Risk is defined as the probability and possible severity of accident or loss from exposure to various hazards, including injury to people and loss of resources [Figure 1]
All Federal Aviation Administration (FAA) operations in the United States involve risk and benefit from decisions that include risk assessment and risk management
Risk management, a formalized way of thinking about these topics, is the logical process of weighing the potential costs of risks against the possible benefits of allowing those risks to stand uncontrolled
Level of Risk:
The level of risk posed by a given hazard is measured in
terms of:
• Severity (extent of possible loss)
• Probability (likelihood that a hazard will cause a
loss)
Assessing Risk
Assessment of risk is an important part of good risk
management. For example, the hazard of a nick in the
propeller poses a risk only if the airplane is flown. If the
damaged prop is exposed to the constant vibration of normal
engine operation, there is a high risk is that it could fracture
and cause catastrophic damage to the engine and/or airframe
and the passengers.
Every flight has hazards and some level of risk associated
with it. It is critical that pilots and especially students are
able to differentiate in advance between a low-risk flight
and a high-risk flight, and then establish a review process
and develop risk mitigation strategies to address flights
throughout that range.
For the single pilot, assessing risk is not as simple as it sounds.
For example, the pilot acts as his or her own quality control
in making decisions. If a fatigued pilot who has flown 16
hours is asked if he or she is too tired to continue flying, the
answer may be no. Most pilots are goal oriented and, when
asked to accept a flight, there is a tendency to deny personal
limitations while adding weight to issues not germane to the
mission. For example, pilots of helicopter emergency services
(EMS) have been known to make flight decisions that add
significant weight to the patient’s welfare. These pilots add
weight to intangible factors (the patient in this case) and fail
to appropriately quantify actual hazards such as fatigue or
weather when making flight decisions. The single pilot who
has no other crew member for consultation must wrestle
with the intangible factors that draw one into a hazardous
position. Therefore, he or she has a greater vulnerability
than a full crew.
Examining National Transportation Safety Board (NTSB)
reports and other accident research can help a pilot learn to
assess risk more effectively. For example, the accident rate
during night VFR decreases by nearly 50 percent once a
pilot obtains 100 hours, and continues to decrease until the
1,000 hour level. The data suggest that for the first 500 hours,
pilots flying VFR at night might want to establish higher
personal limitations than are required by the regulations
and, if applicable, apply instrument flying skills in this
environment.
Several risk assessment models are available to assist in the
process of assessing risk. The models, all taking slightly
different approaches, seek a common goal of assessing risk
in an objective manner.
The most basic tool is the risk matrix. [Figure 9-2] It assesses
two items: the likelihood of an event occurring and the
consequence of that event.
Likelihood of an Event
Likelihood is nothing more than taking a situation and
determining the probability of its occurrence. It is rated as
probable, occasional, remote, or improbable. For example, a
pilot is flying from point A to point B (50 miles) in marginal
visual flight rules (MVFR) conditions. The likelihood of
encountering potential instrument meteorological conditions
(IMC) is the first question the pilot needs to answer. The
experiences of other pilots, coupled with the forecast, might
cause the pilot to assign "occasional" to determine the
probability of encountering IMC.
The following are guidelines for making assignments.
• Probable—an event will occur several times.
• Occasional—an event will probably occur
sometime.
• Remote—an event is unlikely to occur, but is
possible.
• Improbable—an event is highly unlikely to occur.
Severity of an Event
The next element is the severity or consequence of a pilot’s
action(s). It can relate to injury and/or damage. If the
individual in the example above is not an instrument flight
rules (IFR) pilot, what are the consequences of encountering
inadvertent IMC? In this case, because the pilot is not IFR
rated, the consequences are catastrophic. The following are
guidelines for this assignment.
• Catastrophic—results in fatalities, total loss
• Critical—severe injury, major damage
• Marginal—minor injury, minor damage
• Negligible—less than minor injury, less than minor
system damage
Simply connecting the two factors as shown in
Figure 9-2 indicates the risk is high and the pilot must either
not fly or fly only after finding ways to mitigate, eliminate,
or control the risk
Mitigating Risk:
Risk assessment is only part of the equation. After determining
the level of risk, the pilot needs to mitigate the risk. For example, the pilot flying from point A to point B (50 miles)
in MVFR conditions has several ways to reduce risk:
• Wait for the weather to improve to good visual flight
rules (VFR) conditions.
• Take a pilot who is rated as an IFR pilot.
• Delay the flight.
• Cancel the flight.
• Drive.
IMSAFE Checklist
One of the best ways that single pilots can mitigate risk is to
use the IMSAFE checklist [Figure 9-3] to determine physical
and mental readiness for flying: 1. Illness—Am I sick? Illness is an obvious pilot risk.
2. Medication—Am I taking any medicines that might
affect my judgment or make me drowsy?
3. Stress—Am I under psychological pressure from the
job? Do I have money, health, or family problems?
Stress causes concentration and performance
problems. While the regulations list medical conditions
that require grounding, stress is not among them.
The pilot should consider the effects of stress on
performance.
4. Alcohol—Have I been drinking within 8 hours?
Within 24 hours? As little as one ounce of liquor, one
bottle of beer, or four ounces of wine can impair flying
skills. Alcohol also renders a pilot more susceptible
to disorientation and hypoxia.
5. Fatigue—Am I tired and not adequately rested?
Fatigue continues to be one of the most insidious
hazards to flight safety, as it may not be apparent to
a pilot until serious errors are made. 6. Eating—Have I eaten enough of the proper foods to
keep adequately nourished during the entire flight?
The PAVE Checklist
Another way to mitigate risk is to perceive hazards. By
incorporating the PAVE checklist into all stages of flight
planning, the pilot divides the risks of flight into four
categories: Pilot in command (PIC), Aircraft, enVironment,
and External pressures (PAVE) which form part of a pilot’s
decision-making process.
With the PAVE checklist, pilots have a simple way to
remember each category to examine for risk prior to each
flight. Once a pilot identifies the risks of a flight, he or she
needs to decide whether the risk or combination of risks can
be managed safely and successfully. If not, make the decision
to cancel the flight. If the pilot decides to continue with the
flight, he or she should develop strategies to mitigate the
risks. One way a pilot can control the risks is to set personal
minimums for items in each risk category. These are limits
unique to that individual pilot’s current level of experience
and proficiency.
For example, the aircraft may have a maximum crosswind
component of 15 knots listed in the aircraft flight manual
(AFM), and the pilot has experience with 10 knots of direct
crosswind. It could be unsafe to exceed a 10 knots crosswind
component without additional training. Therefore, the 10 kts
crosswind experience level is that pilot’s personal limitation
until additional training with a certificated flight instructor
(CFI) provides the pilot with additional experience for flying
in crosswinds that exceed 10 knots.
One of the most important concepts that safe pilots
understand is the difference between what is "legal" in terms
of the regulations, and what is "smart" or "safe" in terms of
pilot experience and proficiency.
P = Pilot in Command (PIC)
The pilot is one of the risk factors in a flight. The pilot must
ask, "Am I ready for this trip?" in terms of experience,
currency, physical and emotional condition. The IMSAFE
checklist combined with proficiency, recency, and currency
provides the answers.
A = Aircraft
What limitations will the aircraft impose upon the trip? Ask
the following questions:
• Is this the right aircraft for the flight?
• Am I familiar with and current in this aircraft? Aircraft
performance figures and the AFM are based on a brand
new aircraft flown by a professional test pilot. Keep that in mind while assessing personal and aircraft
performance.
• Is this aircraft equipped for the flight? Instruments?
Lights? Navigation and communication equipment
adequate?
• Can this aircraft use the runways available for the trip
with an adequate margin of safety under the conditions
to be flown?
• Can this aircraft carry the planned load?
• Can this aircraft operate at the altitudes needed for the
trip?
• Does this aircraft have sufficient fuel capacity, with
reserves, for trip legs planned?
• Does the fuel quantity delivered match the fuel
quantity ordered?
V = EnVironment
Weather is an major environmental consideration. Earlier
it was suggested pilots set their own personal minimums,
especially when it comes to weather. As pilots evaluate
the weather for a particular flight, they should consider the
following:
• What are the current ceiling and visibility? In
mountainous terrain, consider having higher minimums
for ceiling and visibility, particularly if the terrain is
unfamiliar.
• Consider the possibility that the weather may be
different than forecast. Have alternative plans, and
be ready and willing to divert should an unexpected
change occur.
• Consider the winds at the airports being used and the
strength of the crosswind component.
• If flying in mountainous terrain, consider whether there
are strong winds aloft. Strong winds in mountainous
terrain can cause severe turbulence and downdrafts
and can be very hazardous for aircraft even when there
is no other significant weather.
• Are there any thunderstorms present or forecast?
• If there are clouds, is there any icing, current or
forecast? What is the temperature-dew point spread
and the current temperature at altitude? Can descent
be made safely all along the route?
• If icing conditions are encountered, is the pilot
experienced at operating the aircraft’s deicing or
anti-icing equipment? Is this equipment in good
condition and functional? For what icing conditions
is the aircraft rated, if any? Evaluation of terrain is another important component of
analyzing the flight environment. To avoid terrain and
obstacles, especially at night or in low visibility, determine
safe altitudes in advance by using the altitudes shown on
VFR and IFR charts during preflight planning. Use maximum
elevation figures (MEFs) and other easily obtainable data
to minimize chances of an inflight collision with terrain or
obstacles.
Airport considerations include:
• What lights are available at the destination and
alternate airports? VASI/PAPI or ILS glideslope
guidance? Is the terminal airport equipped with them?
Are they working? Will the pilot need to use the radio
to activate the airport lights?
• Check the Notices to Airmen (NOTAMs) for closed
runways or airports. Look for runway or beacon lights
out, nearby towers, etc.
• Choose the flight route wisely. An engine failure
gives the nearby airports (and terrain) supreme
importance.
• Are there shorter or obstructed fields at the destination
and/or alternate airports?
Airspace considerations include:
• If the trip is over remote areas, are appropriate
clothing, water, and survival gear onboard in the event
of a forced landing?
• If the trip includes flying over water or unpopulated
areas with the chance of losing visual reference to
the horizon, the pilot must be current, equipped, and
qualified to fly IFR.
• Check the airspace and any temporary flight restriction
(TFRs) along the route of flight.
Night flying requires special consideration.
• If the trip includes flying at night over water or
unpopulated areas with the chance of losing visual
reference to the horizon, the pilot must be prepared
to fly IFR.
• Will the flight conditions allow a safe emergency
landing at night?
• Preflight all aircraft lights, interior and exterior, for
a night flight. Carry at least two flashlights—one for
exterior preflight and a smaller one that can be dimmed
and kept nearby. E = External Pressures
External pressures are influences external to the flight that
create a sense of pressure to complete a flight—often at the
expense of safety. Factors that can be external pressures
include the following:
• Someone waiting at the airport for the flight’s
arrival.
• A passenger the pilot does not want to disappoint.
• The desire to demonstrate pilot qualifications.
• The desire to impress someone. (Probably the two
most dangerous words in aviation are "Watch this!")
• The desire to satisfy a specific personal goal ("gethome-itis," "get-there-itis," and "let’s-go-itis").
• The pilot’s general goal-completion orientation.
• Emotional pressure associated with acknowledging
that skill and experience levels may be lower than a
pilot would like them to be. Pride can be a powerful
external factor!
