Aeronautical decision-making (ADM) is a systematic approach to the mental process used by pilots to consistently determine the best course of action in response to a given set of circumstances. The importance of learning effective ADM skills cannot be overemphasized. While progress is continually being made in the advancement of pilot training methods, aircraft equipment and systems, and services for pilots, accidents still occur. Despite all the changes in technology to improve flight safety, one factor remains the same—the human factor. It is estimated that approximately 65 percent of the total rotorcraft accidents are human factors related.
Historically, the term “pilot error” has been used to describe the causes of these accidents. Pilot error means that an action or decision made by the pilot was the cause of, or a contributing factor that lead to, the accident. This definition also includes the pilot’s fail- ure 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 following is an example of the type of scenario illustrating the poor judgment chain.
A helicopter pilot, with limited experience flying in adverse weather, wants to be back at his home airport in time to attend an important social affair. He is already 30 minutes late. Therefore, he decides not to refuel his helicopter, since he should get back home with at least 20 minutes of reserve. In addition, in spite of his inexperience, he decides to fly through an area of possible thunderstorms in order to get back just before dark. Arriving in the thunderstorm area, he encounters lightning, turbulence, and heavy clouds. Night is approaching, and the thick cloud cover makes it very dark. With his limited fuel supply, he is not able to circumnavigate the thunderstorms. In the darkness and turbulence, the pilot becomes spatially disoriented while attempting to continue flying with visual reference to the ground instead of using what instruments he has to make a 180° turn. In the ensuing crash, the pilot is seriously injured and the helicopter completely destroyed.
By discussing the events that led to this accident, we can understand how a series of judgmental errors contributed to the final outcome of this flight. For example, one of the first elements that affected the pilot’s flight was a decision regarding the weather. The pilot knew there were going to be thunderstorms in the area, but he had flown near thunderstorms before and never had an accident.
Next, he let his desire to arrive at his destination on time override his concern for a safe flight. For one thing, in order to save time, he did not refuel the helicopter, which might have allowed him the opportunity to circumnavigate the bad weather. Then he overestimated his flying abilities and decided to use a route that took him through a potential area of thunderstorm activity. Next, the pilot pressed on into obviously deteriorating conditions instead of changing course or landing prior to his destination.
On numerous occasions during the flight, the pilot could have made effective decisions that may have pre- vented this accident. However, as the chain of events unfolded, each poor decision left him with fewer and fewer options. Making sound decisions is the key to preventing accidents. Traditional pilot training has emphasized flying skills, knowledge of the aircraft, and familiarity with regulations. ADM training focuses on the decision-making process and the factors that affect a pilot’s ability to make effective choices.
Human Factors—The study of how people interact with their environments. In the case of general aviation, it is the study of how pilot performance is influenced by such issues as the design of cockpits, the function of the organs of the body, the effects of emotions, and the interaction and communication with the other participants of the aviation community, such as other crew members and air traffic control personnel.
A helicopter pilot, with limited experience flying in adverse weather, wants to be back at his home airport in time to attend an important social affair. He is already 30 minutes late. Therefore, he decides not to refuel his helicopter, since he should get back home with at least 20 minutes of reserve. In addition, in spite of his inexperience, he decides to fly through an area of possible thunderstorms in order to get back just before dark. Arriving in the thunderstorm area, he encounters lightning, turbulence, and heavy clouds. Night is approaching, and the thick cloud cover makes it very dark. With his limited fuel supply, he is not able to circumnavigate the thunderstorms. In the darkness and turbulence, the pilot becomes spatially disoriented while attempting to continue flying with visual reference to the ground instead of using what instruments he has to make a 180° turn. In the ensuing crash, the pilot is seriously injured and the helicopter completely destroyed.
By discussing the events that led to this accident, we can understand how a series of judgmental errors contributed to the final outcome of this flight. For example, one of the first elements that affected the pilot’s flight was a decision regarding the weather. The pilot knew there were going to be thunderstorms in the area, but he had flown near thunderstorms before and never had an accident.
Next, he let his desire to arrive at his destination on time override his concern for a safe flight. For one thing, in order to save time, he did not refuel the heli-copter, which might have allowed him the opportunity to circumnavigate the bad weather. Then he overestimated his flying abilities and decided to use a route that took him through a potential area of thunderstorm activity. Next, the pilot pressed on into obviously deteriorating conditions instead of changing course or landing prior to his destination.
