Written by Charlie Marais on Monday, 26 September 2011 07:00.


As discussed in the previous paragraphs, in order to make good solid decisions one needs to be well developed in the various fields of knowledge, skills and attitude.  The one part that seems to be a bit unfair, the human design part, is where understanding of human functioning, especially under trying circumstances, needs understanding.  We need to understand the potential shortcomings so as to equip us with an early warning system to proceed with caution.


It is clear that we can do something about our present situation of human related accidents.  We should remind ourselves that many technical problems also start with normal human oversight that could be addressed through the same training programs developed for flight crews.  Any person that forms part of a crew to perform their duty should be involved.  Single crew operations also need to be addressed in the training programs as they also have to communicate with other services and thus form a detached crew to complete an operation safely.  They are also team players.

Knowledge is power.  Knowing how to equip oneself for the ultimate test is something valuable only when action is brought to this concept.  The following areas are identified as areas that need attention in the most practical possible way:

  • Knowledge.  We can expand the knowledge base of our crews, or at least ensure that our crews have complete knowledge of their operational environment.  The 6% of accidents found in the research is avoidable and as a contributing factor to the causation of accidents needs our attention.  Knowledge must be expanded as an ongoing process through:
    • Continual Learning.  You need to know more about your environment as covered through the five M’s.  It is said that you stop learning when you die and you die when you stop learning.
    • Exposure.  The “real thing” is more valuable than any simulation.  We cannot force this kind of exposure, but to operate in tough conditions gives first hand knowledge.  There are tougher routes to fly.  We must expose our crews, under supervision, to all the situations we possibly can without risking the operation.
    • Simulation.  The dynamics of an adverse condition is something to be understood.  It is not just the problem facing you, but the total package.  Studies have shown that problems are normally ill-structured and a single cause could have multiple negative results to consider.  Defining the problem still stays the main concern.  Should one be able to define the problem perfectly, its complexity would immediately reduce.
    • Testing.  Knowledge on such items as letdown plates and approach procedures also need testing.  Technical knowledge and knowledge of the mission needs to be tested from time to time and in a structured way.
  • Skills.  The accident rate of 20% due to skills shortage is something unacceptable in our modern flight environment.  Although we pay a lot of attention to motorised skills, we still need a lot of advancement in the cognitive environment.  We must teach our crews to think, to become innovative and to be able to contain stress to such a level where thinking is still possible.  We must teach our students to pick up the tell-tale signs of when things are starting to go wrong.  The anomalies must trigger cautious behaviour.  In the area of skills, the following should be addressed:
    • Simulation.  Simulation of ill-structured situations the crew might face will teach innovation.  To let the crew face the impossible under simulated conditions will lead to thinking far advanced from the normal mundane scenarios used session after session.
    • Decision Making Exercises.  Even with all the knowledge of a situation one could still lack logic.  The application of logic is an art and a skill that could be practiced, but demands solid knowledge of the task environment.  Should fewer facts be known in a situation, assumptions need to take the place of those hard facts not available.  The logic of assumptions is a skill that needs development.
    • Risk Calculation.  Outcome based decision making requires the ability to predict and allocate a risk factor coupled to a specific decision made.  This is another skill that could be practised under simulated conditions in the class room.
    • Communication.  The ability of a crew to communicate freely and relevantly in any situation leads to synergy.  We are reminded that it is not only the language such as English, but it is also the language and knowledge of the medium, machine, management and mission that requires practise.  We must be able to communicate with people and things!
    • Cross Training.  A pilot that is technically minded has an advantage of communicating the problem experienced to technical crews.  If both the pilots are technically minded or have a fair knowledge of the technical side of the operation, decision making is immediately enhanced when faced with a technical problem.  However, the technical crew does not understand pilot and cabin crew language.  Cross training is essential not only between cockpit and cabin crew, but also between all the other parties such as operations, ground crew, ATC, management and other relevant role players.  ATC for instance has direct access to the cockpit and can induce stress into this environment due to a lack of CRM training as well as a lack of technical knowledge of the aircraft capabilities under certain operational conditions.
