The Decision Making Process

Risk management and risk intervention is much more than the simple definitions of the terms might suggest. 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. They provide assistance in organizing the decision process. All these models have been identified as helpful to the single pilot in organizing critical decisions.

Single-Pilot Resource Management (SRM) is about how to gather information, analyze it, and make decisions. Learning how to identify problems, analyze the information, and make informed and timely decisions is not as straightforward as the training involved in learning specific maneuvers. Learning how to judge a situation and “how to think” in the endless variety of situations encountered while flying out in the “real world” is more difficult.

There is no one right answer in ADM, rather each pilot is expected to analyze each situation in light of experience level, personal minimums, and current physical and mental readiness level, and make his or her own decision.

SRM sounds good on paper, but it requires a way for pilots to understand and use it in their daily flights. One practical application is called the “Five Ps (5 Ps).” [Figure 1] 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. Each challenge and opportunity can substantially increase or decrease the risk of successfully completing the flight based on the pilot’s ability to make informed and timely decisions. The 5 Ps are used to evaluate the pilot’s current situation at key decision points during the flight or when an emergency arises. These decision points include preflight, pretakeoff, hourly or at the midpoint of the flight, pre-descent, and just prior to the final approach fix or for VFR operations, just prior to entering the traffic pattern.

The 5 Ps are based on the idea that pilots have essentially five variables that impact his or her environment and forcing him or her to make a single critical decision, or several less critical decisions, that when added together can create a critical outcome. These variables are the Plan, the Plane, the Pilot, the Passengers, and the Programming. This concept stems from the belief that current decision-making models tended to be reactionary in nature. A change has to occur and be detected to drive a risk management decision by the pilot. For instance, many pilots complete risk management sheets prior to takeoff. These form a catalog of risks that may be encountered that day. Each of these risks is assigned a numerical value. If the total of these numerical values exceeds a predetermined level, the flight is altered or cancelled. Informal research shows that while these are useful documents for teaching risk factors, they are almost never used outside of formal training programs. The 5P concept is an attempt to take the information contained in those sheets and in the other available models and use it.

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” can also be called the mission or the task. It contains the basic elements of cross-country planning, weather, route, fuel, publications currency, etc. The “Plan” should be reviewed and updated several times during the course of the flight. A delayed takeoff due to maintenance, fast moving weather, and a short notice TFR may all radically alter the plan. The “plan” is not only about the flight plan, but also all the events that surround the flight and allow the pilot to accomplish the mission. The plan is always being updated and modified and is especially responsive to changes in the other four remaining Ps. If for no other reason, the 5 P check reminds the pilot that the day’s flight plan is real life and subject to change at any time.

Obviously, weather is a huge part of any plan. The addition of datalink weather information gives the advanced avionics pilot a real advantage in inclement weather, but only if the pilot is trained to retrieve and evaluate the weather in real time without sacrificing situational awareness. And of course, weather information should drive a decision, even if that decision is to continue on the current plan. Pilots of aircraft without datalink weather should get updated weather in flight through an FSS and/or Flight Watch.

Both the “plan” and the “plane” are fairly familiar to most pilots. 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.

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.

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.

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.

The necessity of the passengers to make airline connections or important business meetings in a timely manner enters into this pilot’s decision-making loop. Consider a flight to Dulles Airport in which and the passengers, both close friends and business partners, need to get to Washington, D.C. for an important meeting. The weather is VFR all the way to southern Virginia, then turns to low IFR as the pilot approaches Dulles. A pilot employing the 5 P approach might consider reserving a rental car at an airport in northern North Carolina or southern Virginia to coincide with a refueling stop. Thus, the passengers have a way to get to Washington, and the pilot has an out to avoid being pressured into continuing the flight if the conditions do not improve.

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. There is an element of risk in every flight. That is why SRM calls it risk management, not risk elimination. 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 decide to buy an airline ticket or rent a car, 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 advanced avionics aircraft adds an entirely new dimension to the way GA aircraft are flown. The electronic instrument displays, GPS, and autopilot reduce pilot workload and increase pilot situational awareness. While programming and operation of these devices are fairly simple and straightforward, unlike the analog instruments they replace, they 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 vis-à-vis the automation should drive when, where, and how the automation is programmed and used.

