Why does the number of general aviation accidents hover at nearly 2,000 a year every year? The answer is not as complex as it might seem. If we can believe the statistics, we, the pilots, are doing it to ourselves - and it's not because we don't know how to fly. In many ways, flying is the easy part. Thinking is the hard part.
If flying really is 98 percent head and only 2 percent hands, then the quickest way to improve our flying is to improve our thinking-specifically to improve our judgment. The main impediments to good pilot judgment are:
- Misunderstanding of risk.
- Ignorance of the aeronautical decision making (ADM) process.
- Misunderstanding of the influence of personality on decision making.
- Failure to appreciate the role of stress in decision making.
Traditional Emergency Procedures Training
You've just lost an engine...there's smoke in the cockpit...such-and-such a system has failed.... Now what do you do? These are scenarios that we encounter over and over again throughout our pilot training, and the responses are deeply ingrained. The name of the game is always fly the airplane, identify the problem, and try to fix it - in that order.
A proper response to the failed engine situation is straightforward. Your instructor expects you to establish best-glide speed, trim, pick a landing site, go through the motions of an unsuccessful engine restart, simulate shutting down the engine(s), and enter an engine-out pattern until your instructor says, "OK, good job. Now let's head back to the airport." The real world isn't quite that simple. Nobody's in the right seat saying, "Get ready. We're going to have an engine failure today." Instead, real life sneaks up on us without warning.
What really happens is that something goes wrong - engine failure, bad weather, electrical failure, or scores of other problems. Then the pilot doesn't notice, misdiagnoses the problem, or takes the wrong action to correct it. In each case, the pilot potentially makes the situation worse. This is where the seemingly inexorable march to an accident begins. This chain of events that heaps judgment error upon judgment error is typified by what happened to poor old Joe.
The Story Of Old Joe
The accident scene is a nontowered airport outside a small town. Joe made a big mistake and crashed on final. Actually, Joe didn't make just one mistake; he made many. They just kept piling up until the sheer weight of them caught up with him.
The accident report says that Joe crashed because he cross-controlled and stalled while "pulling the nose around" in an attempt to get lined up with the runway. But is that really what caused the accident?
On final that day, there was a strong crosswind from the left. "Pulling it around" was crucial in Joe's mind. He was overshooting the centerline. He would have to go around if he couldn't swing the airplane back on track. He didn't have time to go around. He had to get it on the ground and call Alice.
"Here," as Paul Harvey would say, "is the rest of the story."
Joe had a 13-knot tailwind on base and was slow to notice it. He felt rushed and hadn't thought about wind corrections for the pattern. He didn't complete any of his checklists, either. Things were just too hurried. He knew he would be late returning the rental airplane. Besides, Alice was on his mind, and he flew back into the pattern as fast as he could. Of course, he wouldn't have flown at all that day if his currency hadn't been about to expire. He woke up late, rushed to the airport, and didn't have time to do a preflight. He was really tired, too. He'd slept poorly the night before, worrying about the fight with Alice.
The tragic end to Joe's flight is not surprising given all of the circumstances. Even more tragic is that we can all think of at least 10 ways this accident could have been prevented.
So, why didn't warning flags go up for Joe? If his string of poor choices had been broken anywhere along the line, there probably would have been no accident. Why couldn't Joe see that he was literally setting himself up for disaster?
That's the question each of us must answer because it could happen to us unless we are constantly on guard and understand the process and results of bad decision making. Safe flying is really a series of good decisions.
Judgment - Good and Bad
Good flying judgment involves common sense. You'd think no pilot would fly an airplane without preflighting it or deliberately fly into bad weather. If in doubt, don't go. If things turn sour, turn around or land. We know that's what we should do. And when we read an accident re-port and see that the pilot didn't follow those rules, we wonder why.
We need to be alert to the insidious dangers that creep into a flight. For one thing, sometimes when we make bad decisions we get away with it. Perhaps we're tired, rushed, and frustrated over a problem at work. We decide to fly anyway and nothing happens. The flight is uneventful, and we land safely. Another day we're in a hurry so we do a less-than-thorough preflight and skip the weather briefing. Again, we get lucky. It's easy to see how we might begin to think that the preflight isn't that important, looking at the sky will substitute for a weather briefing, and flying when we're fatigued is no big deal.
Once a poor judgment has been made, we tend to talk ourselves into another, and another. Having created a chain of bad decisions, good options start disappearing. We all make bad decisions from time to time. The trick is to minimize those bad decisions and recognize them once they've been made.
For years, it was taken for granted that good judgment is a byproduct of having spent many hours in the air. That is not necessarily the case. It's not just young or low-time pilots who make mistakes.
Sound ADM is the product of a conscious, consistent, and disciplined application of good judgment as it pertains to flying. ADM principles involve knowledge of the decision making process, risk, personality, and stress as they affect decision making.
