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The poor judgment chain, or the error chain, describes this concept of contributing factors in a human factors related accident. Breaking one link in the chain is all that is usually necessary to change the outcome of the sequence of events. The best way to illustrate this concept to students is to discuss specific situations that lead to aircraft accidents or incidents. The following is an example of the type of scenario that can be presented to illustrate the poor judgment chain.
A private pilot with 100 hours of flight time made a precautionary landing on a narrow dirt runway at a private airport. The pilot lost directional control during landing and swerved off the runway into the grass. A witness recalled later that the aircraft appeared to be too high and fast on final approach, and speculated the pilot was having difficulty controlling the aircraft in high winds. The weather at the time of the incident was reported as marginal VFR due to rain showers and thunderstorms. When the aircraft was fueled the following morning, 60 gallons of fuel were required to fill the 62-gallon capacity tanks.
By discussing the events that led to this incident, instructors can help students 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 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.
On numerous occasions during the flight, the pilot could have made decisions which may have prevented this incident.
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However, as the chain of events unfolded, each poor decision left him with fewer and fewer options. On the positive side, the pilot made a precautionary landing at a time and place of his choosing. VFR into IMC accidents often lead to fatalities. In this case, the pilot landed his aircraft without loss of life.
Teaching pilots to make sound decisions is the key to preventing accidents. Traditional pilot instruction has emphasized flying skills, knowledge of the aircraft, and familiarity with regulations. ADM training focuses on the decision-making process and the factors that affect a pilot’s ability to make effective choices.
Timely decision-making is an important tool for any pilot. The student who hesitates when prompt action is required, or who makes the decision to not decide, has made a wrong decision. Sometimes, sound ADM calls for going against procedure. For example, in the event of an engine fire, the pilot initiates an emergency descent. Some POHs call for mixture to be enriched during an emergency descent, but what if the powerplant is engulfed in flames? Emergencies require the pilot to think—assess the situation, choose and execute the actions that assure safety, not act in a rote manner.
It is important for flight instructors to teach students that declaring an emergency when one occurs is an appropriate reaction. Once an emergency is declared, air traffic control (ATC) gives the pilot priority handling. 14 CFR Section 91.3, Responsibility and Authority of the Pilot in Command, states that “In an inflight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency.”
Flight instructors should incorporate ADM, risk management, situational awareness, and SRM throughout the entire training course for all levels of students. AC 60-22, Aeronautical Decision Making, provides background references, definitions, and other pertinent information about ADM training in the GA environment. [Figure 8-7] The Decision-Making Process
An understanding of the decision-making process provides students 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 students, 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 students in the position of making a decision about a typical flight situation.Defining the Problem
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Aviation Instructor’s Handbook下(69)
