Transcript Pilot Decision Making
Dave Huntzinger PhD, CSP, FRAeS SVP Helicopter Aviation Services
Overview Statistics IHST / EHEST Data Accident Examples Decision Making Theory Pre Departure Risk Assessment SMS and Decision Making Summary
Objectives
Know that… Decision Making is part of the accident chain There are two types of Decision Making theories with different characteristics Pre-flight RAs are excellent DM tool Mission critical decisions can be pre-planned Use RAs as long term metric Know that the RW community is different when it comes to RAs
IHST / EHEST Activities
Goal (by 2016): Reduce accidents worldwide by 80% Method
Analyze
accidents for common causes
Implement
strategies to eliminate same Products Toolkits provided free of charge JHS JHS
A I T
T SMS, Training, Risk Assessment, HFDM, Mx D-V-E DVD Pilot Leaflet (DVE, LTE, Rollover, Vortex Ring State) (www.ihst.org) ( www.easa.europa.eu/essi/ehest)
IHST Data
Study analyzed 523 accidents in 2000, 2001 & 2006 Contributing Factors Pilot Judgment & Actions ……………. 84% Data Issues Safety Management .…………… 73% .…………… 43% Ground Duties Pilot Situation Awareness Part / System Failure Maintenance Mission Risk .…………… 37% .…………… 31% .…………… 28% .…………… 20% .…………… 19%
EHEST Study
Study analyzed 311 accidents in Pilot Judgment & Actions Safety Management Ground Duties Data Issues 2000 ~ 2005 68% 52% 40% 37% Pilot Situation Awareness Mission Risk Part / System Failure Maintenance 34% 28% 22% 14% IHST 84% 43% 37% 73% 31% 19% 28% 20%
Accident # 1
The Aircraft Single pilot, twin engine NVG capable The Pilot Ratings & hours unknown NVG trained The Environment Day VMC then Night IMC
Accident #1
The Flight Pick up hiker from mountain VFR flight plan The Accident Controlled flight into terrain Pilot, hiker killed Spotter survived
Accident #2
The Aircraft Single pilot, twin engine IFR equipped w/ autopilot NVG status unknown The Pilot Commercial, Instrument Helicopter 15+ years in area 8100 hours TPT The Environment Night VFR then Night (2100L) IMC Light Rain, Mist, Fog
Accident #2
The Flight Already offloaded patient Repositioning to base Radar track at 800’ agl The Accident Controlled flight into water Debris path 70’ long by 160’ wide (at 525’ deep) All major components accounted for at site Aircraft broke up Pilot, two flight nurses killed
Accident #3
The Aircraft Single pilot, twin engine IFR equipped w/ autopilot and coupled approach mode NVG capable but not in use, no TAWS The Pilot Commercial, Instrument Helicopter IFR qualified but not proficient 5200 hours TPT The Environment Night VFR then Night (2400L) IMC Fog
Accident #3
The Flight Diverting for weather to offload patient Called Approach for radar vectors to ILS On CL, GS, RoD increased from 500 fpm to 2000+ No level off at either MDA (LOC or ILS) The Accident On centerline 3 nm north of runway Impact 80’ tree, debris path 164’ long All major components accounted for at site Aircraft broke up Pilot, two medics, one patient killed One survivor (patient) (50m)
Accidents Summary
Common elements (in no particular order) Single pilot Instrument rated Aircraft in good working order Weather started out OK, but went down quickly Decision to continue A/C capability not fully used (autopilot) Controlled flight into surface Nearly all killed
Decision Making Theory
Analytical Decision Making Ideal for the following conditions clear goal or outcome plenty of time all conditions, factors are known From this, the decision maker can develop wide range of options evaluate and compare options choose the optimal path
Decision Making Theory
Analytical Methods Example
D
detect the change
E C
estimate choose need to react desirable outcome
I D E
identify do evaluate actions to manage change take action effect on correcting situation Other aviation related analytical methods include IMSAFE, CARE, SADIE, TEAM, PAVE, 5Ps, 3Ss … Do you use these? When? Which one(s)?
