Introduction
Aeronautical decision-making (ADM) is decision-making
in a unique environment—aviation. It is a systematic
approach to the mental process used by pilots to consistently
determine the best course of action in response to a given set
of circumstances. It is what a pilot intends to do based on the
latest information he or she has.
Aeronautical
Decision-Making
Chapter 2
Figure 2-1. The percentage of aviation accidents as they relate to the different phases of flight. Note that the greatest percentage of
accidents take place during a minor percentage of the total flight.
Flight Time
2%
Flight Time
83%
Flight Time
15%
Preflights/
Taxi
Takeoff/
Initial Climb Climb Cruise Descent Maneuvering Approach Landing Other
3.3%
3.5%
23.4%
15.7%
2.6%
13%
9.7%
24.1%
4.7%
Percentage of General Aviation Accidents
The importance of learning and understanding effective
ADM skills cannot be overemphasized. While progress is
continually being made in the advancement of pilot training
methods, aircraft equipment and systems, and services
for pilots, accidents still occur. Despite all the changes in
technology to improve flight safety, one factor remains the
same: the human factor which leads to errors. It is estimated
that approximately 80 percent of all aviation accidents are
related to human factors and the vast majority of these
accidents occur during landing (24.1 percent) and takeoff
(23.4 percent). [Figure 2-1]
ADM is a systematic approach to risk assessment and stress
management. To understand ADM is to also understand
how personal attitudes can influence decision-making and
how those attitudes can be modified to enhance safety in the
flight deck. It is important to understand the factors that cause
humans to make decisions and how the decision-making
process not only works, but can be improved.
This chapter focuses on helping the pilot improve his or
her ADM skills with the goal of mitigating the risk factors
associated with flight. Advisory Circular (AC) 60-22,
“Aeronautical Decision-Making,” provides background
references, definitions, and other pertinent information about
ADM training in the general aviation (GA) environment.
[Figure 2-2]
History of ADM
For over 25 years, the importance of good pilot judgment, or
aeronautical decision-making (ADM), has been recognized
as critical to the safe operation of aircraft, as well as accident
avoidance. The airline industry, motivated by the need to
reduce accidents caused by human factors, developed the first
training programs based on improving ADM. Crew resource
management (CRM) training for flight crews is focused on
the effective use of all available resources: human resources,
hardware, and information supporting ADM to facilitate crew
cooperation and improve decision-making. The goal of all
flight crews is good ADM and the use of CRM is one way
to make good decisions.
Research in this area prompted the Federal Aviation
Administration (FAA) to produce training directed at
improving the decision-making of pilots and led to current
FAA regulations that require that decision-making be taught
as part of the pilot training curriculum. ADM research,
development, and testing culminated in 1987 with the
publication of six manuals oriented to the decision-making
needs of variously rated pilots. These manuals provided
multifaceted materials designed to reduce the number
of decision-related accidents. The effectiveness of these
materials was validated in independent studies where student
pilots received such training in conjunction with the standard
flying curriculum. When tested, the pilots who had received
ADM-training made fewer in-flight errors than those who had
Figure 2-2. Advisory Circular (AC) 60-22, “Aeronautical Decision Making,” carries a wealth of information for the pilot to learn.
not received ADM training. The differences were statistically
significant and ranged from about 10 to 50 percent fewer
judgment errors. In the operational environment, an operator
flying about 400,000 hours annually demonstrated a 54
percent reduction in accident rate after using these materials
for recurrency training.
Contrary to popular opinion, good judgment can be taught.
Tradition held that good judgment was a natural by-product
of experience, but as pilots continued to log accident-free
flight hours, a corresponding increase of good judgment
was assumed. Building upon the foundation of conventional
decision-making, ADM enhances the process to decrease the
probability of human error and increase the probability of a
safe flight. ADM provides a structured, systematic approach
to analyzing changes that occur during a flight and how these
changes might affect the safe outcome of a flight. The ADM
process addresses all aspects of decision-making in the flight
deck and identifies the steps involved in good decision-making.
Steps for good decision-making are:
1. Identifying personal attitudes hazardous to safe flight
2. Learning behavior modification techniques
3. Learning how to recognize and cope with stress
4. Developing risk assessment skills
5. Using all resources
6. Evaluating the effectiveness of one’s ADM skills
Risk Management
The goal of risk management is to proactively identify
safety-related hazards and mitigate the associated risks. Risk
management is an important component of ADM. When a
pilot follows good decision-making practices, the inherent risk
in a flight is reduced or even eliminated. The ability to make
good decisions is based upon direct or indirect experience
and education. The formal risk management decision-making
process involves six steps as shown in Figure 2-3.
