When Goals Get in the Way of Smart Decision-Making
Article appeared in Flying Magazine December, 2015 by Martha King –
“You can’t teach judgment.” “…I’m afraid no amount of ’risk management’ training is going to change your attitude.” These comments were in response to John’s May column “Double Trouble at Denver.” John had revealed our incredible series of risk management failures on a trip in the early 70’s—getting caught in a snowstorm in two separate airplanes with mechanical problems. John then expressed our fond hope that other pilots could learn from our mistakes and practice the habit of risk management.
Then here in the pages of Flying, another columnist opined, “I am rather skeptical about whether risk management (judgment) is something that can be taught and tested…” The readers and the columnist are to be excused. A lot of people confuse risk management with judgment and attitude.
Actually, the practice of risk management, as John and I see it, has two main components. The first is a habit of maintaining situational awareness by systematically thinking about risks. The second is coming up with mitigation strategies for the risks you have thought of. On our trip to Denver John and I clearly failed at both.
Regarding situational awareness, we were in the category of “fat, dumb, and happy.” As we were approaching Denver from the east, the weather was forecast to be good. We didn’t have any concerns.
Suddenly the weather got worse, with abundant snow and ice. We had been caught by the fickle system known as an “upslope condition.” We had never heard of an upslope condition. We were very surprised.
We had, of course, been taught about counterclockwise circulation around lows (in the Northern Hemisphere) and orographic lift. What we had not been taught was where the topside of a low might combine with rising terrain to create orographic lift with copious snow and ice. That “where” is in eastern Colorado.
Many pilots who get into trouble in their flying are, like us, the most surprised people on earth. The problem is that we don’t know what we don’t know. In many cases regarding risk management, we are sent out the door as we leave flight training with, “Y’all be careful, hear?”, but no systematic training on how to identify and mitigate risks.
An ideal way for a learning pilot to develop the habit of maintaining situational awareness is with scenario-based training during which they develop the habit of active risk identification. Much of our aviation knowledge, like counterclockwise flow around a low (in the Northern Hemisphere) and orographic lift, is an abstraction until we apply it in a practical scenario.
A lot of flight instruction is about learning to develop habits like meticulously inspecting our aircraft before taking it into the air, using checklists, fastening seat belts, and many, many more. Risk management is just another one of those habits that, once learned, will serve us well for the rest of our flying.
These habits are often supported with memory aids and sayings like ”GUMP,” ”CIGAR TIPS,” and “Black square–you’re there.” Pilots find them helpful.
Risk management comes with its own memory aids. There’s PAVE for putting risks into the categories of Pilot, Aircraft, enVironment, and External/internal pressures. Plus, there’s C-CARE for Changes, Consequences, Alternatives, Reality, and External/internal pressures.
The cure to the “fat, dumb and happy” status, like John and I were in on the way to Denver, is relatively simple—learn to use habit patterns and tools to help maintain situational awareness and identify risks.
The cure to the risk mitigation component is more complicated. Many pilots are, like John and I previously were, resistant to mitigating the risks.
We’ve all seen pilots who came to grief after continuing in the face of one mounting risk after another. You had to ask, “What were they thinking?” What made them accept risks that, in retrospect at least, were unacceptable to everyone else?
When other pilots see this they tend to call the offending pilot names like “idiot,” “stupid,” “arrogant.” But that response is not an adequate explanation, or helpful in understanding their behavior. The answer, I believe, lies in the last ”E” in both PAVE and C-CARE. It stands for the external and internal pressures that impinge on pilots. Those pressures and how they affect pilots vary with the individual, but they fall into at least two identifiable groups.
The first group is, fortunately, relatively small. It is the Big-Shot/Show-Off/Thrill-Seeker group. They step into risk. Taking risk is a part of the fun of flying for them. This group knows they are taking risks, but are sure they can get away with it.
They think risk-taking makes them look like superior pilots. There is a tendency for these pilots to keep on enjoying risk-taking until they, and their passengers, pay the ultimate price.
