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 13-1]
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.
A Helicopter Air Ambulance (HAA) 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 self-imposed 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 on the factors that affect a pilot’s ability to make effective choices.
Max Trescott, Master Certificated Flight Instructor (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 when 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.