A recent and tragic accident has reminded me of the importance of Aeronautical Decision-Making (ADM) in flight training. ADM starts well before the flight begins, continues after the flight ends, and has a lot more to do with ATTITUDE than ALTITUDE.
Buzz-words and “safety-speak”
The US Federal Aviation Administration (FAA) defines ADM as: “a systematic approach to the mental process used by pilots to consistently determine the best course of action in response to a given set of circumstances. It is what a pilot intends to do based on the latest information he or she has.”
Over the last few decades, the concept of ADM has been attempted to be quantified under the headings of “Human Factors”, “Threat and Error Management”, “Non-Technical Skills” and the like. Personally, I prefer the term “Airmanship” to “ADM”, but what I am ultimately referring to is the ability to pre-plan, manage and mitigate RISK in the aviation environment.
Risk-mitigation and accident causation
Any activity involves an element of risk. Simply getting out of bed can cause an injury, to say nothing of getting in the car and driving to the airport! Statistically, you are far more likely to be injured or die in a car accident than in a light aircraft. However, light aircraft attract a lot more attention than vehicle accidents, and the consequences are usually more dire given the lower level of in-built protective equipment such as airbags and crumple zones.
Most aircraft accidents are attributed to loss of control of the aircraft. However, what is just as important is the conditions which led up to the loss of control. This is usually a result of several factors.
The Reason or “Swiss Cheese” Model of accident causation theorises that every accident is the result of multiple defensive layers being breached to provide a failure path.
Let’s briefly analyse an aircraft accident which I observed a few years ago:
“After a high and fast approach, the aircraft bounced several times and subsequently landed firmly on the nosewheel halfway down the 1000m runway. The nosewheel assembly then separated from the aircraft. The propeller impacted the runway and the aircraft came to a complete and sudden stop. The occupants exited unassisted, one sustaining minor injuries. Surface wind conditions at the time were approximately 8 kts of crosswind and 5 kts of tailwind. The pilot was unfamiliar with the location and it was his first experience at that Controlled Aerodrome. He later stated that he was ‘worried’ about coming to (the location) because it was so busy.”
Thankfully, in this accdident, no-one was seriously injured. Let’s look at some of the factors, the defence(s) and how they may have been negated.
| Factor | Defence(s) | Comments |
| “After a high and fast approach…”
|
TAF
ATIS
Experienced wind
Approach brief
Go-around criteria |
The TAF for the location indicated a wind shift around the time of the aircraft’s arrival.
The ATIS wind only indicates the wind at the surface, and not that on the approach.
The wind experienced by the pilot was substantially different to the surface wind.
Did the pilot conduct an approach brief? Did it include the power setting for the approach given the experienced wind?
Did the pilot set go-around criteria for his approach? IAS / flight path / power considerations? |
| “The aircraft bounced several times…” | Conduct an aborted landing (go-around) | The pilot chose not to abort the landing attempt prior to the flare, or after the first or subsequent bounces. |
| “The pilot was unfamiliar with the location…” | Radio phraseology | The pilot, to assist his situational awareness and provide an additional level of support, could have used the phrase “UNFAMILIAR” on first contact with ATC. |
| “…’worried’ about the location” | ERSA procedures
Safety Pilot |
Standard procedures for arrivals and departures are listed in ERSA. These should have been carefully studied and be available to the pilot in flight.
If the workload for the pilot was expected to be excessive, the additional safety measure of an experienced supernumerary pilot should have been sought. |
This accident should NEVER HAVE HAPPENED. As is often the case however, it was the final layer of defence – pilot skill – which determined the outcome. The holes in the Swiss cheese had lined up. All the pilot had to do was go-around and set up the approach again.
Granted, it’s easy for us “armchair critics” to sit back with a cup of coffee and analyse accidents with the benefit of hindsight. Additionally, we weren’t there, didn’t know what external pressures that pilot was facing, and have no insight into his psyche at the time of the accident – all of which must be taken into account when analysing any incident. The “Miracle on the Hudson” with Capt. Charles “Sully” Sullenberger is a good example of this.
However, as a flying instructor, I routinely see students cognitively “trap” themselves into a event where “all they had to do” was go-around or something similar. This is usually a result of task-focus and inexperience. It is my job to “fish” them out whilst letting them take away a positive learning experience.
