Pilot Judgment and Crew Resource Management

Richard S. Jensen

• Éditeur: Routledge
• Année: 2017
• ISBN:
  9781351911115
• Édition: 1
• Sujet: Technik & Maschinenbau
• Sous-sujet: Luftfahrt

This is the first comprehensive book on pilot judgment. It provides a clear understanding of pilot judgment emphasizing how it can be applied to improving safety in aviation. The author brings together a rich store of personal flying experiences combined with a strong base of personal academic research to support the concepts presented. The book gives not only a strong emphasis to the application of judgment to aviation but also lays particular stress on the principles needed in how to learn, teach and evaluate judgment. For pilots, the main benefits to be gained from the book will be a foundation of knowledge and teaching to enable them to make better, safer decisions. For flight instructors, it teaches how to teach and evaluate judgment in flight students. In addition to pilots and flight instructors, the readership obviously includes aviation classroom instructors, scientists doing aviation-related research and aviation safety specialists.

1 Introduction to judgment error

The remarkable thing about people who fly is not that they are so clever; it's that they are so lucky. The clever ones realize it, and even the least perspicacious catch some spark of a hint of their good fortune. It's what keeps them going despite poverty, divorce and bad horoscopes. Sometimes, it keeps them going despite bad weather as well, and that is the dangerous side of the matter: the sirens' song to which few can stop their ears. The most difficult of the pilot's arts is that of knowing when not to fly. It is also the last test of the real pilot; for if flying is cunning and mastery, it is good sense and self-mastery as well. Until a pilot has learned to transcend the faint glory that shines through flight and to subordinate it to his own will, he has still not learned the most essential part of imitating birds: that birds fly because it is natural to do so, because they need to do so, and not because they admire themselves for doing so...Of all the risks that the joy of flight requires, that of falling to the misuse of it is the greatest of all.

Peter Garrison (1972)

The importance of judgment in aviation was made clear to me, when, as a new hire, my boss and I flew a Cessna 205 with a load of passengers from the USA midwest to Colorado for a meeting at the Air Force Academy during the early spring. After landing for fuel in Kansas, we prepared for our final leg to Colorado Springs where the weather was 'Sky obscured, 1/4 mile visibility' and forecast to remain the same for the rest of the day. At my boss's suggestion, we filed for Colorado Springs, with Denver Arapaho (weather, 'clear') as the alternate. During this leg, my boss (flying in the right seat) was on the radio from time to time asking for updates on the weather at Colorado Springs. 'Has anyone landed there today'? 'No', was the reply, 'One Lear tried earlier in the day but missed'. Despite this, he kept asking me to consider going to Colorado Springs. As we approached Denver (we actually could see Arapaho airport.) he said, 'Let's go to Colorado Springs and give it a try'!

I thought about the situation we would face on a mimmums approach into Colorado Springs. I could see him trying to press me (1 was flying in the left seat.) to go 'A little lower' and arguing with me about whether or not we could see anything on the ground while trying to maintain glideslope and localizer approaching 200 feet from the ground! He was making me feel 'chicken'. Fortunately, at this point, my better judgment took over and I said, 'No, we're going to Arapaho'! and I took the radio and asked for clearance and landed at Arapaho airport. He did not say anything the rest of the way and on the return trip I was given a seat in the rear of the plane.

That was not my introduction to pilot judgment. My roots in aviation judgment began on my first 'check ride' with Dirk van Dam, the director of the Moody Institute of Aviation, the only civilian flight school during the 1960s that actually taught pilot judgment. As we departed the 300 foot traffic pattern altitude from Moody Woodale Airport (located within the Chicago O'Hare Airport Traffic Area about where Runway 27L now ends, see Figure 1.1) to intercept the outbound corridor, seeing no inbound traffic, I made my climb out of 300 feet to 500 feet before passing through the inbound corridor. At this point, van Dam said, 'Take it back, you failed because you used poor JUDGMENT'! After a very uncertain landing and rollout to a stop, he gave me a lecture on judgment. He said that I had flown right through the inbound corridor at its designated altitude. I explained that my instructor had told me to check for inbound traffic and, if there was none, to go ahead and climb to 500 feet through the inbound corridor because good judgment says flying at 300 feet above the congested Bensenville residential area is not a good idea. Van Dam said that I should have at least announced my intentions to him and furthermore, he said that he had noticed that I had a bad attitude in general which I did not understand at all. I did not argue further but put it into the back of my mind for later study.

Moody taught judgment to their students because its purpose was to train missionary pilots to fly alone in isolated 'bush' locations around the world. Moody wanted its pilots to graduate with judgment sufficient to face the many difficult choices between medical passenger requirements and runway limitations, between missionary needs and weather conditions, etc. A fairly extensive judgment training program was in place at Moody as a part of normal training and testing for Federal Aviation Administration (FAA) certification. After completing my training at Moody, Dirk van Dam generously provided a statement on judgment training that I included in the appendix to my first FAA pilot judgment study (Jensen and Benel, 1977). I have used exerpts from that statement throughout this book.