A pilot who lost his pilot’s license twice, first for buzzing the Santa Monica Pier and later for illegally selling rides to the public, was eventually killed along with his very unfortunate passenger while attempting to touch his aircraft’s tires on the water to produce a water-skiing effect for a video.
A Baron pilot killed himself and four passengers attempting the aerobatics he saw performed in a Twin-Beech at Sun ‘n Fun. He had attempted to do the same maneuvers on an earlier flight, but a pilot-passenger in the front seat had prevented him.
These show-off pilots see professionals do things and think they can do them too. They fail to understand that the professionals have worked up to a high level after years of very careful training and practice. Plus, professional show pilots are keenly aware of the risks, and see risk mitigation as integral to what they do for a living. The best hope for the show-off/thrill-seeker is for them to realize that to be anything less than equally focused on risk management is a sign of a rank amateur.
The second group potentially includes most pilots including, I believe, John and me in the 70s. We all became pilots because we were willing to take on a very tough challenge over an extended period of time. We studied a body of knowledge and then submitted to a test on it. We learned difficult skills that we weren’t certain, in the beginning, we could master. Nearly every learning pilot says at one time or another, ”You know, I’m not sure I am going to be able to do this.” Then we soloed and took our lives into our own hands thousands of feet above the ground. We persisted, presented ourselves for evaluation, and became certificated pilots.
Flying self-selects people who are willing to do all this. They are good at almost everything they do. They are the movers and shakers of every community they belong to. They are hard-wired to complete what they set out to do. This goal-orientation is a wonderful characteristic in almost all of life, but as a pilot it can be a risk factor. It tends to make us want to keep on going when good risk mitigation says we should change our plan.
An Episcopalian priest who took one of our classes in the 70s was also a physician. He died on a solo cross country after being begged by the FBO to come in to talk before he turned around and flew the second leg in worsening weather. He had to get back in time to give a speech to a large crowd.
A friend of ours who owned a ski resort was leaving the resort in the evening in his Cardinal when he became disoriented and flew back into the ground. He was late for a meeting back in town.
And of course John and I continued into worsening weather to maintain our schedule into Denver. We weren’t courting risk or showing off. We were simply hard-wired to complete what we set out to do, and resistant to anything that reduced the utility of our flying.
Like the show-offs, the goal-oriented pilots know they are taking some risk, but they think they can get away with it and they hate to give up on goals.
After we had our subsequent accident, John and I spent considerable time reflecting on what it was that made us in particular resistant to mitigating risk. As a result, we came to terms with the concept that while in GA we don’t want or need to be as rigid as the airlines, we have to accept reasonable limitations on our utility. We consider our introspection on the subject time well spent. We highly recommend it to anyone who flies.
Defensive driving and defensive flying are similar. Would that we all had such self-awareness before the accident!
Student pilot at age 77.
Your comment sir, made my day. Been losing courage lately, being a student pilot at 43. Thank you
Wait! What? You guys had an accident? I’ve never heard that story. Please incorporate that into a further article.
There are a couple of stories about it. You can read them here – https://johnandmartha.kingschools.com/2014/05/05/accident-2/ and here – https://johnandmartha.kingschools.com/2014/04/03/accident/
I always think about the saying, “There are old pilots and bold pilots, but no old bold pilots”. With the responsibility of this large grouping of metal, screws, oil, gas etc., comes the requirement of integrity. I have to keep that faith and be true to our craft. I have respect for the risks that I am taking every time I go up wether I have 1 or thousands of hours. I want to keep our rituals sacred, religious. So when faced with a risky decision–I already have the answer, I have to evaluate the mitigation or I can choose to just not go, simple as that. (I am an alpha personality and extroverted. The skill is pivoting). I also think of the core parabole of the Lighthouse, a US Navy battleship captain encounters a light ahead that he believes is a ship moving on a collision course. He orders the other ship to move. The response comes back: “This is a lighthouse. It’s your call”. The Critical Lesson: The captain, focused on ego and “authority” (the “battleship”), fails to analyze the situation properly and nearly causes a disaster by refusing to change course.
