We’ve all done it at one point or another. We were moving happily and uneventfully along in some process or another and then we accidentally skip a step. We may not realize it right away, but eventually the omission comes to light. With a little luck, the mistake doesn’t cost us much in the way of time or money, but in many cases, the repercussions can be disastrous.
In 1983 a new Air Canada Boeing 767 full of passengers was making its way from Montreal to Edmonton. Cruising along at 41,000 feet the unthinkable happened: low pressure alarms relating to the fuel tanks signaled a problem to the pilots and then the plane’s engines stopped, one after the other. Watch this reenactment for the details of the plane that became known as the “Gimli Glider”:
It is estimated that 75% of all aviation accidents are human factor related. In the case of the Gimli Glider, the computerized Fuel Quantity Information Processor was not working properly so the pilots and ground crew resorted to calculating the fuel needs by hand.
Unfortunately, both pilots and ground crew failed to recognize that they were using the wrong factor in a fuel equation used to determine how much fuel would be needed for the two legs of the flight they were making. The plane was the first to use the newly instituted metric system in its computer systems and everyone was used to the old imperial system. Nobody realized the error.
As with Captain Sullenberger and the fated U.S. Airways Flight 1549, Captain Pearson’s glider experience and the cool and collected reaction of the pilots saved the lives of a plane full of passengers [note to self: get glider training].
The FAA does a lot of work to study accident statistics and implement training programs for pilots to make flying safer. I was rereading some of my training books recently and came across a chapter on something the FAA calls “aeronautical decision making” (ADM). According to the FAA, ADM “is a systematic approach to the mental processes used by airplane pilots to consistently determine the best course of action in response to a given set of circumstances.”
The FAA designed a model, called “DECIDE,” to provide pilots with a framework for effective decision making. This model is useful in any field of activity. Check it out!
Detect the fact that a change has occurred.
Estimate the need to counter or react to the change.
Choose a desirable outcome for the success of the flight.
Identify actions which could successfully control the change.
Do the necessary action to adapt to the change.
Evaluate the effect of the action.
Note that there are several steps before choosing a course of action. Impulsive decision making is often dangerous. Note as well that the process isn’t over when the adjustment is made. It is always worth evaluating actions you’ve taken in response to change. Though you may feel like a worker bee at times, you needn’t resort to acting like a drone.
Most failures are preceded by a chain of poor judgments. Sometimes referred to as the “error chain,” it is not uncommon to see one mistake leading to another, rendering the final outcome far from ideal. The good news is that as with any chain, breaking one link in the chain is normally all that is necessary to change the outcome of a sequence of events.
Making sound decisions is the key to preventing accidents. If you are accident-prone or if you tend to miss steps here and there, take note of the DECIDE model. It may save your life some day!