Risk
By its very nature, all flying involves risk. The only way to completely eliminate that risk is to stay on the ground. Understanding this risk potential enables us to manage and reduce risk through conscious application of the skills and techniques that we already have at our disposal. For instance, we can manage our risks on every fight by ensuring that we are proficient, conducting a thorough preflight, checking the weather, planning for the flight, meeting the criteria of the I'M SAFE checklist (free from illness, medication, stress, alcohol, fatigue, and emotional upset), and so on.
Using good judgment means never putting ourselves in a position from which there is no escape. Three risk management principles apply directly to flying. First, avoid unacceptable risks. Second, never risk more than you can afford to lose. Third, don't risk a lot (your life) to gain a little (the time it takes to go around). Following these guidelines prevents the ego from writing checks that our flying skills can't cash.
Personality
Attitude is a make-or-break ingredient for safe flying. You may have been ex-posed to the concept of hazardous attitudes. Five dangerous personality traits - categorized by the FAA - are present in all of us to varying degrees. These attitudes are anti-authority, impulsivity, invulnerability, macho, and resignation ("Five Hazardous Attitudes," AOPA Flight Training, September 1999). Before you decide that they don't apply to you, think about times when you've thought that an accident couldn't happen to you (invulnerability) or you've acted without fully thinking through the consequences (impulsivity). Each of us has experienced every one of these attitudes at some time, and they have affected our judgment. When we experience one of these attitudes while flying, we are setting ourselves up for a serious, maybe even fatal, mistake.
For a better understanding of hazardous attitudes as they affect pilot judgment, and to evaluate your own personal tendencies, get a copy of the FAA's safety pamphlet FAA-P-8740-53, Introduction to Pilot Judgment, from your local flight standards district office or download it from the Internet (www.cyberair.com/tower/faa/app/p8740-53/p8740-53.html ).
Take the 10-question quiz and try to understand how hazardous attitudes can bite any of us at any time. The object of this test is to identify which of these personality tendencies are more and less prevalent in each of us. When the chips are down, these tendencies can cloud our judgment if we are unaware of them. Forewarned is forearmed, particularly in high-stress situations.
Stress
Regardless of how well adjusted we think we are, all of us are under stress. Recognizing stress and admitting that you are suffering from it are signals that a little extra prudence might be required on a given flight.
Stress comes in at least three varieties. The first is physical stress, which includes conditions in our environment such as marginal weather, temperature extremes, and high density altitudes. The second is physiological stress, which includes things that affect our bodies such as lack of sleep, illness, and hunger. The third is psychological stress, which includes things that affect our minds such as worries over work or finances.
Looking Ahead In Hindsight
What if we could find a way to benefit from hindsight up front? The key may lie in the way we look at accidents that have happened to others. Instead of asking, "What caused this accident?" try asking, "How could this accident have been prevented?" In other words, how could the poor judgment chain have been broken?
One of the first things we can all do is to be aware of what's happening while we are flying or preparing to fly. We must be alert to warning flags signaling that a trend of negative events has begun.
The first line of defense against the poor judgment chain is to understand that it exists. Special safety seminars conducted by the AOPA Air Safety Foundation are one way to enhance that awareness. These two-hour evening meetings show the prolonged, slowly developing chain of poor judgments leading up to real accidents. The seminars show how awareness of events as they are progressing can prevent accidents by leading to an intervention of some sort - a break in the sequence of events or decisions. For a schedule of upcoming safety seminars, visit the Web site (www.aopa.org/asf/schedules ).
AOPA's efforts have sound support. The Boeing Company did an extensive analysis of 232 airline accidents. The conclusion: Every one of the accidents could have been prevented. In one case, there were 20 opportunities to prevent the accident. The average number of opportunities to prevent an accident was three. In only one case was there a single opportunity to prevent the accident.
In all, there were 636 separate opportunities to prevent these 232 accidents. Seventy-two percent of the time, the pilot could have stopped the chain of events, usually by following the published procedures for the situation.
The ability to apply sound logic in the cockpit can be enhanced through training. One aircraft operator whose pilots flew more than 400,000 hours per year in the early 1990s reduced its accident rate by 54 percent by giving pilots judgment training. Other pilot groups reduced operational errors by 10 percent to 50 percent through similar training.
The Bottom Line
Thinking about Joe, "Go around if it doesn't look good" might have been a good decision. After all, go arounds are a long-established procedure for fixing botched landings.
We probably couldn't have done much about the argument between Joe and Alice - but there are things Joe could have done to avoid his fate. It might have been helpful if he'd understood how stressed he was. Sleeplessness, fatigue, and inability to concentrate should have been tip-offs that he shouldn't be flying. Hurrying, leaving checklists undone, and self-pressure to get it on the ground should have sounded alarm bells in Joe's head. The sensible thing to do might have been not to fly at all. But once he was in the air, Joe still had the chance to save himself. He probably would have been OK if he'd decided to go around.
Joe just made too many bad calls that day. He was human, just like us all. His biggest mistake was that he didn't recognize, understand, and account for it. That's a mistake you can avoid.
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