From these examples you may begin to believe that judgment may be required of general aviation pilots but is rarely used in the highly standardized world of the airline pilot. This is not the case. Consider the following scenario offered by Fahlgren and Hagdahl (1990):

Figure 1.1 The Moody Woodale Airport from the air in the early 1950s

A DC-9 captain is making an approach to Tromso airport in the most mountainous area of northern Norway. The glide path is steep due to mountain peaks. He has a tailwind. The runway is short and braking action is poor due to snow and ice. His new co-pilot is making his first flight into this area, so the experienced and skilled captain demonstrates how it should be done by calculating everything in detail and making a very precise approach. Due to tailwind and a steep glide path his descent is 1,100 feet per minute when fully established on the ILS at the correct speed.

At 1,000 feet, his co-pilot calls out: 'One thousand feet not stabilized' (their SOP says that descent rate shall be maximum 1,000 feet per minute in the stabilized concept). Below clouds, with field in sight, the captain deliberately leaves the steep glide path knowing that an approach angle of 2.5 to 3 degrees will give the shortest landing distance. This action, in combination with an uphill condition before threshold starts the next warning from the ground proximity warning system: 'Glide path ~ Glide path — Glide Path' and then, 'Rate of descent — Rate of descent -- Rate of descent'.

The captain has made an approach using expert judgment gained during 35 years of flying experience. He has correctly perceived all relevant factors in the situation and expertly used all information. But — his reward is three slaps in the face from a system without a brain. What will be the reaction of the pilot to a system that requires uniformity and standardized procedures and does not appreciate individual expert performance? A system that prescribes rules, and designs technology to make people behave in the same way regardless of the situation. What happens to the ability of the person to create novel solutions still the most important advantage that people have over machines? Does the person fall into blind obedience and complacency rather than use the skills that he or she has gained?

Purposes for this book

My goal in writing this book is not to teach you to make every aviation decision correctly. Instead, it is to make you more aware of and sensitive to the many factors that affect your judgment so that you will improve your chances of making the correct aviation decisions. There is a certain truth to the aviation cliche, 'The superior pilot is one who exercises superior judgment to avoid situations that require superior skill'. Much of what you will learn in this book is aimed at making you sensitive enough to recognize those situations that could be beyond your level of skill and to teach you to have the courage to turn away from those situations in the face of feeling as if you are 'chicken'.

It is my belief that, as pilots are aware or biases that exist in normal human decision making, that awareness is sufficient to reduce those same errors in rational judgment. For example, knowing that our visual/perceptual system will deliver a bias in our perception of distance to the runway depending on the slope of the terrain on the near end, is sufficient to cause a pilot to attempt to control his mental view of the situation and counter the perception given by his or her eyes using other information (e.g. altimeter indications). Accordingly, this book will provide a set of biases in rational cognitive judgment that will enable pilots to compensate for more hazardous biases in difficult decision situations.

During the past 13 years, I have been invited to teach judgment to a variety of aviation audiences in several countries around the world. The audiences have ranged from general aviation pilots, airline pilots, military pilots, Forest Service pilots, balloon pilots, glider pilots and air traffic controllers. Each of these audiences has surprised me with the variety of situations they face involving aviation judgment. The USA FAA for years has required that examiners test pilots for judgment and has suggested that instructors teach it to their flight students. Yet, neither a definition of judgment nor criteria for examining it has been offered in these regulations. More recently, Transport Canada has begun to require judgment training and evaluation for pilots at all levels (Transport Canada, 1992). Other governments are considering such regulations. Accordingly, another purpose of this book is to provide material that judgment and CRM (crew resource management) instructors can use in such courses.

This book is not meant to provide another basic analysis of human decision making including utility theory and many other theories that have been offered in academic texts. Pilot judgment cannot be explained well using such theories anyway. Instead, this book begins with a descriptive approach to decision making and ends with a prescriptive approach to pilot judgment that can make a difference in how pilots make decisions, hopefully to improve safety. Between these two approaches, ideas and models developed in other fields are presented because they advance our understanding of aviation judgment. My method includes an extensive array of my own experiences as a pilot and those of other pilots.

When I first began aviation judgment research, most aviators did not understand what I meant by judgment. After I explained it, few in the FAA (including Pat Russell, the contract monitor) believed anything could be done about it. Today, I occasionally run into an aviator who believes that judgment cannot be taught or evaluated but this is becoming more and more rare. Through a series of experiments in the USA and Canada and through the experiences of flight programs which have used the training concepts as well as the experiences of air carriers and the military with CRM training we now have sufficient proof that judgment and CRM can be taug...