Judgement Calls: Avoiding the Seven Deadly Sins of Pilot Decisions

The professional pilot’s worst nightmare is finding him- or herself in a unique aviation emergency or crisis situation, and being forced to take quick, often life-saving action. Such scenarios require excellent decision making capabilities.

Research clearly shows that most accidents fall into two categories, 1) unavoidable and 2) pilot error. Category one includes unavoidable and uncontrollable weather developments or mechanical failures that result in a complete lack of aircraft airworthiness. Category two consists of one factor: poor decision making on the part of the pilot in command. Accidents in the second category may begin with weather and mechanical failure, but the ultimate cause of the accident is how the pilot in command reacts to the situation.

Accident report archives detail hundreds of situations that were impervious to pilot intervention. However, you may be able to recall a handful of incidents where expert handling in the flight deck turned potential disasters into miracles. Was it pure luck that saved the day, or did these pilots possess certain abilities that enabled them to work their way out of an emergency situation? What does it take to become an “expert” or “master” pilot with respect to decision making in crisis situations? Both experience level and psychological factors come into play. Understanding where you fit in is a first step to having good decision skills.

Pilot Types

Pilots fall into four classifications:

Novice pilot: a beginner or student whose decision making is developing and who is completely dependent upon “check list” or linear thinking. This level of pilot is still engaged in committing safety procedures to memory.
Intermediate pilot: has 1-2 years of active experience and is developing decision making skills based on procedures that have already been committed to memory. This pilot is still working with a “check list” type of solution to problems, but the list is active in what is called “working memory.” Access to solutions and procedures in working memory is far quicker for this person than the novice pilot.
Journeyman pilot: a pilot who is known as a “routine expert.” He or she has many years of active experience and training, with 40-80 hours of flight time per month. This pilot has developed an intuitive approach to routine, but not unique, problems. His/her decision making skills are excellent in routine types of emergencies.
Intuitive expert: known as a “master expert or “adaptive expert,” this pilot has more than 10 years of full time experience and training. He or she can rapidly asses situations, has control over psychological factors and can fully intuit multiple solutions to unique or one-of-a-kind problems. The term “intuitive” sounds almost magical, but it is actually based on a type of thought process that short-circuits the type of decision making that is used by the aforementioned classifications of pilots. This is known as list making or “trying out” solutions.

Intuition is an acquired skill. It is the ability to see patterns and solution without having to “think it through.” As stated in AOPA Pilot, “An intuitive pilot is less likely to be surprised—and avoiding surprises is a key to flying well.” There is nothing magical about the ability to “intuit,” and it can be learned. (More about that later.)

Routine accidents result from emergencies that are encountered with great frequency and include factors such as weather and mechanical failures. Examples: loss of one or more instruments; loss of communications; runway incursions; failure of landing gear; oil pressure loss; abrupt change in weather; etc. These are typically thoroughly discussed in flight training, and procedures exist which are well documented and practiced.

Atypical accidents result from emergencies that cannot be prepared for in advance. These are situations that occur where multiple problems exist at once and there is no training or documented procedure for the situation. A good example of this type of atypical scenario is the catastrophic accident that occurred on July 19, 1989 involving a United DC-10. The aircraft experienced loss of the number 2 engine (tail mounted), which resulted in a loss of hydraulic power and rendered the crew unable to operate flight controls. In essence, landing parameters such as speed attitude and vertical velocity could be controlled separately, but it was impossible to control all parameters simultaneously. The flight crew had no training for such a scenario and had to “intuit” the correct procedures. They did, and were credited with saving 185 lives in what the NTSB stated was a performance that was highly commendable and greatly exceeded reasonable expectations.

Routine accidents are typically mishandled by the first two classifications of pilots while journeymen (routine experts) and intuitive experts tend to handle these extremely well. This is due to the journeymen and intuitive experts not falling prey to what are known as the “Seven Deadly Factors.” Novices and intermediate pilots are vulnerable to these factors mostly due to inexperience, but the factors also have a considerable psychological component that can be deadly. The Seven Deadly Factors are:

1. Stress/fatigue
2. Inattentiveness
3. Arrogance in the cockpit—too confident
4. Lack of preparation for emergencies
5. Inability to manage multiple inputs
6. Too much reliance on automation—lack of a personalized sense of accountability
7. Poor aircraft kinetics/communications

These factors appear to be heavily psychologically based and result in pilots being susceptible to accidents. Research shows that pilots involved in an accident have a significantly increased risk of involvement in future crashes and violations. Because a pilot’s decision making behavior is heavily influenced by the Seven Deadly Factors, half of which are psychological and not related to an operational aspect of the flight, it is logical that a safe pilot is a proactive pilot who keeps psychological factors such as stress, inattentiveness, arrogance and fatigue to a minimum.