  • Attitude.  Poor discipline must be stamped out.  24% causation in non-technical accidents is simply not acceptable.  If poor discipline is the result of human design or human normal functional failure, it could be understood, but when poor discipline is the result of wilfully and deliberately deviating from the norm, action must be taken.  I suggest a tougher approach towards cases where neglect is premeditated or where neglect has no excuse other than sloppy workmanship attributed to an over casual approach.  Discipline is something we demand from our crews, be it air or ground, but when there is a mishap, we tell crews that as long as they own up to the problem we will not prosecute them.  The information is only required to avoid similar accidents in future.  Well, how will we ever stop poor discipline causation if we are merely collecting data with it?  How can we stop bad discipline if we will never discipline those that require discipline?  The following actions are recommended:
    • Discipline Culture.  Ill discipline is not OK!  This message must be preached and practised.  This is a top down approach through example of excellent behaviour.
    • Train Discipline Behaviour.  Only when we have been tempted to stray from the norms will we find out what it takes to stick to the norms.
    • Punitive Action.  If discipline is not appropriately rewarded, positive or negative, your discipline accidents and incidents will never change for the better.  Negative behaviour must not be left alone or ignored.  This is like silent consent.  Discipline needs to be enforced through a disciplined approach.
    • Good Relationships.  There must be good relationships between co-workers, air and ground, between management and crews, between support structures and the cockpit.  Good relationships are based on good behaviour, honesty and putting your company first.  After all, it is where you earn your living.
  • Human Design.  A whopping 50% of accidents due to our design shortcomings are neither a doomsday call nor a reason to be resigned to the inevitable.  There are clear tell tale signs when we enter into a situation where we are prone to become less functional, rational or effective.  If we understand how we function under stress, we could be taught what the signs are to look out for.  We must learn what triggers a set of events that will lead to disaster.  In most accidents we pick it up in the investigation and we stand in amazement that the set of events did not trigger a different set of behaviour.  We might know enough of human design but we are still short in training these factors to crews under realistic (chaotic adverse conditions preceding an accident) conditions so as to equip them to recognise the symptoms and to react to them.  There are so many facets to human design or human factors involved in the way decisions are made.  The following are but a few highlighted for this particular discussion:
    • Individual Stress Behaviour.  Each one of us will have a different capacity to handle stress.  Should we be able to discover the individual’s stress behaviour, we would be able to address possible shortcomings and train to overcome certain anxieties.
    • Understand Human Shortcomings.  It is important for crews to understand their own as well as the general human shortcomings in order to recognise the early signs of being sucked into a trap for which our design cannot cater.
    • Develop SOP’s.  Where possible SOP’s to govern behaviour under certain stressful conditions should be researched and developed.  These SOP’s would govern human behaviour under certain conditions and not the machine or environment.
    • Train Adverse Condition Decision Making.  Crews should be subjected to extraordinary circumstances in which their decision making skills are tested.  Simulations in terms of motorised skills are well defined and tested, but the human mind’s ability to bring order to a chaotic situation is what should be challenged and developed.
    • Crew Composition.  If we know our crews better, we would be able to pair complimentary crew.  The ability to partner the most suitable crew is an art that should be developed.  The operational nightmare of attempting such a roster would indeed be more than challenging.  However, one could start with broader spectrum experience versus newcomers.  Known stress behaviour could become criteria in the pairing of crews.  This field is still wide open for research and development to make crew synergy an optimal tool.


Even if the research is 50% off the mark, we still have a chance to enhance our chances should we understand the dynamics of our environment.  We must do more research, discover individual behaviour at the next level, develop the ability to understand when we enter into the beginning stages of ineffectiveness, formulate SOP’s to restore some order in the chaos preceding an accident and condition rational thought under extreme stress conditions.  We must not tolerate deviations from the norms and values set by the company and the aviation family.  We have a better chance than the one we are giving ourselves at this moment.

