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04/18/23 Aeronautical Decision Making - The Theory Behind the Practice 1
AERONAUTICAL DECISION MAKING
The Theory Behind
The Practice
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Definition of Aeronautical Decision Making (ADM)
“ADM is a systematic approach to the mental process used by all involved in aviation to consistently determine the best course of action in response to a given set of circumstances.”
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PRIMARY CAUSAL FACTORS OFAIRCRAFT ACCIDENTS
0 20 40 60 80
Misc
Airport/ATC
Weather
Maintenance
Airplane
Cockpit Crew
1987-98 1959-98
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PROBABLE CAUSE IN 80% OF ALL ACCIDENTS (NTSB)
0 10 20 30 40 50
UNKNOWN CAUSES
IMPROPER OPERATION OFEQUIPMENT
INFLIGHT JUDGMENT ORDECISION
PILOT TECHNIQUE
VISUAL PERCEPTIONMISJUDGMENT
UNPROFESSIONALATTITUDES 47%
19%
21%
5%
6%
4%
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PRACTICAL TEST STANDARDS REQUIREMENTS
“CRM is not a single TASK. CRM is a set of skill competencies which must be evident in all TASKS in this PTS as applied to the single pilot or the multicrew operation. CRM competencies, grouped into three clusters of observable behaviors are....”
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ADM SKILL MARKERS(“Observable Behaviors”)
COMMUNICATION SITUATION
AWARENESS WORKLOAD
MANAGEMENT PLANNING DECISION
MAKING
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CRM DEFINITION
“THE EFFECTIVE USE OF ALL AVAILABLE
RESOURCES”
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CREW... Pilot-in-Command Second-in-Command
Flight Instructor Aircraft Scheduler Weather Briefer Ramp Personnel Chief Instructor
Flight Attendant Check Airman/ Pilot
Examiner Flight Engineer Non-pilot Air Traffic Control Flight Service/Watch
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RESOURCES...
Time Information Workload Prioritization Strategies/Plans Scheduling
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MANAGEMENT...
Situation Assessment Risk Assessment Planning/Strategizing Prioritizing Tasks Allocating Responsibilities Problem Solving
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ENHANCED CREWMEMBER PERFORMANCE
C R E W M E M B E R N O N -T E C H N IC A L S K IL L S C R E W M E M B E R T E C H N IC A L S K IL L S
E N H A N C E D C R E W M E M B E R P E R F O R M A N C E
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ENHANCED CREWMEMBER PERFORMANCE
BriefingsInquiry/Advocacy/AssertionCrew Self-CritiqueCom m unications/DecisionsConflict Resolution
COM M UNICATIONSPROCESSES AND
DECISION M AKINGCLUSTER
Leadership/Follow ership/Concern for TasksInterpersonal Relationships/Group Clim ateAutom ation M anagem ent
TEAM BUILDINGAND M AINTENANCE
CLUSTER
Preparation/Planning/VigilanceW orkload Distributed/Distractions Avoided
W ORKLOAD M ANAGEM ENTAND SITUATIONAL
AW ARENESSCLUSTER
CR EW MEMBER NO N-T EC HNICAL SK ILLS
Visual Acquisition/Interpretation ofHazardsSystem ControlAircraft Control
M OTORACTIVIT IES
SKILLS
Em ergency/Abnorm alFlight M aneuversATC Com m unicationsSystem Operation
PROCEDURALACTIVIT IES
SKILLS
Com pany Policies/Law s/Rules/RegulationsATC/AirspaceW eatherAircraft Lim itations/Perform ance
INFORM ATION BASE/KNOW LEDGE
CR EW MEMBER T ECHN IC AL SK ILLS
ENHANCED CREW MEMBER PERFORMANCE
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ENHANCED CREWMEMBER PERFORMANCE
Visual Acquisition/Interpretation ofHazardsSystem ControlAircraft Control
M OT ORACT IV IT IES
SKILLS
Em ergency/Abnorm alFlight M aneuversAT C Com m unicationsSystem Operation
PROCEDURALACT IV IT IES
SKILLS
Com pany Polic ies/Law s/Rules/RegulationsAT C/AirspaceW eatherAircraft Lim itations/Perform ance
INFORM AT ION BASE/KNOW LEDG E
C R EW MEMB ER T EC H N IC AL SK ILLS
ENHANCED CREW MEMBER PERFORMANCE
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ADM Focus Non-Technical Skills
BriefingsInquiry/Advocacy/AssertionCrew Self-CritiqueCom m unications/DecisionsConflict Resolution
*COM M UNICAT IONSPROCESSES AND
*DECISION M AKINGCLUST ER
Leadership/Follow ership/Concern for TasksInterpersonal Relationships/Group Clim ateAutom ation M anagem ent
T EAM BUILDINGAND M AINT ENANCE
CLUST ER
Preparation/ *Planning/V igilanceW orkload Distributed/Distractions Avoided
*W ORKLOAD M ANAGEM ENTAND *S IT UATIONAL
AW ARENESSCLUST ER
C R EW MEMB ER N O N -T EC H N IC AL SK ILLS
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ADM SKILL MARKERS(“Observable Behaviors”)
COMMUNICATION SITUATION
AWARENESS WORKLOAD
MANAGEMENT PLANNING DECISION
MAKING
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COMMUNICATIONS
Two-way street Information transfer Clear, concise,
unambiguous Listening Repeating Clarification Understanding
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SITUATIONAL AWARENESS
THE ACCURATE PERCEPTION OR KNOWLEDGE A PILOT MAINTAINS TO THEIR OPERATIONAL ENVIRONMENT IN ORDER TO ANTICIPATE CONTINGENCIES AND TAKE THE NECESSARY ACTIONS.
