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Aeronautical Decision Making • Advanced System Design Service Cockpit Resource Management Washington, DC 20591

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Aeronautical Decision Making • Advanced System Design Service Cockpit Resource Management Washington, DC 20591 "" r, r-",'\ f 1 ' t 'f " l ~ I, ' ,:r unr. , '\' ' "\ .. J ;I DOT/FANPM-86/46 Aeronautical Decision Making • Advanced System Design Service Cockpit Resource Management Washington, DC 20591 Richard S. Jensen • Prepared for: it) Systems Control Technology, Inc. o 1611 North Kent Street, Suite 910 N Arlington, Virgir'l 22209 <t I By: C The Ohio State University Research Foundation « Aviation Psychology Laboratory 1314 Kinnear Road Columbus, Ohio 43210 January 1989 Final Report OTIC ELECT:J\ • FEB 2419.... This document is available to the public . through the National Technl,:,.allnformation S U Service, Springfield, Virginia 22161. <\H • .• , ',J'~' .• _ ~ .......... &) U.R. Department of Transportation Federal Aviation Administration r'89' 085 Teehn_1 Report Doc&.mIIntatlon Page -~-~--,------..,..~-=-----=---:-,~---..,.-~~,:",",:",,~-=-~---:,,:------.., 1. Report No. 2. Government Accession No. 3. Recipient's Catalog No. DOTIFAAI"~i-86/46 4. Title and Subtitle 5. Report Date Aeronr.lutical Decision Making ­ January 1989 Cockpit Resource Management 6. Performing Organization Code 7. Author (s) 8. Performing Organization Report No. Richard S. Jensen 9. Perfor. ning Organization Name and Address 10. Work Unit No. (TRAIS) Systems Control Technology, Inc. 1611 North Kent Strqet, Suite 910 11. Contract or Grant No. Arlington, Virginia 22209 DTFA01-80-C-10080 13. '(ype Report and Period Covered • 12. Sponsoring Agency Name and Address U.S. Department of Transportation Final Report Federal Aviation Administration 800 Independence Avenue, S.W. 14. Sponsoring Agency Code • Washington. D.C. 20591 ADS- 220 15. Supplementary Notes AAM-500 Biomedical and Behavioral SCiences Division ADS - 220 Rotorcraft Technology Branch, System Technology Division 16. Abstract ~. Aviation accident data indicate that the majority of aircraft mishaps are due to judgment error. This training manual is part of a project to develop materials and techniques to help improve pilot decision making. Training programs using prototype versions of these materials have demonstrated substantial reductions in pilot error rates. The results of such tests were statistically significant and ranged from approximately 10% to 50% fewer mistakes. This manual is designed to explain the risks associated with flying activities involving multi-erew aircraft, the underlying behavioral causes of typical accidents. and the effects of stress on pilot decision making. The objective of this material is to enhance interpersonal communication and to facilitate effecti'le leadership and coort1il1ation between crewmembers. It provides a sophisticated approach to developing concerted actior. based on optimal decision making. Several Cockpit Resources Management (CRM) principles are presented in the manual; included are delegation of responsibilities. prioritization. vigilance and monitoring, joint dis­ cussi.:m and planning, and receptive leadership techniques. This manual is one of a series on Aeronautical Decision Making (ADM) prepared for the following pilot audiences: • -':.~ (1') Student and Private J (4) Instrument ' (2) Instructor, (5) Helicopter.., ,.• \ , .(3) Instrument! . ") (6) Multi-erew. L( (. ..', ; .c~ j~, v 17. Key Words Crew Coordination / 18. Distribution Statement " Humann Fpactrf°rs/ This document is available to the U.S. public ..-' Aviation Training,.- AHu.mat~on Seafortmance , through the National Technical Information Pilot Error/ VI ley/ . 'on M k·ng· Service, Springfield. Virginia 22161. Judgment! DeCISI a I I' '\ /. Cockpit Resource Momt. Communication ,. ($; ;.'.') . (-----.- -_ ... 19. Security ClassW. (of this"r~rt) 20. Security Classif. (of this page) 21. No. of Pages 22. Price Unclassified Unclassified 190 L......- -------~-~_._~~~--~~o:__~~.~.-.I------..a.----- Form DOT F 1700.7 (8-72) Reproduction ofthis document Is authorized ..... v\Aq./\.-\.. ~ .' \/ l,~ \ "t \.. FOREWORD This aeronautical decision making training manual for cockpit resource management is the third of three reports in the Professional Pilot Series. The first in this series, Aeronautical Decision Making for Instrument Pilots" contains introductory and other judgment material focused on the instrument pilot. The second report in this series, Aeronautical Decision Making for Commercial Pilots, continues where the instrument manual and focus in partlcular, on the judgment problem of the commercial pilot. This third manual in this series focuses on aeronautical decision making for multi-person crews referred to as Cockpit Resour~e Management. This three-part Professional Pilot Series is the second half of a six part • series of manuals on aeronautical