Yes, we will meet resistance, but the challenge is clear.  Either we invest in human development with less stinginess, or we continue to pay the price.  As a paying passenger I would rather be safe than just feel safe.

Safety can manifest itself only through dedicated and diligent action, but never through a façade of non-action talk and written communication.  We must walk the talk and live the vision!


Decision Making Under Adverse Conditions



Written by Charlie Marais on Monday, 08 August 2011 07:00.

Safety is an AttitudeLife in the present as we experience it is merely a result of the decisions we have made in the past.  Our decisions will shape the future as they have shaped the past.

Decision making should never be by chance, but rather calculated through sufficient knowledge, skills and the correct attitude concerning the issue at hand.  How many times have I heard; “but I was not aware of that!”  By implication this means that should I have had a better understanding of the circumstances surrounding the problem, I would have made a different decision.  The complete and total awareness of the factors affecting the situation, coupled with sufficiently developed skills to work with those factors, sets a point of departure for good decision making.

This might all be true, but most decisions in aviation when things are going wrong are associated with high stress levels.  Stress tends to dull our ability to function at our peak and therefore decreases our ability to make the correct and speedy decisions required in the high dynamic aviation environment.

Our designed capacity to stand adversity manifests itself in the individual’s personality, moderated by the individual’s frequent exposure to adversity in the specific field.

When we consider accidents we come up with some rather interesting statistics on the causation of non-technical accidents when measured against the crew’s knowledge, skills, discipline and the human design factors involved.

On top of all these it still remains a mystery why professional aircrew should at times decide to willingly and knowingly divert from the standard operating procedures or norms and values as advocated to facilitate safe and efficient practices.

It is these findings that have prompted me to consider what it is that we could do to enhance our capability to make better decisions.  What is it that we can do to avoid becoming just another statistic?  What is the individual’s own design capability to stand adverse conditions and more importantly, how can we enhance the individual’s capacity to make decisions under stressful situations, where being defeated is a possibility?

Before I attempt to answer these questions, I would like to set the stage for what I consider to be an adequately equipped crew member to make better decisions in the face of adversity.


In flight safety we refer to the five M’s as Man, Machine, Medium, Mission and Management.  The five M’s are merely a practical way in which we can capture the total area influenced during our interaction in our work place.  In aviation this is a great tool to organise accident investigation results so as to apportion the influence of each sphere to the causation of the accident.  The areas of development are focused on the five M’s.  We need knowledge in each area in order to be able to function professionally in that area.  For instance, flight crew are rarely knowledgeable in terms of Management.  Yet, if crews would understand the functions and challenges of management better, it would influence their decision making to some extent.



The foundation to support decision making in our work place, when focused on the areas of concern, needs to be developed.  The areas that require development in the individual are as follows:

·         Knowledge.  Knowledge is the foundation of all learning and functioning processes.  Knowledge of the past is as powerful as any ingredient in shaping the present.  If we only had fore-knowledge, we would have been able to shape the future perfectly according to our perception of perfection.

·         Skills.  Knowledge without the ability to apply it in a practical sense is of no use.  Skills are taught and rarely instinctive when it comes to complex environments where it is not usual for the human race to function.

·         Attitude.  How we behave in relation to given and accepted norms, values, SOP’s and guidelines, determines our attitude in that respective environment.  As an aircraft’s attitude determines a favourable and desired result or an unsatisfactory result, so our attitude will result in a relative outcome.  Attitude is a measure of our discipline when conforming to that which is accepted as best practice.  When we willingly and knowingly divert from that which is accepted behaviour, the results are not always negative, but the potential for a negative outcome is always present.  When you are misaligned for long enough, statistics will catch up and the negative predicted result will manifest itself.

