Pilot Decision Making - Real World Examples?

[skearns4]

Hi Everyone,

I am writing a pilot decision making course for my m-Safety app and am looking for some real-world examples to help make the material more tangible. According to the FAA, 52% of fatal GA pilot error accidents are associated with DM. However, research suggests that DM training can improve these skills.

I was wondering if anyone would be willing to share some of their experiences with the following 'behavioral traps'? It is one thing to memorize a list of 'traps', but I don't think that would necessarily help students understand why people make these mistakes or avoid them themselves. I think the best way to understand these issues is to hear from other pilots who have gotten into these situations - what happened? what was your motivation at the time? what were you thinking/feeling? what did you learn from the situation?

I thought it may also be a good thread to learn from each other's mistakes - and hopefully avoid repeating them. Thank you for passing along your stories (or those of other pilots you have met along the way). If you are uncomfortable/embarassed to share your stories, please feel free to send me your thoughts privately. I will keep your identity confidential, if you desire.

The DM 'traps' are categorized as the following:

Peer pressure – poor decision making based on emotional response to peers rather than evaluating a situation objectively.

Mind set – the inability to recognize and cope with changes in the situation different from those anticipated or planned

Get-there-it is – tendency to fixate on original goal or destination combined with disregard for any alternative course of action

Duck-under syndrome – sneak a peek by descending below minimums during an approach (based on the belief that there is always a built-in “fudge” factor or an unwillingness to admit defeat and shoot a missed approach)

.. running – pushing the capabilities of the pilot and the aircraft to the limits by trying to maintain visual contact with terrain (while trying to avoid hitting it). Characterized by the joke “if it’s too bad to go IFR, we’ll go VFR”

Continuing visual flight rules (VFR) into IFR often leads to spatial disorientations.

Getting behind the aircraft – allowing events or the situation to control your actions rather than the other way around. Characterized by a constant state of surprise about what happens next.

Loss of positional or situation awareness – another case of getting behind the aircraft which results in not knowing where you are, an inability to recognize deteriorating circumstances, and/or the misjudgment of the rate of deterioration

Operating without adequate fuel reserves – ignoring minimum fuel reserve requirements, either VFR or IFR, is generally the result of overconfidence, lack of flight planning, or ignoring the regulations.

Flying outside the envelope – Unjustified reliance on the (usually mistaken) belief that the aircraft’s high performance capability meets the demands imposed by the pilot’s (usually overestimated) flying skills.

Neglect of flight planning, preflight inspections, checklists, etc. – Unjustified reliance on the pilot’s short and long term memory, regular flying skills, repetitive and familiar routes, etc.

Thanks,

Dr. Suzanne Kearns
University of Western Ontario

[Gannet167]

This is a very interesting field of study and probably deserves a lot more formal academic focus than it gets. Some of the points you've listed I would not put into the pilot decision making category. Getting behind the aircraft and loss of situational awareness happens to everyone from time to time, but they're not decisions.

You're in the right forum but your question is a little vague. It'd be like logging onto a cooking forum, with thousands of recipes and asking if anyone has any general tips on how to make dinner? If you're a little more specific in what you want you may get more responses.

[Meatservo]

I'm having trouble thinking of specific instances right now, but I do know there's been lots of times that I have been aware that "hey, I'm falling for one of those things they talked about in PDM right now" and that awareness (which always surprises me: I normally consider myself to be intellectually above those pedestrian "personality problems") has caused me to think twice and if not "fly right", at least be more alert and careful until I can extricate myself from the situation. I'll think harder and try to get back with some examples.

[Morav]

"Peer pressure"

I can't say I ever felt pushed into a dangerous situation by the thought of what my equals thought of me...

However, I can say that there is a lot of pressure from management to get the job done. Especially for a young pilot starting out with little to no experience.

Identifying these DM traps are great, but it would be even more beneficial for younger pilots to have the tools/knowledge to be able to back a tough decision against his/her employer. A new pilot without a good understanding of the CARs or even their working rights is really at the mercy his or her employer. What I'm trying to say is identifying risks is the easy part, saying NO, is the hard part.

Some of the toughest decisions I've encountered were made on the ground.

[jeta1]

.

[Expat]

Hello Suzanne,

Since the professional pilot rate of accidents seems to be falling, and the GA rate increasing, my comment to assist you would be in the latter category.
You have a good list of topics, and accident causes.
May I just add another one?
As a private pilot, flying in a small plane without a toilet, I was more than once subjected to the get-home-itis, out of an urge to go to the bathroom. I can tell you that too much coffee in the morning can create a tough to deal with urge. And that may lead to the "land-it-first-time-around-no-matter-what" syndrome.
Just one more to add.

[Gannet167]

You can list those common PDM traps and tell guys to "be aware" of them, but more interesting and useful is to talk about the circumstances that are common factors leading guys into them. It would be interesting to take one of those traps and look at factors like length of crew day, weather, number of crew, company pressure, aircraft type, experience level, type of airport, and many more I'm sure.

It might be useful to understand the pattern of events and circumstances that tend to produce the same bad PDM events. Identifying and having a good understanding of those circumstances and the risks they tend to create helps mitigate them.

[Sidebar]

Here's some examples of PDM gone wrong:

Cougar Helicopters S-92A MGB Failure & Ditching: http://www.tsb.gc.ca/eng/rapports-repor ... 9a0016.asp

Perimeter Aviation DHC-8 Insufficient Fuel http://www.tsb.gc.ca/eng/rapports-repor ... 0c0104.asp

Transwest Air King Air CRM Breakdown & Collision With Terrain http://www.tsb.gc.ca/eng/rapports-repor ... 7c0001.asp

Missinippi Airways Cessna 208B Runway Overrun http://www.tsb.gc.ca/eng/rapports-repor ... 1c0102.asp

Aero Peninsule Cessna 310R CFIT http://www.tsb.gc.ca/eng/rapports-repor ... 0a0122.asp

Venture Air Beech 95 Fuel Starvation and Forced Landing http://www.tsb.gc.ca/eng/rapports-repor ... 0c0060.asp

[Gannet167]

Suzanne, the challenge for you is to take those examples of poorly made decisions, and ask why they were made. When you figure out the reason, then ask why again, and so on.

[skearns4]

I have comm/multi/IFR fixed- and rotary-wing licenses (TC & FAA), but I spend far more time doing research than in the air - sadly.

I agree that the safety categories overlap quite a bit (situation awareness, decision making, workload management, communication, etc). I expect most accidents/incidents involve errors or failure to use a number of these.

Thank you all for passing along your insights. Far too often, we aviation researchers study accident and research reports and forget that experienced pilots are probably the best source of information to understand these issues. All your insights are really helpful - especially if you can think back to your thought process while you made a bad decision.

Thanks again!