Decision Making Theory
Analytical Method Characteristics Structured Time consuming Process breaks down with stress, limited time Analytical Methods Deliberate & thoughtful Better suited to Aircraft design Flight planning Aircraft purchasing
Decision Making Theory
Intuitive Methods Fast Simple Memory based Work with limited information Option chosen probably OK, but not optimal Better suited to real time decision making (flying) and other dynamic, fast paced situations car driving, sports, combat
Decision Making Theory
Naturalistic Decision Making (one intuitive DM process) Used in complex, fast paced situations Key features series of decisions interdependent (one affects the other) conditions constantly changing independently and as result of your action real time decision making (not planning) goals not well defined could be competing goals (safety
vs
…) decision maker is knowledgeable, experienced & professional (Peter Simpson)
Decision Making Theory
Naturalistic Decision Making Not so much a
method
as the way we actually do things…
Step 1:
Problem definition identify
Situation Assessment
problem
(SA)
goal(s) information sources needed to succeed prioritize incoming information disregard (“park”) other stuff Risk assessment severity & probability Time available
Decision Making Theory
Naturalistic Decision Making
Step 2: Course of Action (CoA)
Potential solutions considered (in order of use) rule based one solution; procedure memory based; experience, sim, training choice options; this
or
that will work maybe memory but not always Act creative nothing obvious consider similar situations for solution Simulation mental test of potential solutions and outcomes
Factor
Decision Making Types
Comparison Analytical Naturalistic Goals Pace (speed) Time available Stakes Data Environment Participants Decisions Solution defined slow plenty low complete known many as needed optimal varied fast limited high incomplete changeable few immediate OK
Naturalistic DM Errors
Two basic areas Situation Assessment errors poor understanding of situation poor risk assessment misjudge time available Course of Action errors right rule, wrong time right rule, poor application choose wrong procedure or option In general More information, experience helps recognize the situation & solutions
Naturalistic DM Errors Contributing Factor: Motivations and Rationales
Often competing goals Customer Financial Company Personal Peers Duty Rationales Justify the decision Macho Invincible Impulsive Resignation Anti authority Management must eliminate competing goals educate against rationales => Safety is primary goal => Procedural compliance is key
Decision Making Errors
People tend to..
Under estimate the situation Over estimate their ability
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SMS Basics
“Four Pillars of SMS” Safety Policy Safety Risk Management Safety Assurance Safety Promotion ICAO Doc 9859, 2 nd Edition, 2008 Ref: FAA AC 120-92A
Safety Management Systems
Safety Risk Management Risk Assessment Hazard Identification Methods Mitigation
Safety Management Systems
Safety Risk Management Hazard Identification methods Audits Hazard reports Safety surveys Pre Departure Risk Assessments
Pre Flight Risk Assessment
Many to choose from FAA Vendors Operators Industry groups HAI web site www.rotor.com/FRA Most have the same categories Environment / Wx, Crew / HF, Operation / Flight, Aircraft
SMS
Environment Flight Ops Human Factors Helicopter Directions for use
SMS
RISK ASSESSMENT
Some of this can be done at start of shift 30
SMS
Run checklist for mission + return Tally scores and check risk value
Green
=
Go
But major hazard needs mitigation
SMS
Major hazard Risk value Risk range 31
SMS
Mitigation: Obstacles Take credit on first page - 5 points Risk was 15 Now 10
SMS
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SMS
Mitigation codes Points deducted New risk value
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SMS
Different conditions… Weather is worse… Pilot is less experienced Aircraft less capable Higher risk value Mitigation required What can we fix right now?
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SMS
Mitigation: 1. Obstacles 2. Repair Take credit on first page - 7 points Risk was 30 Now 23
SMS
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SMS
Mitigation details from page 2
SMS
New risk score
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>20 with Mitigation.
Waiver required !
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If conditions get worse, then what?
Pre-approved
A chance to think it through in a no-threat environment
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SMS and Decision Making
Review of DM process… Analytical methods… Ultimate goal in mind (safety) No threats at hand Time is not an issue Can think ahead Consult references, others Review multiple options Select optimum solutions Better suited to the
planning
process, so… Do it
before
flying…
Solutions may be the same on many flights Repeat is OK; it builds DM experience and consensus Experience is key element of good Naturalistic DM (SA & CoA) These serve as the limits or boundaries of what you can do Maybe not a lot of planning time but better than while flying
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Back to our RA… Waiver Approved !
Use as briefing tool for crew Keep RA with other paperwork Time to go flying…
SMS
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Waiver Requested 40
Decision Making
Now you are flying...
