Aeronautical Decision Making

"Teaching ADM 101

By David St. George, MCFI

Since more than 80 percent of accidents are pilot error, I argue that the most important airspace is between the pilot’s ears.

Sure, pilots must learn requisite physical skills, and flight instructors must also teach the decision-making skills that keep them out of those situations where extraordinary skill is required. When a pilot rolls a Cessna into a ball while trying to land in a 35-knot crosswind, are his stick skills to blame or his judgment? If we don’t teach aeronautical decision-making (ADM) and risk management, we are not addressing the primary cause of accidents.

A very useful mental model to demonstrate successful safety management is the “Reason Swiss cheese” model, developed by James Reason for the nuclear power industry. Mistakes there are a problem, too.

This model postulates numerous layers of “error defenses” we should always have working for us, insulating us from potential hazards. For most accidents to occur, many levels of safety defenses must be penetrated. An “accident chain” requires denial at each step in order to build into an accident. This chain is always remarkably obvious in retrospect, but quirks of human psychology make it invisible in action.

Your safety barriers start by creating safety awareness at the institutional level: Is my airport, club, or FBO safe? Do they encourage and enforce safety procedures, or are they more interested in maximum utilization at the expense of safety? Are we having too much fun at the expense of discipline? Proceed to the next layer: Is the equipment we fly well-maintained and -suited to the operation I am undertaking?

We often ignore these two levels of defense. Flying in a “safety culture” creates an active awareness of risk management and a constant awareness of our vulnerability. NASA’s analysis of the Columbia and Challenger disasters clearly illustrates the tragic results of “normalizing deviations”—that is, risks or anomalies are accepted as “normal” and escape further scrutiny, moving it closer to a potential accident: “Those O-rings always leak a little,” or “That tank always sheds some foam on liftoff.”

The final safety defense barrier is the aeronautical decision-making psychology of the pilot. A pilot needs an active safety scan of risks and tools to mitigate them. But are we, as CFIs, addressing this issue on every flight and helping the student build up a repertoire of potential safe and unsafe decisions?

If we usurp this responsibility as the “all-knowing CFI,” we deprive the student of one of the most important lessons. By categorically stating that, “It’s fine to fly today,” we remove that important personal decision for the future pilot, and may be “normalizing” a situation that would be hazardous for the student in the future. We all have seen this occur: “This ceiling is low, but we can go today.” Or with equipment: “That nose strut is low, but it’s safe for us.”

Inevitably, the student learns the lesson of ignoring or normalizing an unsafe situation. Instead, we should treat every flight decision as a “teachable moment.” If we are to create safer pilots, addressing the importance of risk management on every lesson and illuminating the dangers of “normalizing deviations” are essential duties of every CFI."