The airlines developed some of the first training programs that focused on improving aeronautical decision making (ADM).
ADM is a systematic approach to the mental process used by airline pilots to consistently determine the best course of action in response to a given set of circumstances. 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 consist of 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: dispatchers, cabin crewmembers, maintenance personnel, and air traffic controllers. The importance of learning effective ADM skills cannot be overemphasized in the airline industry. While progress is continually being made in the advancement of pilot training methods, airline equipment and systems, accidents still occur.
Despite all the changes in technology to improve flight safety, one factor still remains the same – the human factor. It is estimated that approximately 75 percent of all aviation 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, or a contributing factor that led to the accident. This definition also includes the pilot’s failure to make a decision or take action.
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From a broader perspective, the phrase “human factors related” more suitably 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 various factors. The poor judgment chain, sometimes referred to as the error chain, is a term used to describe this concept of contributing factors in human factors-related-accidents. Breaking one link in the chain normally is all that is necessary to change the outcome in a sequence of events.
By discussing events that lead to an accident, it can be understood how a series of judgment errors can contribute to the final outcome of a flight. 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. Traditionally, pilots have been well trained to react to emergencies, but are not as well prepared to make decisions requiring a more reflective response.
Typically during a flight, there is time to examine any changes that occur, gather information, and assess risk before reaching a decision. The steps leading to this conclusion constitute the decision making process are defining the problem, choosing a course of action, and implementing the decision and evaluating the outcome. The first step in the decision making process is problem definition. Defining the problem begins with recognizing that a change has occurred or that an expected change did not take place.
The exact nature and severity of the problem are determined by the pilot’s senses and experience in flying. For 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 is giving a faulty reading. According to the situation, each action by the pilot is taken differently. An important note is that once the pilot has identified the problem, other sources must be used to verify that the conclusion is correct.
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Once the problem has been identified, the pilot must evaluate the need to react to it and determine that actions that must be used to remedy the problem. The expected outcome of each possible action should be considered and the risks assessed before deciding on a response to the situation. Although a decision may be reached and a course of action implemented, the decision making 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, the pilot must continue to evaluate the outcome of the decision to ensure that it is producing the desired result. The decision-making process normally consists of several steps before choosing a course of action. To help remember the elements of the decision-making process, a six-step model has been previously developed using the acronym “decide. ” Detect the fact that a change has occurred Estimate the need to counter or react to the change Choose a desirable outcome for the success of the flight Identify actions which could successfully control the change.
Do the necessary action to adapt to the change Evaluate the effect of the action Another important aeronautical decision making is risk management. During each flight, decisions must be made regarding events involving interactions between the four risk elements: the pilot in command, the airplane, the environment, and the operation. The decision-making process involves an evaluation of these risk elements to achieve an accurate perception of the flight situation. A pilot must continually make decisions about competency, condition of health, mental and emotional state, level of fatigue, and many other factors.
Airplane—a pilot will frequently base decisions on the evaluations of the airplane, such as performance, equipment, or worthiness in the air. Environment—this encompasses many elements not pilot or airplane 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. Operation—the interaction between the pilot, airplane, and the environment is greatly influenced by the purpose of each flight operation.
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Also, exercising good judgment begins prior to taking the control of an airplane. Often, pilots thoroughly check their airplane to determine airworthiness, but they do no evaluate their own fitness for flight. Just as a checklist is used when pilots check their pre-flight of an airplane, a personal checklist based on such factors as experience, currency, and comfort level can help determine if a pilot is prepared for the flight. In addition to a review of personal limitations, use the “i’m safe” Checklist in evaluation of the pilot.
