not paying very close attention to what might seem to be only simple “little things.”

Objective measures of the consequences of not paying attention to the “little things” is one of the factors that the NTSB and the National Highway Traffic Safety Administration (NHTSA) track every year. They graciously call it “distracted driving statistics.” It’s no surprise that the number one distraction while driving is talking on a cell phone and the stats more than justify their recent recommendation for federal laws banning use of cell phones while driving. Consider these numbers the next time you’re driving and are tempted to pick up your phone. There’s one traffic accident every 10 seconds of every day that has a root cause of distracted cell phone occupied drivers not paying attention to the “little things.” That’s a lot of bent metal, about 8,000 crashes a day.

Another statistic the NHTSA reports is estimates of traffic fatalities every year, and in spite of the COVID lockdowns and drastically reduced driving miles, driving deaths went up 20% in 2021 over two years ago. According to the NHSTA, 42,915 Americans were killed in, or by, motor vehicles in 2021 (there were 33,788 vehicle and pedestrian deaths in 2020). For every 100 million miles driven last year, 1.37 people died, a 23% rise from 2019. Compare that to the risk of death in commercial airline travel that varies a little but averages about 0.2 deaths per 10 billion passenger miles. Putting both statistics into the same units, it works out to 137 deaths per 10 billion miles on the road, about 700-fold higher than deaths per air miles. Those 43,000 annual auto deaths are equivalent to a loaded 178-seat Boeing 737 Max 8 falling out of the sky every 36 hours. We know what happened when just two of those planes crashed; the entire fleet was grounded for almost two years.

What’s up with all these car crashes and deaths, especially during this epidemic with so many fewer miles driven? Researchers used GPS tracking and cell tower data to determine that drivers used their phones more frequently while driving since the pandemic began, and that the problem only worsened over time. The NHSTS reports that talking on your cell phone while driving increases the risk of a fatal crash by a 400%. Cell phone use is nothing compared to sending text messages while driving, which they report increases the risk of a crash by more than 2,300%. Even hands-free cell phone conversations reduce drivers’ cognitive capabilities by 40% according the Carnegie Mellon’s Center for Cognitive Brain Imaging, giving the driver a reaction time equal to a blood alcohol level of 0.08 that’s well into the legal limits of being drunk.  

You don’t have to drive over the Golden Gate Bridge to see what happens when you ignore those really important “little things.” There are lots of similar incidents in our aviation world too. Consider the crash a few months ago of a Learjet 35A (N880Z) on December 27, 2021, near Gillespie Field in San Diego, CA. Four people died in the accident – both pilots, a nurse, and a flight paramedic. The airplane was on a short 20-minute repositioning hop from Santa Ana John Wayne airport to its home base at KSEE. Although the investigation is still preliminary at this point, it’s likely the crash was the result of an accelerated stall while trying to make a circling approach to 27R in IFR conditions. It turns out that both pilots had limited experience in the Learjet 35A. The pilot (PIC) was Douglas Grande, who had an ATP but not without restrictions. There was a remark in the FAA database saying his license was “subject to pilot in command limitations.” This means he had gotten his type rating in a simulator and didn’t yet have the required number of turbine/jet hours actually flown in the air. (It might be just that the FAA had not gotten around to deleting this notation if he had reached the required hours; we’ll know in their final report.) The first officer (FO) was Julian Bugaj, who had a commercial pilot license at the time of the crash with a single type rating in the Learjet 20 series. His certificate also had a restriction in the jet limiting him to second in command privileges only since he didn’t have the flight time to qualify as PIC.

The cockpit voice recordings (CVR) indicated that the FO was the pilot flying (PF) the approach and also the one who was making all the radio calls. The final NTSB analysis is a long way off and without casting any dispersions on the crew, it would seem that among other contributing factors, the PIC, who himself had only limited time in the aircraft, had designated both flying the plane and talking on the radio to an even less experienced FO. The FO was attempting to execute one of the most difficult maneuvers we fly: an instrument approach with a circle to land on an intersecting runway, in IMC, at night, at an airport in hilly terrain. At the same time he was on the approach doing all the flying, he was also making the radio calls and talking to the tower. The crucial detail of keeping the jet within its aerodynamic envelope so the wings didn’t stall didn’t seem to be “infinitely the most important thing,” as Holmes would have said. Considering all those statistics cited above about distracted driving, it’s not all that surprising that this flight ended in tragedy.


Why we modern humans find it so hard to pay attention to details while carrying out potentially dangerous tasks isn’t clear to me. One possible, and really scary, scenario we could consider for this behavior is based on several brain studies that show actions we take are often initiated before we have any conscious awareness of having made the decision of what to do. It seems that we do a lot of the things based on unconscious, unchosen brain processes, but we only get around to the actual thinking part of the decision later – maybe too late. Like picking up your cell phone to make a call while driving in traffic, or keying the mike and trying to copy an amendment to your flight plan during a critical phase of flight. These sorts of things are different issues than the TMI problem from last month. It’s not only that we are drowning in too much information to process, it’s that we make choices without considering the information we have right in front of us. “That Little Voice” that we anointed a few months ago whispers to us many of those critical “little things” that affect our safety. These days it seems that lots of drivers (and pilots too) don’t listen to that voice and allow themselves to get so distracted they just don’t pay attention to the “little things.” An ancient Greek gladiator, Oenomaus (72 BC), who had a real personal interest in this issue, once said, “A gladiator’s first distraction is his last.” That’s great advice and it’s even more important and relevant today in our world of multiple distractions. The critical takeaway lesson from the Lear tragedy and the driving statistics is pretty clear: make informed and well thought out decisions before you act, not after, then let your decisions guide your actions. Don’t just act and let the pieces fall where they might afterwards. Decide to pay very close attention to those “little things” by not creating distractions for yourself. That is, above all else, your “infinitely most important” task. It’s dangerous enough here on the ground, but up in the air, not paying attention to those “little things” is an invitation to disaster. Heed Oenomaus’ prescient advice; it might save your life someday.

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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