On numerous occasions during the flight, the pilot could have made effective decisions that may have prevented this accident. However, as the chain of events unfolded, each poor decision left him with fewer and fewer options. Making sound decisions is the key to preventing accidents. Traditional pilot training has emphasized flying skills, knowledge of the aircraft, and familiarity with regulations. ADM training focuses on the decision-making process and the factors
ORIGINS OF ADM TRAINING
The airlines developed some of the first training programs that focused on improving aeronautical decision-making. Human factors-related accidents motivated the airline industry to implement crew resource management (CRM) training for flight crews. The focus of CRM programs is the effective use of all available resources; human resources, hardware, and information. Human resources include all groups routinely working with the cockpit crew (or pilot) who are involved in decisions that are required to operate a flight safely. These groups include, but are not limited to: ground personnel, dispatchers, cabin crewmembers, maintenance personnel, external-load riggers, and air traffic controllers. Although the CRM concept originated as airlines developed ways of facilitating crew cooperation to improve decision-making in the cockpit, CRM principles, such as workload management, situational awareness, communication, the leadership role of the captain, and crewmember coordination have direct application to the general aviation cockpit. This also includes single-pilot operations since pilots of small aircraft, as well as crews of larger aircraft, must make effective use of all available resources-human resources, hardware, and information. You can also refer to AC 60-22, Aeronautical Decision Making, which provides background references, definitions, and other pertinent information about ADM training in the general aviation environment. [Figure 14-1]
Figure 14-1. These terms are used in AC 60-22 to explain concepts used in ADM training.
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. A problem is perceived first by the senses, then is distinguished through insight and expe-rience. These same abilities, as well as an objective analysis of all available information, are used to determine the exact nature and severity of the problem.
While doing a hover check after picking up firefighters at the bottom of a canyon, you realize that you are only 20 pounds under maximum gross weight. What you failed to realize is that they had stowed some of their heaviest gear in the baggage compartment, which shifted the CG slightly behind the aft limits.
Since weight and balance had never created any problems for you in the past, you did not bother to calculate CG and power required. You did, however, try to estimate it by remembering the figures from earlier in the morning at the base camp. At a 5,000-foot density altitude and maximum gross weight, the performance charts indicated you had plenty of excess power. Unfortunately, the temperature was 93°F and the pressure altitude at the pickup point was 6,200
feet (DA = 9,600 feet). Since there was enough power
for the hover check, you felt there was sufficient power to take off.
Even though the helicopter accelerated slowly during the takeoff, the distance between the helicopter and the ground continued to increase. However, when you attempted to establish the best rate of climb speed, the nose wanted to pitch up to a higher-than-normal atti-tude, and you noticed that the helicopter was not gaining enough altitude in relation to the canyon wall a couple hundred yards ahead.
CHOOSING A COURSE OF ACTION
After the problem has been identified, you must evaluate the need to react to it and determine the actions that need to 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 you decide on a response to the situation.
Your first thought was to pull up on the collective and yank back on the cyclic, but after weighing the consequences of possibly losing rotor r.p.m. and not being able to maintain the climb rate sufficiently enough to clear the canyon wall, which is now only a hundred yards away, you realize that your only course is to try to turn back to the landing zone on the canyon floor.
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 the flight.
As the flight progresses, you must continue to evaluate the outcome of the decision to ensure that it is producing the desired result.
As you make your turn to the downwind, the airspeed drops nearly to zero, and the helicopter becomes very difficult to control. At this point, you must increase airspeed in order to maintain translational lift, but since the CG is aft of limits, you need to apply more forward cyclic than usual. As you approach the landing zone with a high rate of descent, you realize that you are in a potential settling-with-power situation if you try to trade airspeed for altitude and lose ETL. Therefore, you will probably not be able to terminate the approach in a hover. You decide to make as shallow of an approach as possible and perform a run-on landing.
The decision-making process normally consists of several steps before you choose a course of action. To help you remember the elements of the decision-making process, a six-step model has been developed using the acronym “DECIDE.” [Figure 14-2]
Figure 14-2. The DECIDE model can provide a framework for effective decision-making.