Consider automotive seat belt use. In just two decades, seat
belt use has become the norm, placing those who do not
wear seat belts outside the norm, but this group may learn to
wear a seat belt by either direct or indirect experience. For
example, a driver learns through direct experience about the
value of wearing a seat belt when he or she is involved in a car
accident that leads to a personal injury. An indirect learning
experience occurs when a loved one is injured during a car
accident because he or she failed to wear a seat belt.
As you work through the ADM cycle, it is important to
remember the four fundamental principles of risk management.
Figure 2-3. Risk management decision-making process.
Identify
Hazards
Assess
Risks
Analyze
Controls
Make Control
Decisions
Monitor
Results
Use
Controls
START
RISK
MANAGEMENT
PROCESS
1. Accept no unnecessary risk. Flying is not possible
without risk, but unnecessary risk comes without a
corresponding return. If you are flying a new airplane
for the first time, you might determine that the risk
of making that flight in low visibility conditions is
unnecessary.
2. Make risk decisions at the appropriate level. Risk
decisions should be made by the person who can
develop and implement risk controls. Remember
that you are pilot-in-command, so never let anyone
else—not ATC and not your passengers—make risk
decisions for you.
3. Accept risk when benefits outweigh dangers (costs).
In any flying activity, it is necessary to accept some
degree of risk. A day with good weather, for example,
is a much better time to fly an unfamiliar airplane for
the first time than a day with low IFR conditions.
4. Integrate risk management into planning at all levels.
Because risk is an unavoidable part of every flight,
safety requires the use of appropriate and effective risk
management not just in the preflight planning stage,
but in all stages of the flight.
While poor decision-making in everyday life does not always
lead to tragedy, the margin for error in aviation is thin. Since
ADM enhances management of an aeronautical environment,
all pilots should become familiar with and employ ADM.
Crew Resource Management (CRM) and
Single-Pilot Resource Management
While CRM focuses on pilots operating in crew environments,
many of the concepts apply to single-pilot operations. Many
CRM principles have been successfully applied to single-pilot
aircraft and led to the development of Single-Pilot Resource
Management (SRM). SRM is defined as the art and science
of managing all the resources (both on-board the aircraft
and from outside sources) available to a single pilot (prior
to and during flight) to ensure the successful outcome of the
flight. SRM includes the concepts of ADM, risk management
(RM), task management (TM), automation management
(AM), controlled flight into terrain (CFIT) awareness, and
situational awareness (SA). SRM training helps the pilot
maintain situational awareness by managing the automation
and associated aircraft control and navigation tasks. This
enables the pilot to accurately assess and manage risk and
make accurate and timely decisions.
SRM is all about helping pilots learn how to gather
information, analyze it, and make decisions. Although the
flight is coordinated by a single person and not an onboard
flight crew, the use of available resources such as auto-pilot
and air traffic control (ATC) replicates the principles of CRM.
Hazard and Risk
Two defining elements of ADM are hazard and risk. Hazard
is a real or perceived condition, event, or circumstance that a
pilot encounters. When faced with a hazard, the pilot makes
an assessment of that hazard based upon various factors. The
pilot assigns a value to the potential impact of the hazard,
which qualifies the pilot’s assessment of the hazard—risk.
Therefore, risk is an assessment of the single or cumulative
hazard facing a pilot; however, different pilots see hazards
differently. For example, the pilot arrives to preflight and
discovers a small, blunt type nick in the leading edge at the
middle of the aircraft’s prop. Since the aircraft is parked on
the tarmac, the nick was probably caused by another aircraft’s
prop wash blowing some type of debris into the propeller.
The nick is the hazard (a present condition). The risk is prop
fracture if the engine is operated with damage to a prop blade.
The seasoned pilot may see the nick as a low risk. He
realizes this type of nick diffuses stress over a large area, is
located in the strongest portion of the propeller, and based
on experience; he does not expect it to propagate a crack that
can lead to high risk problems. He does not cancel his flight.
Figure 2-4. The five hazardous attitudes identified through past and contemporary study.
The Five Hazardous Attitudes Antidote
Anti-authority: “Don’t tell me.”
