U.S. Department of Transportation Federal Aviation Administration Subject: AERONAUTICAL DECISION MAKING
1. PURPOSE. This Advisory Circular (AC) provides introductory material, background information, and reference material on Aeronautical Decision Making (ADM). The material in this AC provides a systematic approach to risk assessment and stress management in aviation, illustrates how personal attitudes can influence decision making and how those attitudes can be modified to enhance safety in the cockpit. This AC also provides instructors with methods for teaching ADM techniques and skills in conjunction with conventional flight instruction. However, this AC is not intended to replace the complete body of knowledge contained in the ADM related reference materials listed in paragraph 4, but rather to support them and to serve as a catalyst for further study.
2. APPLICATION. The material contained in this AC is applicable to pilots who operate airplanes or helicopters under Federal Aviation Regulations (FAR) Parts 61, 91, 121, 125, 133, 135, and 141.
3. FOCUS. This AC is designed to explain the risks associated with aviation activities to pilots.
Underlying behavioral causes of typical accidents and the effects of stress on ADM are emphasized. These materials provide a means for an individual to develop an "Attitude Profile" through a self-assessment inventory and provide detailed explanations of preflight and in-flight stress management techniques. The assumption is that persons exposed to these behavioral techniques will develop a positive attitude toward Advisory Circular Date: 12/13/91 AC No: 60-22 Initiated by: AFS-820 safety and learn ways to manage stress while recognizing and avoiding unnecessary risk. This AC is a learning tool that will help enable a person to make an intelligent determination as to the risk involved before beginning a flight. It is intended that the reader recognize risk factors such as weather, weight and balance, recency of experience, environment, and cockpit stress management so as to deal effectively with them.
4. RELATED REFERENCE MATERIAL.
Twelve years of ADM research, development, and testing culminated in 1987 with the publication of six manuals oriented to the decision making needs of variously rated pilots.
These manuals provide multifaceted materials designed to reduce the number of decision related accidents (the type of accidents which account for 52 percent of fatal general aviation pilot error accidents). The effectiveness of thesc materials has been validated in six independent studies where student pilots received such training in conjunction with the standard flying curriculum. When tested, the pilots who had received ADM training made fewer in-flight errors than those who had not received ADM training. The differences were statistically significant and ranged from about 10 to 50 percent fewer judgment errors. In the operational environment, an operator flying about 400,000 hours annually demonstrated a 54 percent reduction in accident rate after using these materials for recurrency training. For detailed information regarding exposure to risk assessment, stress management, interpersonal
crew coordination and communication, and other Report Number Title ADM techniques, the reader is directed to one or more of the manuals which may be obtained DOT/FA A/PM-86/46 Aeronautical Decision from National Technical Information Service. Making - Cockpit Resource Management.
a. Published Documents. (Price of NTIS identification individual documents is subject to change number ADA205115, without notice.) price $23.00.
Report Number Title b. Any of the series of ADM training manuals may be obtained by writing or calling:
DOT/FAA/PM-86/41 Aeronautical Decision Making for Student and Mailing Address: National Technical Private Pilots. NTIS Information Service identification number 5285 Port Royal Road ADA182549, price Springfield, Virginia 22161 $23.00.
Telephone: (703) 487-4650 (orders) DOT/FAA/PM-86/42 Aeronautical Decision (800) 336-4700 (rush orders only) Making for Commercial (703) 478-4780 (title identification Pilots. NTIS branch) identification number ADA198772, price 5. DEFINITIONS.
$17.00.
a. ADM is a systematic approach to the DOT/FAA/PM-86/43 Aeronautical Decision mental process used by aircraft pilots to Making for Instrument consistently determine the best course of action Pilots. NTIS in response to a given set of circumstances.
identification number N8724880, price $17.00. b. Attitude is a personal motivational predisposition to respond to persons, situations, DOT/FAA/PM-86/44 Aeronautical Decision studior or events in a given manner that can, Making for Instructor nevertheless, be changed or modified through Pilots (how to teach training. A sort of mental shortcut to decision ADM). NTIS making.
identification number ADA182611, price c. Attitude Management is the ability to $17.00. recognize hazardous attitudes in oneself and the willingness to modify them as necessary through DOT/FAA/PM-86/45 Aeronautical Decision the application of an appropriate Making for Helicopter antidote thought.
Pilots. NTIS identification number d. Cockpit Resource Management, ADA180325, price (CRM), in multiperson crew configurations, is $23.00. the effective use of all personnel and material Par 4
12/13/91 assets available to a flight crew. CRM emphasizes good communication and other interpersonal relationship skills.
e. Headwork is required to accomplish a conscious, rational thought process when making decisions. Good decision making involves risk identification and assessment, information processing, and problem solving.
f. Judgment is the mental process of recognizing and analyzing all pertinent information in a particular situation, a rational evaluation of alternative actions in response to it, and a timely decision on which action to take.
Personality is the embodiment of personal traits and characteristics of an individual that are set at a very early age and extremely resistant to change.
h. Poor Judgment (PJ) Chain is a series of mistakes that may lead to an accident or incident. Two basic principles generally associated with the creation of a PJ chain are: (1) one bad decision often leads to another; and (2) as a string of bad decisions grows, it reduces the number of subsequent alternatives for continued safe flight. ADM is intended to break the PJ chain before it can cause an accident or incident.
i. Risk Management is the part of the decision making process which relies on situational awareness, problem recognition, and good judgment to reduce risks associated with each flight.
j. Risk Elements in ADM take into consideration the four fundamental risk elements:
the pilot, the aircraft, the environment, and the fan Cans Thomas C. Accardi Director, Flight Standards Service Par 5 AC 60-22 type of operation that comprise any given aviation situation.
k. Situational Awareness is the accurate perception and understanding of all the factors and conditions within the four fundamental risk elements that affect safety before, during, and after the flight.
1. Skills and Procedures are the procedural, psychomotor, and perceptual skills used to control a specific aircraft or its systems.
They are the stick and rudder or airmanship abilities that are gained through conventional training, are perfected, and become almost automatic through experience.
m. Stress Management is the personal analysis of the kinds of stress experienced while flying, the application of appropriate stress assessment tools, and other coping mechanisms.
n. VOR is a very high frequency omnidirectional range station.
COMMENTS INVITED. Comments regarding this publication should be directed to:
Federal Aviation Administration Flight Standards National Field Office, AFS-500 (Advisory Circular Staff) P.O. Box 20034, Gateway Building Dulles International Airport Washington, DC 20041-2034 Every comment will not necessarily generate a direct acknowledgement to the commenter.
Comments received will be considered in the development of upcoming revisions to AC's or other related technical material.
iii (and iv)
CONTENTS Page No.
CHAPTER 1. INTRODUCTION
1. General
2. ADM Process
3. Conventional Decision Making 2
4. Operational Pitfalls 3 CHAPTER 2. HAZARDOUS ATTITUDE INVENTORY 5
5. Attitude Assessment Test . Seli-Assessment Hazardous Atutude Inventory le . Instruchons for lakıng the Seli-Assessment Hazardol Attitude Inventory Test
8. Scoring Instructions
9. Attitude Profile .
10. Sample Situations for Advanced Rated Pilots 7
11. Profile Explanation
12. Summary CHAPTER 3. DEALING WITH HAZARDOUS ATTITUDES 11
13. Hazardous Attitudes
14. Antidotes for Hazardous Attitudes
15. Antidote Recall Exercise
16. The Importance of Reinforcement Exercises 12
17. Instructions for Using Reinforcement Exercises 12 CHAPTER 4. STRESS AND FLYING 17
18. What Is Stress • 17
19. How Much Stress Is in Your Life? 17
20. Is Stress Bad . 17
21. Handling Stress In Flying 17 CHAPTER 5. RISK MANAGEMENT 21
22. Assessing Risk . 21
23. The Decide Model 21
AC 60- 22 12/13/9 CONTENTS (Continued) Page No.
CHAPTER 6. IDENTIFYING THE ENEMY 23
24. General 23
25. Personal Checklist 23
26. How To Be A Safe Pilot 24
27. Development of Good Decision Making Skills 24
28. Successful Decision Making 25 CHAPTER 7. TEACHING ADM 27
29. Purpose 27
30. Background 27
31. The Flight Instructor's Role in ADM Training 27
32. Principles of ADM Training 27
33. Teaching the Behavioral Aspects of ADM 28
34. Teaching the Application Exercises. 28
35. In-Flight Instruction: The Lesson Plans 29
36. In-Flight Instruction: The Training Scenario 29
37. Typical Training Scenarios. 29
38. Management of ADM Training 29 APPENDIX 1. SAMPLE ATTITUDE INVENTORY ANSWER SHEET • (1 Page) APPENDIX 2. SCORING FORM • (1 Page) APPENDIX 3. ATTITUDE PROFILE . (1 Page) APPENDIX 4. ANTIDOTE RECALL EXERCISE • (1 Page) APPENDIX 5. LIFE EVENTS STRESS TEST • (1 Page) vi
CHAPTER 1. INTRODUCTION
1. GENERAL. Contrary to popular opinion, good judgment can be taught. Heretofore it was supposed to be gained only as a natural by-product of experience. As pilots continued to log accident-free flight hours, a corresponding increase of good judgment was also assumed.
2. ADM PROCESS.
ADM builds upon the foundation of conventional decision making (figure 1), but enhances the process to decrease the probability of pilot ADM provides a structured, systematic approach to analyzing changes that occur during a flight and how these changes might affect a flight's safe outcome. The ADM process addresses all aspects of decision making in the cockpit and identifies the steps involved in good decision making.
Steps for good decision making are:
(1) Identifying personal attitudes hazardous to safe flight.
(2) Leaming behavior modification techniques.
(3) Leaming how to recognize and cope with stress.
(4) Developing risk assessment skills.
(5) Using all resources in a multicrew situation.
(6) Evaluating the effectiveness of one's ADM skills.
PILOT AIRCRAFI ENVIRONME
SITUATION
CHANGE / EVENT OCCURS
RECOGNIZE CHANGE
SKILLS & SELECT HEADWORK
PROCEDURES RESPONSE TYPE REQUTRED
INADEQUATE INADEQUATE MISHAPS !
FIGURE 1. CONVENTIONAL DECISION MAKING PROCESS Chap 1 Par 1
AC 60- 22
3. CONVENTIONAL DECISION MAKING.
In conventional decision making, the need for a decision is triggered by recognition that something has changed or an expected change did not occur. Recognition of the change, or nonchange, in the situation is a vital step in any decision making process. Not noticing the change in the situation can lead directly to a mishap (figure 1). The change indicates that an appropriate response or action is necessary in order to modify the situation (or, at least, one of the elements that comprise it and bring about a desired new situation. Therefore, situational awareness 1S the key to successful and safe decision making. At 12/13/91 this point in the process, the pilot is faced with a need to evaluate the entire range of possible responses to the detected change and to determine the best course of action.
b. Figure 2 illustrates the ADM process, how this process expands conventional decision making, and shows the interactions of the ADM steps and how these steps can produce a safe outcome. Starting with the recognition of change, and following with an assessment of alternatives, a decision to act or not act is made, and the results are monitored. ADM enhances the conventional decision making process with an awareness of the importance of attitudes in decision making, a
AIRCRAFT VVIRONME MISSION
SITUATION SELECT
SKILLS & RESPONSE HEADWORK
PROCEDURES REQUIRED
ATTITUDE
MANAGEMENT CREW (if present) STRESS
HEADWORK MANAGEMENT MANAGEMENT
RESPONSE
PROCESS
CRITIQUE RISK
ACTIONS
MANAGEMENT (Post-Situation) FIGURE 2. AERONAUTICAL DECISION MAKING PROCESS Chap 1 Par 3
12/13/91 learned ability to search for and establish the relevance of all information, and the motivation to choose and execute the actions which assure safety in a timeframe permitted by the situation. These elements of ADM are discussed in depth as they relate to the specific discipline in each of the training manuals.
4. OPERATIONAL PITFALLS. There are a number of classic behavioral traps into which pilots have been known to fall. Pilots, particularly those with considerable experience, as a rule always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they have the "right stuff."
much-talked-about "right stuff" is a fragile image.
The basic drive to demonstrate the "right stuff" can have an adverse effect on safety and can impose an unrealistic assessment of piloting skills under stressful conditions. These tendencies ultimately may lead to practices that are dangerous and often illegal, and may lead to a mishap. All experienced pilots have fallen prey to, or have been tempted by, one or more of these tendencies in their flying careers. These dangerous tendencies or behavior patterns, which must be identified and eliminated,
a. Peer Pressure. Poor decision making based upon 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.
c. Get-There-Itis. This tendency, common among pilots, clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for any alternative course of action.
d. Duck-Under Syndrome. The tendency to sneak a peek by descending below minimums during an approach. Based on a belief that there is always a built-in "fudge" factor that can be used or on an unwillingness to admit defeat and shoot a missed approach.
Chap 1 Par 3 AC 60-22 Scud Running. Pushing the capabilitics of the pilot and the aircraft to the limits by trying to maintain visual contact with the terrain while trying to avoid physical contact with it.
attitude is characterized by the old pilot's joke: "If it's too bad to go IFR, we'll go VFR."
f. Continuing visual flight rules (VFR) into instrument conditions often leads to spatial disorientation or collision with ground/obstacles. It is even more dangerous if the pilot is not instrument qualified or current.
g. 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 at what happens next.
h. Loss of Positional or Situation Aware- 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 Instrument Flight Rules (IFR), is generally the result of overconfidence, lack of flight planning, or ignoring the regulations.
Descent Below the Minimum Enroute Altitude. The duck-under syndrome (mentioned above) manifesting itself during the en route portion of an IFR flight.
k. Flying Outside the Envelope. Unjustificd 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.
3 (and 4)
CHAPTER 2. HAZARDOUS ATTITUDE INVENTORY ATTITUDE ASSESSMENT TEST. In each ADM manual, a chapter addresses five hazardous attitudes that can affect a pilot's judgment, and how these hazardous attitudes can have an impact on safe flying. Subsequent chapters in each of the ADM manuals provide methods of modifying these hazardous attitudes.
Situation 1 (Example)
a. _1_ (your least likely reason)
b._3_
c. _5_ (your most likely reason)
SELF-ASSESSMENT HAZARDOUS ATTI- TUDE INVENTORY TEST. Each ADM student should take the Self-Assessment Hazardous Attitude Inventory Test in order to gain a realistic perspective on his/her attitudes toward flying. The inventory test requires the pilot to provide a response which most accurately reflects the reasoning behind his/her decision. The pilot must choose one of the five given reasons for making that decision, even though the pilot may not consider any of the five choices acceptable. The inventory test presents extreme cases of incorrect pilot decision making in an effort to introduce the five types of hazardous attitudes described in Chapter 3 of this AC.
INSTRUCTIONS FOR TAKING THE
SELF-ASSESSMENT HAZARDOUS ATTI- TUDE INVENTORY TEST.
a. Read over each of the six situations and the five choices contained in the inventory test.
Keep in mind that there are no correct answers.
b. Decide which one of the five choices is the most likely reason for the decision made.
Using a copy of the Attitude Inventory Answer Sheet (appendix 1), place the number 5 in the space provided.
c. Continue by ranking in declining order the remaining four probable reasons from 4 (next most likely) to 3, 2, and 1 (least likely) until all five blanks have been filled. (Figure 3 provides an example of how the alternatives might be ranked.)
d. _2_ FIGURE 3. SAMPLE SET OF RANK
ORDERED ANSWERS Situation 1. You are on a flight to an unfamiliar, rural airport. Flight service states that VFR flight is not recommended since heavy coastal fog is forecast to move into the destination airport area about the time you expect to land. You first consider returning to your home base where visibility is still good, but decide instead to conunue as planned and land safely after some problems. Why did you reach this decision?
You hate to admit that you cannot complete your original flight plan.
You resent the suggestion by flight service that you should change your mind.
You feel sure that things will tum out safely, and that there is no danger.
d. You reason that since your actions would make no real difference, you might as well continue.
e. You feel the need to decide quickly, so you take the simplest alternative.
Chap 2 Par 5 5
AC 60- 22 Situation 2. While taxiing for takeoff, you notice that your right brake pedal is softer than the left.
Once airbome, you are sufficiently concerned about the problem to radio for information. Since strong winds are reported at your destination, an experienced pilot who is a passenger recommends that you abandon the flight and retur to your departure airport. You choose to continue the flight and experience no further difficulties. Why did you continue!
You feel that suggestions made in this type of situation are usually overly cautious.
b. Your brakes have never failed before, so you doubt that they will this time.
c. You feel that you can leave the decision to the tower at your destination.
You immediately decide that you want to continue.
You are sure that if anyone could handle the landing, you can.
Situation 3. Your regular airplane has been grounded because of an airframe problem. You are scheduled in another airplane and discover it is a model you are not familiar with. After your preflight, you decide to take off on your business trip as planned. What was your reasoning?
a. You feel that a difficult situation will not arise so there is no reason not to go.
b. You tell yourself that if there were any danger, you would not have been offered the plane.
You are in a hurry and do not want to take the time to think of alterate choices.
d. You do not want to admit that you may have trouble flying an unfamiliar airplane.
e. You are convinced that your flight instructor was much too conservative and pessimistic when he cautioned you to be thoroughly checked out in an unfamiliar aircraft.
12/13/91 Situation 4. You were briefed about possible icing conditions, but did not think there would be any problem since your departure airport temperature was 60 °F (15 °C). As you near your destination, you encounter freezing precipitation, which clings to your aircraft. Your passenger, who is a more experienced pilot, begins to panic. You consider turning back to the departure airport, but continue instead. Why did you not return?
I have made it this far. What is the use in turing back now?
The panic of the passenger makes you think it will not happen to me - I have encountered ice before and nothing happened.
Why is he panicking? I can handle this situation just like I have done before.
• FAA regulations exaggerate the dangers of icing. I can handle this situation.
I have got to do something. Descend!
That will make everyone realize that I am in control.
Situation 5. You do not bother to check weather conditions at your destination. En route, you encounter headwinds. Your fuel supply is adequate to reach your destination, but there is almost no reserve for emergencies. You continue the flight and land with a nearly dry tank. What most influenced you to do this?
Being unhappy with the pressure of having to choose what to do, you make a snap decision.
You do not want your friends to hear that you had to turn back.
c. You feel that flight manuals always understate the safety margin in fuel tank capacity.
You believe that all things usually tum out well, and this will be no exception.
Chap 2 Par 7
12/13/91
e. You reason that the situation has already been determined because the destination is closer than any other airport.
Situation 6. You are 40 minutes late for a trip in a small airplane. Since the aircraft handled well on the previous day's flight, you decide to skip most of the preflight check. What leads you to this decision?
a. You simply take the first approach to making up time that comes to mind.
b. You feel that your reputation for being on time demands that you cut comers when necessary.
c. You believe that some of the preflight inspection is just a waste of time.
d. You see no reason to think that something unfortunate will happen during this flight.
If any problems develop, the responsibility would not be yours. It is the maintenance of the airplane that really makes the difference.
SAMPLE SITUATIONS FOR ADVANCED RATED PILOTS.
Paragraph 7 presented examples of six situations from the student/private pilot ADM manual. For pilots with advanced ratings, the remaining ADM manuals provide similar situations and self-assessment tests. The following are example situations taken from these texts.
Situation 7. Instrument Pilot ADM Situation.
You plan an important business flight under instrument conditions in an aircraft with no deicing equipment through an area in which light to moderate rime or mixed icing in clouds, and precipitation above the freezing level has been forecast. You decide to make the trip, thinking:
_a. You believe your skills are good enough to handle ice accumulation on the aircraft.
b. You have been in this situation many times and nothing has happened.
Chap 2 Par 7 AC 60- 22 _c. You must get to the business meeting in 2 hours and cannot wait.
d. You don't allow an icing forecast to stop you; weather briefers are usually overly cautious.
_e. There is nothing you can do about atmospheric conditions.
Situation 8. Commercial Pilot ADM Situation.
Your passengers have shown up almost an hour late. You are going to an airport that requires a reservation. Which of the following alternatives best illustrates your reaction?
_a. You think to yourself, if I hurry, maybe I can still make it.
_b. Nothing will happen if I miss this reservation.
_c. I'm smart enough to talk our way in when we arrive.
d. I can't help it if my passengers were late. I don't control them.
_e. The Feds wouldn't dare keep me out.
Situation 9. Helicopter Pilot ADM Situation.
You are to fly a helicopter which you know is old and has been poorly maintained. A higher than normal turbine outlet temperature on startup is indicated, and you suspect the fuel control. Two fellow company pilots, travelling as passengers, do not want to be delayed. After 5 minutes of debate, you agree to make the trip. Why did you permit yourself to be persuaded?
_a. You feel that you must always prove your ability as a pilot, even under less than ideal circumstances.
_b. You believe that regulations overemphasize safety in this kind of situation.
_c. You think that the fuel control will certainly last for just one more flight.
AC 60-22
d. You feel that your opinion may be wrong since the two other pilots are willing to take the risk.
_e. The thought of changing arrangements is annoying, so you jump at the suggestion of the other pilots.
Situation 10. Instructor Pilot ADM Situation.
You perform a slip demonstration during an approach to landing and fly the aircraft to the left of the runway centerline to a position which would make an attempted landing possible but dangerous.
You return control of the aircraft to the student and instruct him toiexecute proper landing procedures. Which of the following best characterizes your attitude about putting the student and yourself in this situation?
I can always handle this even if he can't.
Whatever happens, it's up to him now.
I've never had a problem doing this in the past.
The quicker we get through this, the better.
e. These aircraft can take a lot worse landings than the manuals suggest.
9. SCORING INSTRUCTIONS. After completing the inventory test, transfer the responses for each alternative from the completed Attitude Inventory Answer Sheet (appendix 1) to the appropriate section of the Scoring Form (appendix 2).
Total the ranking scores for each scale and enter the total in the space provided at the bottom of each column. The total score for each situation must be 15, while the total for situations 1 through 6 must be 90. If the totals are not 15 and 90, review for possible errors in the transfer of scores and check addition. These totals are then marked on the Attitude Profile (appendix 3) where indicated for situations 1 through 6.
12/13/91
10. ATTITUDE PROFILE. Using the total scores for each Scale I-V from appendix 2, place an "X" on the corresponding scale profile in appendix 3. Notice that the score values run from bottom to top, so that the highest value should be at the highest point on the profile sheet. Straight lines should be drawn from the score in each scale to the score in the next scale (connect the "X's") so that the profile resembles a graph. Note the hazardous attitude shown at the bottom of each scale on appendix 3.
11. PROFILE EXPLANATION. The profile graph indicates the comparative tendency for each of the five hazardous attitudes. The higher the relative rank (first, second, third, etc.), the greater the propensity to respond with that hazardous attitude. The pilot should keep in mind his/her results while reviewing the explanation. An explanation of the pilot's profile starts with the description of an all-too-common flight situation.
a. A pilot of a single-engine aircraft checks the weather and notes that there is a possibility of a thunderstorm at the destination airport. The pilot has never operated an aircraft in bad weather and knows that a flight instructor would advise against flying. Despite this knowledge, the pilot takes off, crashes in poor weather, and is seriously injured.
b. Why does this occur so often? Because many accidents involve pilots who allow themselves to be influenced by one or more of the five basic hazardous attitudes. These attitudes get pilots into trouble by causing them to take chances that invite an accident. (The five hazardous attitudes are the ones recorded on the assessment inventory just completed.)
12. SUMMARY.
a. The pilot should use the profile to determine which hazardous attitudes dominated his/her responses. The profile will illustrate which hazardous thought patters have a greater tendency to influence a pilot's judgment. The inventory test may indicate the actual tendency of the pilot; however, exhibiting attitudes similar to those described are common and normal. As a pilot's flying career Chap 2 Par 8