Patient is on board Condition is critical and getting worse Flight plan is changing… Weather is getting worse (300’ and 1 nm) Destination hospital is now closed for weather Diverting to new hospital; unknown to you At 90 % limit for fuel burn Points shown here for discussion. We do
NOT
pull out the RA and recalculate 2 > 4 2 > 4 0 > 2 0 > 1 Duty day extended to Back of the Clock Previous total: 23 + 12 = 35 Risk matrix ORANGE band goes RED at 40 20 ~ 39 0 > 5 + 12
Decision Making
Cascading changes things are backing up Conditions deteriorating but still manageable However, fatigue is setting in still have to land, refuel and return you are busy with radio, GPS, fuel planning… not the ideal time to make decisions… But this is
exactly
when a decision is needed (Situation Awareness) You reached your preset limits
Decision Making
What to do? (Course of Action) You are now well into the ORANGE band One more item puts you in the RED… Land?
Land and transfer patient?
Keep going?
Previous RA planning… a) b) weather below FOM minimums LAND !
2 or more conditions changed for the worse LAND !
Coord with ground unit; guide them to you
Decision Making
It is recognized you cannot pre-plan for everything However we know that Real time decisions are hard to get right As conditions get worse, risks increase Recognizing the change (SA) is key, then Execute the well known, pre-planned decision (CoA) Under SMS… We still “Plan the Flight, Fly the Plan” But, we also, under certain circumstances, “Plan to Land, Land to Plan”
Accident #1 NTSB Report
The National Transportation Safety Board determines that the was the probable cause
pilot’s decision
of this accident to take off from a remote, mountainous landing site in dark (moonless), night, windy, instrument meteorological conditions.
Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot’s fatigue, self-induced pressure to conduct the flight, and situational stress.
Decision making Also contributing to the accident were deficiencies in the [operator’s] safety-related policies, including lack of a requirement for a risk assessment at any point during the mission… Competing goals No Risk Assessment
Accidents Revisited
Three fatal CFIT accidents discussed previously… VFR at beginning of flight Then deteriorated to IMC Decision made to continue Could use aircraft automation But, decided to continue visually Using this RA & DM briefing sheet Weather below FOM minimums: Land & Wait (Or, if IFR capable, go IFR)
Fables !
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The Camel
The camel, kneeling, waited patiently for his master to finish loading him. One sack, two sacks, three, four… “When is he going to stop?” the camel said to himself.
Finally, the man clicked his tongue and the camel stood up.
“Let us go,” said the master, pulling on the bridle. But the camel did not move.
“Come on!” cried the man, jerking the rope. But the camel dug in his feet and stayed where he was.
“I see,” said his master, and with a sigh he took two sacks down from the camel’s back.
“That, I think, is a fair weight,” murmured the camel to himself, and at once began to move.
They walked all day at a good speed and the man thought they would be able to reach the village. But, at a certain point the camel stopped.
“Courage,” said the master, “only a few more miles and we are there.” The camel’s only response was to lie down on the ground.
“My legs tell me,” he said to himself, “that we have walked enough for today.” And the man was obliged to unload and to camp beside the camel in the desert.
Fables of Leonardo Da Vinci , Hubbard Press, 1973.
Summary
Decision making errors are real Well known part of accident causation Decision making is a dynamic activity Successful decision making is difficult “on the go” SMS activities can facilitate successful decision making The RA is a good tool for that Works as an excellent crew briefing tool We can modify the way we make decisions Try to make at least some of them in advance if this happens, then I will do that…
(May need separate one for X-country) Consider Morning or Afternoon Modify Modify Different equipment Fire Fighting Morning No night ops No IFR ops Fire base Dip pond Days ON (more days, more points) Longline Bambi bucket (Inspected) 51
Implementation Question
How to get this to (past) the pilots?
More than a box checking exercise… Builds situational assessment Good briefing tool Gives you an (honest) out Defends you if things go wrong Past management?
Long term improvements System wide situational assessment 52
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Closing Comments What to do with all those Risk Assessments?
Risk Assessments NOV 2009 5% 15% Ops Normal Mitigate, Waiver STOP WORK !
80%
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SMS Tips: Safety Assurance
Pre - Departure Risk Assessment
Review
30 days worth 80 in the green 15 in the yellow 05 in the red What caused risky scores?
Are there systemic factors?
Develop corrective, preventive actions
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SMS Tips: Safety Assurance
80 70 60 50 40 30 20 10 0 Jun-09
Risk Assessments Last 6 Months
Jul-09 Aug-09 Sep-09 Oct-09 Nov-09
Ops Normal Waiver, Mitigate STOP WORK
Safety Assurance
This metric shows you are looking ahead at hazards reviewing them for trends tracking efforts at continuous improvement