In atypical or complex accidents where multiple and highly unusual factors make for unique situations, novices, intermediate pilots and journeyman pilots are vulnerable to decision making errors. The first three classifications of pilots are still at the decision making level of “thinking” in a concrete sense. They have to consciously pull out pieces of information from memory and then process this information in a method known as “chunking.” These are types of thought processes such as lists or “if/then” analyses that must be thought through. This takes time and in emergency crisis situations, time is what they do not have. In these situations, intuitive experts are more accurate and safer than other classifications of pilots because of their ability to rapidly organize multiple pieces of information and memories into meaningful units. They don’t have to sort through lists or process ideas in an “if/then” fashion. This is called intuitive thinking. Intuitive thinking facilitates problem solving abilities and allows the intuitive expert to “see” multiple response options simultaneously. Once options are seen, the expert can use this “intuitive integrative” ability to discard options without having to try them out in either an “if/then” thought style format or in actual action. This intuition rapidly narrows the choices of responses and allows the intuitive expert to make rapid, well-fitting choices.

How does this intuition get developed? It appears to be the result of seven characteristics:

1. Low psychological risk factors (as mentioned earlier)
2. Hours of experience (10 years full time)
3. Rapid access to conceptual and procedural knowledge (comes from practice)
4. Quickness and confidence (part personality, part learned)
5. Adaptiveness (can perceive the necessity to alter ingrained procedural knowledge to fit the situation)
6. Personal feelings of accountability which result in less pure “faith” in automation
7. Training in ADM (Aeronautical Decision Making)

Expert pilots have developed the ability to see emergency situations in a “whole” manner. This is known as intuition. They no longer need to break down crises into their component parts and examine each part individually for solutions. This enables them to recognize patterns of information instantaneously without thinking through them in a time consuming manner. This results in a keen, clear analysis of a direct and proper course of action. To reach the level of “intuitive expert” or “master expert” in aviation, you must meet the seven factors given above.

First of all, deal with your personality quirks. Don’t allow an inflated ego or arrogance to cause you to ignore the need to listen and observe in a crisis. Don’t be cocky. Be attentive at all times. If you have a mild attention deficit problem, find an expert in the field of attention deficit disorders and address the issue now. Lower the stress in your life. Lead a balanced life with plenty of time for rest and play. Do relaxation exercises, deep breathing and keep positive thoughts. As much as possible remove irritating and dominating people from your environment. When you cannot remove a relationship that is stressful, get professional help on how to best deal with the person or relationship in an assertive manner. Seek counseling if necessary. Don’t let your ego interfere with recognizing and addressing stress. Don’t think, “I can handle it” and let it keep building. Don’t fly while in a fatigued state. Nothing is so important that you need to fly while groggy or sleep deprived.

Secondly, the novice pilot or intermediate pilot cannot simply jump into the status of “intuitive expert.” It takes hours of practical flying experience to achieve this goal. The more you fly in actual and not simulated situations, the closer you will be to the level of intuitive or master expert. Although long term, real-time practice is necessary, simulator time does help. Practice emergency situations as much as possible in a simulator. The broader the variety of emergency situations you practice, the closer to master you will become. Fly as many types of aircraft as possible in as many simulated emergencies as possible. This will increase your natural access to conceptual or procedural knowledge.

The procedural knowledge must become ingrained in working memory. This takes time. While you are still at the level of attempting to consciously recall procedures, you will struggle with recall, attention, and multitasking. Working memory is the part of your brain that holds and utilizes information without your conscious effort. To ingrain knowledge in the working memory portion of your brain you must treat the knowledge like bits of information being programmed into a computer with a memory glitch. Enter it and reenter it. The more you enter the information, the better it will be “held” in working memory, freeing up your brain’s capacity for decoding the information in patterns that you can intuitively “see” for keen and quick analysis.

Intuitively “seeing” leads to confidence. The more you are assured that you can grasp the details and severity of an emergency situation, the more confident you will become. Don’t confuse self confidence with ego. Ego is an “I can handle anything better than you” attitude. Self confidence comes from knowing you are well trained, attentive and open to input. Self confidence removes self doubt. Self doubt leads to slow response and second guessing of actions. That can be fatal.

The confident pilot who can grasp the nature of the emergency in a clear and instantaneous manner will be able to adapt to the unusual. Emergencies and accidents come in many sizes, shapes and complexities. To be adaptable, you must think outside the procedures list and be able to adapt the procedures when necessary. This comes with time and experience as well as practice. Courses in flexible problem solving and critical thinking are available through counseling services, individual psychologists and universities. Thinking flexibly and being ready for the ever changing situations in a real emergency is a mandatory component of the intuitive expert.

Be accountable. Don’t rely on automation. Use the best computer on the aircraft—your brain. Remember that ultimately, you, the pilot in command, are responsible for the outcome. Relying upon automation to bail you out or to prevent an accident is just bad flying technique.

Take an ADM training course, or three. The more experience you have with aeronautical decision making, the closer to intuitive expert you will become. These courses will verse you in how to remove stress, quickly access your knowledge, adapt your knowledge and be accountable. All of this leads to intuition.

Remember, intuitive expert pilots are those with the greatest ability to face a complex, unique crisis and save lives. They aren’t egotistical, have addressed their psychological issues, know procedures, are adaptive, accountable and have developed intuition. Intuition not only comes from experience but can be learned. The first stop in reaching the goal is to recognize the need to put ego aside and take all the steps necessary to reach the ultimate level of intuitive expert pilot.