Making good choices sounds easy enough. However, there are a multitude of factors that come into play when these choices, and subsequent decisions, are made in the aeronautical world. Many tools are available for pilots to become more self aware and assess the options available, along with the impact of their decision. Yet, with all the available resources, accident rates are not being reduced. Poor decisions continue to be made, frequently resulting in lives being lost and/or aircraft damaged or destroyed. The Risk Management Handbook discusses ADM and SRM in detail and should be thoroughly read and understood.
While progress is continually being made in the advancement of pilot training methods, aircraft equipment and systems, and services for pilots, accidents still occur. Historically, the term “pilot error” has been used to describe the causes of these accidents. Pilot error means an action or decision made by the pilot was the cause of, or a contributing factor that led to, the accident. 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. [Figure 1]
|Figure 1. The pilot has a limited capacity of doing work and handling tasks, meaning there is a point at which the tasking exceeds the pilot’s capability. When this happens, either tasks are not done properly or some are not done at all|
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 is often the only event 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.
An emergency medical services (EMS) helicopter pilot is nearing the end of his shift when he receives a request for a patient pickup at a roadside vehicle accident. The pilot has started to feel the onset of a cold; his thoughts are on getting home and getting a good night’s sleep. After receiving the request, the pilot checks the accident location and required flightpath to determine if he has time to complete the flight to the scene, then on to the hospital before his shift expires. The pilot checks the weather and determines that, although thunderstorms are approaching, the flight can be completed prior to their arrival.
The pilot and on-board medical crews depart the home location and arrive overhead, at the scene of the vehicular accident. The pilot is not comfortable with the selected landing area due to tall trees in all quadrants of the confined area. The pilot searches for a secondary landing area. Unable to find one nearby, the pilot then returns to the initial landing area and decides he can make it work.
After successfully landing the aircraft, he is told that there will be a delay before the patient is loaded because more time is needed to extricate the patient from the wreckage. Knowing his shift is nearly over, the pilot begins to feel pressured to “hurry up” or he will require an extension for his duty day.
After 30 minutes, the patient is loaded and the pilot ensures everyone is secure. He notes that the storm is now nearby and that winds have picked up considerably. The pilot thinks, “No turning back now, the patient is on board and I’m running out of time.” The pilot knows he must take off almost vertically to clear the obstacles, and chooses his departure path based on the observed wind during landing. Moments later, prior to clearing the obstacles, the aircraft begins an uncontrollable spin and augers back to the ground, seriously injuring all on board and destroying the aircraft.
What could the pilot have done differently to break this error chain? More important—what would you have done differently? By discussing the events that led to this accident, you should develop an understanding of how a series of judgmental errors contributed to the final outcome of this flight.
For example, the pilot’s decision to fly the aircraft knowing that the effects of an illness were present was the initial contributing factor. The pilot was aware of his illness, but, was he aware of the impact of the symptoms—fatigue, general uneasy feeling due to a slight fever, perhaps?
Next, knowing the shift was about to end, the pilot based his time required to complete the flight on ideal conditions, and did not take into consideration the possibility of delays. This led to a feeling of being time limited.
Even after determining the landing area was unsuitable, the pilot forced the landing due to time constraints. At any time during this sequence, the pilot could have aborted the flight rather than risk crew lives. Instead, the pilot became blinded by a determination to continue.
After landing, and waiting 30 minutes longer than planned, the pilot observed the outer effects of the thunderstorm, yet still attempted to depart. The pilot dispelled any available options by thinking the only option was to go forward; however, it would have been safer to discontinue the flight.
Using the same departure path selected under different wind conditions, the pilot took off and encountered winds that led to loss of aircraft control. Once again faced with a selfimposed time constraint, the pilot improperly chose to depart the confined area. The end result: instead of one patient to transport by ground (had the pilot aborted the flight at any point), there were four patients to be transported.
On numerous occasions leading to and during the flight, the pilot could have made effective decisions that could have prevented this accident. However, as the chain of events unfolded, each poor decision left him with fewer options. Making sound decisions is the key to preventing accidents. Traditional pilot training emphasizes flying skills, knowledge of the aircraft, and familiarity with regulations. SRM and ADM training focus on the decision-making process and the factors that affect a pilot’s ability to make effective choices.
Max Trescott, Master CFI and Master Ground Instructor and winner of the 2008 CFI of the year, has published numerous safety tips that every pilot should heed. He believes that the word “probably” should be purged from our flying vocabulary. Mr. Trescott contends that “probably” means we’ve done an informal assessment of the likelihood of an event occurring and have assigned a probability to it. He believes the term implies that we believe things are likely to work out, but there’s some reasonable doubt in our mind. He further explains that if you ever think that your course of action will “probably work out,” you need to choose a new option that you know will work out.