decision making which is t~le result of ten years of research, ~.evelopment, testing, and e'..aluation of the effectiveness of teaching pilot decision making. The first half, called the "Basic Pilot Series," consists of three training manuals developed for student, instructor, and helicopter pilots. The material contained in this manual has not been reviewed and tested to the same extent as the prev:ous five ADM manuals of chis series. Consequently, it does not reflect the same level of maturity. However, it is an accurate reflection of the crew resource management efforts currently underway. This manual will serve as a useful introduction for some and a r~view for others. This work has been conducted in parallel with operational reviews by the FAA Office of Flight Standards. We expect that this work will be updated and expanded as new ideas and techniques are developed. The teaching technique used is to expose the student to flight situations and ask for responses. Feedback about the responses is given to help the student learn to make better d~cisions. In all case~, situations are taken from real-world incidents or accidents. That is, all scenarios have actually happened to someone in the aviation community. We have Ilsed these sources because they are more likely to leave a lasting impression than created stories. In other literature, the term "pilot error" is often used to des~ribe an accident cause and is an oversimplifica',ion, implying that the flight crew intended t~ have an accident. Pilots intend to fly safely, but they sometimes • make decisional errors. Their skill or luck is often &ufficient to get them out of situations resulting from poor judgmp.nt. The objective of this manual is to teach multi-pilot crew techniques, including interpersonal communication, to avoid situations that require luck or skill greater than • their capabilities. Good judgment means avoiding situations that require superioc skill to overcome. lr The were a number of people and organizations who contributed their i' material and ideas to this :nanual. The author wishes to thank Major E.H. o Aufderheide, the author of the Air Force manual entitled, Aircrew Coordination o Training: A Military Airlift Command Workshop on Hwnan Resource Management in the Aircraft for significant parts used i~ this manual. The author wishes to express his appreciation to the United Airlines and Captain David Shroyer. formerly with United Airlines, for their generouo support of this effort to I establish a universal CRM evaluation methodology useful throughout the i ,.~. _~ __~_- -------- industry. The author's participation in the SMlfUnited CRM Training Course. observation of United reCUltency training. volumes of reports and data. and many useful phllosoph16,s; and insights were approved and/or provided by Captain Shroyer. The authol' would like to thank KLK and the Crew Management Course instructors. John Costley. Interaction Trainers. LTD. and Alvin Maan Voogd Bergwerf, MATCH. for the opportunity to participate in their most impressive course. John Costly obtained a great deal of additional information for this manual, including data on communication behavior. from both simulator and flight. The author would llke to thank Continental Airlines and the Crew Coordination Concepts instructots. Frank Tullo and Chris Ballin. for the opportunity to participate in their most impressive shorter course. They too provided much additional insight above and beyond the course material itself. • The author would like to thank Bob Mucge for spending time explaining his Cockpit Management Course as wel~ as providing all of the latest material on the course. The author would also like to express my thanks to SimuFlite Training, Inc, for spending a day with me describing their training facility and training philnsophy. The author would like to thank the following additional people and organizations for providing material useful to this investigation: Trans Australia Airlines People Express Qantas Airlines USAir Braniff Airlines \Jorlr~ Airways The Evans Group U.S. Air For<oe Flight Safety Intel"nc"' donal IT. S. Army Finally, the autl 10r wishes to thank the following sources for scenarios. in part, because, until now, they have been responsible for most of our pilot judgment training: "I Learned t\bout Flying from that." .E1:d.D& "Aftermath." lli.!.D& "Never Again," AOPA Pilot "Callback," ASRS "Pilot's Logbook," Private Pilot !\Qproach, U. S. Navy "\..~ampaw Petibone," Naval Aviation News • Flying Safety, U.S. Air Force "A Flight' I'll Never Foq~et," Plane and Pilot "Selection of Judgment Incidents," ASRS • Pilot Erro~, Editors of Flying "Arm Chair Aviator" Weather Flying, Robert Buck Illusions, Richard Bach "The Bush Pilot Syndrome. " Michael MitcDell Various Accident Report Brtefs. NTSB OSU Pilot Judgment Survey Richard S, Jensen ii TABLE OF CONTENTS Chapter 1: BACKGROUND FOR CRM TRAINING
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