Figure 14-3. When situationally aware, you have an overview of the total operation and are not fixated on one perceived significant factor.
RISK MANAGEMENT
During each flight, decisions must be made regarding events that involve interactions between the four risk elements— the pilot in command, the aircraft, the envi-ronment, and the operation. The decision-making process involves an evaluation of each of these risk elements to achieve an accurate perception of the flight situation. [Figure 14-3]
One of the most important decisions that a pilot in command must make is the go/no-go decision. Evaluating each of these risk elements can help you decide whether a flight should be conducted or continued. Let us evaluate the four risk elements and how they affect our decision making regarding the following situations.
Pilot—As a pilot, you must continually make decisions about your own competency, condition of health, mental and emotional state, level of fatigue, and many other variables. For example, you are called early in the morning to make a long flight. You have had only a few hours of sleep, and are concerned that the congestion you feel could be the onset of a cold. Are you safe to fly?
Aircraft-You will frequently base decisions on your evaluations of the aircraft, such as its powerplant, per-formance, equipment, fuel state, or airworthiness. Picture yourself in this situation: you are en route to an oil rig an hour’s flight from shore, and you have just passed the shoreline. Then you notice the oil temperature at the high end of the caution range. Should you continue out to sea, or return to the nearest suitable heliport/airport?
Environment-This encompasses many elements not pilot or aircraft related. It can include such factors as weather, air traffic control, navaids, terrain, takeoff and landing areas, and surrounding obstacles. Weather is one element that can change drastically over time and distance. Imagine you are ferrying a helicopter cross country and encounter unexpected low clouds and rain in an area of rising terrain. Do you try to stay under them and “scud run,” or turn around, stay in the clear, and obtain current weather information?
Operation-The interaction between you as the pilot, your aircraft, and the environment is greatly influenced by the purpose of each flight operation. You must evaluate the three previous areas to decide on the desirability of undertaking or continuing the flight as planned. It is worth asking yourself why the flight is being made, how critical is it to maintain the schedule, and is the trip worth the risks? For instance, you are tasked to take some technicians into rugged mountains for a routine survey, and the weather is marginal. Would it be preferable to wait for better conditions to ensure a safe flight?
How would the priorities change if you were tasked to search for cross-country skiers who had become lost in deep snow and radioed for help?
ASSESSING RISK
Examining NTSB reports and other accident research can help you to assess risk more effectively. For exam-ple, the accident rate 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 should establish higher personal limitations than are required by the regulations and, if applicable, apply instrument flying skills in this environment. [Figure 14-4]
Studies also indicate the types of flight activities that are most likely to result in the most serious accidents.
The majority of fatal general aviation accident causes fall under the categories of maneuvering flight, approaches, takeoff/initial climb, and weather. Delving deeper into accident statistics can provide some important details that can help you to understand the risks involved with specific flying situations. For example, maneuvering flight is one of the largest single produc
ers of fatal accidents. Fatal accidents, which occur during approach, often happen at night or in IFR condi-tions. Takeoff/initial climb accidents frequently are due to the pilot’s lack of awareness of the effects of density altitude on aircraft performance or other improper takeoff planning resulting in loss of control during, or shortly after takeoff. The majority of weather-related accidents occur after attempted VFR flight into IFR conditions.
Figure 14-4. Statistical data can identify operations that have more risk.
FACTORS AFFECTING DECISION MAKING
It is important to point out the fact that being familiar with the decision-making process does not ensure that you will have the good judgment to be a safe pilot. The ability to make effective decisions as pilot in command depends on a number of factors. Some circumstances, such as the time available to make a decision, may be beyond your control. However, you can learn to recognize those factors that can be man-aged, and learn skills to improve decision-making ability and judgment.
PILOT SELF-ASSESSMENT
The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft. In order to effectively exercise that responsibility and make effective decisions regarding the outcome of a flight, you must have an understanding of your limitations. Your performance during a flight is affected by many factors, such as health, recency of experience, knowledge, skill level, and attitude.