Another safety tip details the importance of accumulating flight hours in one specific airframe type. He explains that “statistics have shown that accidents are correlated more with the number of hours of experience a pilot has in a particular aircraft model and not with his or her total number of flight hours. Accidents tend to decrease after a pilot accumulates at least 100 hours of experience in the aircraft he or she is flying. Thus when learning to fly or transitioning into a new model, your goal should be to concentrate your flying hours in that model.” He suggests waiting until you reach 100 hours of experience in one particular model before attempting a dual rating with another model. In addition, if you only fly a few hours per year, maximize your safety by concentrating those hours in just one aircraft model.
The third safety tip that is well worth mentioning is what Mr. Trescott calls “building experience from the armchair”. Armchair flying is simply closing your eyes and mentally practicing exactly what you do in the aircraft. This is an excellent way to practice making radio calls, departures, approaches and even visualizing the parts and pieces of the aircraft. This type of flying does not cost a dime and will make you a better prepared and more proficient pilot.
All three of Max Trescott’s safety tips incorporate the ADM process and emphasize the importance of how safety and good decision-making is essential to aviation.
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 little time for detailed analysis. Called automatic decision-making, it 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 that require a more reflective response when greater analysis is necessary. They often overlook the phase of decisionmaking that is accomplished on the ground: the preflight, flight planning, performance planning, weather briefing, and weight/center of gravity configurations. Thorough and proper completion of these tasks provides increased awareness and a base of knowledge available to the pilot prior to departure and once airborne. Typically during a flight, a pilot has 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
Defining the problem is the first step in the decision-making process and 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 (self-awareness) and experience. Insight, experience, and objective analysis of all available information are used to determine the exact nature and severity of the problem. One critical error that can be made during the decision-making process is incorrectly defining the problem.
While going through the following example, keep in mind what errors lead up to the event. What planning could have been completed prior to departing that may have led to avoiding this situation? What instruction could the pilot have had during training that may have better prepared the pilot for this scenario? Could the pilot have assessed potential problems based on what the aircraft “felt like” at a hover? All these factors go into recognizing a change and the timely response.
While doing a hover check after picking up firefighters at the bottom of a canyon, a pilot realized that she was only 20 pounds under maximum gross weight. What she failed to realize was that the firefighters had stowed some of their heaviest gear in the baggage compartment, which shifted the center of gravity (CG) slightly behind the aft limits. Since weight and balance had never created any problems for her in the past, she did not bother to calculate CG and power required. She did try to estimate it by remembering the figures from earlier in the morning at the base camp. At a 5,000-foot density altitude (DA) and maximum gross weight, the performance charts indicated the helicopter 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, the pilot decided 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 the pilot attempted to establish the best rate of climb speed, the nose tended to pitch up to a higher-than-normal attitude, and the pilot noticed that the helicopter was not gaining enough altitude in relation to the canyon wall approximately 200 yards ahead.
Choosing a Course of Action
After the problem has been identified, a pilot must evaluate the need to react to it and determine the actions to take to resolve the situation in the time available. The expected outcome of each possible action should be considered and the risks assessed before a pilot decides on a response to the situation.
The pilot’s first thought was to pull up on the collective and pull back on the cyclic. After weighing the consequences of possibly losing rotor revolutions per minute (rpm) and not being able to maintain the climb rate sufficiently to clear the canyon wall, which is now only a hundred yards away, she realized the only course was 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, a pilot must continue to evaluate the outcome of the decision to ensure that it is producing the desired result.
As the pilot made the turn to the downwind, the airspeed dropped nearly to zero, and the helicopter became very difficult to control. At this point, the pilot must increase airspeed in order to maintain translational lift, but since the CG was aft of limits, she needed to apply more forward cyclic than usual. As she approached the landing zone with a high rate of descent, she realized that she would be in a potential settling-with-power situation if she tried to trade airspeed for altitude and lost effective translational lift (ETL). Therefore, it did not appear that she would be able to terminate the approach in a hover. The pilot decided to make the shallowest approach possible and perform a run-on landing.
Pilots sometimes have trouble not because of deficient basic skills or system knowledge, but because of faulty decisionmaking 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) it provides.
Therefore, a poor decision early in a flight can compromise the safety of the flight at a later time. It is important to make accurate and decisive choices because good decisionmaking early in an emergency provide greater latitude for later options.
The decision-making process normally consists of several steps before a pilot chooses a course of action. A variety of structured frameworks for decision-making provide assistance in organizing the decision process. These models include but are not limited to the 5P (Plan, Plane, Pilot, Passengers, Programming), the OODA Loop (Observation, Orientation, Decision, Action), and the DECIDE (Detect, Estimate, Choose, Identify, Do, and Evaluate) models. [Figure 2]
|Figure 2. Various models of decision-making are used in problem solving|
Whatever model is used, the pilot learns how to define the problem, choose a course of action, implement the decision, and evaluate the outcome. Remember, there is no one right answer in this process; a pilot analyzes the situation in light of experience level, personal minimums, and current physical and mental readiness levels, and makes a decision.
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