This attitude is found in people who do not like anyone telling them what to do. In a
sense, they are saying, “No one can tell me what to do.” They may be resentful of
having someone tell them what to do or may regard rules, regulations, and procedures
as silly or unnecessary. However, it is always your prerogative to question authority
if you feel it is in error.
Impulsivity: “Do it quickly.”
This is the attitude of people who frequently feel the need to do something, anything,
immediately. They do not stop to think about what they are about to do, they do not
select the best alternative, and they do the first thing that comes to mind.
Invulnerability: “It won’t happen to me.”
Many people falsely believe that accidents happen to others, but never to them. They
know accidents can happen, and they know that anyone can be affected. However,
they never really feel or believe that they will be personally involved. Pilots who think
this way are more likely to take chances and increase risk.
Macho: “I can do it.”
Pilots who are always trying to prove that they are better than anyone else think, “I can
do it—I'll show them.” Pilots with this type of attitude will try to prove themselves by
taking risks in order to impress others. While this pattern is thought to be a male
characteristic, women are equally susceptible.
Resignation: “What’s the use?”
Pilots who think, “What’s the use?” do not see themselves as being able to make a
great deal of difference in what happens to them. When things go well, the pilot is apt
to think that it is good luck. When things go badly, the pilot may feel that someone is
out to get them or attribute it to bad luck. The pilot will leave the action to others, for
better or worse. Sometimes, such pilots will even go along with unreasonable requests
just to be a "nice guy."
Follow the rules. They are usually right.
Not so fast. Think first.
It could happen to me.
Taking chances is foolish.
I’m not helpless. I can make a difference.
The inexperienced pilot may see the nick as a high risk factor
because he is unsure of the affect the nick will have on the
operation of the prop, and he has been told that damage to
a prop could cause a catastrophic failure. This assessment
leads him to cancel his flight.
Therefore, elements or factors affecting individuals are
different and profoundly impact decision-making. These
are called human factors and can transcend education,
experience, health, physiological aspects, etc.
Another example of risk assessment was the flight of a
Beechcraft King Air equipped with deicing and anti-icing.
The pilot deliberately flew into moderate to severe icing
conditions while ducking under cloud cover. A prudent pilot
would assess the risk as high and beyond the capabilities of
the aircraft, yet this pilot did the opposite. Why did the pilot
take this action?
Past experience prompted the action. The pilot had
successfully flown into these conditions repeatedly although
the icing conditions were previously forecast 2,000 feet above
the surface. This time, the conditions were forecast from the
surface. Since the pilot was in a hurry and failed to factor
in the difference between the forecast altitudes, he assigned
a low risk to the hazard and took a chance. He and the
passengers died from a poor risk assessment of the situation.
Hazardous Attitudes and Antidotes
Being fit to fly depends on more than just a pilot’s physical
condition and recent experience. For example, attitude
affects the quality of decisions. Attitude is a motivational
predisposition to respond to people, situations, or events in a
given manner. Studies have identified five hazardous attitudes
that can interfere with the ability to make sound decisions
and exercise authority properly: anti-authority, impulsivity,
invulnerability, macho, and resignation. [Figure 2-4]
Hazardous attitudes contribute to poor pilot judgment but
can be effectively counteracted by redirecting the hazardous
attitude so that correct action can be taken. Recognition of
hazardous thoughts is the first step toward neutralizing them.
After recognizing a thought as hazardous, the pilot should
label it as hazardous, then state the corresponding antidote.
Antidotes should be memorized for each of the hazardous
attitudes so they automatically come to mind when needed.
Figure 2-5. This risk matrix can be used for almost any operation
by assigning likelihood and consequence. In the case presented,
the pilot assigned a likelihood of occasional and the severity as
catastrophic. As one can see, this falls in the high risk area.
Catastrophic Critical Marginal Negligible
Improbable
Remote
Occasional
Probable
Risk Assessment Matrix
Likelihood
Severity
Serious LowMedium
Serious
SeriousHigh High
High
Risk
During each flight, the single pilot makes many decisions
under hazardous conditions. To fly safely, the pilot needs
to assess the degree of risk and determine the best course of
action to mitigate the risk.
Assessing Risk
For the single pilot, assessing risk is not as simple as it sounds.
