Aviation training and flight operations are now seen as a system rather than individual concepts. The goal of system safety is for pilots to utilize all four concepts (ADM, risk management, situational awareness, and SRM) so that risk can be reduced to the lowest possible level.
ADM is a systematic approach to the mental process used by aircraft pilots to consistently determine the best course of action in response to a given set of circumstances. Risk management is a decision-making process designed to systematically identify hazards, assess the degree of risk, and determine the best course of action associated with each flight. Situational awareness is the accurate perception and understanding of all the factors and conditions within the four fundamental risk elements that affect safety before, during, and after the flight. SRM is the art and science of managing all resources (both onboard the aircraft and from outside sources) available to a single pilot (prior and during flight) to ensure the successful outcome of the flight.
These key principles are often collectively called ADM. The importance of teaching learners 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 80 percent of all aviation accidents are human factors related.
By taking a system approach to aviation safety, flight instructors interweave aeronautical knowledge, aircraft control skills, ADM, risk management, situational awareness, and SRM into the training process.
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 contributing factor 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.
By discussing the events that led to this incident, instructors can help learners understand how a series of judgmental errors contributed to the final outcome of this flight.
- Weather decision—on the morning of the flight, the pilot was running late and, having acquired a computer printout of the forecast the night before, he did not self-brief or obtain a briefing from Flight Service before his departure.
- Flight planning decision/performance chart—the pilot calculated total fuel requirements for the trip based on a rule-of-thumb figure he had used previously for another airplane. He did not use the fuel tables printed in the pilot’s operating handbook (POH) for the aircraft he was flying on this trip. After reaching his destination, the pilot did not request refueling. Based on his original calculations, he believed sufficient fuel remained for the flight home.
- Fatigue/failure to recognize personal limitations—in the presence of deteriorating weather, the pilot departed for the flight home at 5:00 p.m. He did not consider how fatigue and lack of extensive night flying experience could affect the flight.
- Fuel exhaustion—with the aircraft fuel supply almost exhausted, the pilot no longer had the option of diverting to avoid rapidly developing thunderstorms. He was forced to land at the nearest airfield available.
Timely decision-making is an important tool for any pilot. The learner who hesitates when prompt action is required, or who makes the decision to not decide, has made a wrong decision. Emergencies require the pilot to think—assess the situation, choose and execute the actions that assure safety.
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| Figure 1. Terms used in AC 60-22 to explain concepts used in ADM training |
The Decision-Making Process
An understanding of the decision-making process provides learners 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, which require a more reflective response. Typically during a flight, the 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. When the decision-making process is presented to learners it is essential to discuss how the process applies to an actual flight situation. To explain the decision-making process, the instructor can introduce the following steps with the accompanying scenario that places the learners in the position of making a decision about a typical flight situation.
Defining the Problem
The first step in the decision-making process is to define the problem. This begins with recognizing that a change has occurred or that an expected change did not occur. A problem is perceived first by the senses, and then is distinguished through insight and experience. 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.
One critical error that can be made during the decision-making process is incorrectly defining the problem. For example, failure of a landing-gear-extended light to illuminate could indicate that the gear is not down and locked into place or it could mean the bulb is burned out. The actions to be taken in each of these circumstances would be significantly different. Fixating on a problem that does not exist can divert the pilot’s attention from important tasks. The pilot’s failure to maintain an awareness of the circumstances regarding the flight now becomes the problem. This is why once an initial assumption is made regarding the problem, other sources should be used to verify that the pilot’s conclusion is correct.
While on a cross-country flight, Brenda discovers her time en route between two checkpoints is significantly longer than the time she originally calculated. By noticing this discrepancy, she has recognized a change. Based on insight, cross-country flying experience, and knowledge of weather systems, she considers the possibility that she has an increased headwind. She verifies that the original calculations are correct and considers factors that may have lengthened the time between checkpoints, such as a climb or deviation off course. To determine if there is a change in the winds aloft forecast and to check recent pilot reports, she contacts Flight Service. After weighing each information source, she concludes that the headwind has increased. To determine the severity of the problem, she calculates a new groundspeed and reassesses fuel requirements.
Choosing a Course of Action
After the problem has been identified, the pilot evaluates the need to react to it and determines the actions that may be taken to resolve the situation in the time available. The expected outcome of each possible action should be considered, and the risks assessed before the pilot decides on a response to the situation.
