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Aeronautical Decision Making

Introduction:

  • Flying safely requires the effective integration of three separate sets of skills:
    • Most obvious are the basic stick-and-rudder skills needed to control the airplane
    • Next, are skills related to proficient operation of aircraft systems
    • Last, but not least, are Aeronautical Decision-Making (ADM) skills
  • ADM is a systematic approach to the mental process (risk and stress management) used by pilots to consistently determine the best course of action in response to a given set of circumstances
    • It is what a pilot intends to do based on the latest information he or she has
  • Two defining elements of ADM are hazard and risk
  • While the FAA strives to eliminate errors through technology, training, systems and improved flight safety programs, one fact remains: humans make errors
  • As you work through the ADM cycle, it is important to apply the principles of risk management

History of Aeronautical Decision Making:

  • For over 25 years, the importance of good pilot judgment, or aeronautical decision-making (ADM), has been recognized as critical to the safe operation of aircraft, as well as accident avoidance. The airline industry, motivated by the need to reduce accidents caused by human factors, developed the first training programs based on improving ADM. Crew resource management (CRM) training for flight crews is focused on the effective use of all available resources: human resources, hardware, and information supporting ADM to facilitate crew cooperation and improve decision-making. The goal of all flight crews is good ADM and the use of CRM is one way to make good decisions
  • Research in this area prompted the Federal Aviation Administration (FAA) to produce training directed at improving the decision-making of pilots and led to current FAA regulations that require that decision-making be taught as part of the pilot training curriculum. ADM research, development, and testing culminated in 1987 with the publication of six manuals oriented to the decision-making needs of variously rated pilots. These manuals provided multifaceted materials designed to reduce the number of decision-related accidents. The effectiveness of these materials was validated in independent studies where student pilots received such training in conjunction with the standard flying curriculum. When tested, the pilots who had received ADM-training made fewer in-flight errors than those who had not received ADM training. The differences were statistically significant and ranged from about 10 to 50 percent fewer judgment errors. In the operational environment, an operator flying about 400,000 hours annually demonstrated a 54 percent reduction in accident rate after using these materials for recurrency training
  • Contrary to popular opinion, good judgment can be taught. Tradition held that good judgment was a natural by-product of experience, but as pilots continued to log accident-free flight hours, a corresponding increase of good judgment was assumed. Building upon the foundation of conventional decision-making, ADM enhances the process to decrease the probability of human error and increase the probability of a safe flight. ADM provides a structured, systematic approach to analyzing changes that occur during a flight and how these changes might affect the safe outcome of a flight

Background:

  • It is estimated that approximately 80% of all aviation accidents are human factors related [Figure 1]
  • The ADM process addresses all aspects of decision making in the flight deck and identifies the steps involved in good decision making
  • While the ADM process will not eliminate errors, it will help the pilot recognize errors, and in turn enable the pilot to manage the error to minimize its effects by:
    1. Identifying personal attitudes hazardous to safe flight
    2. Learning behavior modification techniques
    3. Learning how to recognize and cope with stress
    4. Developing risk assessment
    5. Using all resources
    6. Evaluating the effectiveness of one's ADM skills
  • Historically, the term "pilot error," which means an action made by the pilot was the cause or a contributing factor that led to the accident, has been used to describe the causes of these accidents
    • This definition also includes the pilot's failure to make a decision or take action
  • From a broader perspective, the phrase "human factors related" more aptly describes these accidents since it is usually not a single decision that leads to an accident, but a chain of events triggered by a number of factors
  • The poor judgment chain, sometimes referred to as the "error chain," is a term used to describe this concept of contributing factors in a human factors related accident
  • Breaking one link in the chain normally is all that is necessary to change the outcome of the sequence of events

The Decision-Making Process:

  • An understanding of the decision-making process provides a pilot with a foundation for developing ADM skills
  • Some situations, such as engine failures, require a pilot to respond immediately using established procedures with a little time for detailed analysis
  • This is termed automatic decision-making and is based upon training, experience, and recognition
  • Traditionally, pilots have been well trained to react to emergencies, but are not as well prepared to make decisions requiring a more reflective response where greater analysis is required
  • Typically during a flight, there is time to examine any changes that occur, gather information, and assess risk before reaching a decision
  • The steps leading to this conclusion constitute the decision-making process:
  • Defining the Problem:

    • Problem definition is the first step in the decision-making process
    • Defining the problem begins with recognizing that a change has occurred or that an expected change did not occur
    • One critical error that can be made during the decision-making process is incorrectly defining the problem
      • Example: a low oil pressure reading could indicate that the engine is about to fail and an emergency landing should be planned, or it could mean that the oil pressure sensor has failed
        • The actions to be taken in each of these circumstances would be significantly different
        • One requires an immediate decision based upon training, experience, and evaluation of the situation; whereas the latter decision is based upon an analysis
    • It should be noted that the same indication could result in two different actions depending upon other influences
  • Choosing a Course of Action:

    • After the problem has been identified, the pilot must evaluate the need to react to it and determine the actions that may be taken to resolve the situation in the time available
    • The expected outcome of each possible action should be considered and the risks assessed before deciding on a response to the situation
  • Implementing the Decision and Evaluating the Outcome:

    • Although a decision may be reached and a course of action implemented, the decision-making process is not complete
    • It is important to think ahead and determine how the decision could affect other phases of flight
    • As the flight progresses, the pilot must continue to evaluate the outcome of the decision to ensure that it is producing the desired result

Improper Decision-Making Outcomes:

  • Pilots sometimes get in trouble not because of deficient basic skills or system knowledge, but rather because of faulty decision-making skills
  • Although aeronautical decisions may appear to be simple or routine, each individual decision in aviation often defines the options available for the next decision the pilot must make and the options, good or bad, they provide
  • Therefore, a poor decision early on in a flight can compromise the safety of the flight at a later time necessitating decisions that must be more accurate and decisive
  • Conversely, good decision-making early on in an emergency provide greater latitude for options later on
  • FAA Advisory Circular (AC) 60-22, defines ADM as a systematic approach to the mental process of evaluating a given set of circumstances and determining the best course of action
  • ADM thus builds upon the foundation of conventional decision-making, but enhances the process to decrease the probability of pilot error
  • Specifically, ADM provides a structure to help the pilot use all resources to develop comprehensive situational awareness
Instrument Flying Handbook. Figure 1-11, The Margin of Safety
Figure 1: Instrument Flying Handbook, The Margin of Safety
Instrument Flying Handbook. Figure 1-12, The 3P Model for Aeronautical Decision-Making
Figure 2: Instrument Flying Handbook, The 3P Model for Aeronautical Decision-Making

Decision Making Models:

  • Models allow for structure to the dynamic process of decision making
  • Two types of models associated with ADM are:
  • 3P Model:

    • The Perceive-Process-Perform (3P) model for ADM offers a simple, practical, and systematic approach that can be used during all phases of flight [Figure 2]
    • To use it, the pilot will:
      • Perceive the given set of circumstances for a flight
      • Process by evaluating their impact on flight safety
      • Perform by implementing the best course of action
    • In the first step, the goal is to develop situational awareness by perceiving hazards, which are present events, objects, or circumstances that could contribute to an undesired future event
      • In this step, the pilot will systematically identify and list hazards associated with all aspects of the flight: pilot, aircraft, environment, and external pressures
      • It is important to consider how individual hazards might combine
      • Consider, for example, the hazard that arises when a new instrument pilot with no experience in actual instrument conditions wants to make a cross-country flight to an airport with low ceilings in order to attend an important business meeting
    • In the second step, the goal is to process this information to determine whether the identified hazards constitute risk, which is defined as the future impact of a hazard that is not controlled or eliminated
      • The degree of risk posed by a given hazard can be measured in terms of exposure (number of people or resources affected), severity (extent of possible loss), and probability (the likelihood that a hazard will cause a loss)
      • If the hazard is low ceilings, for example, the level of risk depends on a number of other factors, such as pilot training and experience, aircraft equipment and fuel capacity, and others
    • In the third step, the goal is to perform by taking action to eliminate hazards or mitigate risk, and then continuously evaluate the outcome of this action
      • With the example of low ceilings at destination, for instance, the pilot can perform good ADM by selecting a suitable alternate, knowing where to find good weather, and carrying sufficient fuel to reach it
      • This course of action would mitigate the risk
      • The pilot also has the option to eliminate it entirely by waiting for better weather
    • Once the pilot has completed the 3P decision process and selected a course of action, the process begins anew because now the set of circumstances brought about by the course of action requires analysis
    • The decision-making process is a continuous loop of perceiving, processing and performing
  • The DECIDE Model:

    • Another structured approach to ADM is the DECIDE model, which is a six-step process intended to provide a logical way of approaching decision-making
    • As in the 3P model, the elements of the DECIDE model represent a continuous loop process to assist a pilot in the decision-making required when faced with a situational change that requires judgment
    • [Figure 3] The model is primarily focused on the intellectual component, but can have an impact on the motivational component of judgment as well
    • If a pilot continually uses the DECIDE Model in all decision-making, it becomes natural and results in better decisions being made under all types of situations
    • In conventional decision-making, the need for a decision is triggered by recognition that something has changed or an expected change did not occur
    • Recognition of the change, or lack of change, is a vital step in any decision making process
    • Not noticing change in a situation can lead directly to a mishap
    • [Figure 3a] The change indicates that an appropriate response or action is necessary in order to modify the situation (or, at least, one of the elements that comprise it) and bring about a desired new situation
    • Therefore, situational awareness is the key to successful and safe decision making
    • At this point in the process, the pilot is faced with a need to evaluate the entire range of possible responses to the detected change and to determine the best course of action
    • [Figure 3b] illustrates how the ADM process expands conventional decision-making, shows the interactions of the ADM steps, and how these steps can produce a safe outcome
    • Starting with the recognition of change, and following with an assessment of alternatives, a decision to act or not act is made, and the results are monitored
    • Pilots can use ADM to enhance their conventional decision-making process because it:
      1. Increases their awareness of the importance of attitude in decision-making
      2. Teaches the ability to search for and establish relevance of information
      3. Increases their motivation to choose and execute actions that ensure safety in the situational time frame
Instrument Flying Handbook. Figure 1-13, Decision Making
Figure 3: Instrument Flying Handbook, Decision Making

Risk Management:

  • Hazard and Risk:

    • Hazard is a real or perceived condition, event, or circumstance that a pilot encounters
    • When faced with a hazard, the pilot makes an assessment of that hazard based upon various factors
    • That assessment of a single or cumulative hazard facing a pilot is considered as risk
    • The pilot assigns a value (numerical or otherwise) to the potential impact of the hazard, which qualifies the pilot's assessment of the hazard—risk
    • During each flight, the single pilot makes many decisions under hazardous conditions
    • To fly safely, the pilot needs to assess the degree of risk and determine the best course of action to mitigate the risk
      • Assessing Risk:

        • For the single pilot, assessing risk is not as simple as it sounds. For example, the pilot acts as his or her own quality control in making decisions. If a fatigued pilot who has flown 16 hours is asked if he or she is too tired to continue flying, the answer may be “no.” Most pilots are goal oriented and when asked to accept a flight, there is a tendency to deny personal limitations while adding weight to issues not germane to the mission. For example, pilots of helicopter emergency services (EMS) have been known (more than other groups) to make flight decisions that add significant weight to the patient’s welfare. These pilots add weight to intangible factors (the patient in this case) and fail to appropriately quantify actual hazards, such as fatigue or weather, when making flight decisions. The single pilot who has no other crew member for consultation must wrestle with the intangible factors that draw one into a hazardous position. Therefore, he or she has a greater vulnerability than a full crew
        • Examining National Transportation Safety Board (NTSB) reports and other accident research can help a pilot learn to assess risk more effectively. For example, the accident rate during night visual flight rules (VFR) decreases by nearly 50 percent once a pilot obtains 100 hours and continues to decrease until the 1,000 hour level. The data suggest that for the first 500 hours, pilots flying VFR at night might want to establish higher personal limitations than are required by the regulations and, if applicable, apply instrument flying skills in this environment
        • Several risk assessment models are available to assist in the process of assessing risk. The models, all taking slightly different approaches, seek a common goal of assessing risk in an objective manner. The most basic tool is the risk matrix. [Figure 2-5] It assesses two items: the likelihood of an event occurring and the consequence of that event
          • Likelihood of an Event:
            • Likelihood is nothing more than taking a situation and determining the probability of its occurrence. It is rated as probable, occasional, remote, or improbable. For example, a pilot is flying from point A to point B (50 miles) in marginal visual flight rules (MVFR) conditions. The likelihood of encountering potential instrument meteorological conditions (IMC) is the first question the pilot needs to answer. The experiences of other pilots, coupled with the forecast, might cause the pilot to assign “occasional” to determine the probability of encountering IMC
            • The following are guidelines for making assignments
              • Probable—an event will occur several times
              • Occasional—an event will probably occur sometime
              • Remote—an event is unlikely to occur, but is possible
              • Improbable—an event is highly unlikely to occur
          • Severity of an Event:
            • The next element is the severity or consequence of a pilot’s action(s). It can relate to injury and/or damage. If the individual in the example above is not an instrument rated pilot, what are the consequences of him or her encountering inadvertent IMC conditions? In this case, because the pilot is not IFR rated, the consequences are catastrophic. The following are guidelines for this assignment
              • Catastrophic—results in fatalities, total loss
              • Critical—severe injury, major damage
              • Marginal—minor injury, minor damage
              • Negligible—less than minor injury, less than minor system damage
            • Simply connecting the two factors as shown in Figure 2-5 indicates the risk is high and the pilot must either not fly or fly only after finding ways to mitigate, eliminate, or control the risk
            • Although the matrix in Figure 2-5 provides a general viewpoint of a generic situation, a more comprehensive program can be made that is tailored to a pilot’s flying. [Figure 2-6] This program includes a wide array of aviation-related activities specific to the pilot and assesses health, fatigue, weather, capabilities, etc. The scores are added and the overall score falls into various ranges, with the range representative of actions that a pilot imposes upon himself or herself
      • Mitigating Risk:

        • Risk assessment is only part of the equation. After determining the level of risk, the pilot needs to mitigate the risk. For example, the pilot flying from point A to point B (50 miles) in MVFR conditions has several ways to reduce risk:
          • Wait for the weather to improve to good visual flight rules (VFR) conditions
          • Take an instrument-rated pilot
          • Delay the flight
          • Cancel the flight
          • Drive
        • One of the best ways single pilots can mitigate risk is to use the IMSAFE checklist to determine physical and mental readiness for flying:
          1. Illness—Am I sick? Illness is an obvious pilot risk
          2. Medication—Am I taking any medicines that might affect my judgment or make me drowsy?
          3. Stress—Am I under psychological pressure from the job? Do I have money, health, or family problems? Stress causes concentration and performance problems. While the regulations list medical conditions that require grounding, stress is not among them. The pilot should consider the effects of stress on performance
          4. Alcohol—Have I been drinking within 8 hours? Within 24 hours? As little as one ounce of liquor, one bottle of beer, or four ounces of wine can impair flying skills. Alcohol also renders a pilot more susceptible to disorientation and hypoxia
          5. Fatigue—Am I tired and not adequately rested? Fatigue continues to be one of the most insidious hazards to flight safety, as it may not be apparent to a pilot until serious errors are made
          6. Emotion—Am I emotionally upset?
  • Risk Management Decision Making Process

    • Risk Management is a systematic, decision making process used to identify and manage hazards that endanger resources
    • Risk Management is a tool used to make informed decisions by providing the best baseline of knowledge and experience available
    • The goal of risk management is to proactively identify safety-related hazards and mitigate the associated risks
    • When a pilot follows good decision-making practices, the inherent risk in a flight is reduced or even eliminated
    • The ability to make good decisions is based upon direct or indirect experience and education
    • The formal risk management decision-making process involves six steps as shown in [Figure 4]
    • Consider automotive seat belt use. In just two decades, seat belt use has become the norm, placing those who do not wear seat belts outside the norm, but this group may learn to wear a seat belt by either direct or indirect experience
    • For example, a driver learns through direct experience about the value of wearing a seat belt when he or she is involved in a car accident that leads to a personal injury
    • An indirect learning experience occurs when a loved one is injured during a car accident because he or she failed to wear a seat belt
Pilot Handbook of Aeronautical Knowledge. Figure 2-3, Risk Management Decision-Making Process
Figure 4: Pilot Handbook of Aeronautical Knowledge,
Risk Management Decision-Making Process
  • Four Principles of Risk Management:

    1. Accept no unnecessary risk:

      • Flying is not possible without risk, but unnecessary risk comes without a corresponding return
      • If you are flying a new airplane for the first time, you might determine that the risk of making that flight in low visibility conditions is unnecessary
    2. Make risk decisions at the appropriate level:

      • Risk decisions should be made by the person who can develop and implement risk controls
      • Remember that you are pilot-in-command, so never let anyone else—not ATC and not your passengers—make risk decisions for you
    3. Accept risk when benefits outweigh dangers (costs):

      • In any flying activity, it is necessary to accept some degree of risk
      • A day with good weather, for example, is a much better time to fly an unfamiliar airplane for the first time than a day with low IFR conditions
    4. Integrate risk management into planning at all levels:

      • Because risk is an unavoidable part of every flight, safety requires the use of appropriate and effective risk management not just in the preflight planning stage, but in all stages of the flight
  • Risk Management Levels:

    • Risk Management can be applied on three levels, based upon time and assets available:
      • Time-critical:

        A quick mental review of the five-step process when time does not allow for any more (i.e., in-flight mission/situation changes)
      • Deliberate:

        Experience and brain storming are used to identify hazards and is best done in groups (i.e., aircraft moves, fly on/off)
      • In-depth:

        More substantial tools are used to thoroughly study the hazards and their associated risk in complex operations (i.e., weapons detachment)
Instrument Flying Handbook. Figure 1-14, The Five Antidotes to Hazardous Attitudes
Figure 5: Instrument Flying Handbook,
The Five Antidotes to Hazardous Attitudes

Hazardous Attitudes:

  • Being fit to fly depends on more than just a pilot's physical condition and recent experience
  • Studies have identified five hazardous attitudes that can interfere with the ability to make sound decisions and exercise authority properly: anti-authority, impulsivity, invulnerability, macho, and resignation
  • Hazardous attitudes, which contribute to poor pilot judgment, are dangerous personalities we must learn to recognize within ourselves and others
    • A pilot who exhibits a hazardous trait may not recognize it him/herself and it may be up to you to prevent catastrophe
  • Early recognition of these hazardous attitudes sets the stage for proper corrective action to be taken [Figure 5]
    • A pilot who will risk his/her own life will likely do the same with their passengers!
  • Research (which later evolved into the Crew Resource Management concept, has identified five overarching hazardous attitudes that can affect a pilot's judgment, as well as the corresponding antidotes for each
  • Anti-Authority:

    • "Don't tell me"
    • This attitude is found in those who do not like anyone telling them what to do
    • They may be resentful of having someone tell them what to do, or may regard rules, regulations, and procedures as silly or unnecessary
    • While it is always your prerogative to question authority if you feel it is in error, understand you may be in error
  • Impulsively:

    • "Do it quickly"
    • This is the attitude of people who frequently feel the need to do something, anything, immediately
    • They do not stop to think about what they are about to do; they do not select the best alternative, and they do the first thing that comes to mind
  • Invulnerability:

    • "It won't happen to me"
    • Many people feel that accidents happen to others, but never to them
    • They know accidents can happen, and they know that anyone can be affected
    • They never really feel or believe that they will be personally involved
    • Experience can be a large contributing factor
    • Pilots who think this way are more likely to take chances and increase risk
  • Macho:

    • "I can do it"
    • Pilots who are always trying to prove that they are better than anyone else are thinking, "I can do it. I'll show them"
    • Pilots with this type of attitude will try to prove themselves by taking risks in order to impress others
    • While this pattern is thought to be a male characteristic, women are equally susceptible
  • Resignation:

    • "What's the use?"
    • Pilots feeling resignation do not see themselves as being able to make a great deal of difference in what happens to them
    • When things go well, the pilot is apt to think that it is good luck
    • When things go badly, the pilot may feel that someone is out to get me, or attribute it to bad luck
    • The pilot will leave the action to others, for better or worse
    • Sometimes, such pilots will even go along with unreasonable requests just to be a "nice guy"

Conclusion:

  • Remember, ADM is a Special Emphasis Item in the Practical Test Standards/Airman Certification Standards
  • Human factors and your personal day-to-day attitudes will dictate what you bring to the airplane
  • While poor decision-making in everyday life does not always lead to tragedy, the margin for error in aviation is thin
    • Since ADM enhances management of an aeronautical environment, all pilots should become familiar with and employ ADM
  • It is critical that hazardous attitudes can be understood so they can be recognized, labeled as hazardous, and the appropriate antidote applied
  • The Federal Aviation Administration publishes a newsletter titled Callback
    • This newsletter, combined with reviews of past mishaps will ensure you keep grounded to the basic principles and safety practices you learned as that young private pilot on their first solo

References: