This course includes the concepts of Aeronautical Decision Making (ADM) and Crew Resource Management (CRM). Provides a discussion of the human factors involved in aviation including an exploration of the interactions between people and their work environment and between fellow workers and crew members. Includes relevant topics from basic learning theory, human heuristics and biases, aviation safety, aviation accident investigations, and aviation education and training. Surveys the study of human behavior as it relates to the aviator's adaption to the flight environment including function allocation between human and machine, human-computer interface, work environment, person-to-person communications, performance measurement, supervision of crewmembers, accountability, role management, crew communications, teamwork, leadership, followership, decision-making, and situational awareness.

There is no single textbook for this course. I have not located a single textbook that covers all of the material that I want to be able to cover in this course.

All of the references for this course can be read online and / or downloaded at no charge using the URL addresses provided.

1. Reference #1. U.S. Department of Transportation, Federal Aviation Administration. (2016). Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25B).Retrieved from https://www.faa.gov/sites/faa.gov/files/2022-03/pilot_handbook.pdfLinks to an external site.

2. Reference #2. U.S. Department of Transportation, Federal Aviation Administration. (2009). Risk Management Handbook (FAA-H-8083-2a). Retrieved from https://www.faa.gov/sites/faa.gov/files/2022-06/risk_management_handbook_2A.pdfLinks to an external site.

3. Reference #3. U.S. Department of Transportation, Federal Aviation Administration. (1991). Advisory Circular 60-22: Aeronautical Decision Making. Retrieved from https://www.faa.gov/documentLibrary/media/Advisory_Circular/A C_60-22.pdf

4. Reference #4. U.S. Department of Transportation, Federal Aviation Administration. (2004). Advisory Circular 120-51E: Crew Resource Management Training. Retrieved from AC_120-51E.pdf

5. Reference #5. U.S. Department of Transportation, Federal Aviation Administration. (2008). Aeronautical Decision Making (FAA-P-8740-69: AFS-8). Retrieved from P-8740-69.indd (faasafety.gov)

6. Reference #6. U.S. Department of Transportation, Federal Aviation Administration. (no date). The Art of Aeronautical Decision-Making. Retrieved from Microsoft Word - The Art of Aeronautical Decision.doc (faasafety.gov)

7. Reference #7. U.S. Department of Transportation, Federal Aviation Administration. The Evolution of Crew Resource Management Training in Commercial Aviation. Retrieved from crmhistory.pdf (faa.gov)

8. Reference #8. Air Transport Safety Articles. (2014). The Role of Cognitive Bias in Aircraft Accidents. Retrieved from The role of Cognitive Bias in Aircraft Accidents | Air Transport Safety Articles by Shem Malmquist (airlinesafety.blog)

9. Reference #9. Aircraft Owners and Pilot’s Association, Air Safety Foundation, Safety Advisor, Operations and Proficiency No. 11. (no date). Do The Right Thing: Decision Making for Pilots. Retrieved from https://www.aopa.org/training-and-safety/online-learning/online-courses/do-the-right-thing-decision-making-for-pilots

10. Reference #10. Aarons, R. N. (no date). Accident Prevention Program: Always Leave Yourself an Out. Retrieved from Microsoft Word - p8740-25.doc (cfidarren.com)

11. Reference #11. Swartz, L. (no date). Overwhelmed by Technology: How Did User Interface Failures Onboard the U.S.S. Vincennes Lead to 290 Dead? Retrieved from vincennes.pdf (stanford.edu)

12. Reference #12. U.S. Department of Transportation, Federal Aviation Administration. Avoid the Dirty Dozen. Retrieved from DirtyDozenWeb3.pdf (faasafety.gov)

13. Reference #13. U.S. Department of Transportation, Federal Aviation Administration. Human Error in Commercial Aviation Accidents. Retrieved from Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS (faa.gov)

14. Reference #14. SKYbrary Aviation Safety. (no date). Stress and Stress Management. Retrieved from Stress and Stress Management (OGHFABN) | SKYbrary Aviation Safety

15. Reference #15. U.S. Department of Transportation, Federal Aviation Administration FAA TV. (2012). Stress in Aviation. Retrieved from faastress in aviation - Search (bing.com)

