Signal Charlie

Great article on Aeronautical Decision Making from NAFI:

Teaching Tip
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.

Got a favorite teaching tip that’s worked for you? Share it with us at nafi@eaa.org.

Fly Smart

Kent

NASA ASRS conducted a study for the FAA Office of Runway Safety in 2003 to analyze Airport Surface Movement Event Transgressions (ASMET).

“The identification of an ASMET event was based on the NASA ASRS definition: “The ASRS defines an ASMET as an  incident that involved the erroneous occupation of a runway or its immediate environs by an aircraft, pedestrian or vehicle so as to pose a potential collision hazard to other aircraft that could be using the runway, even if no such other aircraft  were actually present. ASMET events also include erroneous takeoffs or landings on the airport surface.””

2772 events were entered into the NASA database over a 4 year period.  The FAA categorized approx 1000 events during the same period. These ASRS reports represent the part of the iceberg that is underwater, an equally dangerous part that we don’t see.

Take a few minutes to read through the material, the analysts did a great job of breaking out the most common errors at 75 high threat airports. All of these airports had Air Traffic Control towers. What types of events do you think happened at non-towered fields, and were they reported?

ASMET Summary

ASMET Observations

ASMET FY RI Charts

ASMET Data Charts

ASMET Scenarios

My thanks to the reporters and NASA ASRS analysts.

Fly (and Taxi) Smart

Clark

Wednesday January 9, 2008 ATW

US FAA yesterday proposed extending the requirement that the US’s 75 largest airports make enhancements to taxiway centerline markings to all 567 certificated airports as part of its ongoing effort to mitigate the risk of runway incursions.

The agency also is recommending “regular recurrent driver training for all persons with access to the movement area and ramp areas at certificated airports.” Acting Administrator Bobby Sturgell said the nation’s largest airports have heeded FAA’s runway safety “call to action” (ATWOnline, Oct. 23, 2007) and that yesterday’s proposals are intended to extend the safety improvements to smaller facilities.

The 75 largest airports are required to upgrade runway centerline markings by June 30. “Most have already completed the work,” FAA said. Of the 567 certificated airports, more than 300 “are in some stage of voluntarily adopting the standard.” The agency added that 385 airports now “require recurrent training for nonairport employees such as Fixed-Based Operators or airline mechanics” operating vehicles on runways and said such training should be a requirement for all certified airports. Interested parties have until Feb. 26 to comment on yesterday’s proposals.

While FAA touts success in reducing the risk of incursions, the US Government Accountability Office issued a report last month casting doubt on claims of progress, concluding that “the rate of runway incursions has not decreased over the last five years” (ATWOnline, Dec. 6, 2007).

by Aaron Karp

Fly Smart

Clark