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Stuck Mics and Stuck Brains

A couple of things happened over the past two weeks, one an unmitigated tragedy and the other mostly harmless, that got me thinking about something pilots call “a stuck mic”.  I’ll  address the easy one first.  Basically an airplane radio has two modes – you can transmit or you can listen but you can’t do both at the same time.  So if you’re transmitting all incoming

Guglielmo Marconi, inventor of the “wireless radio”

communications are blocked and the only way you can hear what’s going on around you is if you are not holding down the “transmit” button and that puts the radio in the “receive” mode.

I was flying south along the coast line the other evening and I heard an announcement by a commercial pilot to his passengers that was obviously meant to be on intercom but was actually broadcast out to the world on the Air Traffic Control Center (ATC) frequency that the center controllers were using to communicate with all the other airplanes in the sky.  He was polite and informative but his “stuck mic” totally shut off communication to him and everyone else by ATC until he was finished and then reminded by ATC that he was blocking the center control frequency.  No real harm done but potentially a real problem for the safety of those of us in the air at the time if there had been a traffic alert or other important message.  Also a bit inconvenient and I guess a little embarrassing to the pilot who was obviously a real professional.  This happens every once in a while and almost every pilot has done it once or twice and it’s usually not a big deal but it could be – so it’s one of those “near misses”.

Have you ever tried to have a “conversation” with someone who has a “stuck mic” and who can only broadcast and not receive?  They have no interest in what you have to say and at best, are only waiting for a moment of quiet to start to broadcast again to tell you what you should be thinking.  A real conversation and the true “high reliability mindset” exchange of critical information involves taking your thumb off the transmit button and truly listening to the other person, absorbing it into your brain and then responding and discussing it.  Highly reliable teams communicate two ways – listen and transmit – not one way with their thumb on the broadcast button.

The other incident was an incredible tragedy – it happened a while ago but the NTSB just published its final report on a crash that took the life of a friend of mine along with his son, who went to school with my daughter and sat next to her in a number of classes.  He was flying a single engine airplane (also with his wife and another adult and his child on board) that caught fire due to a fracture in one of the fuel lines, the crash killed all five people and orphaned his daughter.  What I had wanted to know was how long he tried to stay up in the air after the fire started because I know exactly where he was and that was over a rural area with a number of low traffic roads that might have been a suitable and safe emergency landing strip.  I read the ATC transcripts and was really upset – he reported the fire about 7 minutes before the radar signal was lost and the actual crash occurred.  If you are piloting a single engine airplane and the engine catches fire you have climbed up a decision tree with no branches – you shut off the fuel and shut down the engine and land – anywhere.  The ATC transcript shows that he was trying to get back to the airport while on fire and just like having a “stuck mic” – he had a “stuck brain” that was fixated on getting back and he didn’t consider other possible solutions.

High reliability theory refers to this source of error as “task fixation” which basically means that you get so focused and stuck on one idea you can’t move on to consider other options.  This is well described by Lawrence Gonzalez in “Deep Survival” a great book that I have previously recommended on this blog site.  Once your brain goes into broadcast mode to your body and you hold the transmit button down, you block off all other internal communications that might lead you to revisit your decision and go to plan B.  He was so fixated on getting back to the airport that he didn’t see the obvious and potentially life-saving option of landing on a rural highway right under him.  He was about 15 minutes from the airport more than twice the length of time he could stay in the air while on fire.  The tragedy is almost unthinkable and I would never try to second guess another experienced pilot – but there seems to have been an opportunity to avoid disaster.

Every error and bad outcome is full of a lot of “what ifs” that frustrates those who study the incidents because it always seems so obvious in retrospect.  But “what if” he had pulled out the emergency check list (he flew the same plane I own so I know it’s there) to help him “unstick the mic in his head”.  It’s a real short check list – pull the fuel levers off to starve the fire and shut off the fuel pumps, tell ATC you’re on fire and where you are and use the last of the power to lower the landing gear and then shut the main power switches off to take away the sparks from the burning fuel. And then immediately LAND THE AIRPLANE – ANYWHERE.  A four lane rural highway that is right under you and gets little traffic on it is a great option.

For those of us who believe and practice the high reliability mindset this is a tragic but important lesson in internal and external communication so let’s learn from it.  First – take your thumb off the transmit button when you need to discuss patient critical information so you can really listen to what your team mates have to report and contribute to everyone’s situational awareness.  And as you make your decision, take your mind of your internal transmit button so you can listen to “those little voices in that back of your head”, hear your own thoughts as well as those of your team mates and come to a correct and timely course of action that has evaluated and weighed ALL the possible options.

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Posted in communication, CRM, Error Producing Conditions, Human Factors.


4 Responses

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  1. Tony Kern says

    Ken

    Great post. As you point out, the challenge of hyper stress often calls for “immediate action” and leaves no room for reflection or option analysis. Its why the old “wind the clock” trick (as the first step in any emergency) works – it unsticks the mic long enough for our big brains to get back to work.

    tk

  2. skulljockey says

    Interesting post . May I provide a counter point?
    Carole Anne Moulton, a surgical educator, from the University of
    Toronto has described the concept of “slowing down when you should”. Her PHd thesis argues that ” a critical function of expertise is the ability to transform from an automatic mode to the more effortful mode when required.” Her research involves working with surgeons to better understand the deliberate tactic of slowing down in the anticipation that things are unfolding in a way that does not respect the surgical or “flight plan”. Although stress is certainly an epiphenomena, and can hinder the slowing down process, the real question is what are the conditions to promote this “slowing down” mind set? Many a surgeon has found themselves in a situation of torrential bleeding. With experience ( and perhaps age!), we know that as we temporary stop the haemorrhaging with some automaticity, we pause and think actively about the next steps. Ken, you are correct this in part of the complex internal communication process.

  3. Billy Schmidt says

    Excellent topic. To follow up on the previous point, “to better understand the deliberate tactic of slowing down,” here’s a short video of Gordan Graham explaining high-risk, low-frequency events and the need to “slow down.” http://www.youtube.com/watch?v=Og9Usv82CdU

    • kenstahl says

      Excellent video – thanks for posting this for “high reliability” practitioners to see. There is an entire science on making time critical decisions that I will be addressing in the upcoming posts.



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