16. Reference #16. The Adrenal Fatigue Solution. (2015). How Do Airline Pilots Cope with Stress. Retrieved from Airline Pilots: Recognizing And Coping With Stress (adrenalfatiguesolution.com)

17. Reference #17. Stress and Pilot Performance - Parts 1 and 2. Part 1: Retrieved from Stress, and Pilot Performance: Part 1 – Society of Aviation and Flight Educators (safepilots.org) Part 2: Retrieved from Stress and Pilot Performance: Part 2 – Society of Aviation and Flight Educators (safepilots.org)

18. Reference #18. Stress and Stress Management. Retrieved from https://skybrary.aero/articles/stress-and-stress-management-oghfa-bn

19. Reference #19. Situational Awareness. Retrieved from Situational Awareness? - Aviation Safety (aviationsafetymagazine.com)

20. Reference #20. How to Improve Your Situational Awareness: 7 Tips. Retrieved from https://toughprey.com/how-to-improve-your-situational-awareness/

21. Reference #21. Situational Awareness. Retrieved from Situational Awareness - AviationKnowledge (wikidot.com)

22. Reference #22. Automation in Aviation. Retrieved from Automation in aviation - AviationKnowledge (wikidot.com)

23. Reference #23. The Denver Post. (2016). Human Error is Biggest Obstacle to 100 Percent Flight Safety. Retrieved from Human error is biggest obstacle to 100 percent flight safety – The Denver Post

24. Reference #24. Olson Brooksby PC. (2013). Aviation Fatalities: Most are Caused by Human Error. Retrieved from Aviation Fatalities: Most are Caused by Human Error | Olson Brooksby PC

25. Reference #25. U.S. Department of Transportation, Federal Aviation Administration. FAA AC- 120-51E: Crew Resource Management Training. Retrieved from AC 120-51B (skybrary.aero)

26. Reference #26: U.S. Department of Transportation, Federal Aviation Administration. The Evolution of Airline Crew Resource Management. Retrieved from crmhistory.pdf (faa.gov)

27. Reference #27: Crew Resource Management: Head in the Game. Retrieved from Crew Resource Management: Head in the game - AOPA

28. Reference #28. U.S. Department of Transportation, Federal Aviation Administration. CRM Aspects in Incidents / Accidents. Retrieved from Human Factors Aspects in Incidents/Accidents (faa.gov)

29. Reference #29. Aeronautical Decision Making (ADM) and Crew Resource Management (CRM) related accidents for case studies.

30. Reference #30. U.S. Department of Transportation, Federal Aviation Administration. Tips for Teaching Practical Risk Management. Retrieved from https://www.faa.gov/sites/faa.gov/files/regulations_policies/handbooks_ manuals/aviation/pilot_risk/1.0-Practical-Risk-Management.pdf

31. Reference #31. U.S. Department of Transportation, Federal Aviation Administration. 3P Risk Management Process. Retrieved from https://www.faasafety.gov/files/gslac/courses/content/28/200/3P%20Ris k%20Management%20Process.pdf

Accident References

Reference #29. Aeronautical Decision Making (ADM) and Crew Resource Management (CRM) related accidents for case studies.

I have selected these accidents because they represent excellent examples of human errors rather than technical errors.

I am generally not a big fan of Wikipedia, but it does have reasonably good aircraft accident reviews, so it is a good place to start.

• Air Florida Flight 90. 01/13/1982. Boeing 737-200. Crashed into the 14th Street Bridge Over the Potomac River in Washington, D.C., just after takeoff from Washington National Airport. Killed 74 of the 79 people on board the plane and four people on the ground. Pilot chose to make the takeoff with ice on the airplane wings.

• Air France Flight 4590. 07/25/2000. Concorde. Crashed just after takeoff from the Charles de Gaulle International Airport in Paris, France. Killed all 109 people on board the airplane and four people on the ground. On takeoff the airplane hit debris that was not removed from the runway. The debris burst the airplane tires, damaged a fuel tank, and the airplane caught fire in flight.

• American Airlines Flight 191. 05/25/1979. McDonnell Douglas DC-10. Crashed just after takeoff from Chicago O’Hare International Airport. Killed all 271 people on board the plane and two people on the ground. The left engine came off of the wing on takeoff due to a maintenance error.