For example, the pilot acts as his or her own quality control
in making decisions. If a fatigued pilot who has flown 16
hours is asked if he or she is too tired to continue flying, the
answer may be “no.” Most pilots are goal oriented and when
asked to accept a flight, there is a tendency to deny personal
limitations while adding weight to issues not germane to the
mission. For example, pilots of helicopter emergency services
(EMS) have been known (more than other groups) to make
flight decisions that add significant weight to the patient’s
welfare. These pilots add weight to intangible factors (the
patient in this case) and fail to appropriately quantify actual
hazards, such as fatigue or weather, when making flight
decisions. The single pilot who has no other crew member
for consultation must wrestle with the intangible factors that
draw one into a hazardous position. Therefore, he or she has
a greater vulnerability than a full crew.
Examining National Transportation Safety Board (NTSB)
reports and other accident research can help a pilot learn to
assess risk more effectively. For example, the accident rate
during night visual flight rules (VFR) decreases by nearly
50 percent once a pilot obtains 100 hours and continues to
decrease until the 1,000 hour level. The data suggest that for
the first 500 hours, pilots flying VFR at night might want to
establish higher personal limitations than are required by the
regulations and, if applicable, apply instrument flying skills
in this environment.
Several risk assessment models are available to assist in the
process of assessing risk. The models, all taking slightly
different approaches, seek a common goal of assessing risk
in an objective manner. The most basic tool is the risk matrix.
[Figure 2-5] It assesses two items: the likelihood of an event
occurring and the consequence of that event.
Likelihood of an Event
Likelihood is nothing more than taking a situation and
determining the probability of its occurrence. It is rated as
probable, occasional, remote, or improbable. For example, a
pilot is flying from point A to point B (50 miles) in marginal
visual flight rules (MVFR) conditions. The likelihood of
encountering potential instrument meteorological conditions
(IMC) is the first question the pilot needs to answer. The
experiences of other pilots, coupled with the forecast, might
cause the pilot to assign “occasional” to determine the
probability of encountering IMC.
The following are guidelines for making assignments.
• Probable—an event will occur several times
• Occasional—an event will probably occur sometime
• Remote—an event is unlikely to occur, but is possible
• Improbable—an event is highly unlikely to occur
Severity of an Event
The next element is the severity or consequence of a pilot’s
action(s). It can relate to injury and/or damage. If the
individual in the example above is not an instrument rated
pilot, what are the consequences of him or her encountering
inadvertent IMC conditions? In this case, because the pilot
is not IFR rated, the consequences are catastrophic. The
following are guidelines for this assignment.
• Catastrophic—results in fatalities, total loss
• Critical—severe injury, major damage
• Marginal—minor injury, minor damage
• Negligible—less than minor injury, less than minor
system damage
Simply connecting the two factors as shown in Figure 2-5
indicates the risk is high and the pilot must either not fly or
fly only after finding ways to mitigate, eliminate, or control
the risk.
Although the matrix in Figure 2-5 provides a general viewpoint
of a generic situation, a more comprehensive program can be
made that is tailored to a pilot’s flying. [Figure 2-6] This
program includes a wide array of aviation-related activities
specific to the pilot and assesses health, fatigue, weather,
RISK ASSESSMENT
Column total
Column total
SLEEP
1. Did not sleep well or less than 8 hours
2. Slept well
2
0
HOW DO YOU FEEL?
1. Have a cold or ill
2. Feel great
3. Feel a bit off
4
0
2
WEATHER AT TERMINATION
1. Greater than 5 miles visibility and 3,000 feet
ceilings
2. At least 3 miles visibility and 1,000 feet ceilings,
but less than 3,000 feet ceilings and 5 miles
visibility
3. IMC conditions
1
3
4
HOW IS THE DAY GOING?
1. Seems like one thing after another (late,
making errors, out of step)
2. Great day
3
0
IS THE FLIGHT
1. Day?
2. Night?
1
3
PLANNING
1. Rush to get off ground
2. No hurry
3. Used charts and computer to assist
4. Used computer program for all planning Yes
No
5. Did you verify weight and balance? Yes
No
6. Did you evaluate performance? Yes
No
7. Do you brief your passangers on the Yes
ground and in flight? No
3
1
0
3
0
0
3
0
3
0
2
Pilot’s Name Flight From To
TOTAL SCORE
0 10 20 30 Not complex flight Exercise caution Area of concern
Endangerment
Low risk
Figure 2-6. Example of a more comprehensive risk assessment program.