AOPA Pilot Magazine - May 2018 - 30

SAFETY SPOTLIGHT

Think you're immune?
Decision-making pitfalls affect everyone

"Why Good Pilots
Make Bad Decisions"
is RICHARD
MCSPADDEN'S 2018
seminar topic. Join
him in the discussion
at AOPA Fly-Ins this
year (www.aopa.
org/fly-ins).

30 | AOPA PILOT May 2018

WHY DO GOOD PILOTS MAKE BAD DECISIONS? Talented,
smart pilots, successful in the airplane and in their
lives-and yet, a lapse in judgment and a poor decision
proved costly. Frequently when I review accidents the
thought occurs to me: If these pilots, some of whom
I admired and respected, could make such a decision,
then I'm not immune, and it would benefit me to understand the dynamics that led to their decisions so I can
learn from them.
Recently, two events made me realize this question
needed more serious and deliberate contemplation.
I read an excerpt from the 2008 book Think Again:
Why Good Leaders Make Bad Decisions and How to
Keep It From Happening to You. The article includes
an interesting explanation about the brain's decisionmaking process. Shortly after reading the article, a
horrific accident came across my news feed. A pilot in
a twin with four family members attempted a takeoff
in near-zero-visibility conditions in fog. The takeoff
ended tragically with the aircraft crashing just after
liftoff and prior to the airport boundary. All on board
perished. The final investigation won't be complete
for some time, but regardless of what the NTSB determines, the decision to depart heavy weight, with four
family members in near-zero-visibility conditions for
a leisurely out-and-back flight is troubling. The flight
was not "necessary." The fog was expected to burn off
later that morning. What leads an experienced pilot
to make a decision to fly under those circumstances,
so fraught with risk?
The Harvard Business Review article may provide
some insight. The authors explain that our brains
aren't naturally inclined to lay out all the options, consider the pros and cons, assess the consequences, and
then make a decision. We're wired to make a quick
assessment based on previous patterns in our memory,
tag it with an emotion, make a decision, and move on.
Some elements associated with this decision process
are problematic in the dynamic and fluid aviation environment. First, patterns can be associated with previous
encounters, despite small differences that significantly
change the situation. Think about a takeoff in near-zerovisibility conditions and all the variables that would
have to be consistent for this pattern to be truly repetitive. Has the pilot executed this kind of takeoff before?
How proficient was he when he did it? How rested was
he? What were field conditions? Was the airplane this

BY RICHARD MCSPADDEN
Executive Director
AOPA Air Safety Institute

heavy? Were there distractions of family and friends
on board? A change in any of these parameters affects
the dynamics of the situation. So while it might appear
to be similar to our brains, it could in fact be a significantly different situation, requiring a modified, or
perhaps an entirely contrary decision.
The second problem with our natural decision-making process in an aviation environment is
emotional tagging. Our emotional attachment is highly
influenced by our own self-interest. This is in part why
"get-home-itis" is a phenomenon in aviation. We can
talk ourselves into a decision because the outcome
serves our self-interest. We also tend to favor advice
from people we like, and we get attached to things such
as our "home field."
Another challenge is our natural inclination to stick
with a decision once it's made, and look for corroborating evidence the decision is a good one. In the face of
significant evidence that we are on a bad path, or that
the situation has changed unfavorably, we tend to find
the morsel of information that confirms our original
decision and heavily overweighs that evidence to stay
the course. I'm thinking of the accidents I've reviewed
where there was plenty of evidence that should have
encouraged the pilot to cancel a flight or divert to an
alternate, yet he continued to tragic results.
Given the limitations of our natural decision-making process in the aviation environment, we must be
especially aware of any challenging situations in which
we find ourselves influenced by the fact that "we've
done this before," or we have an emotional bond to a
person or place in the situation; that we have strong
self-interest in arriving somewhere; or that we seem
to keep discounting adverse information. Our mitigation strategies can include checking our memories
to be sure we have encountered this exact situation
with all of the variables; discussing the situation with
a knowledgeable and trusted colleague; allowing ourselves to consider the full range of options rather than
just variations on the "go decision"; and fully assessing each new piece of information in context of the
entire decision.
Decision making lies at the heart of aviation excellence. Go fly-but before you do, double-check your
decision process and look for warning signs.
AOPA
EMAIL richard.mcspadden@aopa.org

http://www.aopa.org/fly-ins http://www.aopa.org/fly-ins

AOPA Pilot Magazine - May 2018

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