• Colgan Air Flight 3407. 02/12/2009. Bombardier Q400. Crashed into a house in Clarence Center, New York. Killed all 49 people on board the plane and one person on the ground. Pilots failed to recognize an impeding aerodynamic stall.

• Comair Flight 5191. 08/27/2006. Bombardier Canadair Regional Jet 100ER. Crashed on takeoff at Blue Grass Airport in Fayette County, Kentucky (just outside Lexington, Kentucky). Killed 49 of the 50 people on board the plane. Pilots attempted to takeoff from the wrong runway which was too short for the airplane.

• Eastern Airlines Flight 401. 12/29/1972. Lockheed L-1011-1. Crashed into the Florida Everglades while maneuvering west of Miami, Florida. Killed 101 of the 176 people on board the plane. Pilots were distracted in the cockpit and lost control of the airplane.

• Ethiopian Airlines Flight 302. 03/10/2019. Boeing 737 Max 8. Crashed six minutes after takeoff from the Bole International Airport in Adis Abba, Ethiopia. Killed all 157 people on board the plane. The airplane went out of control due to an onboard aircraft system failure that Boeing knew about.

• Iran Air Flight 655. 07/03/1988. Airbus A-300. Crashed into the Persian Gulf shortly after takeoff from the Bandar Abbas International Airport. Killed all 290 people onboard the plane. The aircraft was mistakenly shot down by two surface-to-air missiles fired from the guided missile cruiser USS Vincennes.

• KLM Flight 4805 and Pan Am Flight 1736. 03/27/1977. Two Boeing 747 airplanes. Two airplanes crashed into each other head on while still on the ground at the Los Rodeos Airport on the Spanish Island of Tenerife. Killed all 248 people on board the KLM airplane and 335 of the 396 people on board the Pan Am airplane for a total of 583 people. The KLM pilot failed to follow air traffic control instructions.

• Lion Air Flight 610. 10/29/2018. Boeing 737 Max. Crashed into the Java Sea 13 minutes after takeoff from the Soekarno-Hatta International Airport in Tangerang. Killed all 189 people on board the plane. The airplane went out of control due to an onboard aircraft system failure that Boeing knew about.

• TAM Flight 3054. 07/17/2007. Airbus A-320. Crashed after overrunning the runway on landing at Congonhas Airport in Sao Paulo, Brazil. Killed all 187 people on board the plane and 12 people on the ground. Pilot error on landing.

• United Airlines Flight 173. 12/28/1978. McDonnell Douglas DC-8-61. Crashed into a suburban neighborhood in Portland, Oregon, six miles short of the Portland International Airport. Killed 10 of the 189 people on board the airplane. Pilots allowed the airplane to run out of fuel.

• United Airlines Flight 232. 07/19/1989. McDonnell Douglas DC-10. Crashed on the Sioux Gateway Airport at Sioux City, Iowa, during an emergency landing. Killed 112 of the 296 people onboard the airplane. The explosive failure of an internal engine component due to an undetected manufacturing flaw severed all three airplane hydraulic systems and disabled all of the airplane flight controls.

• USAir Flight 1016. 07/02/1994. McDonnell Douglas DC-9-31. Crashed next to the airport at Charlotte / Douglas International Airport in Charlotte, North Carolina. Killed 37 of the 57 people onboard the airplane. Pilot made a failed landing into known thunderstorm and microburst weather conditions.

• John F. Kennedy Jr. 07/16/1999. Piper Saratoga. Crashed into the Atlantic Ocean on approach to landing at the Martha’s Vineyard Airport at Martha’s Vineyard, Massachusetts. Killed all three people on board the airplane. Pilot lost control of the airplane due to weather conditions that he was not trained to handle.

• John Denver. 10/12/1997. Experimental Amateur-Built Long-Eze. Crashed into Monterey Bay near Pacific Grove, California. Killed the single person on board the plane. Pilot failure to maintain aircraft control while working an onboard airplane system.

At the completion of this course the learners will be able to:

• Be able to discuss and apply the historical foundations and development of both Aeronautical Decision Making (ADM) and Crew Resource Management (CRM).

• Be able to discuss and apply the principles of Risk Management.

• Be able to discuss and apply the decision-making process.

• Be able to discuss and apply models of the decision-making process.