Pilot skill – the LAST line of defence
The final arbiter of flight safety in these situations is often a last-minute decision by the pilot which requires two things:
- A mental re-set on the situation, and
- The timely execution of correct piloting skills.
Teaching good ADM is an important responsibility of the flying instructor. I often have to make a decision for a student, or execute piloting skills beyond the student’s ability to perform, for them to see outcome of their lack of appropriate ADM.
Unfortunately, most flying instructors in this country who teach new students, who know nothing about ADM, are young Grade Three instructors starting with about 250 hours of total aeronautical experience. At this point, the INSTRUCTOR is still gaining relevant experience in flying as well as instructing. They simply have not yet seen enough go wrong as a result of their own underdeveloped ADM skills to pass this on to their students. So, what hope has the student?!
Teaching the student pilot without compromising safety – experience counts!
An experienced instructor will have the ability to recognise an impending situation well before it eventuates. Moreso, they should let the situation progress as far as safely possible to allow the student to learn a valuable lesson. I was very fortunate to have such instructors myself; one of whom knew the lesson I was to learn that flight about over-confidence because of a single radio call made with an air of smugness.
In my experience, the average Grade Three instructor will not let a student go far enough, for fear of letting the situation get beyond the instructor’s control, OR, let the situation go too far which may compromise safety. Neither situation is ideal – both for the student and aircraft’s longevity!
This situation is NOT the fault of the new instructor. It is also not fair to criticize these instructors for wanting to teach others at their level of experience. Don’t get me wrong; some of these instructors have a natural talent for flying, or teaching, but very rarely both – for each is a learned skill. It is an ongoing and latent failure of the licencing system to permit inexperienced instructors to teach ab-initio flying – but that is a totally different philosophical argument, one which I will not delve into here.
It is often said that “Experience is the sum total of all screw-ups you have managed to live through.” I agree. But you must have the skill, and a little bit of luck, to survive them and learn from the experience. Tragically some never gain that experience before events catch up with them – usually at an altitude too low to do enough about it.
Increasing capacity for good Aeronautical Decision Making with increased skill
Piloting skill is the last line of defence. It needs to be used correctly, instinctively and is subject to both proficiency and recency. A pilot more comfortable in the air has a greater capacity for good ADM. In order to increase the capacity for good ADM, a pilot needs to be able to master flying the aeroplane without fear or misunderstanding of its control.
The addition of aerobatics, spinning and UPRT in flying training certainly provides these additional skills. Normalizing the human “startle” reaction and ingraining instinctive and correct piloting skill is VITAL in a pilot’s early flight training.
Practice makes PERMANENT!
The practice of emergency procedures should never be allowed to become a degraded skill. For example, you will likely never KNOW when an engine failure will occur! I always ask my Aeroplane Flight Review candidates when their last practice forced landing or glide approach was. The number of times the words “last flight review” are uttered truly shock me. I then direct them to the “General Competency Requirement” of CASR 61.385 which states that:
(1) The holder of a pilot licence is authorised to exercise the privileges of the licence in an aircraft only if the holder is competent in operating the aircraft to the standards mentioned in the Part 61 Manual of Standards for the class or type to which the aircraft belongs, including in all of the following areas:
(a) operating the aircraft’s navigation and operating systems;
(b) conducting all normal, abnormal and emergency flight procedures for the aircraft;
(c) applying operating limitations;
(d) weight and balance requirements;
(e) applying aircraft performance data, including take‑off and landing performance data, for the aircraft.
If you can’t effectively cope with an emergency, not only are you putting you, your passengers and others’ lives at risk, you are also breaking the law! How would your aircraft’s insurer look upon reckless endangerment of life and property due to a lack of proficiency?
Hoping for the best while spending the least – a recipe for disaster!
Some people regrettably choose to ignore the relevance, or completely miss the point of, experience and skill in flight instruction. Students sometimes don’t see past the “dollar-to-qualification” ratio. A number of instructors look upon their role as merely a stepping-stone to gain experience at the student’s expense. I have met student pilots who view the training process as simply a “box-ticking” exercise. Others are ignorant of the importance of ingraining a safe operating culture in an environment foreign to human beings.
The aviation environment is statistically far safer than many other activities we take for granted, but is cruelly unforgiving of inattention, neglect or foolishness.
Skill is a defence. Attitude is everything.
There are many ways to enhance safety. Increase your defences with good training from experienced instructors skilled in the art of flight. It’s never too late to start!
