Premium on Safety - Issue 35, 2020 - 9

ASI MESSAGE
LESSONS
LEARNED

Why Do Good Pilots Make Bad Decisions?
Reasons to Be On Guard
This year marked a
disappointing first in my
safety career. I attended a
type club safety conference,
and at the conclusion of
the conference, on the
same day I departed for
Frederick Municipal Airport
in Maryland, one of the type
club members crashed on his flight home and died. Crashed. On
the way home from a type club safety conference.
The NTSB is still investigating, but from online tracking
sources, it appears the pilot departed in his highperformance, single-engine experimental airplane and was
attempting to fly below the weather at approximately 1,000
feet agl, while flying in excess of 200 knots when he crashed.
This flight profile is commonly called "scud running," which
escalates in difficulty with increased speed. It was a tragic,
ironic end to the safety conference.
Typical of type club fly-ins, the group began trickling in early
in the week from all over the country. They reconnected with
each other, many of them obviously friends for decades, sharing
the joys of their airplane and showing off new upgrades. Type
clubs are everything good about general aviation: a wealth of
knowledge, exceptional and specific instruction, healthy culture,
and social events that help build lifelong friendships.
The conference for this energetic club began mid-week with
safety seminars, panels, and deep-dive tech talks. Some took
the opportunity for some flying and flight reviews on the side.
We enjoyed a hangar dance and barbecue Friday night while
strolling the flight line and ogling especially gorgeous airplanes
and curious airplanes with unique modifications. This is
especially interesting with experimental aircraft type clubs.
Saturday was a full day of seminars to include a talk on "Why
Good Pilots Make Bad Decisions." The discussion stems from
my experience losing friends in both military and GA flying,
and in reading accidents of highly experienced and obviously
skilled pilots who made uncharacteristically poor decisions.
Seeing people I respect make a poor decision with devastating
consequences made me realize I could be susceptible to
the same peril. "Why Good Pilots Make Bad Decisions"
acknowledges that we are all susceptible to poor decisions and
focuses a discussion around how to avoid them.
The discussion pulls from two books dealing with decision
making: Think Again, published by the Harvard Business Review,
and Thinking Fast and Slow, by Daniel Kahneman: Both books

shed light on how the brain operates and explain that despite
our best efforts, our decision-making process is sometimes
hopelessly flawed. We are prone to make quick decisions, more
than optimum decisions, and we place too much faith in our
intuition or our "gut feel!' We are powerfully susceptible to
biased logic when we have a keen self-interest at stake. Once
we make a decision, we tend to over-value data that sup-ports
our decision and undervalue data that suggests we should
reconsider. In an aviation setting, the brain's processing-so vital
to the thousands of decisions we make every day-can lead to
an oversight of critical information and incite poor decisions. We
must be aware and on guard.
At the banquet Saturday evening, many of us shared
observations about the weather, which had been better
than forecast all weekend. We awoke Sunday to surprisingly
deteriorating conditions. A line of weather moving from the
southwest had intensified and would arrive overhead in just a
couple of hours. We were already experiencing mist and light
rain. The environment was set with just the kind of elements
we talked about in the seminar Saturday that can lead to
imprudent decisions.
Sunday departures are already prejudiced by a desire to put
a neat end to the week, get home, and make it to work the
next day. We've already said our goodbyes, checked out of the
hotel, and turned in the rental car; we've made our decision
and it's time to go. We have an extreme bias to execute on our
decision to get home and we have a difficult time stepping
back to review our entire range of options and reconsider. The
approaching weather that Sunday added more stress and more
self-interest, since the system appeared to be the kind likely to
result in a long delay. Either we departed that morning, or we
were likely to be stuck until Tuesday.
The mishap pilot chose to depart in the direction of the
encroaching weather. We don't know what his thinking was, or
his plan. It will take close to two years before the NTSB releases
a probable cause that may shed light on whether or not the
pilot's decisions were contributing factors. Until then, we can
ponder the setting, put ourselves in the same position, and ask
what protections we have in place to strengthen our decisions-
especially in capricious situations.

RICHARD G. MCSPADDEN, JR.

EXECUTIVE DIRECTOR, AOPA AIR
SAFETY INSTITUTE

9



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