Brenda determines the fuel burn if she continues to her destination and considers other options: turning around and landing at a nearby airport, diverting off course, or landing prior to her destination at an airport en route. She considers the expected outcome of each possible action and assesses the risks involved. After studying the chart, she concludes an airport with fueling services is within a reasonable distance along her route. She can refuel there and continue to her destination without a significant loss of time.
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, the pilot should continue to evaluate the outcome of the decision to ensure that it is producing the desired result.
To implement her decision, Brenda plots the course changes and calculates a new estimated time of arrival. She also amends her flight plan and checks weather conditions at the new destination. As she proceeds to the airport, she continues to monitor groundspeed, aircraft performance, and weather conditions to ensure no additional steps need to be taken to guarantee the safety of the flight.
Factors Affecting Decision-Making
It is important to stress to a learner that being familiar with the decision-making process does not ensure he or she has the good judgment to be a safe pilot. The ability to make effective decisions as PIC depends on a number of factors. Some circumstances, such as the time available to make a decision, may be beyond the pilot’s control. However, a pilot can learn to recognize those factors that can be managed, and learn skills to improve decision-making ability and judgment.
Recognizing Hazardous Attitudes
While the ADM process does not eliminate errors, it helps the pilot recognize errors, and in turn enables the pilot to manage any errors to minimize their effects. In addition, two steps to improve flight safety are identifying personal attitudes hazardous to safe flight and learning behavior modification techniques.
Flight instructors should be able to spot hazardous attitudes in a learner because recognition of hazardous thoughts is the first step toward neutralizing them. Flight instructors should keep in mind that being fit to fly depends on more than just a pilot’s physical condition and recency of experience. Hazardous attitudes contribute to poor pilot judgment and affect the quality of 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 affect a pilot’s ability to make sound decisions and exercise authority properly. [Figure 2]
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| Figure 2. Pilots should examine their decisions carefully to ensure that their choices have not been influenced by a hazardous attitude |
In order for a learner to self-examine behaviors during flight, the learner should be taught the potential risks caused from hazardous attitudes and, more importantly, the antidote for each. [Figure 3] For example, if a learner has an easy time with flight training and seems to understand things very quickly, there may be a potential for that learner to develop a hazardous attitude regarding their ability. A successful flight instructor points out the potential for the behavior and teaches the learner the antidote for that attitude. Hazardous attitudes need to be noticed immediately and corrected with the proper antidote to minimize the potential for any flight hazard.
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| Figure 3. Learners in training can be asked to identify hazardous attitudes and the corresponding antidotes when presented with flight scenarios |
Stress Management
Learning how to recognize and cope with stress is another effective ADM tool. Stress is the body’s response to demands placed upon it. These demands can be either pleasant or unpleasant in nature. The causes of stress for a pilot can range from unexpected weather or mechanical problems while in flight to personal issues unrelated to flying. Stress is an inevitable and necessary part of life; it adds motivation and heightens an individual’s response to meet any challenge.
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, the 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 flight deck. [Figure 4]
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| Figure 4. Three types of stressors that can affect pilot performance |
One way of exploring the subject of stress with a learner is to recognize when stress is affecting performance. If a learner seems distracted, or has a particularly difficult time accomplishing the tasks of the lesson, the instructor can query the learner. Was the learner uncomfortable or tired during the flight? Is there some stress in another aspect of the learner’s life that may be causing a distraction? This may prompt the learner to evaluate how these factors affect performance and judgment. The instructor should also try to determine if there are aspects of pilot training that are causing excessive amounts of stress for the learner. For example, if the learner consistently makes a decision not to fly, even though weather briefings indicate favorable conditions, it may be due to apprehension regarding the lesson content. Stalls, landings, or an impending solo flight may cause concern. By explaining a specific maneuver in greater detail or offering some additional encouragement, the instructor may be able to alleviate some of the learner’s stress.
To help learners manage the accumulation of life stresses and prevent stress overload, instructors can recommend several techniques. 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 pilots avoid heavy pressures imposed by getting behind schedule and not meeting deadlines. While these pressures may exist in the workplace, learners may also experience the same type of stress regarding their flight training schedule. Instructors can advise learners to self-assess to determine their capabilities and limitations and then set realistic goals. In addition, avoiding stressful situations and encounters can help pilots cope with stress.
