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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
  • The ADM process addresses all aspects of decision making in the flight deck and identifies the steps involved in good decision making
  • 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
  • An understanding of the decision-making process provides a pilot with a foundation for developing ADM skills
    • It is what a pilot intends to do based on the latest information he or she has
    • Models such as the 3P and DECIDE models allow for structure to the dynamic process of decision making
  • 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
  • There is an element of risk in every flight and therefore pilots must apply the principles of risk management throughout the ADM process

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
  • 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
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

The Decision-Making Process:

  • An understanding of the decision-making process provides the pilot with a foundation for developing ADM skills
    • While some situations, such as engine failure, require an immediate pilot response using established procedures, there is usually time during a flight to analyze any changes that occur, gather information, and assess risks before reaching a decision
    • This is termed automatic decision-making and is based upon training, experience, and recognition
  • Risk management and risk intervention are decision-making processes designed to systematically identify hazards, assess the degree of risk, and determine the best course of action
    • These processes involve the identification of hazards, followed by assessments of the risks, analysis of the controls, making control decisions, using the controls, and monitoring the results
  • The steps leading to this decision constitute a decision-making process
    • Three models of a structured framework for problem-solving and decision-making are the 5P, the 3P using PAVE, CARE and TEAM, and the DECIDE models
  • The 5 Ps Check:

    • The 5 Ps consist of "the Plan, the Plane, the Pilot, the Passengers, and the Programming"
      • Each of these areas consists of a set of challenges and opportunities that every pilot encounters which can substantially impact the pilot’s ability to make informed and timely decisions
    • The 5 Ps are based on the idea that pilots have essentially these five variables which impact his or her environment and forcing him or her to make a critical decisions, that when added together can create a critical outcome
    • The 5P concept relies on the pilot to adopt a “scheduled” review of the critical variables at points in the flight where decisions are most likely to be effective. For instance, the easiest point to cancel a flight due to bad weather is before the pilot and passengers walk out the door and load the aircraft. So the first decision point is preflight in the flight planning room, where all the information is readily available to make a sound decision, and where communication and Fixed Base Operator (FBO) services are readily available to make alternate travel plans
    • The second easiest point in the flight to make a critical safety decision is just prior to takeoff. Few pilots have ever had to make an “emergency takeoff.” While the point of the 5P check is to help the pilot fly, the correct application of the 5 P before takeoff is to assist in making a reasoned go/no-go decision based on all the information available. That decision will usually be to “go,” with certain restrictions and changes, but may also be a “no-go.” The key idea is that these two points in the process of flying are critical go/no-go points on each and every flight
    • The third place to review the 5 Ps is at the midpoint of the flight. Often, pilots may wait until the Automated Terminal information Service (ATIS) is in range to check weather, yet, at this point in the flight, many good options have already passed behind the aircraft and pilot. Additionally, fatigue and low-altitude hypoxia serve to rob the pilot of much of his or her energy by the end of a long and tiring flight day.This leads to a transition from a decision-making mode to an acceptance mode on the part of the pilot. If the flight is longer than 2 hours, the 5 P check should be conducted hourly
    • The last two decision points are just prior to descent into the terminal area and just prior to the final approach fix, or if VFR, just prior to entering the traffic pattern as preparations for landing commence. Most pilots execute approaches with the expectation that they will land out of the approach every time. A healthier approach requires the pilot to assume that changing conditions (the 5 Ps again) will cause the pilot to divert or execute the missed approach on every approach. This keeps the pilot alert to all manner of conditions that may increase risk and threaten the safe conduct of the flight. Diverting from cruise altitude saves fuel, allows unhurried use of the autopilot and is less reactive in nature. Diverting from the final approach fix, while more difficult, still allows the pilot to plan and coordinate better, rather than executing a futile missed approach. Let’s look at a detailed discussion of each of the Five Ps
    • The Plan:

      • Flight planning results in not just a flight plan but familiarization of all events that surround the flight
      • The flight plan consists of the basic elements of cross-country planning, weather, route, fuel, publications currency, etc.
      • However, no matter how perfect the plan, external factors such as weather and aircraft status are subject to change at any time
      • It is for any number of factors that can impact the flight that the "Plan" should be reviewed and updated throughout the flight
      • Several resources such as datalink weather, FSS and/or Flight Watch, Pilot Reports, and ATC can help augment the flight plan
    • The Plane:

      • The "plane" consists of the usual array of mechanical and cosmetic issues that every aircraft pilot, owner, or operator can identify
      • With the advent of advanced avionics, the "plane" has expanded to include database currency, automation status, and emergency backup systems that were unknown a few years ago
      • Much has been written about single pilot IFR flight, both with and without an autopilot
      • While this is a personal decision, it is just that-a decision
      • Low IFR in a non-autopilot equipped aircraft may depend on several of the other Ps to be discussed
      • Pilot proficiency, currency, and fatigue are among them
    • The Pilot:

      • Flying, especially when business transportation is involved, can expose a pilot to risks such as high altitudes, long trips requiring significant endurance, and challenging weather
      • Advanced avionics, when installed, can expose a pilot to high stresses because of the inherent additional capabilities which are available
      • When dealing with pilot risk, it is always best to consult the “IMSAFE” checklist (see page 2-6). The combination of late nights, pilot fatigue, and the effects of sustained flight above 5,000 feet may cause pilots to become less discerning, less critical of information, less decisive, and more compliant and accepting
      • Just as the most critical portion of the flight approaches (for instance a night instrument approach, in the weather, after a 4-hour flight), the pilot’s guard is down the most
      • The 5 P process helps a pilot recognize the physiological challenges that they may face towards the end of the flight prior to takeoff and allows them to update personal conditions as the flight progresses
      • Once risks are identified, the pilot is in a better place to make alternate plans that lessen the effect of these factors and provide a safer solution
    • The Passengers:

      • One of the key differences between CRM and SRM is the way passengers interact with the pilot
        • The pilot of a highly capable single-engine aircraft maintains a much more personal relationship with the passengers as he/she is positioned within an arm’s reach of them throughout the flight
      • Passengers can also be pilots. If no one is designated as pilot in command (PIC) and unplanned circumstances arise, the decision-making styles of several self-confident pilots may come into conflict
      • Pilots also need to understand that non-pilots may not understand the level of risk involved in flight. While a pilot may feel comfortable with the risk present in a night IFR flight, the passengers may not. A pilot employing SRM should ensure the passengers are involved in the decision-making and given tasks and duties to keep them busy and involved. If, upon a factual description of the risks present, the passengers are not comfortable, then a good decision has generally been made. This discussion also allows the pilot to move past what he or she thinks the passengers want to do and find out what they actually want to do. This removes self-induced pressure from the pilot
    • The Programming:

      • The electronic instrument displays, GPS, and autopilot reduce pilot workload and increase pilot situational awareness
      • These devices however, tend to capture the pilot’s attention and hold it for long periods of time
        • To avoid this phenomenon, the pilot should plan in advance when and where the programming for approaches, route changes, and airport information gathering should be accomplished, as well as times it should not
        • Pilot familiarity with the equipment, the route, the local ATC environment, and personal capabilities in relation to the automation should drive when, where, and how the automation is programmed and used
  • Perceive, Process, Perform (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
    • Use the Perceive, Process, Perform, and Evaluate method as a continuous model for every aeronautical decision that you make. Although human beings will inevitably make mistakes, anything that you can do to recognize and minimize potential threats to your safety will make you a better pilot
    • Depending upon the nature of the activity and the time available, risk management processing can take place in any of three timeframes. [Figure 2-10] Most flight training activities take place in the “time-critical” timeframe for risk management. The six steps of risk management can be combined into an easy-to-remember 3P model for practical risk management: Perceive, Process, Perform with the PAVE, CARE and TEAM checklists. Pilots can help perceive hazards by using the PAVE checklist of: Pilot, Aircraft, enVironment, and External pressures. They can process hazards by using the CARE checklist of: Consequences, Alternatives, Reality, External factors. Finally, pilots can perform risk management by using the TEAM choice list of: Transfer, Eliminate, Accept, or Mitigate
    • PAVE Checklist: Identify Hazards and Personal Minimums:

      • 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, which makes up the PAVE checklist. [Figure 2-11] For each element, ask “what could hurt me, my passengers, or my aircraft?” All four elements combine and interact to create a unique situation for any flight. Pay special attention to the pilot aircraft combination, and consider whether the combined “pilot-aircraft team” is capable of the mission you want to fly. For example, you may be a very experienced and proficient pilot, but your weather flying ability is still limited if you are flying a 1970s-model aircraft with no weather avoidance gear. On the other hand, you may have a new technically advanced aircraft with moving map GPS, weather datalink, and autopilot—but if you do not have much weather flying experience or practice in using this kind of equipment, you cannot rely on the airplane’s capability to compensate for your own lack of experience
    • CARE Checklist: Review Hazards and Evaluate Risks:

      • 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). The goal is to evaluate their impact on the safety of your flight, and consider “why must I CARE about these circumstances?"
      • For each hazard that you perceived in step one, process by using the CARE checklist of: Consequences, Alternatives, Reality, External factors. [Figure 2-12] For example, let's evaluate a night flight to attend a business meeting:
        • Consequences—departing after a full workday creates fatigue and pressure
        • Alternatives—delay until morning; reschedule meeting; drive
        • Reality —dangers and distractions of fatigue could lead to an accident
        • External pressures—business meeting at destination might influence me
      • A good rule of thumb for the processing phase: if you find yourself saying that it will “probably” be okay, it is definitely time for a solid reality check. If you are worried about missing a meeting, be realistic about how that pressure will affect not just your initial go/no-go decision, but also your inflight decisions to continue the flight or divert
    • TEAM Checklist: Choose and Implement Risk Controls:

      • Perform risk management by using the TEAM checklist of: Transfer, Eliminate, Accept, Mitigate to deal with each factor. [Figure 2-13]:
        • Transfer—Should this risk decision be transferred to someone else (e.g., do you need to consult the chief flight instructor?)
        • Eliminate—Is there a way to eliminate the hazard?
        • Accept—Do the benefits of accepting risk outweigh the costs?
        • Mitigate—What can you do to mitigate the risk?
      • 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. With practice and consistent use, running through the 3P cycle can become a habit that is as smooth, continuous, and automatic as a well-honed instrument scan. This basic set of practical risk management tools can be used to improve risk management
      • Your mental willingness to follow through on safe decisions, especially those that require delay or diversion is critical. You can bulk up your mental muscles by:
        • Using personal minimums checklist to make some decisions in advance of the flight. To develop a good personal minimums checklist, you need to assess your abilities and capabilities in a non-flying environment, when there is no pressure to make a specific trip. Once developed, a personal minimums checklist will give you a clear and concise reference point for making your go/no-go or continue/discontinue decisions
        • In addition to having personal minimums, some pilots also like to use a preflight risk assessment checklist to help with the ADM and risk management processes. This kind of form assigns numbers to certain risks and situations, which can make it easier to see when a particular flight involves a higher level of risk
        • Develop a list of good alternatives during your processing phase. In marginal weather, for instance, you might mitigate the risk by identifying a reasonable alternative airport for every 25–30 nautical mile segment of your route
        • Preflight your passengers by preparing them for the possibility of delay and diversion, and involve them in your evaluation process
        • Another important tool—overlooked by many pilots—is a good post-flight analysis. When you have safely secured the airplane, take the time to review and analyze the flight as objectively as you can. Mistakes and judgment errors are inevitable; the most important thing is for you to recognize, analyze, and learn from them before your next flight
      • The goal is to perform by taking action to eliminate hazards or mitigate risk, and then continuously evaluate the outcome of this action
  • The DECIDE Model:

    • DECIDE means to Detect, Estimate, Choose a course of action, Identify solutions, Do the necessary actions, and Evaluate the effects of the actions
    • Detect (the Problem):

      • Detection begins with (correctly) recognizing a change occurred or an expected change did not occur
      • A problem is perceived first by the senses and then it is distinguished through insight and experience
      • These same abilities, as well as an objective analysis of all available information, are used to determine the nature and severity of 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
    • Estimate (the Need To React):

      • 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
      • In many cases, overreaction and fixation excludes a safe outcome. For example, what if the cabin door of your aircraft suddenly opened in flight while the aircraft climbed through 1,500 feet on a clear sunny day? The sudden opening would be alarming, but the perceived hazard the open door presents is quickly and effectively assessed as minor. In fact, the door’s opening would not impact safe flight and can almost be disregarded. Most likely, a pilot would return to the airport to secure the door after landing
      • The pilot flying on a clear day faced with this minor problem may rank the open cabin door as a low risk. What about the pilot on an IFR climb out in IMC conditions with light intermittent turbulence in rain who is receiving an amended clearance from ATC? The open cabin door now becomes a higher risk factor. The problem has not changed, but the perception of risk a pilot assigns it changes because of the multitude of ongoing tasks and the environment. Experience, discipline, awareness, and knowledge influences how a pilot ranks a problem
    • Choose (a Course of Action):

      • After the problem has been identified and its impact estimated, the pilot must determine the desirable outcome and choose a course of action
      • The expected outcome of each possible action should be considered and the risks assessed before deciding on a response to the situation
    • Identify (Solutions):

      • The pilot formulates a plan that will take him or her to the objective. Sometimes, there may be only one course of action available. In the case of the engine failure already at 500 feet or below, the pilot solves the problem by identifying one or more solutions that lead to a successful outcome. It is important for the pilot not to become fixated on the process to the exclusion of making a decision
    • Do (the Necessary Actions):

      • Once pathways to resolution are identified, the pilot selects the most suitable one for the situation. The multiengine pilot given the simulated failed engine must now safely land the aircraft
    • Evaluate (the Effect of the Action):

      • Finally, after implementing a solution, evaluate the decision to see if it was correct
      • 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
    • 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
    • [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

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 1-13, Decision Making
Figure 3: Instrument Flying Handbook, Decision Making

Decision-Making in a Dynamic Environment:

  • A solid approach to decision-making is through the use of analytical models, such as the 5 Ps, 3P, and DECIDE. Good decisions result when pilots gather all available information, review it, analyze the options, rate the options, select a course of action, and evaluate that course of action for correctness
  • In some situations, there is not always time to make decisions based on analytical decision-making skills. A good example is a quarterback whose actions are based upon a highly fluid and changing situation. He intends to execute a plan, but new circumstances dictate decision-making on the fly. This type of decision-making is called automatic decision-making or naturalized decision-making. [Figure 2-14B]
  • Automatic Decision-Making:

    • In an emergency situation, a pilot might not survive if he or she rigorously applies analytical models to every decision made as there is not enough time to go through all the options. Under these circumstances he or she should attempt to find the best possible solution to every problem
    • For the past several decades, research into how people actually make decisions has revealed that when pressed for time, experts faced with a task loaded with uncertainty first assess whether the situation strikes them as familiar. Rather than comparing the pros and cons of different approaches, they quickly imagine how one or a few possible courses of action in such situations will play out. Experts take the first workable option they can find. While it may not be the best of all possible choices, it often yields remarkably good results
    • The terms “naturalistic” and “automatic decision-making” have been coined to describe this type of decision-making. The ability to make automatic decisions holds true for a range of experts from firefighters to chess players. It appears the expert’s ability hinges on the recognition of patterns and consistencies that clarify options in complex situations. Experts appear to make provisional sense of a situation, without actually reaching a decision, by launching experience-based actions that in turn trigger creative revisions
    • This is a reflexive type of decision-making anchored in training and experience and is most often used in times of emergencies when there is no time to practice analytical decision-making. Naturalistic or automatic decision-making improves with training and experience, and a pilot will find himself or herself using a combination of decision-making tools that correlate with individual experience and training
    • Operational Pitfalls:

      • Although more experienced pilots are likely to make more automatic decisions, there are tendencies or operational pitfalls that come with the development of pilot experience. These are classic behavioral traps into which pilots have been known to fall. More experienced pilots, as a rule, try to complete a flight as planned, please passengers, and meet schedules. The desire to meet these goals can have an adverse effect on safety and contribute to an unrealistic assessment of piloting skills. All experienced pilots have fallen prey to, or have been tempted by, one or more of these tendencies in their flying careers. These dangerous tendencies or behavior patterns, which must be identified and eliminated, include the operational pitfalls shown in Figure 2-15
    • Stress Management:

      • Everyone is stressed to some degree almost all of the time. A certain amount of stress is good since it keeps a person alert and prevents complacency. Effects of stress are cumulative and, if the pilot does not cope with them in an appropriate way, they can eventually add up to an intolerable burden. Performance generally increases with the onset of stress, peaks, and then begins to fall off rapidly as stress levels exceed a person’s ability to cope. The ability to make effective decisions during flight can be impaired by stress. There are two categories of stress—acute and chronic. These are both explained in Chapter 17, “Aeromedical Factors"
      • Factors referred to as stressors can increase a pilot’s risk of error in the flight deck. [Figure 2-16] Remember the cabin door that suddenly opened in flight on the Mooney climbing through 1,500 feet on a clear sunny day? It may startle the pilot, but the stress would wane when it became apparent the situation was not a serious hazard. Yet, if the cabin door opened in IMC conditions, the stress level makes significant impact on the pilot’s ability to cope with simple tasks. The key to stress management is to stop, think, and analyze before jumping to a conclusion. There is usually time to think before drawing unnecessary conclusions
      • There are several techniques to help manage the accumulation of life stresses and prevent stress overload. For example, to help reduce stress levels, set aside time for relaxation each day or maintain a program of physical fitness. To prevent stress overload, learn to manage time more effectively to avoid pressures imposed by getting behind schedule and not meeting deadlines
    • Use of Resources:

      • To make informed decisions during flight operations, a pilot must also become aware of the resources found inside and outside the flight deck. Since useful tools and sources of information may not always be readily apparent, learning to recognize these resources is an essential part of ADM training. Resources must not only be identified, but a pilot must also develop the skills to evaluate whether there is time to use a particular resource and the impact its use will have upon the safety of flight. For example, the assistance of ATC may be very useful if a pilot becomes lost, but in an emergency situation, there may be no time available to contact ATC
      • Internal Resources:
        • One of the most underutilized resources may be the person in the right seat, even if the passenger has no flying experience. When appropriate, the PIC can ask passengers to assist with certain tasks, such as watching for traffic or reading checklist items. The following are some other ways a passenger can assist:
          • Provide information in an irregular situation, especially if familiar with flying. A strange smell or sound may alert a passenger to a potential problem
          • Confirm after the pilot that the landing gear is down
          • Learn to look at the altimeter for a given altitude in a descent
          • Listen to logic or lack of logic
        • Also, the process of a verbal briefing (which can happen whether or not passengers are aboard) can help the PIC in the decision-making process. For example, assume a pilot provides a lone passenger a briefing of the forecast landing weather before departure. When the Automatic Terminal Information Service (ATIS) is picked up, the weather has significantly changed. The discussion of this forecast change can lead the pilot to reexamine his or her activities and decision-making. [Figure 2-17] Other valuable internal resources include ingenuity, aviation knowledge, and flying skill. Pilots can increase flight deck resources by improving these characteristics
        • When flying alone, another internal resource is verbal communication. It has been established that verbal communication reinforces an activity; touching an object while communicating further enhances the probability an activity has been accomplished. For this reason, many solo pilots read the checklist out loud; when they reach critical items, they touch the switch or control. For example, to ascertain the landing gear is down, the pilot can read the checklist. But, if he or she touches the gear handle during the process, a safe extension of the landing gear is confirmed. It is necessary for a pilot to have a thorough understanding of all the equipment and systems in the aircraft being flown. Lack of knowledge, such as knowing if the oil pressure gauge is direct reading or uses a sensor, is the difference between making a wise decision or poor one that leads to a tragic error
        • Checklists are essential flight deck internal resources. They are used to verify the aircraft instruments and systems are checked, set, and operating properly, as well as ensuring the proper procedures are performed if there is a system malfunction or in-flight emergency. Students reluctant to use checklists can be reminded that pilots at all levels of experience refer to checklists, and that the more advanced the aircraft is, the more crucial checklists become. In addition, the pilot’s operating handbook (POH) is required to be carried on board the aircraft and is essential for accurate flight planning and resolving in-flight equipment malfunctions. However, the most valuable resource a pilot has is the ability to manage workload whether alone or with others
      • External Resources:
        • ATC and flight service specialists are the best external resources during flight. In order to promote the safe, orderly flow of air traffic around airports and, along flight routes, the ATC provides pilots with traffic advisories, radar vectors, and assistance in emergency situations. Although it is the PIC’s responsibility to make the flight as safe as possible, a pilot with a problem can request assistance from ATC. [Figure 2-18] For example, if a pilot needs to level off, be given a vector, or decrease speed, ATC assists and becomes integrated as part of the crew. The services provided by ATC can not only decrease pilot workload, but also help pilots make informed in-flight decisions
        • The Flight Service Stations (FSSs) are air traffic facilities that provide pilot briefing, en route communications, VFR search and rescue services, assist lost aircraft and aircraft in emergency situations, relay ATC clearances, originate Notices to Airmen (NOTAM), broadcast aviation weather and National Airspace System (NAS) information, receive and process IFR flight plans, and monitor navigational aids (NAVAIDs). In addition, at selected locations, FSSs provide En Route Flight Advisory Service (Flight Watch), issue airport advisories, and advise Customs and Immigration of transborder flights. Selected FSSs in Alaska also provide TWEB recordings and take weather observations

Situational Awareness:

  • Situational awareness is the accurate perception and understanding of all the factors and conditions within the five fundamental risk elements (flight, pilot, aircraft, environment, and type of operation that comprise any given aviation situation) that affect safety before, during, and after the flight. Monitoring radio communications for traffic, weather discussion, and ATC communication can enhance situational awareness by helping the pilot develop a mental picture of what is happening
  • Maintaining situational awareness requires an understanding of the relative significance of all flight related factors and their future impact on the flight. When a pilot understands what is going on and has an overview of the total operation, he or she is not fixated on one perceived significant factor. Not only is it important for a pilot to know the aircraft’s geographical location, it is also important he or she understand what is happening. For instance, while flying above Richmond, Virginia, toward Dulles Airport or Leesburg, the pilot should know why he or she is being vectored and be able to anticipate spatial location. A pilot who is simply making turns without understanding why has added an additional burden to his or her management in the event of an emergency. To maintain situational awareness, all of the skills involved in ADM are used
  • Obstacles to Maintaining Situational Awareness:
    • Fatigue, stress, and work overload can cause a pilot to fixate on a single perceived important item and reduce an overall situational awareness of the flight. A contributing factor in many accidents is a distraction that diverts the pilot’s attention from monitoring the instruments or scanning outside the aircraft. Many flight deck distractions begin as a minor problem, such as a gauge that is not reading correctly, but result in accidents as the pilot diverts attention to the perceived problem and neglects proper control of the aircraft
    • Workload Management:
      • Effective workload management ensures essential operations are accomplished by planning, prioritizing, and sequencing tasks to avoid work overload. [Figure 2-19] As experience is gained, a pilot learns to recognize future workload requirements and can prepare for high workload periods during times of low workload. Reviewing the appropriate chart and setting radio frequencies well in advance of when they are needed helps reduce workload as the flight nears the airport. In addition, a pilot should listen to ATIS, Automated Surface Observing System (ASOS), or Automated Weather Observing System (AWOS), if available, and then monitor the tower frequency or Common Traffic Advisory Frequency (CTAF) to get a good idea of what traffic conditions to expect. Checklists should be performed well in advance so there is time to focus on traffic and ATC instructions. These procedures are especially important prior to entering a high density traffic area, such as Class B airspace
      • Recognizing a work overload situation is also an important component of managing workload. The first effect of high workload is that the pilot may be working harder but accomplishing less. As workload increases, attention cannot be devoted to several tasks at one time, and the pilot may begin to focus on one item. When a pilot becomes task saturated, there is no awareness of input from various sources, so decisions may be made on incomplete information and the possibility of error increases. [Figure 2-20]
      • When a work overload situation exists, a pilot needs to stop, think, slow down, and prioritize. It is important to understand how to decrease workload. For example, in the case of the cabin door that opened in VFR flight, the impact on workload should be insignificant. If the cabin door opens under IFR different conditions, its impact on workload changes. Therefore, placing a situation in the proper perspective, remaining calm, and thinking rationally are key elements in reducing stress and increasing the capacity to fly safely. This ability depends upon experience, discipline, and training

    • Managing Risks:
      • The ability to manage risks begins with preparation. Here are some things a pilot can do to manage risks:
        • Assess the flight’s risk based upon experience. Use some form of risk assessment. For example, if the weather is marginal and the pilot has little IMC training, it is probably a good idea to cancel the flight
        • Brief passengers using the SAFETY list:
          • S Seat belts fastened for taxi, takeoff, landing. Shoulder harness fastened for takeoff, landing. Seat position adjusted and locked in place
          • A Air vents (location and operation). All environmental controls (discussed). Action in case of any passenger discomfort
          • F Fire extinguisher (location and operation)
          • E Exit doors (how to secure; how to open). Emergency evacuation plan. Emergency/survival kit (location and contents)
          • T Traffic (scanning, spotting, notifying pilot). Talking, (“sterile flight deck” expectations)
          • Y Your questions? (Speak up!)
        • In addition to the SAFETY list, discuss with passengers whether or not smoking is permitted, flight route altitudes, time en route, destination, weather during flight, expected weather at the destination, controls and what they do, and the general capabilities and limitations of the aircraft
        • Use a sterile flight deck (one that is completely silent with no pilot communication with passengers or by passengers) from the time of departure to the first intermediate altitude and clearance from the local airspace
        • Use a sterile flight deck during arrival from the first radar vector for approach or descent for the approach
        • Keep the passengers informed during times when the workload is low
        • Consider using the passenger in the right seat for simple tasks, such as holding the chart. This relieves the pilot of a task

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)

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
  • 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
  • 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
  • It is important to reiterate that these models are not linear thought processes
    • The decision-making process is a continuous loop of perceiving, processing and performing
  • Use of these models is formal at first but become secondary in nature over time
    • At least five times before and during the flight, the pilot should review and consider the “Plan, the Plane, the Pilot, the Passengers, and the Programming” and make the appropriate decision required by the current situation. It is often said that failure to make a decision is a decision. Under SRM and the 5 Ps, even the decision to make no changes to the current plan is made through a careful consideration of all the risk factors present

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