RE: Procedures in real time

Subject: RE: Procedures in real time
From: "McLauchlan, Kevin" <Kevin -dot- McLauchlan -at- safenet-inc -dot- com>
To: "neilson -at- windstream -dot- net" <neilson -at- windstream -dot- net>, Gene Kim-Eng <techwr -at- genek -dot- com>, "techwr-l -at- lists -dot- techwr-l -dot- com" <techwr-l -at- lists -dot- techwr-l -dot- com>
Date: Fri, 18 Jun 2010 15:33:04 -0400



> ---- Gene Kim-Eng <techwr -at- genek -dot- com> wrote:
> > In most heavy industries there are indeed procedures to
> follow in disaster-like situations, and I expect there were
> some on the platform as well. Whether they were not followed
> or were and proved to be wholly or partially ineffective
> remains to be seen. It is possible that someone following an
> emergency procedure of some sort prevented the death toll
> from being even higher than it was.


.... and neilson -at- windstream -dot- net replied:
>
> In yet another point of view is the EMERGENCY STOP LEVER. The
> crew are instructed (and maybe even trained) NEVER to pull
> the lever except in the case of an emergency. Suddenly,
> something dreadful happens, or at least gives an appearance
> of happening. THIS JUST MIGHT BE THE EMERGENCY!!! I'M PULLING
> THE DAMNED LEVER!!!
>
> Doesn't matter what you wrote in the instruction book. Joe's
> pulling that lever!

Reminds me of an experience... "picture this; Sicilly 1922..."
... sorry... wrong flashback... let me root around just a little
more... and .... here we go:

The student is about to take his third or fourth freefall.
He and I will leave the aircraft together, me with a
two-handed side-grip on his harness (at waist and shoulder).
We'll level out and he'll try a couple of
basic attitude/direction control actions, while I either
maintain a single-hand grip, or perhaps release if he seems
to be stable and functional.

He's been instructed that if we get separated, he's to
deploy his parachute, and not wait for the planned
opening altitude - an unstable neophyte can get in all
kinds of trouble in 45 seconds of uncontrolled freefall;
the sort of trouble that could make it a bit more than
45 seconds.

I weigh (then) 190 plus my gear. He weighs 235 of solid
farmer, plus his gear. The plane is a Cessna 182.
We're on jump-run at 12,500 feet over Gananoque, Ontario.

He steps out onto the wheel-strut (there's a small step),
holding onto the wing strut, and I follow, halfway out
the door, with my harness grip on his left side.
At the count, he is to step slightly to his right, releasing
his grip on the strut, and laying his body flat on the
relative wind (which is mostly horizontal while we're
still with the plane). I will just flow out with him
as he goes. Nice'n'easy.

"Ready", "Set" - he does a really, really enthusiastic
backflip off the step (that was not in the play-list),
torquing out of my hands like they were clothespins.

I'm diving even as he's coming out of the first loop,
maybe twenty feet above him and ten or twelve feet
in front, closing fast. He flattens out looks up,
sees me just a few feet away... whoops! that must
mean we've separated! His eyes get big, his hands
move, and as I'm mere inches from gripping his
forearms, he's reaching for his deployment handle.

"No-o-o-o-o-o-o-ooooooo!" I say.

About 4 seconds later, I'm on my back watching his
parachute deploy at more than 11,000 feet AGL.
Crud.
I amuse myself down to proper deployment attitude,
fly to the dropzone, and then spend nearly 20 minutes
watching the student tootle around way, way overhead
(lots of nice thermals that day, and big guy that he
was, he got our biggest student 'chute).

Anyway, he got a really long canopy ride instead of a
freefall lesson, and I got a dressing down for not
having better anticipated his action, but we couldn't
fault him for having done exactly what he'd been told
to do, even though the evidence of his eyes - I had been
completely filling the field of view when he pulled the
plug - suggested that any potential emergency was pretty
much over before he acted, with no harm.

Now, the OPPOSITE situation can occur as well, where
Joe has been made so fearful of the consequences (shutting
down the line, costing the company millions, causing
co-workers to be laid off until the investigation and
re-start can be done...) that he hesitates to pull the
darn lever until he's really, really, really sure...
and it's too late. I don't have an anecdote for
that one, just now. :-)

Training for tense situations implies recognition criteria
for important failures and emergencies. If people don't
take on-board the training they get, then all bets are
off. If people DO take on-board the training they get,
their response under stress is only as good as your
training was relevant. At the same time, you simply
can't anticipate a lot of specific emergency situations
when you develop training or documentation, not because
your imagination fails, but because the brain of the
trainee is going to encompass only a very small number
of scenarios. "Relevance" of training changes according
to the experience and temperament of the trainee.

An inexperienced person needs a small set of things to
recognize and a small set of possible responses that
they should perform. Too much of their brain is occupied
with basic stuff that eventually becomes background
or "second-nature" to an older, more experienced hand
performing the same tasks in the same environment.

A more experienced person can be relaxed and assured
enough to let judgement and a wider focus come into
play.
A baby, learning to walk must focus on the mechanics
of getting one foot in front of the other while
remaining upright (and controlling that big,
floppy head).
A wrinkle in the carpet or the dog trotting by is
too much to incoporate, and the diapered bottom hits
the floor. Later, as a rambunctious toddler, the
same child can check-stride slightly - on automatic -
and reach to pat the doggie's rump while barreling
down the hall in full pursuit of the cat. He's
internalized the mechanics of bipedal motion and has
brain-space left to focus on other aspects of his
situation and "time" to make casual - or more serious -
judgements about them.

As Gene has been hinting, while some procedure and
instruction must be in place to address bad situations,
the vast bulk of training and documentation - and
the procedures for getting the contents into the
personnel - must focus on preventing bad situations.

The only people who can be trusted to respond coolly
and precisely in desperately urgent situations are
trained-and-experienced emergency personnel. Almost
by definition, those are not the people on the spot
as a disaster is taking shape and taking the wraps off.

And then, we get into the matter of trade-offs between
infinitely comprehensive docs and procedures and training...
and profitability. At some point, the burden of
legislation/regulation becomes so heavy that it isn't
worth starting an enterprise. You know in advance that
meeting the doc and oversight requirements will cost
more than you can charge.

- Kevin

<bumpf-start>

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Follow-Ups:

References:
RE: Re: Procedures in real time: From: Gene Kim-Eng
Re: Procedures in real time: From: neilson

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