Management of external pressure is the single most important
key to risk management because it is the one risk factor
category that can cause a pilot to ignore all the other risk
factors. External pressures put time-related pressure on the
pilot and figure into a majority of accidents.
The use of personal standard operating procedures (SOPs) is
one way to manage external pressures. The goal is to supply a
release for the external pressures of a flight. These procedures
include but are not limited to:
• Allow time on a trip for an extra fuel stop or to make
an unexpected landing because of weather.
• Have alternate plans for a late arrival or make backup
airline reservations for must-be-there trips.
• For really important trips, plan to leave early enough
so that there would still be time to drive to the
destination.
• Advise those who are waiting at the destination that
the arrival may be delayed. Know how to notify them
when delays are encountered.
• Manage passengers’ expectations. Make sure
passengers know that they might not arrive on a firm
schedule, and if they must arrive by a certain time,
they should make alternative plans. • Eliminate pressure to return home, even on a casual
day flight, by carrying a small overnight kit containing
prescriptions, contact lens solutions, toiletries, or other
necessities on every flight.
The key to managing external pressure is to be ready for
and accept delays. Remember that people get delayed when
traveling on airlines, driving a car, or taking a bus. The pilot’s
goal is to manage risk, not create hazards.
During each flight, decisions must be made regarding events
involving interactions between the four risk elements—PIC,
aircraft, environment, and external pressures. The decisionmaking process involves an evaluation of each of these risk
elements to achieve an accurate perception of the flight
situation [Figure 9-4]
Three-P Model for Pilots:
Risk management is a decision-making process designed to
perceive hazards systematically, assess the degree of risk
associated with a hazard, and determine the best course of
action (see Appendix F). For example, the Perceive, Process,
Perform (3P) model for aeronautical decision-making (ADM)
offers a simple, practical, and structured way for pilots to
manage risk. [Figure 9-5]
To use the 3P model, the pilot:
• Perceives the given set of circumstances for a flight.
• Processes by evaluating the impact of those
circumstances on flight safety.
• Performs by implementing the best course of action. In the first step, the goal is to develop situational awareness
by perceiving hazards, which are present events, objects, or
circumstances that could contribute to an undesired future
event. In this step, the pilot systematically identifies and
lists hazards associated with all aspects of the flight: pilot,
aircraft, environment, and external pressures. It is important
to consider how individual hazards might combine. Consider,
for example, the hazard that arises when a new instrument
pilot with no experience in actual instrument conditions wants
to make a cross-country flight to an airport with low ceilings
in order to attend an important business meeting.
In the second step, the goal is to process this information to
determine whether the identified hazards constitute risk, which
is defined as the future impact of a hazard that is not controlled
or eliminated. The degree of risk posed by a given hazard
can be measured in terms of exposure (number of people or
resources affected), severity (extent of possible loss), and
probability (the likelihood that a hazard will cause a loss).
If the hazard is low ceilings, for example, the level of risk
depends on a number of other factors, such as pilot training
and experience, aircraft equipment, and fuel capacity.
In the third step, the goal is to perform by taking action to
eliminate hazards or mitigate risk, and then continuously
evaluate the outcome of this action. With the example of low
ceilings at destination, for instance, the pilot can perform
good ADM by selecting a suitable alternate, knowing where
to find good weather, and carrying sufficient fuel to reach
it. This course of action would mitigate the risk. The pilot
also has the option to eliminate it entirely by waiting for
better weather. Once the pilot has completed the 3P decision process and
selected a course of action, the process begins again because
the set of circumstances brought about by the course of
action requires analysis. The decision-making process is a
continuous loop of perceiving, processing, and performing.
It is never too early to start teaching students about risk
management. Using the 3P model gives CFIs a tool to teach
them a structured, efficient, and systematic way to identify
hazards, assess risk, and implement effective risk controls.
Practicing risk management needs to be as automatic in
general aviation (GA) flying as basic aircraft control.
Consider making the 3P discussion a standard feature of the
preflight discussion. As is true for other flying skills, risk
management habits are best developed through repetition
and consistent adherence to specific procedures
Hazard List for Aviation Technicians:
AMTs should learn about risk management early in training,
also. Instructors tasked with integrating risk management into
instruction can turn to hazard assessments that identify the
safety risks associated with the facility being used, the tools
used in the procedure, and/or the job being performed.
The process for identifying hazards can be accomplished
through the use of checklists, lessons learned, compliance
inspections/audits, accidents/near misses, regulatory
developments, and brainstorming sessions. For example,
aviation accident reports from the National Transportation
Safety Board (NTSB) can be used to generate discussions
pertaining to faulty maintenance that led to aircraft accidents.
All available sources should be used for identifying,
characterizing, and controlling safety risks. The 3P model can also be adapted for use in a nonflight
environment, such as a maintenance facility. For example,
the AMT perceives a hazard, processes its impact on shop
or personnel safety, and then performs by implementing the
best course of action to mitigate the perceived risk
Pilot Self-Assessment:
Setting personal minimums is an important step in mitigating
risk, and safe pilots know how to properly self-assess. For
example, in the opening scenario, the aircraft Mary plans
to fly may have a maximum crosswind component of 15
knots listed in the aircraft flight manual (AFM), but she
only has experience with 10 knots of direct crosswind. It
could be unsafe to exceed a 10 knots crosswind component
without additional training. Therefore, the 10 knot crosswind
experience level is Mary’s personal limitation until additional
training with Daniel provides her with additional experience
for flying in crosswinds that exceed 10 knots.
Pilots in training must be taught that exercising good judgment
begins prior to taking the controls of an aircraft. Often, pilots
thoroughly check their aircraft to determine airworthiness,
yet do not evaluate their own fitness for flight. Just as a
checklist is used when preflighting an aircraft, a personal
checklist based on such factors as experience, currency, and
comfort level can help determine if a pilot is prepared for a
particular flight. The FAA’s "Personal Minimums Checklist"
located in Appendix D is an excellent tool for pilots to use in
self-assessment. This checklist reflects the PAVE approach to
risk mitigation discussed in the previous paragraphs.
Worksheets for a more in-depth risk assessment are located
in the "FAA/Industry Training Standards Personal and
Weather Risk Assessment Guide" located online at www.
faa.gov. This guide is designed to assist pilots in developing
personal standardized procedures for accomplishing PIC
responsibilities and in making better preflight and inflight
weather decisions. CFIs should stress that frequent review of
the personal guide keeps the information fresh and increases a
pilot’s ability to recognize the conditions in which a new risk
assessment should be made, a key element in the decision-making process
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. Maintaining situational awareness requires
an understanding of the relative significance of these factors
and their future impact on the flight. When situationally
aware, the pilot has an overview of the total operation and is
not fixated on one perceived significant factor. Some of the elements inside the aircraft to be considered are the status
of aircraft systems, pilot, and passengers. In addition, an
awareness of the environmental conditions of the flight, such
as spatial orientation of the aircraft and its relationship to
terrain, traffic, weather, and airspace must be maintained.
To maintain situational awareness, all of the skills involved
in ADM are used. For example, an accurate perception of
the pilot’s fitness can be achieved through self-assessment
and recognition of hazardous attitudes. A clear assessment of
the status of navigation equipment can be obtained through
workload management, and establishing a productive
relationship with ATC can be accomplished by effective
resource use.
Obstacles to Maintaining Situational Awareness
Many obstacles exist that can interfere with a pilot’s ability
to maintain situational awareness. For example, fatigue,
stress, or work overload can cause the pilot to fixate on a
single perceived important item rather than maintaining an
overall awareness of the flight situation. A contributing factor
in many accidents is a distraction, which diverts the pilot’s
attention from monitoring the instruments or scanning outside
the aircraft. Many flight deck distractions begin as a minor
problem, such as a gauge that is not reading correctly, but
result in accidents as the pilot diverts attention to the perceived
problem and neglects to properly control the aircraft.
Fatigue, discussed as an obstacle to learning, is also an
obstacle to maintaining situational awareness. It is a
threat to aviation safety because it impairs alertness and
performance. [Figure 9-5] The term is used to describe a
range of experiences from sleepy, or tired, to exhausted. Two
major physiological phenomena create fatigue: sleep loss and
circadian rhythm disruption. Fatigue is a normal response to many conditions common
to flight operations because characteristics of the flight deck
environment, such as low barometric pressure, humidity,
noise, and vibration, make pilots susceptible to fatigue. The
only effective treatment for fatigue is adequate sleep. As
fatigue progresses, it is responsible for increased errors of
omission, followed by errors of commission, and microsleeps,
or involuntary sleep lapses lasting from a few seconds to a
few minutes. For obvious reasons, errors caused by these
short absences can have significant hazardous consequences
in the aviation environment.
Sleep-deprived pilots may not notice sleepiness or other
fatigue symptoms during preflight and departure flight
operations. Once underway and established on altitude and
heading, sleepiness and other fatigue symptoms tend to
manifest themselves. Extreme fatigue can cause uncontrolled
and involuntary shutdown of the brain. Regardless of
motivation, professionalism, or training, an individual who
is extremely sleepy can lapse into sleep at any time, despite
the potential consequences of inattention. There are a number
of countermeasures for coping with fatigue, as shown in
Figure 9-6. Complacency presents another obstacle to maintaining
situational awareness. Defined as overconfidence from
repeated experience on a specific activity, complacency
has been implicated as a contributing factor in
numerous aviation accidents and incidents. Like fatigue,
complacency reduces the pilot’s effectiveness in the flight
deck. However, complacency is harder to recognize than
fatigue, since everything is perceived to be progressing
smoothly. Highly reliable automation has been shown to
induce overconfidence and complacency. This can result
in a pilot following the instructions of the automation even
when common sense suggests otherwise. If the pilot assumes
the autopilot is doing its job, he or she does not crosscheck
the instruments or the aircraft’s position frequently. If the
autopilot fails, the pilot may not be mentally prepared to fly
the aircraft manually. Instructors should be especially alert to
complacency in students with significant flight experience.
For example, a pilot receiving a flight review in a familiar
aircraft may be prone to complacency.
Advanced avionics have created a high degree of redundancy
and dependability in modern aircraft systems, which can
promote complacency and inattention. During flight training,
the CFI should emphasize that routine flight operations may
lead to a sense of complacency, which can threaten flight
safety by reducing situational awareness.
By asking about positions of other aircraft in the traffic
pattern, engine instrument indications, and the aircraft’s
location in relation to references on a chart, the instructor can
determine if the student is maintaining situational awareness.
The instructor can also attempt to focus the student’s
attention on an imaginary problem with the communication
or navigation equipment. The instructor should point out
that situational awareness is not being maintained if the
student diverts too much attention away from other tasks,
such as controlling the aircraft or scanning for traffic. These
are simple exercises that can be done throughout flight
training, which help emphasize the importance of maintaining
situational awareness. Operational Pitfalls
There are numerous classic behavioral traps that can
ensnare the unwary pilot. Pilots, particularly those with
considerable experience, try to complete a flight as planned,
please passengers, and meet schedules. This basic drive to
demonstrate achievements can have an adverse effect on
safety, and can impose an unrealistic assessment of piloting
skills under stressful conditions. These tendencies ultimately
may bring about practices that are dangerous and sometimes
illegal, and may lead to a mishap. Students develop awareness
and learn to avoid many of these operational pitfalls through
effective ADM training. The scenarios and examples provided
by instructors during ADM instruction should involve these
pitfalls [Figure 9-7]
Single-Pilot Resource Management (SRM):
Single pilot resource management (SRM) is defined as the art
and science of managing all the resources (both onboard the
aircraft and from outside sources) available to a single pilot
(prior to and during flight) to ensure the successful outcome
of the flight. SRM includes the concepts of ADM, Risk
Management (RM), Task Management (TM), Automation
Management (AM), Controlled Flight Into Terrain (CFIT)
Awareness, and Situational Awareness (SA). SRM training
helps the pilot maintain situational awareness by managing
the automation and associated aircraft control and navigation
tasks. This enables the pilot to accurately assess and manage
risk and make accurate and timely decisions.
