Pilot Decision Making & SMS

1. Pilot Decision Making&SMS Dave Huntzinger PhD, CSP, FRAeS SVP Helicopter Aviation Services

2. Overview Statistics IHST / EHEST Data Accident Examples Decision Making Theory Pre Departure Risk Assessment SMS and Decision Making Summary

3. Objectives Know that… Decision Making is part of the accident chain There are two types of Decision Making theories with different characteristics Pre-flight RAs are excellent DM tool Mission critical decisions can be pre-planned Use RAs as long term metric Know that the RW community is different when it comes to RAs

4. IHST / EHEST Activities Goal (by 2016): Reduce accidents worldwide by 80% Method Analyze accidents for common causes JHSAT Implement strategies to eliminate same JHSI T Products Toolkits provided free of charge SMS, Training, Risk Assessment, HFDM, Mx D-V-E DVD Pilot Leaflet (DVE, LTE, Rollover, Vortex Ring State) (www.ihst.org) (www.easa.europa.eu/essi/ehest)

5. IHST Data Study analyzed 523 accidents in 2000, 2001 & 2006 Contributing Factors Pilot Judgment & Actions ……………. 84% Data Issues .…………… 73% Safety Management .…………… 43% Ground Duties .…………… 37% Pilot Situation Awareness .…………… 31% Part / System Failure .…………… 28% Maintenance .…………… 20% Mission Risk .…………… 19%

6. EHEST Study Study analyzed 311 accidents in 2000 ~ 2005 IHST Pilot Judgment & Actions 68% 84% Safety Management 52% 43% Ground Duties 40% 37% Data Issues 37% 73% Pilot Situation Awareness 34% 31% Mission Risk 28% 19% Part / System Failure 22% 28% Maintenance 14% 20%

7. Accident # 1 The Aircraft Single pilot, twin engine NVG capable The Pilot Ratings & hours unknown NVG trained The Environment Day VMC then Night IMC

8. Accident #1 The Flight Pick up hiker from mountain VFR flight plan The Accident Controlled flight into terrain Pilot, hiker killed Spotter survived

9. Accident #2 The Aircraft Single pilot, twin engine IFR equipped w/ autopilot NVG status unknown The Pilot Commercial, Instrument Helicopter 15+ years in area 8100 hours TPT The Environment Night VFR then Night (2100L) IMC Light Rain, Mist, Fog

10. Accident #2 The Flight Already offloaded patient Repositioning to base Radar track at 800’ agl The Accident Controlled flight into water Debris path 70’ long by 160’ wide (at 525’ deep) All major components accounted for at site Aircraft broke up Pilot, two flight nurses killed

11. Accident #3 The Aircraft Single pilot, twin engine IFR equipped w/ autopilot and coupled approach mode NVG capable but not in use, no TAWS The Pilot Commercial, Instrument Helicopter IFR qualified but not proficient 5200 hours TPT The Environment Night VFR then Night (2400L) IMC Fog

12. Accident #3 The Flight Diverting for weather to offload patient Called Approach for radar vectors to ILS On CL, GS, RoD increased from 500 fpm to 2000+ No level off at either MDA (LOC or ILS) The Accident On centerline 3 nm north of runway Impact 80’ tree, debris path 164’ long (50m) All major components accounted for at site Aircraft broke up Pilot, two medics, one patient killed One survivor (patient)

13. Accidents Summary Common elements (in no particular order) Single pilot Instrument rated Aircraft in good working order Weather started out OK, but went down quickly Decision to continue A/C capability not fully used (autopilot) Controlled flight into surface Nearly all killed

14. Decision Making Theory Analytical Decision Making Ideal for the following conditions clear goal or outcome plenty of time all conditions, factors are known From this, the decision maker can develop wide range of options evaluate and compare options choose the optimal path

15. Decision Making Theory Analytical Methods Example D detect the change E estimate need to react C choose desirable outcome I identify actions to manage change D do take action E evaluate effect on correcting situation Other aviation related analytical methods include IMSAFE, CARE, SADIE, TEAM, PAVE, 5Ps, 3Ss… Do you use these? When? Which one(s)?