Exercising good judgment begins prior to taking the controls of an aircraft. Often, pilots thoroughly check their aircraft to determine airworthiness, yet do not evaluate their own fitness for flight. Just as a checklist is used when preflighting an aircraft, a personal checklist based on such factors as experience, cur-rency, and comfort level can help determine if you are prepared for a particular flight. Specifying when refresher training should be accomplished and designating weather minimums, which may be higher than those listed in Title 14 of the Code of Federal Regulations (14 CFR) part 91, are elements that may be included on a personal checklist. In addition to a review of personal limitations, you should use the I’M SAFE Checklist to further evaluate your fitness for flight. [Figure 14-5]
Figure 14-5. Prior to flight, you should assess your fitness, just as you evaluate the aircraft’s airworthiness.
RECOGNIZING HAZARDOUS ATTITUDES
Being fit to fly depends on more than just your physical condition and recency of experience. For example, attitude affects the quality of your decisions. Attitude can be defined as a personal motivational predisposition to respond to persons, situations, or events in a given manner. Studies have identified five hazardous attitudes that can interfere with your ability to make sound decisions and exercise authority properly.
[Figure 14-6]
Hazardous attitudes can lead to poor decision making and actions that involve unnecessary risk. You must examine your decisions carefully to ensure that your choices have not been influenced by hazardous attitudes, and you must be familiar with positive alternatives to counteract the hazardous attitudes. These substitute attitudes are referred to as antidotes. During a flight operation, it is important to be able to recognize
Figure 14-6. You should examine your decisions carefully to ensure that your choices have not been influenced by a hazardous attitude.
Figure 14-7. You must be able to identify hazardous attitudes and apply the appropriate antidote when needed.
a hazardous attitude, correctly label the thought, and then recall its antidote. [Figure 14-7]
STRESS MANAGEMENT
Everyone is stressed to some degree all the time. A certain amount of stress is good since it keeps a person alert and prevents complacency. However, effects of stress are cumulative and, if not coped with adequately, they 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. Factors, referred to as stressors, can increase a pilot’s risk of error in the cockpit. [Figure 14-8]
There are several techniques to help manage the accumulation of life stresses and prevent stress overload.
For example, including relaxation time in a busy schedule and maintaining a program of physical fitness can help reduce stress levels. Learning to manage time more effectively can help you avoid heavy pressures imposed by getting behind schedule and not meeting deadlines. Take an assessment of yourself to determine your capabilities and limitations and then set realistic goals. In addition, avoiding stressful situations and encounters can help you cope with stress.
USE OF RESOURCES
To make informed decisions during flight operations, you must be aware of the resources found both inside and outside the cockpit. 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 you must develop the skills to evaluate whether you have the time to use a particular resource and the impact that its use will have upon the safety of flight. For example, the assistance of ATC may be very useful if you are lost. However, in an emergency situation when action needs be taken quickly, time may not be available to contact ATC immediately.
INTERNAL RESOURCES
Internal resources are found in the cockpit during flight. Since some of the most valuable internal resources are ingenuity, knowledge, and skill, you can expand cockpit resources immensely by improving these capabilities. This can be accomplished by frequently reviewing flight information publications, such as the CFRs and the AIM, as well as by pursuing additional training.
A thorough understanding of all the equipment and systems in the aircraft is necessary to fully utilize all resources. For example, advanced navigation and autopilot systems are valuable resources. However, if pilots do not fully understand how to use this equip-ment, or they rely on it so much that they become complacent, it can become a detriment to safe flight.
Checklists are essential cockpit resources for verifying that the aircraft instruments and systems are checked set, and operating properly, as well as ensuring that the proper procedures are performed if there is a system malfunction or in-flight emergency. In addition, the FAA-approved rotorcraft flight manual, which is required to be carried on board the aircraft, is essential for accurate flight planning and for resolving in-flight equipment malfunctions. Other valuable cockpit resources include current aeronautical charts, and pub-lications, such as the Airport/Facility Directory.
Passengers can also be a valuable resource. Passengers can help watch for traffic and may be able to provide information in an irregular situation, especially if they are familiar with flying. A strange smell or sound may alert a passenger to a potential problem. As pilot in command, you should brief passengers before the flight to make sure that they are comfortable voicing any concerns.
EXTERNAL RESOURCES
Possibly the greatest external resources during flight are air traffic controllers and flight service specialists.