The pilot should also consider what his or her capabilities are in response to last minute changes of the approach (and the reprogramming required) and ability to make large-scale changes (a reroute for instance) while hand flying the aircraft. Since formats are not standardized, simply moving from one manufacturer’s equipment to another should give the pilot pause and require more conservative planning and decisions.

The SRM process is simple. 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.

The Perceive, Process, Perform (3P) model for ADM offers a simple, practical, and systematic approach that can be used during all phases of flight. To use it, the pilot will:

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] 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.

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 3] 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.

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 4] For example, let’s evaluate a night flight to attend a business meeting:

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.

Once you have perceived a hazard (step one) and processed its impact on flight safety (step two), it is time to move to the third step, perform. Perform risk management by using the TEAM checklist of: Transfer, Eliminate, Accept, Mitigate to deal with each factor. [Figure 5]

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 the acronym “DECIDE,” the six-step process DECIDE Model is another continuous loop process that provides the pilot with a logical way of making decisions. [Figure 6] DECIDE means to Detect, Estimate, Choose a course of action, Identify solutions, Do the necessary actions, and Evaluate the effects of the actions.

First, consider a recent accident involving a Piper Apache (PA23). The aircraft was substantially damaged during impact with terrain at a local airport in Alabama. The certificated airline transport pilot (ATP) received minor injuries and the certificated private pilot was not injured. The private pilot was receiving a checkride from the ATP (who was also a designated examiner) for a commercial pilot certificate with a multi-engine rating. After performing airwork at altitude, they returned to the airport and the private pilot performed a single-engine approach to a full stop landing. He then taxied back for takeoff, performed a short field takeoff, and then joined the traffic pattern to return for another landing. During the approach for the second landing, the ATP simulated a right engine failure by reducing power on the right engine to zero thrust. This caused the aircraft to yaw right.

The procedure to identify the failed engine is a two-step process. First, adjust the power to the maximum controllable level on both engines. Because the left engine is the only engine delivering thrust, the yaw increases to the right, which necessitates application of additional left rudder application. The failed engine is the side that requires no rudder pressure, in this case the right engine. Second, having identified the failed right engine, the procedure is to feather the right engine and adjust power to maintain descent angle to a landing.

However, in this case the pilot feathered the left engine because he assumed the engine failure was a left engine failure. During twin-engine training, the left engine out is emphasized more than the right engine because the left engine on most light twins is the critical engine. This is due to multiengine airplanes being subject to P-factor, as are single-engine airplanes. The descending propeller blade of each engine will produce greater thrust than the ascending blade when the airplane is operated under power and at positive angles of attack. The descending propeller blade of the right engine is also a greater distance from the center of gravity, and therefore has a longer moment arm than the descending propeller blade of the left engine. As a result, failure of the left engine will result in the most asymmetrical thrust (adverse yaw) because the right engine will be providing the remaining thrust. Many twins are designed with a counter-rotating right engine. With this design, the degree of asymmetrical thrust is the same with either engine inoperative. Neither engine is more critical than the other.

Since the pilot never executed the first step of identifying which engine failed, he feathered the left engine and set the right engine at zero thrust. This essentially restricted the aircraft to a controlled glide. Upon realizing that he was not going to make the runway, the pilot increased power to both engines causing an enormous yaw to the left (the left propeller was feathered) whereupon the aircraft started to turn left. In desperation, the instructor closed both throttles and the aircraft hit the ground and was substantially damaged.

This case is interesting because it highlights two particular issues. First, taking action without forethought can be just as dangerous as taking no action at all. In this case, the pilot’s actions were incorrect; yet, there was sufficient time to take the necessary steps to analyze the simulated emergency. The second and more subtle issue is that decisions made under pressure are sometimes executed based upon limited experience and the actions taken may be incorrect, incomplete, or insufficient to handle the situation.

Problem detection is the first step in the decision-making process. It begins with 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. One critical error made during the decision-making process is incorrectly detecting the problem. In the previous example, the change that occurred was a yaw.

In the engine-out example, the aircraft yawed right, the pilot was on final approach, and the problem warranted a prompt solution. In many cases, overreaction and fixation excludes a safe outcome. For example, what if the cabin door of a Mooney 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.

After the problem has been identified and its impact estimated, the pilot must determine the desirable outcome and choose a course of action. In the case of the multiengine pilot given the simulated failed engine, the desired objective is to safely land the airplane.

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.

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.

Finally, after implementing a solution, evaluate the decision to see if it was correct. If the action taken does not provide the desired results, the process may have to be repeated.