16. Decision Making Theory Analytical Method Characteristics Structured Time consuming Process breaks down with stress, limited time Analytical Methods Deliberate & thoughtful Better suited to Aircraft design Flight planning Aircraft purchasing

17. Decision Making Theory Intuitive Methods Fast Simple Memory based Work with limited information Option chosen probably OK, but not optimal Better suited to real time decision making (flying) and other dynamic, fast paced situations car driving, sports, combat

18. Decision Making Theory Naturalistic Decision Making (one intuitive DM process) Used in complex, fast paced situations Key features series of decisions interdependent (one affects the other) conditions constantly changing independently and as result of your action real time decision making (not planning) goals not well defined could be competing goals (safety vs …) decision maker is knowledgeable, experienced & professional (Peter Simpson)

19. Decision Making Theory Naturalistic Decision Making Not so much a method as the way we actually do things… Step 1: Situation Assessment (SA) Problem definition identify problem goal(s) information sources needed to succeed prioritize incoming information disregard (“park”) other stuff Risk assessment severity & probability Time available

20. Decision Making Theory Naturalistic Decision Making Step 2: Course of Action (CoA) Potential solutions considered (in order of use) rule based one solution; procedure memory based; experience, sim, training choice options; this or that will work maybe memory but not always creative nothing obvious consider similar situations for solution Simulation mental test of potential solutions and outcomes Act

21. Decision Making Types Comparison FactorAnalyticalNaturalistic Goals definedvaried Pace (speed) slowfast Time availableplentylimited Stakeslowhigh Datacompleteincomplete Environmentknown changeable Participantsmanyfew Decisionsas neededimmediate SolutionoptimalOK

22. Naturalistic DM Errors Two basic areas Situation Assessment errors poor understanding of situation poor risk assessment misjudge time available Course of Action errors right rule, wrong time right rule, poor application choose wrong procedure or option In general More information, experience helps recognize the situation & solutions

23. Naturalistic DM Errors Contributing Factor: Motivations and Rationales Rationales Justify the decision Macho Invincible Impulsive Resignation Anti authority Often competing goals Customer Financial Company Personal Peers Duty Management must eliminate competing goals educate against rationales => Safety is primary goal => Procedural compliance is key

24. Decision Making Errors People tend to.. Under estimate the situation Over estimate their ability

26. “Four Pillars of SMS” Safety Policy Safety Risk Management Safety Assurance Safety Promotion ICAO Doc 9859, 2nd Edition, 2008 Ref: FAA AC 120-92A SMS Basics 26

27. Safety Management Systems Safety Risk Management Risk Assessment Hazard Identification Methods Mitigation

28. Safety Management Systems Safety Risk Management Hazard Identification methods Audits Hazard reports Safety surveys Pre Departure Risk Assessments

29. Pre Flight Risk Assessment Many to choose from FAA Vendors Operators Industry groups HAI web site www.rotor.com/FRA Most have the same categories Environment / Wx, Crew / HF, Operation / Flight, Aircraft

30. SMS SMS Environment RISK ASSESSMENT Flight Ops Some of this can be done at start of shift Human Factors Helicopter Directions for use

31. SMS SMS Major hazard Run checklist for mission + return Tally scores and check risk value Risk value Green = Go Risk range But major hazard needs mitigation

32. SMS SMS Mitigation: Obstacles Take credit on first page - 5 points Risk was 15 Now 10

33. SMS Mitigation codes Points deducted New risk value

34. SMS Different conditions… Mitigation required Weather is worse… What can we fix right now? Pilot is less experienced Aircraft less capable Higher risk value

35. SMS SMS Mitigation: 1. Obstacles 2. Repair Take credit on first page - 7 points Risk was 30 Now 23

36. SMS SMS Mitigation details from page 2 >20 with Mitigation. Waiver required ! New risk score

37. SMS Final step on RA If conditions get worse, then what? Pre-approved A chance to think it through in a no-threat environment

38. SMS and Decision Making Review of DM process… Analytical methods… Ultimate goal in mind (safety) No threats at hand Time is not an issue Can think ahead Consult references, others Review multiple options Select optimum solutions Better suited to the planning process, so… Do it before flying…

39. Solutions may be the same on many flights Repeat is OK; it builds DM experience and consensus Experience is key element of good Naturalistic DM (SA & CoA) These serve as the limits or boundaries of what you can do Maybe not a lot of planning time but better than while flying

40. SMS Back to our RA… Waiver Approved ! Use as briefing tool for crew Waiver Requested Keep RA with other paperwork Time to go flying…

41. Points shown here for discussion. We do NOT pull out the RA and recalculate Decision Making Now you are flying... Patient is on board Condition is critical and getting worse Flight plan is changing… Weather is getting worse (300’ and 1 nm) 2 > 4 Destination hospital is now closed for weather 2 > 4 Diverting to new hospital; unknown to you 0 > 2 At 90 % limit for fuel burn 0 > 1 Duty day extended to Back of the Clock 0 > 5 Previous total: 23 + 12 = 35 + 12 Risk matrix ORANGE band 20 ~ 39 goes REDat40

42. Decision Making Cascading changes things are backing up Conditions deteriorating but still manageable However, fatigue is setting in still have to land, refuel and return you are busy with radio, GPS, fuel planning… not the ideal time to make decisions… But this is exactly when a decision is needed (Situation Awareness) You reached your preset limits

43. Decision Making What to do? (Course of Action) You are now well into the ORANGE band One more item puts you in the RED… Land? Land and transfer patient? Keep going? Previous RA planning… a) weather below FOM minimums LAND ! b) 2 or more conditions changed for the worse LAND ! Coord with ground unit; guide them to you

44. Decision Making It is recognized you cannot pre-plan for everything However we know that Real time decisions are hard to get right As conditions get worse, risks increase Recognizing the change (SA) is key, then Execute the well known, pre-planned decision (CoA) Under SMS… We still “Plan the Flight, Fly the Plan” But, we also, under certain circumstances, “Plan to Land, Land to Plan”

45. Accident #1 NTSB Report The National Transportation Safety Board determines that theprobable causeof this accident wasthepilot’s decisionto take off from a remote, mountainous landing site in dark (moonless), night, windy, instrument meteorological conditions. Contributing to the accident were an organizational culture that prioritized mission execution over aviation safety and the pilot’s fatigue, self-induced pressure to conduct the flight, and situational stress. Decision making Also contributing to the accident were deficiencies in the [operator’s] safety-related policies, including lack of a requirement for a risk assessment at any point during the mission… Competing goals No Risk Assessment

46. Accidents Revisited Three fatal CFIT accidents discussed previously… VFR at beginning of flight Then deteriorated to IMC Decision made to continue Could use aircraft automation But, decided to continue visually Using this RA & DM briefing sheet Weather below FOM minimums: Land & Wait (Or, if IFR capable, go IFR)

47. Fables !

48. The Camel The camel, kneeling, waited patiently for his master to finish loading him. One sack, two sacks, three, four… “When is he going to stop?” the camel said to himself. Finally, the man clicked his tongue and the camel stood up. “Let us go,” said the master, pulling on the bridle. But the camel did not move. “Come on!” cried the man, jerking the rope. But the camel dug in his feet and stayed where he was. “I see,” said his master, and with a sigh he took two sacks down from the camel’s back.

49. “That, I think, is a fair weight,” murmured the camel to himself, and at once began to move. They walked all day at a good speed and the man thought they would be able to reach the village. But, at a certain point the camel stopped. “Courage,” said the master, “only a few more miles and we are there.” The camel’s only response was to lie down on the ground. “My legs tell me,” he said to himself, “that we have walked enough for today.” And the man was obliged to unload and to camp beside the camel in the desert. Fables of Leonardo Da Vinci, Hubbard Press, 1973.

50. Summary Decision making errors are real Well known part of accident causation Decision making is a dynamic activity Successful decision making is difficult “on the go” SMS activities can facilitate successful decision making The RA is a good tool for that Works as an excellent crew briefing tool We can modify the way we make decisions Try to make at least some of them in advance if this happens, then I will do that…