On the Nature of Pilot Error

Let’s take a quick look at errors and the decision-making process as seen by people who study the human brain.

When thinking about how pilots make decisions, one of the first things we should look at is the environment within which these decisions are made.

Cramped and noisy, the flight deck can be a terrible place to work.

Like others who work in high-risk environments, pilots often have to make decisions within the context of very challenging conditions, each of which can shape and influence the decision being made.

These conditions can include:

1. Limited time available to solve the problem.
2. Dynamically changing conditions.
3. Conflicting goals.
4. Varying levels of information quality, reliability and ambiguity.
5. Limited outside support.
6. Limited human computational capability.
7. Significant personal consequences for mistakes.

An understanding of the mental processes that pilots use to make real-world decisions can help us to understand the strengths and weaknesses of our thinking.

Don’t dismiss this stuff as purely academic.

It’s easy enough to understand and can help you see the holes in your own decision-making.

Let’s dig in…

When faced with an abnormal event, pilots tend to employ two distinct decision-making processes.

The first process is known as Situation Assessment:

This is the ideal process and when done correctly, includes:

• Defining the problem.
• Assessing the risk that the problem introduces to the operation.
• Assessing the time available to solve the problem.

However, as you may have guessed, this is rarely done in a well thought out, complete fashion which means that things get missed.

This is likely due to the fact that most pilots have never learned a standardised way of achieving these goals, something we’ll address throughout the course.

The truth of the matter is that when assessing a situation, most pilots tend to rely on Situational Recognition techniques rather than the above mentioned Situational Assessment process.

Situational Recognition simply means that a possible solution is retrieved from memory, quickly evaluated, and applied if it is believed to solve the problem.

So if something has worked before, it’s likely that a pilot will try it again.

While this allows for a workable solution to be retrieved quickly, it does come with its own set of drawbacks, such as:

• Because the first plausible pattern is usually chosen, all options are not usually considered.
• Without the consideration of all options, all options cannot be evaluated. This means that better solutions may be missed.
• Less experienced pilots may not have adequate or relevant situational patterns to draw upon.

Options found through situational recognition processes tend to involve the decision-making strategy known as satisficing.

Satisficing refers to the choosing of an option that:

• Works.
• Is more adequate than perfect.
• Is often the minimum satisfactory outcome.

While pattern recognition and satisfying techniques do not always produce the most well-explored decisions, they often strike a good balance between the limited computational capacity of the human brain, and the time available to come up with a solution.

Keep in mind that an aircraft is always moving.

Stopping to think is a luxury that pilots do not always have, especially when things are going wrong.

Once the situation has been assessed, the pilot must choose a Course of Action (COA).

In this second step of the process, pilots invariably use one of two decision options to help them choose the appropriate course of action (COA).

These decision options are:

• Rule-based
• Choice-based

Let’s take a look at each.

A Rule-Based decision is one in which there is a single prescribed action to take in response to a particular condition.

For example, when the aircraft encounters icing conditions, most pilots will immediately turn on the engine anti-ice.

For a rule-based process to work, the pilot must be able to retrieve the appropriate response, often from memory.

In the event that a pilot lacks the required knowledge, the appropriate response is unlikely to be retrieved.

Choice Based decisions are those that offer multiple options with legitimate tradeoffs between them and thus a “choice” must be made.

For example, when selecting an alternate airport, many choices may be available and the understanding of which one is “correct” will depend on the prevailing goals, limitations and conditions of the situation.

For the most part, we can lump pilot decision-making errors into two main types.

The first occurs when a pilot fails to define the problem correctly.

The second is when the pilot manages to define the problem correctly but chooses the wrong course of action.

Let’s take a look at each.

Type 1:

A pilot’s failure to define the problem correctly can occur when relevant cues and clues are misinterpreted, misdiagnosed, mishandled or ignored completely.

This can be caused by a lack of knowledge, awareness, skill or mental capacity.

Risks posed by the problem as well as the time available to solve it can also be misjudged.

The main problem here is that when a problem has not been correctly defined, it’s highly likely that the wrong problem is being solved!

Type 2:

In the second type of decision-making error, the problem is correctly defined but the pilot chooses the wrong course of action.

There are three main causes of this error type:

The first is when a pilot fails to retrieve the appropriate option from memory.

This is often due to a lack of knowledge, but can also be due to a pilot being overwhelmed with the situation and thus unable to think clearly.

The second occurs when a pilot considers only one option when multiple options exist.

While this is also most often due to a lack of knowledge, it can also be the result of inexperience and limited patterns available for recognition.

The third cause arises when the pilot fails to consider the possible outcomes of different options.

This type of error is caused by a failure to adequately or correctly mentally project the consequences of a course of action into the future.

Diverting, without proper consideration of the fuel penalties incurred due to a system failure, could be one obvious example of this.

Experience, Information and Mental Simulation are all important tools in a pilot’s decision -making toolbox.

Let’s see how each can impact the quality of our decision-making ability.

Experience:

A lack of experience creates a lack of knowledge.

This lack of knowledge can result in a pilot not being able to create the correct representation of the problem or situation.

Without a correct understanding of the problem, pilots end up solving the wrong one.

Information:

A lack of information is quite obviously a knowledge problem.

There are several reasons why a crew might be lacking in information.

For example, things that should be known and understood may not be.

In other cases, information that could help the crew reach a better decision might be unobtainable inflight as lines of support are often limited.

In addition, information received by the crew can be vague, incomplete, misleading or conflicting.

Inadequate Mental Simulation:

Inadequate Mental Simulation refers to the failure of a pilot to mentally project the current situation into the future. Mental projection is important as it can help a pilot gain a more complete understanding of a particular course of action, its possible outcomes, and its overall suitability.

We’ve already seen that errors can occur when pilots:

• Don’t possess the required knowledge.
• Don’t have the flexibility of thought to see and consider other options.
• Don’t have the mental capacity to consider possible outcomes.

The good news is that Checkmate has been designed to ensure your ability to make better in-flight decisions by addressing all three of these important areas.

1. Checkmate focuses your information gathering process so that you are in possession of the knowledge that’s vital to making safe, sensible and timely inflight decisions.
2. Because Checkmate gives you a complete template to work your way through any emergency, you always know where you are in the process. This frees up mental capacity which allows your thinking to be more flexible, which in turn helps you to consider more options and mentally project their consequences.
3. Since Checkmate is based on sound airmanship principles, industry best practice and Airbus SOP, you are learning the experience patterns of the very best aviators on the planet.

In our next section, we’ll begin to look at the stuff you need in any emergency.