SRM is all about helping pilots learn how to gather
information, analyze it, and make decisions. Although the
flight is coordinated by a single person and not an onboard
flightcrew, the use of available resources such as air traffic
control (ATC) and automated flight service station (AFSS)
replicates the principles of CRM. SRM and the 5P Check
SRM is about gathering information, analyzing it, and making
decisions. Learning how to identify problems, analyze the
information, and make informed and timely decisions is not
as straightforward as the training involved in learning specific
maneuvers. Learning how to judge a situation and "how to
think" in the endless variety of situations encountered while
flying out in the "real world" is more difficult. There is no
one right answer in ADM; rather, each pilot is expected to
analyze each situation in light of experience level, personal
minimums, and current physical and mental readiness level,
and make his or her own decision.
SRM sounds good on paper, but it requires a way for pilots
to understand and use it in their daily flights. One practical
application is called the "Five Ps" (5 Ps). [Figure 9-8] The
5 Ps consist of "the Plan, the Plane, the Pilot, the Passengers,
and the Programming." Each of these areas consists of a
set of challenges and opportunities that face a single pilot.
And each can substantially increase or decrease the risk
of successfully completing the flight based on the pilot’s
ability to make informed and timely decisions. The 5 Ps are
used to evaluate the pilot’s current situation at key decision
points during the flight, or when an emergency arises. These
decision points include preflight, pretakeoff, hourly or at the
midpoint of the flight, predescent, and just prior to the final
approach fix or for visual flight rules (VFR) operations, just
prior to entering the traffic pattern. The 5 Ps are based on the idea that the pilot has essentially
five variables that impact his or her environment and that can
cause the pilot to make a single critical decision, or several
less critical decisions, that when added together can create a critical outcome. This concept stems from the belief that
current decision-making models tend to be reactionary in
nature. A change must occur and be detected to drive a risk
management decision by the pilot. For instance, many pilots
use risk management sheets that are filled out by the pilot
prior to takeoff. These form a catalog of risks that may be
encountered that day and turn them into numerical values.
If the total exceeds a certain level, the flight is altered or
cancelled. Informal research shows that while these are useful
documents for teaching risk factors, they are almost never
used outside of formal training programs. The 5P concept is
an attempt to take the information contained in those sheets
and in the other available models and use it.
The 5P concept relies on the pilot to adopt a scheduled
review of the critical variables at points in the flight where
decisions are most likely to be effective. For instance, the
easiest point to cancel a flight due to bad weather is before
the pilot and passengers walk out the door to load the aircraft.
So, the first decision point is preflight in the flight planning
room, where all the information is readily available to make
a sound decision, and where communication and Fixed
Base Operator (FBO) services are readily available to make
alternate travel plans.
The second easiest point in the flight to make a critical safety
decision is just prior to takeoff. Few pilots have ever had
to make an emergency takeoff. While the point of the 5P
check is to help the pilot fly, the correct application of the
5P before takeoff is to assist in making a reasoned go/no-go
decision based on all the information available. These two
points in the process of flying are critical go/no-go points on
each and every flight.
The third place to review the 5 Ps is at the midpoint of the
flight. Often, pilots may wait until the Automated Terminal
information Service (ATIS) is in range to check weather, yet
at this point in the flight many good options have already
passed behind the aircraft and pilot. Additionally, fatigue
and low-altitude hypoxia serve to rob the pilot of much of
his or her energy by the end of a long and tiring flight day.
This leads to a transition from a decision-making mode to an
acceptance mode on the part of the pilot. If the flight is longer
than 2 hours, the 5P check should be conducted hourly.
The last two decision points are just prior to decent into the
terminal area and just prior to the final approach fix, or if
VFR just prior to entering the traffic pattern, as preparations
for landing commence. Most pilots execute approaches with
the expectation that they will land out of the approach every
time. A healthier approach requires the pilot to assume that
changing conditions (the 5 Ps again) will cause the pilot to
divert or execute the missed approach on every approach. This keeps the pilot alert to all conditions that may increase
risk and threaten the safe conduct of the flight. Diverting
from cruise altitude saves fuel, allows unhurried use of the
autopilot, and is less reactive in nature. Diverting from the
final approach fix, while more difficult, still allows the pilot
to plan and coordinate better, rather than executing a futile
missed approach. Let’s look at a detailed discussion of each
of the Five Ps.
The Plan
The plan can also be called the mission or the task. It contains
the basic elements of cross-country planning, weather, route,
fuel, publications currency, etc. The plan should be reviewed
and updated several times during the course of the flight. A
delayed takeoff due to maintenance, fast moving weather,
and a short notice temporary flight restriction (TFR) may all
radically alter the plan. The plan is not only about the flight
plan, but also all the events that surround the flight and allow
the pilot to accomplish the mission. The plan is always being
updated and modified and is especially responsive to changes
in the other four remaining Ps. If for no other reason, the 5P
check reminds the pilot that the day’s flight plan is real life
and subject to change at any time.
