Why do we do what we do?
Being pressed for time, working in poor surroundings, having a lack of resources, inavailability of instructions, having availalble instructions that we choose not to use — these and a number of other less-than-ideal conditions describe a typical day in aviation maintenance. Under these conditions, we are left to our own devices to make decisions so we do the best we can do. We make decisions under conditions of uncertainty, taking into account probable risk and using past experience.
Experience can be a blessing that helps us do our jobs. It can also lead us astray. How would you do your job if you had no deadline to meet, worked under ideal conditions with no manager looking over your shoulder questioning your every move, and had adequate resources? The probability that you would be inclined to follow the maintenance manual would be high. When any one or more of those factors are missing, you are more inclined to rely on your experience because it is more expedient.
Usually employers want employees with experience. There is a learning curve with new employees, especially in aviation, to have a higher rate of accidents and a higher incidence of mistakes. As we gain experience, the rate of accidents decreases because we also gain a conscious awareness of our surroundings. However, and oddly enough, as we gain experience we initially display a dip in our incidents of mistakes but over time the mistake rate increases. Although there are many reasons for this phenomenon, two are the anchoring effect and escalation of deviation.
The anchoring effect is based on the “rule of thumb” concept, or as it is called in the scientific community, a heuristic. We do this all the time. We use our foot to make an approximate measure of 12 inches; a pinch of salt, a dash of pepper — you get the idea. Someone may have noticed that his foot was 12 inches long and used it for a measure and others picked up the idea. Some cook long ago found that the correct amount of seasoning was a pinch of salt and a dash of pepper, but isn’t this dependent on the size of a person’s fingers and number of holes in the pepper shaker? You might recall the saying, “you will do in a pinch.” The origin behind this came out of the west during the gold rush when a drink at a tavern was paid for with a pinch of gold. The tavern owners wised up and would only employ bartenders with large hands. The point is that these “rules of thumb” are inaccurate, inconsistent and subject to bias, but experience anchors our decisions.
The anchoring effect can lock us into a train of thought that blocks out other solutions. We get used to doing a task in a particular methodology. I recall the problem with installing a slide on 727 galley doors. They would fall off all the time. I was taught how to install them by a senior mechanic and I took him as being experienced, which he was. About half the time the method taught worked perfectly, but the other half of the time it turned into a struggle. One day I had some time on my hands and decided to read the maintenance manual — how unique. What I discovered was the proper way of installing the slide. I did the next slide change by the manual, and although it took longer than the way I was taught, it was consistent in its application. I no longer had to contend with struggling with the slide half the time. Sometime in the past, someone found a technique for changing the slide that cut down on the time and this is how it was passed down to the new employees. The procedure stuck and became a norm and an anchor point.
Research has discovered that anchor points are also readily manipulated. You see this in TV ads all the time. The cost of the product is advertised as $19.95, but if you act within the next 24 hours you will get two products for $19.95. If you consider $19.95 as the price of one item and the anchor point, you will think you are getting a bargain with two for the price of one. Anchor points are also manifested when we consider stereotypes. What is your image of a retired Marine drill sergeant? The image is anchored in the vision that one has gained from the media but it may not fit the person.
Anchor points can also be useful because of a technique called mnemonic devices. You can remember the mathematical order of operation by memorizing the mnemonic device “my dear aunt Sally” (multiply, divide, add, subtract). You may not know the consonants, but you learned to identify the vowels in grade school with the rhythmic; a,e,i,o,u and sometimes y. You probably have a number of your own mnemonic devices, but what happens when something new comes along? Unlearning those memory devices is difficult.
The lesson learned here is to use the anchors but be aware that you don’t close the door to other inputs. Conspiracy theorists tend to see conspiracy in everything because they are anchored and refuse to accept any outside influence that is contrary.
Escalation of Deviation
Escalation of deviation is interesting and more insidious because it can creep up on us. We are not aware of a problem until we are in the middle of it and we don’t know how we got there. Those that are daring are cognizant of the escalation. It’s called pushing the envelope. Evel Knievel didn’t start by jumping great distances, but moved up to that with calculation and numerous mistakes. That was intentional movement. Many times this is carefully-calculated risk to reduce the element of danger, but in Evel Knievel’s case and many others, a daredevil’s danger is an accepted consequence. When you experience deviation from current processes and it appears to be an improvement, you are more likely to deviate a little more until the improvement is not attained and is met with failure. You have either pushed the limits of safety, reached the breaking point, or probability has caught up with you.
We obey the speed limit but also know that we can push that without getting a ticket. How did we find a speed that didn’t attract a cop and a traffic ticket? We slowly move faster and faster — we escalate the deviation. So we slowly learn that there is a five mph buffer in the speed limit becoming an anchor point. However, we can still get a ticket driving five mph over the limit but we play the probability. We know we are not supposed to step on the top two rungs of a ladder but how many of us have pushed it? Stepping on the top two steps even for a moment is wrong. You may think that you will be OK because you are just going to step on the top step for a short time. If there is a 30 percent probability of falling from the top two steps of a ladder, it is 30 percent regardless if you on the step for 30 seconds or 30 minutes. However, if you step on the top step for 30 seconds with no problems, then you are going to be more likely to step on the top step for longer and longer. Although your probability doesn’t change, your exposure will increase significantly. Look at it this way: if a slot machine pays out 30 percent of the time, it will pay out 30 percent whether you play 30 seconds or 30 minutes.
Don’t get blinded by being anchored in an idea and be cautious of creeping deviation. Stay vigilant, remain cognizant of your surroundings and stay safe.
Patrick Kinane joined the Air Force after high school and has worked in aviation since 1964. Kinane is a certified A&P with Inspection Authorization and also holds an FAA license and commercial pilot certificate with instrument rating. He earned a B.S. in aviation maintenance management, MBA in quantitative methods, M.S. in education and Ph.D. in organizational psychology. The majority of his aviation career has been involved with 121 carriers where he has held positions from aircraft mechanic to director of maintenance. Kinane currently works as Senior Quality Systems Auditor for AAR Corp. and adjunct professor for DeVry University instructing in Organizational Behavior, Total Quality Management (TQM) and Critical Thinking. PlaneQA is his consulting company that specializes in quality and safety system audits and training. Speaking engagements are available with subjects in Critical Thinking, Quality Systems and Organizational Behavior. For more information, visit www.PlaneQA.com.