Crew Resources Management • Lecture 4: • Cognitive Skills: • Decision Making
Learning Outcomes • At the end of this lecture, student should be able to: • Realize the importance of good decision making process especially in the flight. • Acquire the skills in decision making process. • Understand the impact of good/bad decision making.
Outline for the Presentation • CRM skills (review) • Introduction • Factors influence the Decision Making • Factors of poor Decision making • Factors promote good Decision Making • Decision Making Process • Case Study • Successful Decision Making • Conclusion
Cognitive and Interpersonal Skills Cognitive Skills • Situational Awareness • Decision Making Interpersonal Skills • Communications • Teamwork 4
Major Causes of Human Error in Aircraft Accidents Lack of Situational Awareness Poor Decision Making Lack of Communication Lack of Teamwork Lack of Resources Lack of Knowledge Lack of Assertiveness Distraction Pressure & Stress Crew Fatigue
What is your Decision ? Introduction
Decision Making Every time, we faced to a condition so that we have to make a decision: In the morning, when the bell ringing, . . . Wake up or not . .?
What is DECISION MAKING? The ability to use logical and sound judgment to make decisions based on available information.
What is DECISION MAKING? • An understanding of decision-making process provides a flight crew with a foundation for developing decision-making skills. • Some situations, such as engine failures, require a flight crew to respond immediately using established procedures with little time for detailed analysis. • Typically during flight, there is a little time to examine any changes occur (problem), gather information, and assess risk before reaching a decision.
The Dominant factors influence human decision making • Perception /Situational awareness • Stress • Human cultural
WHAT CAUSES ACCIDENTS? • From the study, approximately 80 percent of all air crashes caused by human error. the NTSB (National Transportation Safety Board)further breaks down human errors into the following categories: NTSB HUMAN ERROR CHART
Factors that lead to Poor Decision Making • What’s are the factors lead to poor decision making?: • Initiating flights under poor conditions. (ex: heavy fog) • Continuing flights in worst conditions. (ex: fire catch in the cabin, unpressurized aircraft) • Operating aircraft beyond their limits. (ex: No adequate fuels, flying outside the envelope) • Operating an un-airworthy aircraft.
Factors which promote good Decision Making • Teamwork • Extra time to make decision • Alert crew members • Decision strategies and experience
Example when the decision making takes place: Situation 1 • Time is late and the captain is in a hurry to take-off. But the runway visibility is poor due to fog. DECISION? Situation 2 • Low oil pressure reading indicate that the engine is about to fail. DECISION?
Cont. Situation 3 • The pilot recognize there is insufficient fuel to reach the destination. DECISION? Situation 4 • The aircraft is flying to towards a thunderstorm and the co-pilot see a big re dot in aircraft weather radar. But, captain don’t want to avoid the thunderstorm. DECISION?
Ans.: Use DECISION MAKING PROCESS Every problems needs good decision. How you would create decisions in order to overcome problems?
Decision Making Process What needs to be corrected? What resources do you have? Evaluate decision
Begins with good SA • SA is an important factor in preventing accidents as it encompasses all available information. • Define the problem correctly. • Evaluate Situation: Evaluate the need to react to it and determine the actions that may be taken to resolve the situation in the time available. • Gather all available information. What resources do you have? • Identify all possible solutions. How can the resources be best used? • Consider consequences of all possible actions. Choose best solution. • Make a decision, informs all. Act on decision. Evaluate the results of the decision.
1. Good Situational Awareness • Situational awareness is the accurate perception of the operational and environmental factors that affect safety of the flight. • Maintaining SA requires an understanding of the relative significance of these factors and their future impact on the flight. For examples: • Status of aircraft system • Status of flight crew and passenger • Environmental condition.
2. Define the Problems Correctly • Problem definition is the first step in the decision making process. • Recognizing that a change has occurred (problem) or that an expected change did not occur. • How to recognize the problem?
2. Define the Problems Correctly • How to recognize the problem? • A problem is perceived first by the senses, and then distinguished through insight (deep perception) and experience. • An objective analysis of all available information that use to determine the exact nature and severity of the problem.
Cont. • INCORRECT DEFINING THE PROBLEM can lead to the error in decision making. (Example: a low oil pressure reading could indicate that the engine is about to fail and an emergency landing should be planned or it could mean that the oil pressure sensor has failed.) • The problem that does not exist can divert attention from important tasks. • So, once initial assumption is made regarding the problem, other sources must be used to verify that the conclusion is correct.
3. Evaluate Situations • Evaluate the need to react to the identified/defined problem. • Determine the actions that may be taken to resolve the situations.