Obviously weather is a huge part of any plan. The addition
of real time data link weather information give the advanced
avionics pilot a real advantage in inclement weather, but only
if the pilot is trained to retrieve, and evaluate the weather in
real time without sacrificing situational awareness. And of
course, weather information should drive a decision, even
if that decision is to continue on the current plan. Pilots of
aircraft without datalink weather should get updated weather
in flight through an AFSS and/or Flight Watch.
The Plane
Both the plan and the plane are fairly familiar to most pilots.
The plane consists of the usual array of mechanical and
cosmetic issues that every aircraft pilot, owner, or operator
can identify. With the advent of advanced avionics, the plane
has expanded to include database currency, automation
status, and emergency backup systems that were unknown
a few years ago. Much has been written about single-pilot
IFR flight both with and without an autopilot. While this is
a personal decision, it is just that—a decision. Low IFR in
a non-autopilot equipped aircraft may depend on several of
the other Ps to be discussed. Pilot proficiency, currency, and
fatigue are among them.
The Pilot
Flying, especially when used for business transportation,
can expose the pilot to high altitude flying, long distance
and endurance, and more challenging weather. An advanced
avionics aircraft, simply due to its advanced capabilities can expose a pilot to even more of these stresses. The traditional
"IMSAFE" checklist is a good start.
The combination of late night, pilot fatigue, and the effects
of sustained flight above 5,000 feet may cause pilots to
become less discerning, less critical of information, less
decisive, and more compliant and accepting. Just as the most
critical portion of the flight approaches (for instance, a night
instrument approach in the weather after a 4-hour flight), the
pilot’s guard is down the most. The 5P process helps a pilot
recognize the physiological situation at the end of the flight
before takeoff, and continues to update personal conditions
as the flight progresses. Once risks are identified, the pilot is
in an infinitely better place to make alternate plans that lessen
the effect of these factors and provide a safer solution.
The Passengers
One of the key differences between CRM and SRM is the
way passengers interact with the pilot. The pilot of a high
capability single-engine aircraft has entered into a very
personal relationship with the passengers. In fact, the pilot
and passengers sit within an arm’s reach all of the time.
The desire of the passengers to make airline connections or
important business meetings enters easily into this pilot’s
decision-making loop. Done in a healthy and open way, this
can be a positive factor. Consider a flight to Dulles Airport and
the passengers, both close friends and business partners, need
to get to Washington, D.C., for an important meeting. The
weather is VFR all the way to southern Virginia, then turns
to low IFR as the pilot approaches Dulles. A pilot employing
the 5P approach might consider reserving a rental car at an
airport in northern North Carolina or southern Virginia to
coincide with a refueling stop. Thus, the passengers have a
way to get to Washington, and the pilot has an out to avoid
being pressured into continuing the flight if the conditions
do not improve.
Passengers can also be pilots. If no one is designated as pilot
in command (PIC) and unplanned circumstances arise, the
decision-making styles of several self-confident pilots may
conflict.
Pilots also need to understand that non-pilots may not
understand the level of risk involved in the flight. There is
an element of risk in every flight. That is why SRM calls it
risk management, not risk elimination. While a pilot may feel
comfortable with the risk present in a night IFR flight, the
passengers may not. A pilot employing SRM should ensure
the passengers are involved in the decision-making and given
tasks and duties to keep them busy and involved. If, upon a
factual description of the risks present, the passengers decide
to buy an airline ticket or rent a car, then a good decision has generally been made. This discussion also allows the pilot
to move past what he or she thinks the passengers want to
do and find out what they actually want to do. This removes
self-induced pressure from the pilot.
The Programming
The advanced avionics aircraft adds an entirely new
dimension to the way GA aircraft are flown. The electronic
instrument displays, GPS, and autopilot reduce pilot
workload and increase pilot situational awareness. While
programming and operation of these devices are fairly simple
and straightforward, unlike the analog instruments they
replace, they tend to capture the pilot’s attention and hold it
for long periods of time. To avoid this phenomenon, the pilot
should plan in advance when and where the programming
for approaches, route changes, and airport information
gathering should be accomplished as well as times it should
not. Pilot familiarity with the equipment, the route, the local
air traffic control environment, and personal capabilities vis-
à-vis the automation should drive when, where, and how the
automation is programmed and used.
The pilot should also consider what his or her capabilities
are in response to last-minute changes of the approach (and
the reprogramming required) and ability to make largescale changes (a reroute for instance) while hand flying the
aircraft. Since formats are not standardized, simply moving
from one manufacturer’s equipment to another should give
the pilot pause and require more conservative planning and
decisions.
The SRM process is simple. At least five times before
and during the flight, the pilot should review and consider
the "Plan, the Plane, the Pilot, the Passengers, and the
Programming" and make the appropriate decision required
by the current situation. It is often said that failure to make
a decision is a decision. Under SRM and the 5 Ps, even the
decision to make no changes to the current plan is made
through careful consideration of all the risk factors present.
Information Management
The volume of information presented in aviation training
is enormous, but part of the process of good SRM is a
continuous flow of information in and actions out. How a
student manages the flow of information definitely has an
effect on the relative success or failure of each and every flight
because proper information contributes to valid decisions.
SBT plays an important part in teaching the student how to
gather pertinent information from all available sources, make
appropriate decisions, and assess the actions taken.
For a transitioning pilot, the primary flight display (PFD),
multifunction display (MFD), and GPS/very high frequency (VHF) navigator screens seem to offer too much information
presented in colorful menus and submenus. In fact, the student
may be overwhelmed and unable to find a specific piece of
information. The first critical information management
skill for flying with advanced avionics is to understand the
system at a conceptual level. Remembering how the system
is organized helps the pilot manage the available information.
Simulation software and books on the specific system used
are of great value in furthering understanding for both the
CFI and the student.
Another critical information management skill is reading.
The best strategy for accessing and managing the available
information from PFD to navigational charts is to stop, look,
and read. The goal is for the student to learn how to monitor,
manage, and prioritize the information flow to accomplish
specific tasks.
Task Management (TM)
Task management (TM), a significant factor in flight safety,
is the process by which pilots manage the many, concurrent
tasks that must be performed to safely and efficiently fly a
modern aircraft. A task is a function performed by a human,
as opposed to one performed by a machine (e.g., setting the
target heading in the autopilot).
The flight deck is an environment in which potentially many
important tasks compete for pilot attention at any given time.
TM determines which of perhaps many concurrent tasks
the pilot(s) attend to at any particular point in time. More
specifically, TM entails initiation of new tasks; monitoring of
ongoing tasks to determine their status; prioritization of tasks
based on their importance, status, urgency, and other factors;
allocation of human and machine resources to high-priority
tasks; interruption and subsequent resumption of lower
priority tasks; and termination of tasks that are completed
or no longer relevant.
Humans have a limited capacity for information. Once
information flow exceeds a person’s ability to mentally
process the information, any additional information becomes
unattended or displaces other tasks and information already
being processed. Once the information flow reaches its limit,
two alternatives exist: shed the unimportant tasks or perform
all tasks at a less than optimal level. Like an electrical circuit
being overloaded, either the consumption must be reduced
or a circuit failure is experienced. Once again, SBT helps the
student learn how to effectively manage tasks and properly
prioritize them.
Automation Management
Automation management is the demonstrated ability to
control and navigate an aircraft by means of the automated systems installed in the aircraft. One of the most important
concepts of automation management is knowing when to
use it and when not to use it. Ideally, the goal of the flight
instructor is to train the student until he or she has learned
how to perform PTS maneuvers and procedures in the aircraft,
using all the available automation and/or the autopilot.
However, the flight instructor must ensure the student also
knows how to turn everything off and hand fly the maneuver
when the safety of the flight is threatened.
Advanced avionics offers multiple levels of automation,
from strictly manual flight to highly automated flight. No
one level of automation is appropriate for all flight situations,
but in order to avoid potentially dangerous distractions
when flying with advanced avionics, the student must know
how to manage the course indicator, the navigation source,
and the autopilot. It is important for a student to know the
peculiarities of the particular automated system being used.
This ensures the student knows what to expect, how to
monitor for proper operation, and promptly take appropriate
action if the system does not perform as expected.
At the most basic level, managing the autopilot means
knowing at all times which modes are engaged and which
modes are armed to engage. The student needs to verify that
armed functions (e.g., navigation tracking or altitude capture)
engage at the appropriate time. Automation management is a
good place to practice the callout technique, especially after
arming the system to make a change in course or altitude
Teaching Decision-Making Skills:
When instructor pilots discuss system safety, they generally
worry about the loss of traditional stick-and-rudder skills.
The fear is that emphasis on items such as risk management,
ADM, SRM, and situational awareness detracts from the
training necessary in developing safe pilots.
It is important to understand that system safety flight training
occurs in three phases. First, there are the traditional stick
and rudder maneuvers. In order to apply the critical thinking
skills that are to follow, pilots must first have a high degree of
confidence in their ability to fly the aircraft. Next, the tenets of
system safety are introduced into the training environment as
students begin to learn how best to identify hazards, manage
risk, and use all available resources to make each flight as safe
as possible. This can be accomplished through scenarios that
emphasize the skill sets being taught. Finally, the student is
introduced to more complex scenarios demanding focus on
several safety-of-flight issues. Thus, scenarios should start
out rather simply, then progress in complexity and intensity
as the student can handle the learning load. A traditional stick-and-rudder maneuver such as short
field landings can be used to illustrate how ADM and risk
management can be incorporated into instruction. In phase l
the initial focus is on developing the stick-and-rudder skills
required to execute this operation safely. These include power
and airspeed management, aircraft configuration, placement
in the pattern, wind correction, determining the proper aim
point and sight picture, etc. By emphasizing these points
through repetition and practice, a student eventually acquires
the skills needed to execute a short field landing.
Phase II introduces the many factors that come into play
when performing a short field landing, which include
runway conditions, no-flap landings, airport obstructions,
and rejected landings. The introduction of such items need
not increase training times. In fact, all of the hazards or
considerations referenced in the short field landing lesson
plan may be discussed in detail during the ground portion
of the instructional program. For example, if training has
been conducted at an airport that enjoys an obstruction-free
6,000-foot runway, consider the implications of operating
the same aircraft out of a 1,800-foot strip with an obstruction
off the departure end. Add to that additional considerations,
such as operating the aircraft at close to its maximum gross
weight under conditions of high density altitude, and now
a single training scenario has several layers of complexity.
The ensuing discussion proves a valuable training exercise,
and it comes with little additional ground and no added flight
training.
Finally, phase III takes the previously discussed hazards,
risks, and considerations, and incorporates them into a
complex scenario. This forces a student to consider not only
a specific lesson item (in this case, short-field landings), but
also requires that it be viewed in the greater context of the
overall flight. For example, on a cross-country flight, the
student is presented with a realistic distraction, perhaps the
illness of a passenger. This forces a diversion to an alternate
for which the student has not planned. The new destination
airport has two runways, the longest of which is closed due
to construction. The remaining runway is short, but while
less than ideal, should prove suitable for landing. However,
upon entering the pattern, the student finds the electrically
driven flaps do not extend. The student must now consider
whether to press on and attempt the landing, or proceed to a
secondary alternate.