I appreciate these experiences. My comment is that true, some people will never get it and will get killed. However I do not accept the idea that it can not be taught. It simply is far too small a slice of the curriculum. I think back to some stupid things i did too, and it they were , yes, ” you dont know what you dont know” . If we have a stronger than average fear of death we will go searching on our own by reading about accidents, but attitude can often be taught. It is just not done. All we get are the 5 hazardous attitudes and a single example. It just does not cut it. While we are at it, installing AOA indicators in GA is not going to save one person. Why? because anti- lock brakes have not cut collisions one bit. What is worse is cars that will engage the brakes for you and beep at you if your lane use gets sloppy are never going to accomplish anything except teach the idea that you do not need to pay attention. After working in the auto body shop for 52 years I am qualified to make these statements.
Part of the problem is that the average single seat pilot is also the de facto maintenance controller, dispatcher, copilot, flight manager etc, meaning he has no authoritative resource to bounce ideas off of. Having a system of experienced individuals to discuss options with is valuable yet usually unavailable in these cases.
As a retired corporate pilot and Safety manager in your FIRC I find it refreshing for you two with your experience in the cockpit and training environment to expose your vulnerabilities. With over 18,000 flight hours I have always realized it is not if I make a mistake, but WHEN I make a mistake. The term “Bad news does not get better with time”. I realize that I am a good pilot, so I get ahead of mistakes and have enough confidence to expose my errors and share them with the aviation not only to better my skills in retrospect but prevent others from these error traps hoping to fill some holes in the Swiss cheese model.
Thank You
risk management discussed beautifully, not just acronyms but examples. thanks to John & Martha
Agree with all above comments. Very touchy subject, no one wants to be “reigned in” but we have to be honest with ourselves and that is the toughest of all situations in today’s world.
Any lack of ethics, concern and integrity is a recipe for disasters. Most of us have personally known or witnessed the cowboy pilot, the dare devil, they lack discipline and respect for themselves and those around them. What to do about it is bigger problem and I believe one has to proceed with great caution in dealing with these types.
I like your comment that change is possible….it really needs to be emphasized!
The idea is to incorporate the behavior, not the words.
Every now and again the FAA feels it has to reinvent the wheel. Situational awareness, risk management are the latest. Despite all the hoopla about how much more safer we’ll all be I=f we just incorporate these new words into our pilot speak. But they’re just words, not actions. A careless person or cowboy whether he’s in a car, a boat or a plane. Its a personality characteristic and something that can’t be taught. You can’t learn to be intelligent, You are or you’re not.
Maybe that’s why GA safety stats have remained flat for the last twenty years regardless what
“new” and “improved” programs some new administrator wants to call them.
While it is a good thing for the FAA, head of the flight department, chief pilot, or whoever else to remind us to be safe every so often, sitting down to fill out an SMS form is probably a distraction from looking at weather/NOTAMS, doing a preflight, verifying fuel level and walking the wingtips during pullout immediately after getting the midnight call to take an air ambulance emergency flight to transport a heart attack patient, a burn victim or a guy that’s bleeding to death from a gunshot to the neck. Some of us are already intensely aware of the dangers we face in icing conditions at night, in the snow and mountains with fog, thunderstorms and all kinds of obstacles and closures that may not have made it into the NOTAMS that we only had minutes to check along with weather while running to the airplane, calling the fueler, getting a clearance and a host of other details. You can’t put just anybody in these situations to fly a 20 minute leg, hard IFR, at 2 AM with additional legs after picking up the patient and then expect everyone to live through it. Single pilot is helpful, because there is one less person to keep informed of all the changes happening during each of those minutes, and therefore one less person to keep on track and in the decision making loop at critical, fast moving moments. But I think you are right. Most people just don’t see or anticipate danger and they just don’t get it. They don’t structure their flying or their life as if anything could go wrong. That is bad judgement right there. I once flew with a pilot who told me that he assumes that if something is supposed to work, it will work. Other pilots walk into dangerous situations with the attitude that we can always do (whatever) to escape. So they actually create an emergency situation rather than thinking defensively. A good captain can train a new copilot to think and act defensively and make acceptable decisions within limits, but when a new set of circumstances comes along that he has never seen before, that’s when you find out if he has good judgement.