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WORKLOAD MANAGEMENT
PRIORITIZE AND DELEGATE
SHARE AND COMMUNICATE
ACKNOWLEDGE PERSONAL LIMITS
ACTIVELY MONITOR
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PREPARATION, PLANNING, AND VIGILANCE
PREPARING FOR REQUIRED ACTIVITIES
PLANNING FOR ALL POSSIBILITIES MAINTAINING AWARENESS FOR
CHANGE
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Decision Making Process
1. Is there a decision to make?
2. Gather all available information.
3. Identify all possible alternatives.
4. Evaluate alternatives.
5. Choose an alternative (make a decision).
6. Act on decision.
7. Evaluate the results of the decision.
(if necessary, return to the beginning)
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THE EFFECTS OF STRESS AND FATIGUE
Human PerformanceError Management
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ADM MODELS AND PROGRAMS TODAY
PTS/CRM Pilot Judgment Training Manuals Personal Minimums FAA’s Model DECIDE Model Hazardous Attitudes Decision Making Process
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The Effects ofStress & Fatigue
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Stress & Fatigue
Not unique to the airline industry, or the transportation industry!
Our entire society is now driven by a 24/7 economy and lifestyle
It’s our individual responsibility to implement alertness management strategies
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Stress & Fatigue
What are causes of “chronic stress”?
How did the pilots surveyed deal with chronic stress?
What is your chronic stress level?
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Stress & Fatigue
Stress-Coping Strategies:
About half stated they were physically active to some degree
Remainder were less physically active, but involved in relaxation-type activities
All strategies provide a welcome diversion from stress.
What is your strategy?
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Human PerformanceStress & Fatigue
12 am 12 noon 12 am
3 - 5 am 3 - 5 pm
Performance level+_
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Stress & Fatigue
AA 1420 Little Rock, AR June 1, 1999
30
“You start with a bag full of luck and an empty bag of experience. The
trick is to fill the bag of experience before you empty the bag of luck.”
Human PerformanceAnd Error Management
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Human Errors Leading To Accidents...
How many errors need to occur before we have an accident?
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The “Roach Theory” of Errors
Errors are like roaches...
For every one you see...
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Errors are like roaches
There are different varieties…CommunicationsProceduralProficiencyIntentional Non-complianceOperational Decision
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Errors are like roaches
There are different species and sizesSlips - meant to do the right thing but
took incorrect actionLapses - omitted an itemMistakes - intention was incorrectViolations - (procedural non-
compliance) i.e. intentionally deviated from SOP or accepted procedure
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Error Enhancers
HurryFatigue/excessive stressLack of oxygen/water/foodDistractions/interruptions“First learned, best learned” Insufficient situation awarenessWorkload -too low or high
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More Error Enhancers
Language barriersCultural differencesInconsistencies in trainingInsufficient knowledge and skillsNon-standardized interfacesNight/weather
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Human Responses to Errors
Trap - error is detected and managed before it becomes consequential
Exacerbate - error is detected but the crew’s action or inaction becomes consequential
Fail to Respond - lack of a response to an error (undetected or ignored) that can either end up being inconsequential or consequential
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What Do We Do About Errors?
Prevent as many as possiblePractice detection and recoveryUnderstand and be vigilant for
potential “error enhancers”
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“Roach Prevention and Exterminators”
Planning Leadership Communications Decision Making Situation Awareness Workload
Management
Oh Noooo...
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Error Management and Roach Control
It is not possible to prevent all errors Error detection, prevention, and
recovery - error tolerance is the goal.The goal is met by improving human
performance in all facets of aviation.
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What about these?