Use of Resources
To make informed decisions during flight operations, learners should be familiar with the resources found both 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 should not only be identified, but learners should also develop the skills to evaluate whether they have the time to use a particular resource and the impact that its use would have upon the safety of flight. For example, the assistance of ATC may be very useful if a pilot is lost. However, in an emergency situation when action needs be taken quickly, time may not be available to contact ATC immediately. During training, flight instructors can routinely point out resources to learners.
Internal Resources
Internal resources are found in the flight deck during flight. However, some of the most valuable internal resources include ingenuity, knowledge, and skill. Pilots can enhance flight deck resources by improving their own capabilities. This can be accomplished by pursuing additional training and by frequently reviewing flight information publications including the Aeronautical Information Manual (AIM), instruction manuals for on board equipment, and safety journals.
With the advent of advanced avionics with glass displays, GPS, and autopilot, flying has become more complex. Avionics and automation systems are valuable resources, and flight instructors should teach learners how to use this equipment properly. If learners do not fully understand how to use the equipment, or if they rely on it so much that they become complacent, it can become a detriment to safe flight.
Checklists are essential flight deck 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 inflight emergency. Learners 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. With the advent of electronic checklists, it has become easier to develop and maintain personal checklists from the manufacturer’s checklist with additions for specific aircraft and operations.
In addition, the AFM/POH, which is required to be carried onboard the aircraft, is essential for accurate flight planning and for resolving inflight equipment malfunctions. Other valuable flight deck resources include current aeronautical charts and publications, such as the Chart Supplement (CS).
It should be pointed out to learners that 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. The PIC 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. ATC can help decrease pilot workload by providing traffic advisories, radar vectors, and assistance in emergency situations. When learners use ATC during training, they develop the confidence to ask controllers to clarify instructions and to use ATC as a resource for assistance in unusual circumstances or emergencies. Fight Service specialists can provide updates on weather, answer questions about airport conditions, and may offer direction-finding assistance on frequencies used for flight plan communications. These services can be invaluable in enabling pilots to make informed inflight decisions.
Throughout training, learners can be asked to identify internal and external resources, which can be used in a variety of flight situations. For example, if a discrepancy is found during preflight, what resources can be used to determine its significance? In this case, the learner’s knowledge of the aircraft, the POH, an instructor or other experienced pilot, or an AMT can be a resource which may help define the problem. During cross-country training, learners may be asked to consider the following situation. On a cross-country flight, you become disoriented. Although you are familiar with the area, you do not recognize any landmarks, and fuel is running low. What resources do you have to assist you? Learners should be able to identify their own skills and knowledge, aeronautical charts, ATC, Flight Service, and navigation equipment as some of the resources that can be used in this situation.
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, a pilot learns to recognize future workload requirements and can prepare for high workload periods during times of low workload. Instructors can teach this skill by prompting their learners to prepare for a high workload. For example, when en route, the learner can be asked to explain the actions that need to be taken during the approach to the airport. The learner should be able to describe the procedures for traffic pattern entry and landing preparation. Reviewing the appropriate chart and setting radio frequencies well in advance of need helps reduce workload as the flight nears the airport. In addition, the learner should listen to the Automatic Terminal Information Service (ATIS), Automated Surface Observing Systems (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.
To manage workload, items should be prioritized. This concept should be emphasized to learners and reinforced when training procedures are performed. For example, during a go-around, adding power, gaining airspeed, and properly configuring the aircraft are priorities. Informing the tower of the balked landing should be accomplished only after these tasks are completed. learners should understand that priorities change as the situation changes. If fuel quantity is lower than expected on a cross-country flight, the priority can shift from making a scheduled arrival time at the destination, to locating a nearby airport to refuel. In an emergency situation, the first priority is to fly the aircraft and maintain a safe airspeed.
Another important part of managing workload is recognizing a work overload situation. The first effect of high workload is that the pilot begins to work faster. As workload increases, attention cannot be devoted to several tasks at one time, and the pilot may begin to focus on one item. When the pilot becomes task saturated, there is no awareness of inputs from various sources; decisions may be made on incomplete information, and the possibility of error increases. [Figure 5]
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| Figure 5. 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 |
During a lesson, workload can be gradually increased as the instructor monitors the learner’s management of tasks. The instructor should ensure that the learner has the ability to recognize a work overload situation. When becoming overloaded, the learner should stop, think, slow down, and prioritize. It is important that the learner understand options that may be available to decrease workload. For example, 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.