·         Human Design.  Here we acknowledge human design limitations when considering the aviation environment.  Yes, personal discipline is also classified as a human factor, but because it is defined as a wilful way of behaviour, I elected to separate it from other human factors where we are subject to automated or designed behaviour. 


Now that we have areas defined that should be developed and we have defined the areas that we should focus on, it is time to analyse what the product of our development should be:

·         Knowledge.  In the development of Knowledge, the following products should be attained:

o   Facts.  Facts represent the truth.  We must know how things work and especially the cause and effect loop.  We have to know the facts concerning the five M’s.

o   Concepts.  Concepts represent all fundamentals.  What are the results when certain actions are taken?  When we apply the facts, how will the outcome be influenced when the parameters become different?  These are the recipes for success and disaster.

o   SOP’s.  SOP’s represent rules.  Everything we have ever manufactured has operating procedures to ensure safe and efficient usage.  SOP’s are promulgated due to the results of behaviour.  Certain behaviours result in death or destruction.  The blood now gained is utilised to write the new set of behaviours in order to avoid another blood session.  SOP’s when they exist, ensures in many cases that a potential complex situation becomes less complicated and achievable.  Again, if you follow the now tried and tested recipe for survival under the specific conditions facing you, the outcome becomes predictable.  SOP’s are there to make decision making easy under stressful and complicated conditions.

o   Experience.  Experience is represented by knowing through own discovery.  Knowledge as a result of experience is first hand and normally believable, but there are discoveries we need not make through our own experience.  It is better to learn from another’s experiences than your own, especially when the potential of harm is great.

o   Becoming Aware.  To become aware represents your ability to be aware of the true and complete situation presenting itself.   You need your senses to become aware.  Under normal circumstances this comes naturally, but when we operate in an environment where we have not been before, or where our attention is forced to split between different issues presenting itself, our ability to fully comprehend deteriorates.

·         Skills.  In the development of Skills, the following products should be attained:

o   Motor Skills.  Co-ordination skills are crucially important in all the development focus areas.

o   Verbal.  Being conversant in the international aviation language is not the only requirement.  One must also understand the technical language of the environment.  To be able to speak “technical” as a language, one needs to understand the air vehicle technical to a very high degree.  The language we speak must cover all the focus areas and must be of such a standard that one can reason well enough in any situation presented in the cockpit or cabin.

o   Cognitive.  The ability to think on the spot, to use information and to utilise logic to come to a point of decision making, takes not only knowledge and experience, but practice in any conceivable situation.  The ability to apply knowledge under varied circumstances is a developed skill and not just IQ.

o   Emotional.  The ability to contain and restrain one’s emotions is also a skill that needs training and constant attention.  Due to the fact that our strongest instinct is that of survival and the associated chemical release in our bodies when faced with adverse conditions, we need to learn to maintain our composure in order to attend efficiently to the crisis situation.

o   People.  Our interactive skills need development.  As a crew member we need to have the ability to take advantage of the crew concept of synergy.  The team must be practised and well prepared for any situation that might arise.  People skills is an art that should be taught to suit the operational environment.

·         Attitude.  In the development of Attitude, the following products should be attained:

o        Discipline.  One must be aligned with the facts, the norms and values and ultimately with the truth.  It is when we stray from the SOP’s with no negative results that we interpret this as a safe shortcut.  The human ability to accept dangerous situations, especially when exposure to those situations yields no negative effect initially, creates a huge challenge to stay away from short cuts and wrong practices.  The fact is that negative behaviour will be rewarded with negative results, we just don’t know when

o        Motive.  If our motives are honest, then we would follow procedure, but when dishonesty enters the equation, disaster is bound to follow sooner or later.