ATC can help decrease pilot workload by providing traffic advisories, radar vectors, and assistance in emergency situations. Flight service stations can provide updates on weather, answer questions about airport conditions, and may offer direction-finding assistance.
The services provided by ATC can be invaluable in enabling you to make informed in-flight decisions.
WORKLOAD MANAGEMENT
Effective workload management ensures that essential operations are accomplished by planning, prioritizing, and sequencing tasks to avoid work overload. As experience is gained, you learn 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 your flight nears the airport.
In addition, you should listen to ATIS, ASOS, or AWOS, if available, and then monitor the tower frequency or 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.
To manage workload, items should be prioritized. For example, during any situation, and especially in an emergency, you should remember the phrase “aviate, navigate, and communicate.” This means that the first thing you should do is make sure the helicopter is under
Figure 14-9. Accidents often occur when flying task requirements exceed pilot capabilities. The difference between these two factors is called the margin of safety. Note that in this idealized example, the margin of safety is minimal during the approach and landing. At this point, an emergency or distraction could overtax pilot capabilities, causing an accident.
control. Then begin flying to an acceptable landing area. Only after the first two items are assured, should you try to communicate with anyone.
Another important part of managing workload is recognizing a work overload situation. The first effect of high workload is that you begin to work faster. As workload increases, attention cannot be devoted to several tasks at one time, and you may begin to focus on one item. When you become task saturated, there is no awareness of inputs from various sources, so decisions may be made on incomplete information, and the possibility of error increases. [Figure 14-9]
When becoming overloaded, you should stop, think, slow down, and prioritize. It is important that you understand options that may be available to decrease workload. For example, tasks, such as locating an item on a chart or setting a radio frequency, may be delegated to another pilot or passenger, an autopilot, if available, may be used, or ATC may be enlisted to provide assistance.
SITUATIONAL AWARENESS
Situational awareness is the accurate perception of the operational and environmental factors that affect the aircraft, pilot, and passengers during a specific period of time. Maintaining situational awareness requires an understanding of the relative significance of these factors and their future impact on the flight. When situationally aware, you have an overview of the total operation and are not fixated on one perceived significant factor. Some of the elements inside the aircraft to be considered are the status of aircraft systems, you as the pilot, and passengers. In addition, an awareness
of the environmental conditions of the flight, such as spatial orientation of the helicopter, and its relationship to terrain, traffic, weather, and airspace must be maintained.
To maintain situational awareness, all of the skills involved in aeronautical decision making are used. For example, an accurate perception of your fitness can be achieved through self-assessment and recognition of hazardous attitudes. A clear assessment of the status of navigation equipment can be obtained through workload management, and establishing a productive relationship with ATC can be accomplished by effective resource use.
OBSTACLES TO MAINTAINING SITUATIONAL AWARENESS
Fatigue, stress, and work overload can cause you to fixate on a single perceived important item rather than maintaining an overall awareness of the flight situa-tion. 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 cockpit 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 to properly control the aircraft.
Complacency presents another obstacle to maintaining situational awareness. When activities become routine, you may have a tendency to relax and not put as much effort into performance. Like fatigue, complacency reduces your effectiveness in the cockpit. However, complacency is harder to recognize than fatigue, since everything is perceived to be progressing smoothly. For example, you have just dropped off another group of fire fighters for the fifth time that day. Without think-ing, you hastily lift the helicopter off the ground, not realizing that one of the skids is stuck between two rocks. The result is dynamic rollover and a destroyed helicopter.
OPERATIONAL PITFALLS
There are a number of classic behavioral traps into which pilots have been known to fall. Pilots, particularly those with considerable experience, as a rule, always try to complete a flight as planned, please pas-sengers, and meet schedules. The basic drive to meet or exceed goals can have an adverse effect on safety, and can impose an unrealistic assessment of piloting skills under stressful conditions. These tendencies ultimately may bring about practices that are dangerous and often illegal, and may lead to a mishap. You will develop awareness and learn to avoid many of these operational pitfalls through effective ADM training.
[Figure 14-10]
Figure 14-10. All experienced pilots have fallen prey to, or have been tempted by, one or more of these tendencies in their flying careers.