4. Gather all information and available Resources • A flight crew must become aware of the resources found both inside and outside the cockpit. • Resources must be identified first. • Evaluate whether there is time to use a particular resource and the impactthat its use will have upon the safety of the flight. • For example, the assistance of air traffic control (ATC) may be very useful if a flight crew become lost. However, in an emergency situation when action needs to be taken quickly, time may not be available to contact ATC immediately.
5. Identify all possible solution • In depth understanding of all the equipment and systems in the airplane is necessary to fully utilize all resources. • For example, advanced navigation and autopilot systems are valuable resources. However, if flight crews do not fully understand how to use this equipment, or they rely on it so much it can become harm to safe flight.
Cont. • Examples of available resources that can used: • Equipment • E.g. Autopilot system, navigation system and other cockpit instruments. • Checklist • Essential cockpit resources for verifying that the airplane instruments and systems are checked, set, operating properly, and proper procedures are performed if there is a system malfunction or in-flight emergency.
Cont. • Flight Manual • E.g.: Airplane Flight Manual (AFM) and Flight crew’s Operating Handbook (POH) • Essential for accurate flight planning and for resolving in-flight malfunction. • Passengers • Help watch the traffic • Provide information of irregular situation • Flight Crew • Provide information of irregular situation to the captain. • Provide the status of passenger.
Cont. • ATC and flight service specialist • Greatest external resources during flight. • ATC can help decrease flight crew workload by providing traffic advisories, radar vectors, and assistance in emergency situations. • Flight service stations can provide updates on weather, answer questions about airport conditions, and may offer direction-finding assistance.
6. Consider consequences • The consequence of all possible action should be considered and the risks assessed before deciding on a response to the situation. • The expected outcome of each possible action must be considered along with the an assessment of the risk involved.
Cont. • For example, the flight crew determines there is insufficient fuel to reach the destination, and considers other options, such as turning around and landing at a nearby airport that has been passed, diverting off course, or landing prior to the destination at an airport on the route. After studying aeronautical chart, the flight crew concludes that there is an airport that has fuelling services within the remaining fuel range along the route. The time expended for the extra fuel stop is a worthwhile investment to ensure a safe completion of the flight. An aeronautical chart is a map designed to assist in navigation of aircraft,
7. Make Decision and evaluate • It is important to think ahead and determine how the decision could affect other phases of the flight. • Flight crew must continue to evaluate the outcome of the decision to ensure that it is producing the desired result.
Cont. • For example, to implement the decision, the flight crew determines the necessary course changes and calculates a new estimated time of arrival, as well as contacts the nearest flight service station to improve the flight plan and check weather conditions at the fuel stop. Proceeding to the airport, continue to monitor the groundspeed, fuel status, and the weather conditions to ensure that no additional steps need to be taken to guarantee the safety of the flight.
Case Study • 1980, Lockheed Tri-Star Riyadh to Jeddah. • Safe landing but all 301 persons died. WHY?
Synopsis • The flight experienced a fire in the aft cargo compartment 6 minutes after taking off from Riyadh. • The plane returned to the airport and landed but because of a delay in evacuating the plane, all aboard were killed by smoke and fire. • Half a minute before landing the captain decided not to order an emergency evacuation. • When he landed, he did not stop immediately but instead proceeded to make a normal landing delaying the fire equipment from putting out the fire. • It took a full twenty-three minutes after touchdown before the doors were opened. • Although the plane landed safely, all 301 aboard died before rescue crews could reach them.
Conclusion • Remember!!: • Don’t overlook the basic airman tasks at hand while addressing other priorities. • Good decisionsminimize errors, while poor decisions increase them. • Each decision affects your future options • Poor decision making is a leading cause of failure to complete missions and of mishaps
Poor Decision Making • Don’t overlook the basic airman tasks at hand while addressing other priorities. The aircraft experienced a landing gear problem while on approach to runway 28R at Portland International Airport. The aircraft ran out of fuel while the crew circled in an attempt to remedy the problem.
Good Decision Making • Although the aircraft crashed, the crew managed to land on a runway saving 187 of 298. The CRM & Decision Making utilized by the crew is professionalism in aviation. A United Air Lines DC-10 crashed at Sioux City, Iowa after an engine explosion caused the total loss of all hydraulics at FL370. The crew was able to control the plane only with engine throttle settings. Miraculously, 187 of 298 aboard survived. (July 19, 1989)
Successful Decision Making • Successful decision making requires a pilot to evaluate an entire range of possible responses to the detected changeand determine the best course of action. • Use all available informationfrom human and hardware sources in identifying potential or real problems. • Always evaluate and crosscheck the available informationin the operational environment to support or re-evaluate your actions.