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Great Expectations….for Ourselves

Charles Dickens’ “Great Expectations” is among the most classic of all the classics in literature.  The book traces the unexpected ups and downs of the protagonist, “Pip” Pirrip as he grows up expectations 1and deals with the incredibly sad circumstances of his early life and the “great expectations” of his unforeseen good fortunes later on.  At one point he confronts the return of his child-hood sweetheart, Estella.  Dickens shows that Pip has developed some insight into his own actions.  He admits that when he tries to judge his own actions he is guilty of only fooling himself:

“All other swindlers upon earth are nothing to the self-swindlers, and with such pretenses did I cheat myself.”

Dickens’ point is simple; we do a really poor job at the task of self-evaluation and self-criticism.  That’s because we’re always bargaining with ourselves and “swindling” ourselves when we try to judge our own actions. So, in an honest attempt to try this out on myself, I decided to keep a diary one day when I took a simple flight with my daughter up and back to central Florida, maybe an hour each way.  How bad could that be thought I in my own naïve way?  I’m very focused on this issue of personal performance and I have written previously on this subject. My post on It All Comes Down to the Last Slice of Cheese details our incredible aptitude at being “self-swindlers” and the great risk that this poses to ourselves and to other in the system that we operate.  If Convergent Performance is about nothing else we are about understanding and controlling the risks of errors originating in our own personal performance and our unique and individual role as the last “slice of cheese” with no safety net beyond ourselves.

Another thing I know is that, although it’s really important to be on guard for our own sources of mistakes, it’s hard to objective about it.  I have also learned that yet another one of our big faults is that we are continuously giving ourselves just a little more leeway each time, just a little more rope to play with.   Human factors and safety experts call this “normalization of deviancy”.  It refers to our tendency to let ourselves, bit by bit, get farther and farther outside the safety box.  This is another topic I have written about in the past in my blog post entitled, Bingo, Other Parlor Games and Thinking Outside the Box.   A good example of normalization of deviancy was the first mistake I caught myself in – going at a good clip over the speed limit on the way to the airport before I even got started collecting my mistakes.  We all drive (at least) 15 miles or so over the speed limit because we used to drive 5 miles over the speed limit and being just a little outside the box didn’t cause any problems with the Highway Patrol.  So what the heck, let’s normalize more deviancies and go farther outside the box and 10 miles over.  When that still doesn’t get any attention from the FHP, go for it, all the way up to 15 miles over and so it goes, farther and farther from safety.  When we leave ourselves unchecked as the only ones to evaluate our performance we can gradually normalize almost any deviancy so it only gets worse.

I finally made it to the airport and I took the back of my flight plan form, a pen, and a jaundiced eye on my own performance.   I caught myself in 11 mistakes in those two hours.  If I made more I missed them so that would increase my list two for one but I found 11.  None of them were horrible but all were significant, at least from a near miss standpoint. A sample of the kinds of errors I made started with my flight plan – I had (mistakenly) filed a wrong airport identifier code so ATC couldn’t even find my plan in the computer until we bargained back and forth on the radio for a minute and found the error.  The controller was nice about it, and also wasn’t too busy, and kindly corrected my flight plan and re-filed it for me from the tower so, after a brief delay, I was cleared for takeoff and departed.

Flying the published instrument departure out of Miami airspace I found myself a little off assigned heading but it was more of those “normalization of deviancy” issues than a real error (unintentional or otherwise). Miami Center air traffic controllers always keep you going west to join up on the published procedure but since I was heading north I didn’t want to get too far west so I cheated a bit to head north early.  But since I was grading myself seriously, I checked it off and then got back on my assigned heading to wait out the clearance north.  The next mistake was misreading my altimeter when asked for my altitude. I read it wrong by 1000 feet but I was in the right place (thanks to correctly programing the autopilot) but I did get a big “Huh??” from the controller when I flubbed his question until I looked at the instrument again and made the correction – still another mistake but still no harm.  Two times in two hours I dialed the wrong frequency into the radio and both times ATC told me to check on it and sent me to the right frequency – two more dings but still not too major and no harm done. But it was a delay in communication with the right sector controller that could have caused a problem in really busy airspace.

Another mistake I made was in the airway navigation.  I guess I just didn’t hear ATC or thought I heard something else and started down the wrong aviation highway.  ATC asked me to confirm my heading and I told them I was doing what I thought I was supposed to, but they corrected me and I turned a few degrees to catch the right routing.  Again a near miss that could have been an issue, but with the safeguards in the aviation system my little errors were caught and corrected.

So it went for me over two hours, a total of 11 mistakes; that average out to 5.5 mistakes per hour. How bad is this – even if all of my mistakes were pretty minor, caused no incidents and got very little attention?  A while back one of the European airline carriers did a study of pilots on a short hop from London to Glasgow, also about an hour each way.  They found that these commercial pilots made an average of 15.6 errors per hour.  Nothing major and no aircraft lost but a significant assessment of personal performance.  So I guess I was a little better than these guys – maybe a ‘C’ grade if these guys were a ‘D’?  You tell me what I get for this less than stellar showing.

This was a valuable lesson for me and I recommend the exercise to everyone – follow yourself around for a day with pad and pen and write down every little mistake (and large ones too) that come up.   See how critical your own self-evaluation can be or if you only “swindle yourself”.  You can learn a lot about yourself, your personal performance of complex tasks, and your ability to supervise your own actions.   It made me more aware of these issues and as an adopter of The High Reliability Mindset it gave me a chance to re-read many of the previous blog posts and review ways to keep my passengers, my patients and myself safe in dangerous environments.

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