If he or she decides to go forward and attempt the landing, this
proves an excellent time to test the requisite stick and rudder
skills. If the student decides to proceed to a second alternate,
this opens new training opportunities. Proceeding further tests cross-country skills, such as navigation, communication,
management of a passenger in distress, as well as the other
tasks associated with simply flying the aircraft. The outlined
methodology simply takes a series of seemingly unrelated
tasks and scripts them into a training exercise requiring both
mechanical and cognitive skills to complete it successfully.
SBT helps the flight instructor effectively teach ADM and
risk management. The what, why, and how of SBT has been
discussed extensively throughout this handbook. In teaching
ADM, it is important to remember the learning objective
is for the student to exercise sound judgment and make
good decisions. Thus, the flight instructor must be ready
to turn the responsibility for planning and execution of the
flight over to the student as soon as possible. Although the
flight instructor continues to demonstrate and instruct skill
maneuvers, when the student begins to make decisions, the
flight instructor should revert to the role of mentor and/or
learning facilitator.
The flight instructor is an integral part of the systems
approach to training and is crucial to the implementation
of an SBT program which underlies the teaching of ADM.
Remember, for SBT instruction to be effective, it is vital
the flight instructor and student establish the following
information:
• Scenario destination(s)
• Desired student learning outcome(s)
• Desired level of student performance
• Possible inflight scenario changes
It is also important for the flight instructor to remember that
a good scenario:
• Is not a test.
• Will not have a single correct answer.
• Does not offer an obvious answer.
• Engages all three learning domains.
• Is interactive.
• Should not promote errors.
• Should promote situational awareness and opportunities
for decision-making.
• Requires time-pressured decisions.
The flight instructor should make the situation as realistic
as possible. This means the student knows where he or she
is going and what transpires on the flight. While the actual
flight may deviate from the original plan, it allows the student to be placed in a realistic scenario. The student will plan the
flight to include:
• Route
• Destination(s)
• Weather
• NOTAMS
• Possible emergency procedures
Since the scenarios may have several good outcomes and
a few poor ones, the flight instructor should understand in
advance which outcomes are positive and/or negative and
give the student the freedom to make both good and poor
decisions. This does not mean that the student should be
allowed to make an unsafe decision or commit an unsafe act.
However, it does allow the students to make decisions that fit
their experience level and result in positive outcomes.
Teaching decision-making skills has become an integral part
of flight training. The word "decision" is used several times in
each PTS and applicants are judged on their ability to make
a decision as well as their ability to perform a task. Thus, it
is important for CFIs to remember that decision-making is
a component of the PTS
Assessing SRM Skills:
A student’s performance is often assessed only on a technical
level. The instructor determines whether maneuvers are
technically accurate and that procedures are performed in
the right order. In SRM assessment, instructors must learn
to assess students on a different level. How did the student
arrive at a particular decision? What resources were used?
Was risk assessed accurately when a go/no-go decision was
made? Did the student maintain situational awareness in the
traffic pattern? Was workload managed effectively during
a cross-country flight? How does the student handle stress
and fatigue?
Instructors should continually evaluate student decisionmaking ability and offer suggestions for improvement. It is
not always necessary to present complex situations, which
require detailed analysis. By allowing students to make
decisions about typical issues that arise throughout the course
of training, such as their fitness to fly, weather conditions,
and equipment problems, instructors can address effective
decision-making and allow students to develop judgment
skills. For example, when a discrepancy is found during
preflight inspection, the student should be allowed to initially
determine the action to be taken. Then the effectiveness of the
student’s choice and other options that may be available can be discussed. Opportunities for improving decision-making
abilities occur often during training. If the tower offers the
student a runway that requires landing with a tailwind in
order to expedite traffic, the student can be directed to assess
the risks involved and asked to present alternative actions
to be taken. Perhaps the most frequent choice that has to be
made during flight training is the go/no-go decision based on
weather. While the final choice to fly lies with the instructor,
students can be required to assess the weather prior to each
flight and make a go/no-go determination.
In addition, instructors should utilize SBT to create lessons
that are specifically designed to test whether students are
applying SRM skills. Planning a flight lesson in which the
student is presented with simulated emergencies, a heavy
workload, or other operational problems can be valuable in
assessing the student’s judgment and decision-making skills.
During the flight, student performance can be evaluated for
workload and/or stress management.
As discussed in chapter 5, SRM grades are based on these
four components:
• Explain—the student can verbally identify, describe,
and understand the risks inherent in the flight scenario.
The student needs to be prompted to identify risks and
make decisions.
• Practice—the student is able to identify, understand,
and apply SRM principles to the actual flight situation.
Coaching, instruction, and/or assistance from the CFI
quickly corrects minor deviations and errors identified
by the CFI. The student is an active decision maker.
• Manage/Decide—the student can correctly gather the
most important data available both within and outside
the flight deck, identify possible courses of action,
evaluate the risk inherent in each course of action, and
make the appropriate decision. Instructor intervention
is not required for the safe completion of the flight.
• Not Observed—any event not accomplished or
required. Postflight, collaborative assessment or learner centered
grading (LCG) (also discussed in chapter 5), is a vital
component of assessing a student’s SRM skills. As a
reminder, collaborative assessment includes two parts:
learner self-assessment and a detailed assessment by the
flight instructor. The purpose of the self-assessment is to
stimulate growth in the student’s thought processes and,
in turn, behaviors. The self-assessment is followed by an
in-depth discussion between the flight instructor and the
student which compares the CFI’s assessment to the student’s
self-assessment.
An important element of SRM skills assessment is that the
CFI provides a clear picture of the progress the student
is making during the training. Grading should also be
progressive. During each flight, the student should achieve
a new level of learning. For flight one, the automation
management area might be a "describe" item. By flight
three, it would be a "practice" item, and by flight five, a
"manage-decide" item
Conclusion:
This chapter introduced aviation instructors to the underlying concepts of safety risk management, which the FAA is integrating into all levels of the aviation community
