Some time ago I wrote about a review of a Decision Making Model (FORDEC).

During that
article I clarified that there is a clear difference between a Decision Making Model versus
a Non Normal Management Model. Usually you have to deal with the NNM first before
you get as far into the flight as having to make real decisions with conflicting information
and requirements. Im using ANC AAM
Aviate Navigate Communicate Assess Action Manage.
Please note that :

(a) Diagrams are NOT my forte; and

(b) Im NOT doing anything new here.

Non Normal Management Model ANC AAM

Many pilots, in most situations, have no need of a non-normal management model to
follow. Their training, practice and experience combined with SOPs and the support of a
good PM/PF to take them through most NNM events to a good result without incident.

However outside of these beneficial influences, pilots at the beginning of their careers;
pilots who dont benefit from a common structure that promotes functioning as part of a
team on the flight deck; pilots new to type, to a set of SOPs, to a Company; pilots
experiencing a NNM the like of which they havent been directly trained for in all of
these situations a common management model framework brings direction and control
to a NNM event. Encouraging both process and flow through the procedures while
emphasising the importance of the basics Blue Side Up; Power + Attitude =
Performance; Whos Flying The Plane?; and all that good stuff.

It must be appreciated that ANC (most particularly Aviate) underpins all NNM
management. At no point should the instructor be able to lean forward and ask that
terrible question So Whos Flying The Plane?
 Non Normal Management Model

Aviate Navigate Communicate (ANC)

ANC is an axiomatic industry standard to assist crew in task prioritization at any stage of
flight not just during NNMs.

Aviate emphasizes aircraft flight path and control both PF controlling flight
path; PM monitoring both flight path and the PF.
Navigate is a priority with the inherent aspects of Terrain Clearance; awareness
of Weather and other wider navigation goals including ATC compliance.
Communicate follows once aircraft flight path is assured and short term
navigation has been agreed and implemented by the crew.
Assess Action Manage (AAM)
AAM structures the less immediate non-normal handling sequences for the crew. When a
NNM presents (after ANC) AAM inputs flow and process to the next crew response to the
NNM event.
An Assessment phase requires crew to slow down, review indications and think
prior to selecting the
Action which can range from Memory Items, NNM checklist, or just the
agreement that an immediate response is not required. After that
Management of the NNM at the end of AAM release the crew into more
traditional handling aspects of decisions relating to Return/Diversion; Weather and
Terrain assessment; Aircraft Configuration Impact; Passenger Needs; Aircraft
Performance Impact and how these impact back on the Return/Diversion
decision.
Note that at either the Assessment or Management phase the crew may well be
required to utilise a Decision Making Model when the correct resolution is not clear to all
involved or especially if theres conflicting views on the best (that is, safest) way
forward.
Change. Not as good as a Holiday
Should the scenario change (such as a change to the NNM; an additional NNM; change
to the conditions of weather/fuel/passengers, etc) the pilot may well be required to
abandon the current process (whether in the midst of Navigate/Communicate or
Assess/Action/Manage) and return to Aviate Fly The Plane.
Sample Scenario : Engine Failure After Takeoff (EFATO)
During takeoff, an engine malfunction (severe damage) results in a failed engine with
the additional loss of a hydraulic system. Apart from thrust loss, the primary means of
flap retraction has also failed. The PF has dealt with the initial yaw response of the
failure and safely delivered the aircraft to 400 feet, where the memory items associated
with any applicable NNM checklist would normally be commenced. What do the crew do
now?

EFATO and ANCAAM

Aviate Navigation Communicate ? Assess Action Manage

Aviate : Flight path always remains the highest calling for both the PF and the PM.
Power, Attitude and Performance are the active task of the PF; monitoring remains the
primary task of the PM to keep the aircraft safe.
Navigate : In this specific NNM the PF/PM must consider the requirement for any
Engine Out Procedure (EOP) to keep the aircraft clear of terrain. The EOP takes priority
over everything else other than Aviate. Note that while navigation has come in at 400 ft
during this narrative its entirely possible that a turn may have been required earlier to
comply with an EOP that keeps the aircraft clear of obstacles close in on the takeoff
flightpath.
Communicate : Communications can be a priority for several reasons whether to
advise the intention to deviate from clearance to satisfy the requirements of the EOP; or
to ensure that ATC are in the picture to be able to offer assistance when it becomes
required. Of course, Aviate/Navigate remains a priority over Communicate.
Assess : Having ensured ANC, the crew now need to assess the required response to
the NNM. In this situation, this is a formalised assessment of the EICAS and engine
failure indications as well as any immediate requirements of a hydraulic system loss
(this is a 777 there arent any). In this situation its a formalised assessment of EICAS
commencing with an EICAS message Review (noting both Engine and Hydraulic failure
indications) as well as assessing airframe vibration indications. In this case checklist
memory items will be required.
Action : The PF now calls for the action phase, Engine Severe Damage Separation
Left Memory Items. Both crew are involved in actioning the checklist memory items.
As always ANC remains paramount with both PF and PM required to ensure/monitor
flight path and compliance with the EOP during the Action phase.
Manage : Management commences after the required Assess/Action responses to the
NNM are complete. By this time the aircraft is clean, clear of terrain and any relevant
NNM and NM checklists are complete. Management at this point necessitates Decision
Making in which FORDEC may be required. The aircraft is damaged, with a landing
performance impact from both the engine and hydraulic failures. These and
other Facts such as weather and terrain will require the crew to determine and evaluate
the available Options?and the Risk/Benefit to flight those options present, before
agreeing on a Decision as to a course of action. Once a decision is reached the crew
will Execute the decision along with all the necessary communication of intent that
implies. Any good decision making process requires follow up and at some point the
crew must implement a positive?Check that the outcomes are as expected.
 ANC AAM - Circles within Circles

ANC and AAM do not exist in isolation. ANC overrides any sequence of events from the
beginning to the end of the flight. AAM is continually in use during various phases of
flight in response to stimuli external to the crew for example:

During acceleration and cleanup after takeoff, the failed hydraulic system results
in the EICAS alert [] FLAPS PRIMARY. The crew response? First response is always
ANC Fly The Aircraft. The crew will Assess the failure, understanding that
the FLAPS PRIMARY alert indicates that the flaps are attempting (and
succeeding) to retract using the secondary (electric) system. As such, the
only Action required is perhaps to monitor airspeed as flap retraction will be slow
and speed intervention may be required to keep clear of the flap limit speed. The
flap system failure will involve itself later in the Management phase as
aFact when deciding the final disposition of the flight.
Having completed the acceleration and flap retraction phase of the takeoff the
crew have to decide what to do next. ANC requires that the crew ensure continued
safe flight path, and suggests the requirement to make a short
term Navigation decision. This navigation decision is typically between continuing
away from the departure airfield; holding in the area; or diverting to a takeoff
alternate. Much of this decision making is often made on the ground as part of the
departure brief.
 The 777 EICAS incorporates AAM principles as part of the EICAS Review / Memory Items /
Checklist / Notes /Non-Normal before Normal methodology. During the above scenario,
EICAS prompts crew during the takeoff (within the bounds of takeoff inhibits) with a
series of alert messages (Warning, Caution, _Advisory) some of which have
checklists, some of those checklists require early completion of memory items. ANC
requires that crew ignore these during the first critical phase of flight to 400 ft
(unless Aviate is compromised). At 400 ft with ANC established the crew Assess the
need for a response and Action the required memory items.

Hydraulic Problems: Guidance for Flight Crews

Categories:
Aircraft Emergency and Unusual Situations
Flight Technical
Article Information

Category: Emergency & Contingency

Content source: SKYbrary

Content control: Air Pilots

Contents

[hide]

1 Description

2 Overview

3 Effects

4 Failure Recognition

5 General Considerations

6 Immediate Actions

7 Secondary Actions
 8 Formulate, Communicate and Execute Plan of Action

9 Accidents & Incidents

10 Related Articles
Description
This article provides guidance to pilots on the recognition and consequences of hydraulic problems, and also
some of the factors they should consider during their decision process and subsequent operation of the aircraft
to help ensure a safe outcome.

Overview
Hydraulic systems of some description are present on virtually all aircraft types. In a light or general aviation
aircraft, the use of hydraulic power may be limited to the application of wheel brakes only. In larger and more
complex aircraft multiple systems may be used to provide the muscle to operate a wide variety of components
and systems. For example, these could include primary and secondary flight controls, the landing gear,
nosewheel steering, wheel brakes, thrust reversers and cargo doors.

As the dependency upon hydraulic power increases, the integrity of the hydraulic systems becomes ever more
critical to the safety of flight. Based on this hydraulic system criticality, many design features are incorporated to
ensure reliability, redundancy and the ability to maintain control of the aircraft in the event of one or more
failures. Often two or more hydraulic systems are built into the design of an aircraft.

Each system is provided with different sources of fluid pressurization and power generation. This power is
transmitted by the hydraulic fluid through system specific hydraulic lines and used to drive the motors and
actuators associated with that system. While hydraulic systems may be designed to exchange power under
controlled conditions via a Power Transfer Unit (PTU), there are very rarely provisions for any exchange of
fluids incorporated into system designs.

Effects
Depending on the specific failure or the extent of damage to the hydraulic system(s), the following effects could
result:

Loss of control

Partial or complete loss of control over specific control surfaces

Loss of autopilot

Reversion to a degraded flight control law

Impact on/collateral damage to other systems (e.g. due to a ruptured hydraulic pipe)

Possible loss of ETOPS and/or RVSM capability

 Loss of low visibility landing capability due to degraded autopilot or flight controls

Difficulties with normal landing gear extension

Inability to retract landing gear

Inability to extend/retract high lift devices such as flaps or slats

Reduced braking capability upon landing

Loss of anti-skid systems

Inability to actuate thrust reversers

Loss of nosewheel steering

Failure Recognition
Hydraulic failures can be subtle (as would be the case with a slow fluid leak) or immediate (as the result of a
pump failure, an actuator failure or the rupture of a hydraulic line). Depending upon the sophistication level of
the aircraft warning systems in question, the failure could be presented to the crew by means of
an EICAS or ECAM message, a Master Caution or Master Warning light, an annunciator panel fail light, a
system warning light or by means of a pressure or quantity gauge indication. An aural warning may also be
associated with the failure.

Pilots should acknowledge the failure annunciation by cancelling any aural warnings and, where possible,
confirm the failure in accordance with the aircraft operator's Standard Operating Procedures and with the
manufacturer's guidance prior to carrying out the immediate corrective actions.

General Considerations
Manufacturers provide aircrew with comprehensive abnormal and emergency procedures for use in the event of
a single or multiple failure. These procedures and the associated protocols will include the immediate actions
required to secure the emergency, limitations and system losses resulting from the failure and, when applicable,
the appropriate configuration and performance penalties to be utilized for continuing the flight and subsequent
landing. The consequences of multiple failures are taken into consideration where applicable.

As is the case with any unusual or emergency situation, pilots should complete the required memory items and
then comply with the manufacturers procedures, checklists and protocols and with any applicable company
policies or directives. They should then consider the consequences of the failure and the associated impact on
the continuation of the flight.

Pilots should consider all available information, inclusive of but not limited to, aircraft controllability, range,
operating altitudes, runway requirements and weather, and exercise their best judgement when making
diversion decisions. In all cases, the primary pilot responsibility is to FLY THE AIRCRAFT.

Immediate Actions
 FLY THE AIRCRAFT. A hydraulic failure may or may not result in loss of some primary or secondary
control surfaces. It may also result in the loss of the autopilot. Therefore, it is critical that the pilot flying (PF)
maintain focus on the continued safe control of the aircraft. With multiple hydraulic system or component
failures, control of the aircraft may be difficult. The extreme, but highly unlikely, case of a total loss of
aircraft hydraulics could necessitate the non-standard use of engine thrust to maintain aircraft control (e.g.
DC-10, Sioux City, 1989).

Perform Memory Actions. If there are memory drills associated with the failure, they should be
completed in a timely fashion. In a multi-crew aircraft, memory items and the follow-on checklists and
procedures will be completed by the pilot monitoring (PM) with confirmation of critical actions, when
appropriate, from the PF, using challenge and response.

Complete Associated Checklists. Perform QRH, checklist or ECAM procedures as appropriate to the
aircraft type.
Secondary Actions
The type of aircraft, the complexity of the failure, previous and/or subsequent failures, and the circumstances
under which the malfunction has occurred will determine what secondary actions should be taken. Actions that
could be applicable to the situation include:

Advise ATS. Depending upon the specifics of the failure, it may be prudent to declare an emergency
using the appropriate Emergency Communications (MAYDAY or PAN) format. While the crew may not have
yet formulated their plan of action, advising ATC of the hydraulic problem(s) will permit them to provide
early assistance which may include:

separation of the aircraft from other traffic

providing diversion clearance or facilitating delaying tactics by providing vectors or a holding

clearance

prioritisation of the emergency aircraft for landing allowing for a long final if requested

assigning a discrete radio frequency when possible

advising the airport emergency services and all concerned parties in accordance with local
procedures/protocols

providing any information that might be requested by the crew such as weather, type of
approaches available, runway length and other pertinent aerodrome details

Confirm Aircraft Systems Status. The crew should ascertain the status of not only the hydraulic
system(s), but also any other aircraft system(s) that may have been affected by the failure.
 Calculate Approach Speeds and Landing Distance. In many cases, a hydraulic failure will have an
impact on approach and landing speeds, cross-wind limits and landing distance required. Higher approach
and landing speeds will be required if flight controls are degraded or if high lift devices cannot be extended
due to the failure. Higher approach speeds will result in significantly longer than normal landing distances
as landing distance is a function of mv2. Landing distances will also be increased should the failure result in
degradation of braking capability, loss of ground spoilers or the inability to deploy thrust reversers.

Determine Landing Weather Requirements. Some hydraulic failures can result in the loss of the
aircraft all weather capability due to loss of the autopilot, the resultant landing flap position or to
degradation in flight control function.

Confirm Range and Endurance. If the hydraulic failure has resulted in the inability to retract the
undercarriage, flaps or slats, a higher than normal rate of fuel consumption will result. It may also be
necessary to operate at a lower than normal altitude, in which case minimum safe altitudes must be
checked. In these cases, it is critical that flight crew fuel management takes the abnormal configuration or
operating level into consideration. During any hydraulic emergency, the time required before the crew is
ready to land may be extensive due to the requirement for a diversion and/or to otherwise prepare for the
landing. The crew must remain aware of the fuel state at all times.

Gather Any Other Pertinent Information. Use onboard information sources such as approach charts
and the MEL plus external resources (via ATS, ACARS or Company communications) to compile airfield
data, weather reports, runway condition and other information to be considered in the decision process.
Request technical support as required.

Consider the Implications of the Failure. Develop a clear picture of the impact of the failure on the
approach, landing and post landing operations. For example:

will the failure require an alternate landing gear extension procedure?

if an alternate extension is required, when would be the most prudent time to carry out
the procedure?

if an alternate extension is required, will the inability to retract the gear compromise
missed approach obstacle clearance in the event a go around is required?

on a fly by wire aircraft, will the failure result in a change of control law when the landing gear
is extended?

will the failure allow for normal braking or will it require alternate braking techniques due to the
loss of anti-skid or to sole reliance on accumulator pressure?

are thrust reversers available?

 is the nosewheel steering functional?

Should the landing procedure consider leaking hydraulic fluid might come into contact with hot
brakes on landing?

can the aircraft be taxied clear of the active runway?

Formulate, Communicate and Execute Plan of Action
Once the applicable secondary actions have been completed, pilots can determine their best course of action.
The salient details of the plan should be transmitted to ATC and to Company Operations to enable co-ordination
of any required support. ATC will need to know:

diversion aerodrome, requested runway and intended approach.

distance at which the crew would like to join the final approach course.

If the aircraft will need to configure earlier than normal during approach and require non-standard
speed control/vertical profile.

approach speed if it will be significantly higher than normal.

if the aircraft will be stopped on the runway.

if the aircraft will be able to vacate the runway under its own power.

Company Operations should also be advised so maintenance co-ordination (such as arrangements to tow the
aircraft off of the runway) and commercial considerations (customs, passenger handling etc.) can be arranged.

Contents

[hide]

1 Definition

2 Choice part of the Decision-Making Process

3 Situational Awareness

4 Creating Choice - Alternative Solutions

5 Judgement

6 Choices
 7 Limitations to Choice

8 Related Articles

9 Further Reading

10 References
Definition
Choice is used interchangeably between a noun (a chosen item or course of action - My choice is the green
one or My choice is to turn back) and a verb (choosing an option, deciding between possibilities, making a
selection). From these definitions it can be seen that it is common in English usage to interchange the word
choice for both alternative options and decisions. E.g. I have a number of choices from which I can make my
decision and There are several alternative options from which I can make my choice.

In aviation the process of making a choice is more frequently referred to as decision-making. So, for the
purposes of this article, choice here will refer to the creation of alternative options (creating choice) and what
makes an alternative option valid and viable (useful and realistic choice). These are two crucial steps in
the decision-making process:

1. generating possible solutions to complete a task or fulfil a goal, and

2. assessing each of these possible solutions (options) for viability.

These will be explained in more detail below.

Primarily, we are concerned here with choice being made in the moment when dealing with real-time problems
during operations. It could be considered as a normal part of TEM and tactical decision-making.

This is not to distract from the importance, in aviation, of strategic decision-making and the importance of choice
when planning. In these cases there will be a greater amount of time available to consider potential impacts on
other elements of the organisation/system, and ideally it should be used to exhaust the possibilities of setting a
latent error.

Choice part of the Decision-Making Process

Decision-making can be defined as the cognitive process of selecting a course of action from among multiple
alternatives; however, it is better described as a process with several steps, one of which is the creation of
those multiple alternatives.

Decision-making needs to be a structured procedure in order to facilitate collection of all relevant facts,
elimination of instinctive analyses, biased thinking (such as inferences and assumptions), setting of viable
goals, creation of viable options, assessment of those options for risk versus outcome, making a logical choice
(the decision itself), and implementing a plan and process for continually assessing the progress and impact of
the chosen course of action.
These steps are most easily seen in the many decision-making models that are used by pilots and air traffic
controllers as decision-making aids. Two are shown below:

D-E-C-I-D-E Model[1]

1. Detect a change, or Describe the situation

2. Estimate significance threat, error and risk assessment

3. Choose a safe outcome set/agree a goal

4. Identify possible actions/options in what ways can the outcome/goal be achieved

5. Do - take action (this implies that a choice has been made from the possible actions/options)

6. Evaluate the result success in achieving a goal/outcome must ultimately be measurable, but it is
deviations from the implemented action/option that need to be monitored which either confirm that the
goal remains achievable or is no longer likely without further changes.

In this model, step 3 is choosing a safe outcome we are not concerned here with this choice; often the safe
outcome will be known and/or clear, such as, landing safely, avoiding conflict, or completing the task
successfully. Instead our definition of choice is more closely linked with steps 4 and 5: I Identifying possible
actions/options, which is about creating choice; and, D prior to taking action choosing one of the options
preferably the most favourable (see Judgement below).

G-R-A-D-E Model

1. Gather Information about the situation

2. Review Information increase situational awareness and assess risks

3. Analyse Alternatives predict (from experience) those alternative options that are most likely to
succeed safely.

4. Decide i.e. select one of the alternatives (and act)

5. Evaluate Outcome of Action

In this model the element of choice is implied, but not stated, between steps 3 and 4: A Analyse Alternatives,
assumes that alternative courses of action have been created to allow some choice; and, D Decide (what to
do) assumes that a choice has been made.

Situational Awareness
This is a short paragraph, but probably contains the most important sentence written on this whole page.
A pilots level of situational awareness determines the solutions that will be considered and helps guide
the choice of a response.

Creating Choice - Alternative Solutions

To make a choice one needs alternatives to choose from. Choice-making/creating also benefits from being
structured when constraints of time, resources and the presence of threats exist i.e. when manning a busy ATC
sector, or making an approach to land. In such situations choice options are often limited by immediacy, the
operator(s) past experience and confidence in their own abilities and the abilities of others. If time is plentiful
and threats are not imminent i.e. when making long-term management decisions, then choice-creation can be
much less structured to the point where extremely flamboyant options can be, and ought to be, considered
(thinking outside the box).

* One option is no choice. We often use the phrase theres only one thing to do (or something similar); this is
often code for Its the first thing that came into my head and therefore is the most obvious, so it must be right,
and its what we are going to do any questions?. The first solution that comes into our mind, or is voiced
between a crew or team tends to have the greatest attraction and importance; therefore, it is important to
recognise this and create alternatives with equal weight.

* Two options: decision-makers may be drawn to one option in preference to the other, but not always due to its
merits; e.g. it is possible to be primarily persuaded by aversion to the rejected solution, or attracted to another
because it was the first that came to mind. Neither attraction nor aversion should guide choice; attraction and
aversion are driven by our instinctive and impulsive mind and not our rational mind [2]. Relying on instincts,
because they feel right is a human tendency in preference to doing the hard work of thinking.

* Three options: this allows for the seemingly logical rejection of extremes. At one extreme the alternative may
be deemed the most likely to succeed but also the most risky, and at the other extreme the alternative may be
unlikely to achieve the goal but considered the least risky. This is the production v safety dilemma. However, the
remaining (middle) option is not necessarily the best. Our logical analysis can convince us that our final choice
is the ideal, however, this is lazy logic; weve convinced ourselves that we have thought about the problem
when we havent at all.

* 4 options or more: ideally this requires the brain to engage and, if adequate time is available, to reach a
conclusion, then it can lead to a real choice between workable solutions.

*NB: The comments above refer to situations where no Standard Procedure exists, otherwise, in those cases
there would be only one option.

Judgement
Making a choice requires judgement, and the process of judging requires making an assessment. This process
requires that we estimate and then compare: we estimate if something is right or wrong, good or bad, works or
doesnt work etc.; and, we compare alternatives with each other to determine which is the best option. We tend
to assess and judge in two distinct ways [2], intuitively and rationally:

Rational judgement is made expertly using experience, skills, knowledge, and all available and
relevant resources. It is fact based, logical, and this judgement can be altered, adjusted, and changed
when new evidence emerges.
 Instinctual judgement is irrational and value based. It is prone to bias and other cognitive and social
influences. Instinctive judgements are less likely to be changed, even when contrary evidence is presented.
Instead, due to the emotional elements of ego, pride, self-esteem etc, these judgements are more likely to
be reinforced, and supporting evidence sought.
Choices
Options for managing risk from which a choice is made can include:

No go, or cease operation

Limiting operation in some way to reduce exposure to risk by imposing boundaries and limits e.g.

daylight operations only

no single crew operations

tailwind and crosswind limits

Making no changes and continuing to operate, but with increased monitoring

As above, but with the additional requirement to delay making a choice until further information is
available and/or a specific point is reached e.g.:

Deciding to continue to destination aerodrome may be dependant on a satisfactory TAF, but

this may not be available for a period of time, but would need to be obtained before the last point of
diversion. An unsatisfactory TAF may then require mandatory diversion to either of two different
alternative aerodromes. The choice of which alternative can be made in advance, but no action taken
until destination weather is assessed. In effect, choices are made in advance and dependent on further
information.

When unstabilised at 1500ft on approach due to localised turbulence, a crew may select
several pre-set choices (decisions) i.e. continue with approach until 1000ft: if still unstabilised go
around and make one more attempt; if stabilised continue approach; if approach becomes
unstabilised below 1000ft go around and divert.

No further or alternative action required.

Limitations to Choice
When considering solutions to a problem, some options may be perfectly valid, and even ideal, except certain
elements preclude them from being considered as a viable choice, e.g.:

Time constraints when the option requires more time than is available
 Technological restraints when the option requires the use of of some technical equipment or software
which is absent or not functioning correctly

Resource limitations when there is insufficient manpower, technology, procedures, support etc

Lack of knowledge, skill or experience when all the resources are present, but the person, or crew,
are lacking sufficient knowledge, skill or experience between them (this could also pertain to a crew/team
who are qualified in a procedure, but who have not practiced it recently and therefore lack confidence and
certainty)

Unacceptable Risk when the consequences of failure are unacceptable and the risk of failure is
assessed as too high; especially when other available options involve lower risk

Cost solutions are available, and would work very well, but the cost is prohibitive to an operation e.g.
mandating that all gliders (sailplanes) be fitted with weather radar!
Related Articles

Decision Making

Critical Thinking - An Introduction to Situation Awareness and Decision Making - Presentation