U.S. Department
of Transportation

Federal Aviation

St. Louis
Flight Standards District Office

10801 Pear Tree Lane
Suite 200
St. Ann, Missouri 63074


March 2005




Thought for the month.....
The sooner an error can be caught, the less time it has to gain energy to hurt us.

Discipline is a bedrock principle of airmanship... Although we often look at a variety of factors in an accident investigation, the real cause of most accidents can be distilled down to a failure of self-discipline. With regard to flying safety, self-discipline is defined as the strength of will to systematically develop all areas of airmanship and execute sound judgment in the presence of temptations to do otherwise. To safely plan and employ an aircraft within all operational, regulatory, organizational and common sense guidelines.

What is it that tempts us to move to a region of poor judgment? Why do we allow ourselves to get into a position where we place more emphasis on accomplishing the flight, and less on safety? The modern pilot must be able to perceive and process a lot of information and make decisions in the time available. Discipline provides a framework in which to make those decisions. If we perceive information incorrectly or we don't frame our decisions in a disciplined way, errors can accumulate and result in an accident or incident that will be labeled, "pilot error".

Aviation is really a complex system and every system has layers of defense against failure. Think of it as a line of dominoes. Each domino represents a rule, procedure, or piece of equipment designed to prevent an accident. The first domino might be the FARs or AIM. Procedures have been established as a result of things we have learned that are related to accidents or unsafe operations. If there is no rule or procedure in place, that layer of protection is not available to us. This could be an underlying cause of an
accident. The second domino might be the aircraft's operating limitations. The manufacturer has determined that if the aircraft is operated within certain limits, it should remain structurally sound and safe. If the manufacturer has failed to identify something as a limitation, it could be the basic cause of an accident. The center domino is us, the operator. If we are ignorant of, or choose to ignore the first two dominos, we eliminate those layers of defense, and must rely on our own ability and dominoe four to prevent an accident. Domino three is considered to be the immediate cause of an accident.

Domino number four represents safety defenses. These are things like gear warning horns, caution lights, airspace warnings on a GPS, etc. Domino number four is there as a last effort to capture errors before they can result in an accident or incident. It also represents things we can do to mitigate the consequences of errors that haven't been captured up to this point. These might be having a flight plan on file so someone will know to come looking for us if we don't arrive at our destination, or having a survival kit aboard the aircraft. Domino five represents the consequences. The severity of the consequences will depend on how important dominoes 1 - 4 were. If we routinely ignore the manufacturer's engine operating limitations and it quits on us on a cold night over the Mark Twain Forest with no flight plan or survival gear, domino number five might be unsurvivable when it lands on us.

The key to a safe flight is ensuring that we have as many dominoes standing as we can. This is where discipline fits into the equation. If we have the self-discipline to plan well, know and comply with good procedures, and maintain and operate the aircraft according to the limitations and guidance provided, there will be fewer opportunities for us to be tempted to make poor judgments. If we have good safety defenses in place, like filing a flight plan or having an autopilot and knowing how to operate it, they can capture errors that might slip through. In any case, the better support we can provide in dominoes one through four, the less it will hurt if domino five falls on us. Maybe it will only result in a bruised ego. The sooner an error can be caught, the less time it has to gain energy to hurt us.

Upcoming Events
Clicking on the date (if underlined)will take you to the FAA's website
for a descripton of the event.

March 15
Airport User Meeting and Operation Rain Check
Mid-Coast Training Center
St. Louis Downtown Airport
Cahokia, IL
1:00 p.m. and again at 7:00 p.m.

April 4
Keith's Café
Memphis, MO
Light Sport Aircraft and Runway Safety
7 to 9 p.m.

May 12
Maryland Heights Centre
2344 McKelvey Rd
Maryland Heights, MO
Working CFI Seminar
8:30 a.m. to 1:30 p.m.

May 21
EAA Hangar
St. Charles Co.
Smartt Field
EAA Sport Pilot Tour
8:00 a.m.

Register at http//faasafety.gov for E-mail notification of safety seminars in the St. Louis District.

Let's Not Meet By Accident
Fred Harms
Operations Safety Program Manager
800-322-8876 ext 4835