• Be able to recognize and discuss the effects of stress and apply the principles of stress management.

• Be able to recognize and discuss how biases affect human judgment and decision making and recognize and avert their effects.

• Be able to recognize and discuss the effects of automation on Aeronautical Decision Making (ADM) and Crew Resource Management (CRM).

• Be able to recognize and discuss how technical limitations can affect Aeronautical Decision Making (ADM) and Crew Resource Management (CRM).

• Be able to review and understand relevant accident reports involving errors in both Aeronautical Decision Making (ADM) and Crew Resource Management (CRM)

Grades

Student performance in the course will be measured by ten (10) discussion boards, four (4) written assignments, three (3) quizzes, one (1) research paper, and one (1) final exam.

Discussion Boards

The ten (10) discussion boards combined are worth 20% of the course grade (20 points each). Each student will post one (1) original response to the question and post one (1) response to a fellow student’s response to the discussion question.

The goal is to have an active and timely discussion. Postings made after the assignment deadline will not be counted for a grade.

I expect substantive comments that indicate that you have given some thought to the issue(s).

Grading rubric: grammar - 5 points, content - 15 points.

Written Assignments

The four (4) written assignments combined are worth 20% of the course grade (50 points each). The written assignments require three (3) typed double spaced pages (not including a Title Page or the References page) on the topic given with at least two (2) cited references in addition to the course text.

No particular format is required but good ideas, grammar, and spelling are expected.

Grading rubric: grammar - 5 points, citations - 5 points, content - 30 points.

Quizzes

The three (3) quizzes combined are worth 30% of the course grade (100 points each). Each quiz will involve answering multiple choice and/or short answer questions on the material covered.

Research Paper

The research paper (1) is worth 15% of the course grade (150 points). The topic of the paper may be an issue of your choice dealing with a contemporary aerospace industry ADM or CRM topic.

Note: The paper topic must be approved in advance by the instructor.

The paper (1) must be eight (8) pages typed and double spaced (not including a Title Page or a References page) with at least five (5) cited references in addition to the course text.

Grading rubric: grammar - 20 points, citations - 20 points, content - 160 points.

Final Exam

The final exam (1) is worth 15% of the course grade (150 points).

The final exam will involve answering multiple choice and/or short answer type questions and an analysis of an ADM / CRM related accident that was not reviewed in class. The final exam will cover the entire course.

Grading System

• 10 Discussion Boards 20% 200 points (20 points each)

• 4 Written Assignments 20% 200 points (50 points each)

• 3 Quizzes 30% 300 points (100 points each)

• 1 Research Paper 15% 150 points

• Final Exam 15% 150 points

• Total 100% 1,000 points

Letter grades will be calculated as follows:

93.5% and above=A 82.5-86.5%=B 72.5-76.5%=C 60-66.5%=D

89.5-93.5%=A- 79.5-82.5%=B- 69.5-72.5%=C- below 60%=F

86.5-89.5%=B+ 76.5-79.5%=C+ 66.5-69.5%=D+

Weeks 1 & 2

Learning Objectives

• 1. Describe the basic concepts of Aeronautical Decision Making (ADM).

• 2. Describe the three components of risk management.

• 3. Articulate what constitutes a risk.

• 4. Articulate what constitutes a hazard.

Reading Assignments

• Reference #1: Chapter 2

• Reference #2: Chapters 1 – 5

• Reference #3: All

• Reference #5: All

• Reference #6: All

• Reference #30: All

• Reference #31: All

Graded Assignments

• Discussion Question #1

• Discussion Question #2

Weeks 3 & 4

Learning Objectives

• 1. Describe the basic concepts of Aeronautical Decision Making (ADM).

• 2. Describe the three components of risk management.

• 3. Articulate what constitutes a risk.

• 4. Articulate what constitutes a hazard.

• 5. Discuss what is meant by cognitive bias.

• 6. Summarize the dirty dozen and their effects on human decision making.

Reading Assignments

• Reference #8: All

• Reference #12: All

• Reference #13: All

• Reference #23: All

• Reference #24: All

Graded Assignments

• Discussion Question #3

• Written Assignment #1

• Quiz #1

Weeks 5 & 6

Learning Objectives

• 1. Describe and analyze the challenges to good judgment and decision making called The Dirty Dozen.