·         Human Design.   The human design or human factors considered here are those that are uncontrollable design attributes and limitations.  When things get out of hand and the human brain can no longer cope with the variety of stimuli.  We can only assimilate so much, pay so much attention, consider so many factors etc.  The following capabilities or capacities in the development of Human Design/Factors, need attention:

o        Data Computation.  Data assimilated can only be computed at a certain design maximum rate.  One can only compute one set of data at any given time.  Complex situations will take longer to compute into usable form at the expense of time.

o        Awareness.  We have only so many sensors to become aware, and we are designed to be aware only to a certain extent.  Awareness could be as little as zero, with an average of around 20% and when we only concentrate on one item, close to 100%.  However, when the complete set of circumstances is considered, we simply can’t be totally aware of everything around us.  Our attention span is not capable of doing so.

o        Stimulation Vs Performance.  We need stimuli in order to have any level of performance.  There could be too little stimuli and on the other hand too much stimuli and thus an overload of the designed system. 

 Performance vs Stimulus Graph


o        Stress Handling.  Some of us have a greater capacity to handle stress and to perform under stressful conditions.  Ones designed emotional strength or EQ differ from person to person.  The human design of Flight or Fight is seated in the Amygdala. This is our prehistoric brain, which is triggered before our thinking brain, seated in the neocortex.  This means that our emotions can take control before our rational brain has made sense of the situation.   With chemicals released our reactive motor skills get a boost, but our ability to be rational is dulled.  Excessive stress does make us less intelligent.

o        Risk Acceptance.  Doing a dead stick landing is risky business.  The student will be petrified the first time, but as the student experiences that when the correct procedures are followed, that no harm comes with the experience.  This leads to the conscious or sub-conscious belief that “it is not that dangerous”.  A more relaxed attitude towards this danger now takes the place of the initial terror experience.  The more dangers we are exposed to and the more we get away without having experienced any harm, the more we believe that we are invulnerable.  Should these beliefs be solely based on positive results that flowed from positive and correct actions, we are on the right path.  These beliefs are strengthened when no harm comes to us as short cuts are taken or when the SOP’s are not followed.  The result is that we are in for a nasty surprise down the line.  Risk acceptance is thus good when it is controlled and supported by tried and tested procedures such as the action when faced with an engine cut.  Risk acceptance, when we have been lucky to get away with it until now, sets the stage for disaster in the future.



Research quoted results were derived from accidents where there were no mechanical failures and could be attributed to human shortcomings only.  These accidents were randomly selected over a period of three years from the accident investigations of the Flight Safety Foundation.  A further commonality was that all the case studies were classified as CFIT accidents.  The four areas measured as direct contributors to the accidents utilised were knowledge, skills, attitude (discipline) and human design.



The following results were obtained:

Knowledge.  The first building block towards sound decision making is knowledge.  The lack of knowledge has shown in my research to have a direct influence on 6% of the accidents.  Without the correct knowledge, a sound decision is not possible.  When knowledge of the problem and its building blocks are not known, decision making is said to be calculated.  The true facts, the understanding of concepts, the knowledge of SOP’s, to know something from experience and to be fully aware of the problem, its development and consequences, are all supplements to knowledge required when an informed decision has to be made.  The risk then becomes more truly calculated.

·     Skills.  We need to be skilful in many ways to be able to transform our knowledge of the problem into an effective antidote.  Motorised, verbal, cognitive, emotional and people skills are but a few essentials to move from knowledge to action in resolving the problem though sound decision making.  My research has shown that the lack of skills have had a direct influence on 20% of accidents.

·         Attitude.  Our attitude is merely a measure of how well we are aligned with the norms, truths and values of our environment.  When we knowingly and willingly deviate from those standards, we are said to be ill disciplined.  This lack of discipline by aviators has shown to contribute as many as 24% of accidents.

·        Human Design.  My research has shown that at least 50% of the accidents due to human error were due to the nature of our design.  Our ability to compute information, to become aware of deviations from the required norms, our gradual acceptance of high risk areas where no adverse effects have materialised and our ability to perform when stress levels are extremely high, are amongst the factors affecting sound decision making.  It is in this last area of human factors that I would like to focus the presentation on and more specifically that of the human’s ability to perform under adverse conditions when the possibility of being defeated is very high.



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