pilot offset the one unchanging factor that remains despite all the changes in improved flight safety—the human factor. It
is estimated that 90 percent of balloon accidents are human factors related.
ADM builds on the foundation of conventional decision- making, but enhances the process to decrease the probability
of pilot error. ADM provides a structure to analyze changes that occur during a flight and determine how these changes
might affect a flight’s safe outcome. This process includes identifying personal attitudes hazardous to safe flight, learning
to recognize and cope with stress, developing risk assessment skills, and evaluating the effectiveness of one’s ADM skills.
Hazardous Attitudes & Antidotes
A hazardous attitude, which contribute to poor pilot judgment, can be effectively counteracted by redirecting that hazardous
attitude so that correct action can be taken. Recognition of a hazardous thought is the first step toward neutralizing it.
After recognizing a thought as hazardous, the pilot should label it as hazardous, then state the corresponding antidote.
The antidotes for each hazardous attitude should be memorized so it automatically comes to mind when needed. Each
hazardous attitude with its appropriate antidote or learning modification is shown in Figure 1-5.
Taking
chances is
foolish.
Follow the
rules. They are
usually right.
It could
happen to me.
Not so fast.
Think first.
I'm not
helpless.
I can make a
difference.
HAZARDOUS ATTITUDES ANTIDOTES
Macho—Brenda often brags to her friends
about her skills as a pilot and wants to
impress them with her abilities. During her
third solo flight she decides to take a friend
for a balloon ride.
Anti-authority—In the air, she thinks “It’s
great to be up here without an instructor
criticizing everything I do. His
do-it-by-the-book attitude takes all of the fun
out of flying.”
Invulnerability—Brenda soon realizes that
the winds are much stronger than she had
thought and in a different direction than
forecast. But she feels confident that her
skill will still allow a long flight from the
launch site so she can show her friend the
countryside. She thinks, “It’s no more
difficult than many of the flights with my
instructor.”
Impulsivity—While flying low over a
neighborhood preparing to land, Brenda
notices a number of adults and children in
the middle of the street watching the
balloon pass overhead. She decides to
descend even lower, to rooftop level, to
impress both the spectators and Sarah, her
passenger. As she levels out, she notices
the power lines running just below the
treetops and narrowly misses one of them.
Resignation—At the end of a local flight,
Brenda does not adequately plan for a fast,
hard landing. She fails to vent sufficiently
on touchdown, and ends up draping the
balloon envelope over the trees on the far
edge of the landing area, with no damage.
As she and her passenger exit the balloon,
she says to herself, “Oh well, it’s all part of
learning to fly."
Figure 1-5. A pilot should be able to identify hazardous attitudes and apply the appropriate antidote when needed.
Stress Management
An important component of the ADM system is the ability to recognize stress. Stress is a term used to describe the body’s
nonspecific response to demands placed on it. Stress can be emotional, physical, or behavioral, and it is important for a
pilot to become knowledgeable about stress and how to cope with it.
Risk Assessment Analysis
An examination of the National Transportation Safety Board (NTSB) reports and other accident research can help a pilot
to assess risk more effectively. For example, studies indicate the types of flight activities that are most likely to result in
the most serious accidents. For balloons, landing accidents consistently account for over 90 percent of the total number of
accidents in any given year.
These accidents consistently account for the majority of injury to pilots and damage to balloons. Accidents are more
likely during landing because the tolerance for error is greatly diminished and opportunities for pilots to overcome errors
in judgment and decision-making become increasingly limited, particularly in high wind conditions. The most common
causal factors for landing accidents include collision with obstructions in the intended landing area. Prior to a flight, a pilot
should assess personal fitness. The “I’m Safe Checklist” helps a pilot determine their ability to fly. [Figure 1-6]
Illness—Do I have any symptoms?
Medication—Have I been taking prescription or
over-the-counter drugs?
Stress—Am I under psychological pressure from
the job? Worried about financial matters, health
problems, or family discord?
Alcohol—Have I been drinking within 8 hours?
Within 24 hours?
Fatigue—Am I tired and not adequately rested?
Eating—Am I adequately nourished?
I’M SAFE CHECKLIST
Figure 1-6. Prior to flight, a pilot should assess personal fitness, just as they evaluate the balloon’s airworthiness.
Evaluating ADM Skills
The “What If” discussions an instructor pilot has with a student pilot are designed to accelerate development of decision-
making skills by posing situations for the trainee to ponder. Research has shown that these types of discussions help build
judgment and offset low experience. Once a student pilot has obtained their certification, it is important that they continue
to evaluate flight decisions. To self-evaluate:
• Pose an open-ended question about the situation encountered during flight.
• Examine the decision made.
• Explore other ways to solve the problem.
• Evaluate whether or not the best solution was used.
Crew Resource Management (CRM)
ADM originated with the airline industry in an attempt to reduce human factors in aircraft accidents. The airlines developed
a training program for flight crews called Crew Resource Management (CRM). It focuses on the effective use of all
available resources to prevent accidents. While CRM focuses on pilots operating in crew environments, many of the
concepts apply to single-pilot operations, but are not a “best fit” for balloon operations.
Single-Pilot Resource Management (SRM)
A variant of the CRM model that may be of more practical application to the balloon pilot is Single-Pilot Resource
Management (SRM), which may be defined as “the art and science of managing all resources (both from on-board and
external sources) available to the single-pilot (prior to and during flight) to ensure the successful outcome of the flight.”
Virtually all ballooning is done as a single-pilot operation; there is no “crew resource” available from the perspective of
having a co-pilot to assist in workload management.
For any single pilot, the primary emphasis of SRM is to integrate the underlying thinking skills needed by the pilot to
consistently determine the best course of action to take in response to a given set of circumstances. SRM integrates the
following concepts:
• Human Resources.
• Risk Management.
• Situational Awareness.
• Training.
• Decision-Making Process.
Human Resources
Balloons differ from general aviation aircraft in the balloon pilot’s reliance on diverse human resources for flight. Human
resources include all groups working with pilots to ensure flight safety. A safe balloon flight includes, but is not limited
to, a crew chief and ground crew, weather briefers, volunteers, spectators, “locals” with current and often unpublished
information on roads and landing sites, landowners, and others who contribute assistance or information. Balloons differ
from airplanes in their reliance on unlicensed, non-FAA-certified/recognized, and even first time volunteers to assemble
and support ground handling of the balloon. Crew action—or inaction—at any stage of flight can contribute as much or
more to flight safety than pilot input. Balloon flight safety often relies on many people beyond those onboard.
For example, a routine inflation on most balloons requires several sets of hands; moderate winds can quickly mean more
help is needed. Having someone to handle a drop line offers a pilot landing site options inaccessible through onboard
maneuvering. Added weight or “hands on” allows a pilot to choose a smaller landing site than when landing unassisted, or
it can mean avoiding trees, power lines, or other obstacles
Crew members make important information contributions to flight safety because crew can access real time flight related
information before a pilot. For example, precipitation is often visible on the chase vehicles long before it compromises a
balloon’s in-flight performance or gains a pilot’s attention. The crew can also warn a pilot who is contour flying into the
sun of power lines downwind or of livestock behind trees or buildings. A crew report on the current state of variable surface
conditions can alert a pilot who is descending or landing into winds different from those of launch or flight. Crew action
can easily mean the difference between a safe flight and an accident.
The essential and decisive roles crew and other human resources play in ballooning also create an ironic dilemma/dynamic
between legal and operational realities. 14 CFR part 91 requires a pilot to act as the sole and final authority regarding
operation of the balloon, yet every pilot also relies on crew who are not trained, certified, or even recognized by any
governing body for a flight to occur. Each pilot thus leads an integral, yet legally invisible team on each flight. Overlooking,
minimizing, or dismissing the crew’s role opens the door to mishaps. Safety often lies in recognizing how the crew’s skill,
knowledge, and experience complement and enhance the pilot’s own. While all final decisions and the responsibility for
safety still rest with the pilot, this broader than usual SRM model recognizes the human resources upon which every pilot
relies for safe flight planning and decision-making.
Risk Management
Flying involves risk. To stay safe, a pilot needs to know how to judge the level of risk, how to minimize it, and when to
accept it. The risk management decision path is best seen through the Perceive-Process-Perform model [Figure 1-7] which
offers a structured way to manage risk.
Figure 1-7. The Perceive-Process-Perform model.
Perceive hazards by looking at:
Aircraft—A pilot frequently bases decisions to fly on personal evaluations of the aircraft, such as its powerplant,
performance, equipment, fuel state, or airworthiness. A situation to consider: en route to an oil rig an hour’s flight from
shore, having just passed the shoreline, the pilot notices the oil temperature at the high end of the caution range. Should the
pilot continue out to sea or return to the nearest suitable heliport/airport?
• Aircraft performance, fuel.
• Environment (weather, terrain).
• External factors.
Process risk level by considering:
• Consequences posed by each hazard.
• Alternatives that eliminate hazards.
• Reality (avoid wishful thinking).
• External factors (get-home-itus).
Perform risk management:
• Transfer—can someone be consulted?
• Eliminate—can hazards be removed?
• Accept—do benefits outweigh risk?
• Mitigate—can the risk be reduced?
During each flight, pilots make decisions regarding events that involve interactions between the four risk elements—the
pilot in command, the aircraft, the environment, and the operation. [ Figure 1-8] One of the most important decisions a
pilot in command makes is the go/no-go decision. Evaluating each of these risk elements can help a pilot decide whether a
flight should be conducted or continued. Below is a review of the four risk elements and how they affect decision-making.
To maintain situational awareness, an accurate
perception must be attained of how the pilot, balloon,
environment, and operation combine to affect the flight.
Situation
RISK ELEMENTSRISK ELEMENTS
EnvironmentAircraftPilot Operation
Factors, such as weather and
airport conditions, must be
examined.
The balloon performance,
limitations, equipment, and
airworthiness must be deter-
mined.
The purpose of the flight is a
factor which influences the
pilot’s decision on undertaking
or continuing the flight.
The pilot’s fitness to fly must
be evaluated including com-
petency in the balloon, currency,
and flight experience.
Figure 1-4. Risk elements.
Figure 1-8. When situationally aware, a pilot has an overview of the total operation and is not fixated on one perceived significant
factor.
• Pilot—a pilot continually makes decisions about their competency, condition of health, mental and emotional state,
level of fatigue, etc. For example, a pilot may plan for an early morning flight after an all night drive, which means
little sleep. Tired, achy, congested from the beginnings of a cold, is that pilot safe to fly?
• Balloon—a pilot frequently bases decisions on the evaluations of the balloon, such as performance, equipment, or
airworthiness. A pilot is on an afternoon flight in a rural area. Landing areas are becoming sparse because the terrain
is mostly swampland. The wind is decreasing and sunset is only half and hour away. Should they continue to fly
over this terrain?
• Environment—this encompasses many elements not pilot or balloon related. It includes, but is not limited to, such
factors as weather, terrain, launch and landing areas, and surrounding obstacles. Weather is one element that can
change drastically over time and distance. During an afternoon flight with an indefinite ceiling, slight precipitation
and the rumble of thunder is encountered. Should the pilot stay aloft, trusting the weather briefing’s assertion that
“there is no precipitation in the area,” or land at the first available site as soon as possible?
• Operation—the interaction between the pilot, the balloon, and the environment is greatly influenced by the purpose
of each flight operation. The pilot should evaluate the three previous elements to decide on the desirability of
undertaking or continuing the flight as planned. It is worth asking why the flight is being made, how critical it is to
maintain the original intent, and if the continuation of the flight is worth the risks?
Effective Situational Awareness
Situational awareness is the accurate perception and understanding of all the factors and conditions within the four
fundamental risk elements that affect safety before, during, and after the flight. To maintain situational awareness, a
pilot needs to understand the relative significance of these factors and their future impact on the flight. When a pilot is
situationally aware, they have an overview of the total operation.
Some obstacles to maintaining situational awareness include (but are not limited to) fatigue, stress, and work overload;
complacency; and classic behavioral traps such as the drive to meet or exceed flight goals. Situational awareness depends
on the ability to switch rapidly between a number of different, and possibly competing, information sources and tasks
while maintaining a collective view of the environment. Experienced pilots are better able to interpret a situation because
of their base of experience, but newer pilots can compensate for lack of experience with the appropriate fundamental
core competencies acquired during initial and recurrent flight training. SRM training helps the pilot maintain situational
awareness, which enables the pilot to assess and manage risk and make accurate and timely decisions. To maintain
situational awareness, all of the skills involved in ADM are used.
The Decision-Making Process
Understanding the decision-making process provides a foundation for developing the necessary ADM skills. Some
situations, such as an extinguished pilot light, require an immediate response using established procedures. While pilots
are well trained to react to emergencies, they are not as prepared to make decisions that require a more reflective response.
The ability to examine any changes that occur during a flight, gather information, and assess risk before reaching a decision
constitutes the steps of the decision- making process.
Defining the Problem
Problem definition is the first step in the decision-making process. Defining the problem begins with recognizing a change
has occurred or an expected change did not occur. A problem is perceived first by the senses and then is distinguished
through insight and experience. This “gut” reaction, coupled with an objective analysis of all available information,
determines the exact nature and severity of the problem.
Choosing a Course of Action
After the problem has been identified, the pilot should evaluate the need to react to it and determine the actions that need to
be taken to resolve the situation in the time available. The expected outcome of each possible action should be considered
and the risks assessed before deciding on a response to the situation.
Although a decision may be reached and a course of action implemented, the decision-making process is not complete. It
is important to think ahead and determine how the decision could affect other phases of the flight. As the flight progresses,
the pilot should continue to evaluate the outcome of the decision to ensure that it is producing the desired result.
The DECIDE Model
A common approach to decision-making for the last decade has been the rational choice model. This concept holds that
good decisions result when a pilot gathers all the information related to a particular scenario, reviews it, analyzes the
options available, and decides on the best course of action to follow.
The DECIDE Model, a six-step process intended to provide the pilot with a logical way of approaching decision-making,
is an example of this concept. The six elements of the DECIDE Model represent a continuous loop process to assist a pilot
in decision-making. If a pilot uses the DECIDE Model in all decision-making, it becomes natural and results in better
decisions being made under all types of situations. [Figure 1-9]
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 action necessary to adapt to the change.
Evaluate the effect of the action.
DECIDE MODEL
Figure 1-9. The DECIDE Model can provide a framework for effective decision-making.
The OODA Loop
Colonel John Boyd, USAF (Retired), coined the term and developed the concept of the “OODA Loop” (Observation,
Orientation, Decision, Action). [Figure 1-10] The ideas, words, and phrases contained in Boyd’s briefings have penetrated
not only the United States military services, but the business community and academia around the world. The OODA Loop
is now used as a standard description of decision-making cycles.
Dave has received his weather information
for an afternoon flight, and finds the winds
are forecast to stay above 7 mph until just
before sunset. He goes ahead with
planning the flight, believing the winds will
decrease, and will soon be going out to the
launch site to start preparations for launch.
In this example, Dave is in the Observe part
of the decision cycle. He will continue to
Observe until he detects a condition that
would cause him to cancel the flight. Dave
has completed a full cycle of the OODA
Loop, but has returned to the Observe node
to continue to monitor the weather.
Upon reaching the launch site, Dave
checks the winds using a pibal and finds
that winds are decreasing. He believes a
flight can be safely conducted, and goes
ahead with his launch plans. After launch,
Dave finds that the winds are in a direction
that is not quite what was forecast, and are
taking him into an area with few good
landing areas. He continues the flight, and
watches the direction closely to detect any
further change of direction.
In this example, Dave has completed an
OODA decision-making cycle, and has
returned to the Orient node. He will contin-
ue to monitor the situation, being aware of
changes, and is prepared to make a
decision when the situation warrants.
Twenty minutes into the flight, Dave notices
frost forming on the outside of the fuel fitting
leading to the burner. Since he cannot
tighten the fitting (it is a fixed fitting), he
decides to shut off the fuel on that side, vent
the line, and land as soon as practicable in
accordance with the established “emergen-
cy” procedure.
Here, Dave has completed an entire
Decision cycle in a very short time due to
the circumstances of the situation. He will
now move to the Act node, and will take
action to resolve the issue before it causes
danger to him or his passenger.
While making an approach to land, Dave’s
passenger, Pat, alerts him to powerlines
running across the near side of the small
field. Dave evaluates his approach and Acts
to land accordingly, knowing that winds
may shift somewhat as he descends. He
touches down well past the powerlines,
never having put him or his passenger at
risk, and has an uneventful deflation.
Dave again completed an OODA Loop
decision-making cycle. Had there been an
indication that the approach could not be
safely completed, Dave could have made a
decision to abort the landing (Decide), and
then performed an Act to effect a change.
ACT
OBSERVE
ORIENT
DECIDE
OBSERVE
ORIENT
DECIDE
ACT
ORIENT
DECIDE
ACT
OBSERVE
DECIDE
ACT
OBSERVE
ORIENT
Figure 1-10. Using the OODA Loop as a model, it is possible to have multiple decision-making cycles in progress, in different stages
of completion. While these examples show a sequence, this is not always the case; the OODA Loop cycles may overlap in any stage of
execution.