• 2. Identify and recognize some of the challenges to good judgment and decision making caused by a lack of situational awareness.

• 3. Summarize some of the challenges to good judgment and decision making caused by stress.

Reading Assignments

• Reference #12: All

• Reference #13: All

• Reference #14: All

• Reference #15: All

• Reference #16: All

• Reference #17: All

• Reference #18: All

• Reference #19: All

• Reference #20: All

• Reference #21: All

Graded Assignments

• Discussion Question #4

• Discussion Question #5

• Written Assignment #2

Weeks 7 & 8

Learning Objectives

• 1. Describe and analyze the challenges to good judgment and decision making created by a lack of cockpit resource management (CRM).

• 2. Summarize some of the challenges to good judgment and decision making caused by stress.

• 3. Identify and recognize some of the challenges to aviation safety caused by the increasing level of automation and technology used in today’s aircraft and air traffic control systems.

• 4. Review the incident / accident involving the USS Vincennes.

Reading Assignments

NOTE: Don't spend a lot of time analyzing these models. Just take a look at the various models and get an idea of what is available. Some will make sense to you, and some may not. No problem. A model serves the same function as a checklist. It helps us to avoid missing things, avoid getting things out of order, and avoid adding things that don't belong there.

Not all of the models will work in every situation. Some are more appropriate to specific situations than others.

• Reference #1. U.S. Department of Transportation, Federal Aviation Administration. (2016). Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25B). Review Models 2.2, 2.4, 2.5, 2.6, 2.7, 2.13, 2.16, 2.17, 2.18, 2.19, 2.22, and 2.25

• Reference #2. U.S. Department of Transportation, Federal Aviation Administration. (2009). Risk Management Handbook (FAA-H-8083-2). Review Models 1.6, 1.7, 3.2, 3.4, 4.3, 5.5, and 5.10

• Reference #3. U.S. Department of Transportation, Federal Aviation Administration. (1991). Advisory Circular 60-22: Aeronautical Decision Making. Review Models 1, 2, and 21

• Reference #4. U.S. Department of Transportation, Federal Aviation Administration. (2004). Advisory Circular 120-51E: Crew Resource Management Training.

• Reference #5. U.S. Department of Transportation, Federal Aviation Administration. (2008). Aeronautical Decision Making (FAA-P-8740-69: AFS-8). Review Models 2 and 4

• Reference #6. U.S. Department of Transportation, Federal Aviation Administration. (no date). The Art of Aeronautical Decision-Making. Read All. Note: This article has some PDFs of checklists of various types that are very good.

• Reference #7. U.S. Department of Transportation, Federal Aviation Administration. The Evolution of Crew Resource Management Training in Commercial Aviation.

• Reference #9. Aircraft Owners and Pilot’s Association, Air Safety Foundation, Safety Advisor, Operations and Proficiency No. 11. (no date). Do The Right Thing: Decision Making for Pilots.

• Reference #10. Aarons, R. N. (no date). Accident Prevention Program: Always Leave Yourself an Out.

• Reference #11. Swartz, L. (no date). Overwhelmed by Technology: How Did User Interface Failures Onboard the U.S.S. Vincennes Lead to 290 Dead?

• Reference #22. Automation in Aviation.

• Reference #25. U.S. Department of Transportation, Federal Aviation Administration. FAA AC- 120-51E: Crew Resource Management Training.

• Reference #26: U.S. Department of Transportation, Federal Aviation Administration. The Evolution of Airline Crew Resource Management.

• Reference #27: Crew Resource Management: Head in the Game. Retrieved from Crew Resource Management: Head in the game - AOPA

• Reference #28. U.S. Department of Transportation, Federal Aviation Administration. CRM Aspects in Incidents / Accidents.

Graded Assignments

• Discussion Question #6

• Written Assignment #3

• Quiz #2

Weeks 9 & 10

Learning Objectives

• 1. Review and analyze the Eastern Airlines Flight 401 accident and discuss the accident specifically as it relates to the principles of Crew Resource Management (CRM)

• 2. Review and analyze the United Airlines Flight 232 accident and discuss the accident specifically as it relates to the principles of Crew Resource Management (CRM)

Reading Assignments

• Eastern Air Lines Flight 401 accident data

• United Airlines Flight 232 accident data

Graded Assignments

• Discussion Question #7

• Discussion Question #8

• Written Assignment #4

Weeks 11 & 12

Learning Objectives

• 1. Analyze and summarize the key issues in some important aviation accidents that resulted from major lapses in aeronautical decision making and crew resource management. Choose any two of the accidents listed in Reference #29 to review. Which two accidents you choose to review is entirely up to you. Review the ADM and CRM issues associated with these accidents. Note: Do not choose Eastern Airlines Flight 401 or United Airlines Flight 232 that we reviewed in Module #5. Note: Do not choose both the Ethiopian Airlines Flight 302 and the Lion Air Flight 610 accidents. They are different accidents, but they have the same root cause. In your reviews be sure to cover at least the following points:

  • Review of the facts of the accident

  • Review of the qualifications, experience, and fate of the flight crew

  • Review of the qualifications, experience, and fate of the cabin crew

  • Review of the number and fate of the passengers

  • Review of the accident investigation process

  • Review the results of the accident investigation

  • Review the FAAs, or the foreign country’s “FAA”, initial response to the accident

  • Review the FAAs, or the foreign country’s “FAA”, final response to the accident

  • Review the initial response to the accident from the aircraft manufacturer

  • Review the final response to the accident from the aircraft manufacturer

  • Did the aircraft manufacturer ever accept any responsibility for this accident

Graded Assignments

• Discussion Question #9

• Discussion Question #10

• Quiz #3

Weeks 13 & 14

Learning Objectives

• 1. Analyze and summarize the key issues in some important aviation accidents that resulted from major lapses in aeronautical decision making and crew resource management.

Choose any two of the accidents listed in Reference #29 to review. Which two accidents you choose to review is entirely up to you. Review the ADM and CRM issues associated with these two accidents. Note: Do not choose Eastern Airlines Flight 401 or United Airlines Flight 232 that we reviewed in Module #5. Note: Do not choose both the Ethiopian Airlines Flight 302 and the Lion Air Flight 610 accidents. They are different accidents, but they have the same root cause. Note: Do not choose either of the two accidents that you reviewed in Module #6.

In your reviews be sure to cover at least the following points:

• Review of the facts of the accident

• Review of the qualifications, experience, and fate of the flight crew

• Review of the qualifications, experience, and fate of the cabin crew

• Review of the number and fate of the passengers

• Review of the accident investigation process

• Review the final results of the accident investigation

• Review the FAAs, or the foreign country’s “FAA”, initial response to the accident

• Review the FAAs, or the foreign country’s “FAA”, final response to the accident

• Review the initial response to the accident from the aircraft manufacturer

• Review the final response to the accident from the aircraft manufacturer

• Did the aircraft manufacturer ever accept any responsibility for this accident

• Review of ADM and CRM issues associated with these accidents

Graded Assignments

• Final Course Paper

• Final Exam

I am expecting that all course work will be submitted on time per the course schedule.

Discussion Questions. The purpose of a discussion question is to engage the class. After the assignment has been closed there can no longer be class discussions. Discussion questions cannot be made up after the assignment has been closed.

Written Assignments. Written assignments that are submitted up to a week late will be awarded a maximum of 50% of the possible points. Written assignments that are more than a week late will not be accepted.

Quizzes. Quizzes that are submitted up to a week late will be awarded a maximum of 50% of the possible points. Quizzes that are more than a week late will not be accepted.

Course Final Papers. Due to the limited time available for submitting final course grades, final course papers will not be accepted late.

Final Exams. Due to the limited time available for submitting final course grades, final exams will not be accepted late.

I have been experimenting with using AI on aviation topics.

My experience so far has been that it is sporadic for use in aviation technical applications.

The results I have had indicate that the results that AI currently produces on aviation technical topics are very often ambiguous, incomplete, inaccurate, and sometimes technically incorrect.

When you turn in work for an SUU aviation class, your work is reflective of your understanding of the topic, your ability to apply that understanding, and your ability to communicate that understanding.

If the work you submit is excellent, you own it.

If the work you submit is ambiguous, incomplete, inaccurate, and sometimes technically incorrect - as I have found AI to be on aviation technical topics - you own that too.