Definitions Risk Management Risk management is a decision-making process designed to identify hazards systematically, assess the degree of risk, and determine the best course of action. It is a practical approach to managing uncertainty. Hazards are a source of danger. Examples include fatigue, improper fueling, and the use of unapproved hardware on an aircraft. Risk is the future impact of a hazard that is not controlled or eliminated. It can be viewed as future uncertainty created by a hazard. The level of risk is measured by the number of people or resources affected (exposure), the extent of possible loss (severity), and the likelihood of loss (probability). If the risk involves skill sets, the same situation may yield different risk for different individuals. Pilots accept risk by their background, education, predisposition, attitude, and training. Risk becomes a problem when a situation builds, and its complexity exceeds the pilot s capability. Types of Risk Total: The sum of identified and unidentified risks. Identified: The risk that has been determined through various analysis techniques. The first task of system safety is to identify all possible risks. Unidentified: The risk not yet identified. Some unidentified risks are subsequently identified when a mishap occurs. Some risk is never known. Unacceptable: The risk that cannot be tolerated by the activity. It is a subset of identified risk that must be eliminated or controlled. Acceptable: The part of the identified risk that is allowed to persist without action. Deciding to accept any risk is a difficult responsibility. The decision is made with full knowledge that the user is exposed to the risk. Residual: The risk remaining after system safety efforts have been fully employed. It is not necessarily the same as acceptable risk. Residual risk is the sum of acceptable risk and unidentified risk. This is the total risk passed on to the user. Principles of Risk Management Accept No Unnecessary Risk: Everything involves risk. Unnecessary risk is that which carries no commensurate return of benefits. The goal is to meet all operational requirements with the minimum acceptable risk. The corollary to this axiom is accept necessary risk required to complete the operation or task successfully. Make Risk Decisions at the Appropriate Level: Anyone can make a risk decision, but a good decision-maker can develop and implement risk controls. The decision-maker must be authorized to accept levels of risk typical of the planned operation. In a single-pilot situation, the pilot decides to accept certain levels of risk. Accept Risk when Benefits Outweigh the Costs: All identified benefits should be compared against all identified costs. Even high-risk endeavors may be undertaken when there is clear knowledge that the sum of the benefits exceeds the sum of the costs. In any flying activity, it is necessary to accept some degree of risk. Integrate Risk Management into Planning at All Levels: Risks are more easily assessed and managed in the planning stages of an operation. The later changes are made in the process of planning and executing, the more expensive and time consuming they become. Because risk is an unavoidable part of every flight, safety requires the use of effective risk management in all stages of the flight. Version: 0.1.0 Page 1 of 6
Risk Management Process 1. Identify the Hazard: Experience, common sense, and analytical tools can be used to identify conditions, events, objects, or circumstances that could lead to or contribute to an accident. 2. Assess the Risk: Determine the probability and severity of an accident that could result from the hazards. 3. Analyze Risk Control Measures: Investigate strategies to reduce, mitigate, or eliminate the risk. 4. Make Control Decisions: Identify the appropriate decision-maker. That decision-maker must choose the best control or combination of controls, based on the analysis of steps 1 and 2. 5. Implement Risk Controls: A plan for applying the selected controls must be formulated, the time, materials, and personnel needed to put these measures in place must be provided. 6. Supervise and Review: Once controls are in place, the process must be reevaluated periodically to ensure their effectiveness. The risk management process continues throughout the life cycle of the system, mission, or activity. Implementing the Risk Management Process Apply the Steps in Sequence: Each step is a building block for the next and must be completed before proceeding to the next. If a hazard identification step is interrupted to focus on the control of a particular hazard, more critical hazards may be overlooked. Maintain a Balance in the Process: All steps are important. Allocate the time and resources to perform all. Apply the Process in a Cycle: The supervise and review step should include a brand new look at the operation being analyzed to see whether new hazards can be identified. Involve People in the Process: Ensure that risk controls are mission supportive, and the people who must do the work see them as positive actions. The people who are exposed to risks usually know best what works and what does not. Levels of Risk Every flight has hazards and some level of risk associated with it. It is critical that pilots and especially students can 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. The level of risk posed by a given hazard is measured in terms of: Severity (extent of possible loss); and Probability (likelihood that a hazard will cause a loss). Assessing Risk Assessment of risk is an integral part of proper risk management. Example: The hazard of a nick in a 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 that it could fracture and cause catastrophic damage to the engine, airframe, and occupants. Risk Assessment Matrix Probability/Severity Catastrophic Critical Marginal Negligible Frequent High High Serious Medium Probable High High Serious Medium Occasional High Serious Medium Low Remote Serious Medium Medium Low Improbable Medium Medium Medium Low Using a risk assessment matrix helps the pilot differentiate between low-risk and high-risk flights. When armed with the predicted assessment of activity, pilots can manage and reduce (mitigate) their risk. Page 2 of 6 My CFI Book
Likelihood of an Event Likelihood is nothing more than taking a situation and determining the probability of its occurrence. Frequent: Likely to occur often. 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. Example: When flying in marginal visual flight rules (MVFR) conditions, the likelihood of encountering potential IMC might be classified as occasional. Severity of an Event The next element is the severity or consequence of a pilot s action(s). It can relate to injury or damage. 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. Mitigating Risk After determining the level of risk, the next step is to mitigate it. Risk can be mitigated by: Utilizing established industry methods including: The I M SAFE checklist; The PAVE checklist; and The DECIDE model. Establishing and adhering to personal weather minimums; Maintaining situational awareness; Applying the principles of single-pilot resource management; Understanding human factors in aviation; and Examining the common causes of aircraft accidents. Example: A pilot flying in MVFR conditions has several ways to reduce risk: wait for the weather to improve, fly with a friend who is instrument rated, delay the flight, or drive. The I M SAFE Checklist The I M SAFE checklist can be used to determine a pilot s physical and mental readiness for flying. Illness: Even a minor illness can severely impair performance as a pilot. Fever and other distracting symptoms can impair judgment, memory, alertness, and the ability to make calculations. The safest rule is not to fly while suffering from any illness. Medication: Pilot performance can be severely impaired by both prescribed and over-the-counter medications. Stress: Stress is a term to describe the body s nonspecific response to demands placed upon it. Alcohol: The regulations prohibit pilots from performing crew-member duties within eight hours after drinking any alcoholic beverage (eight hours from bottle to throttle ) or while under the influence of alcohol. Alcohol makes the body much more susceptible to disorientation and hypoxia. Fatigue: Fatigue can be treacherous because it may not be apparent until serious errors are made. Version: 0.1.0 Page 3 of 6
Emotion: Emotionally upsetting events may render a pilot unable to fly an airplane safely. Anger and depression will decrease alertness and lead to the pilot taking self-destructive risks. Related: Technical Subjects: Aeromedical Factors The PAVE Checklist Pilots should incorporate the PAVE checklist into all stages of flight planning to help perceive and mitigate risks. The PAVE checklist divides risks of flight into four categories: Pilot, Aircraft, environment, and External pressures. The DECIDE Model The DECIDE model is a continuous loop process that provides the pilot with a logical way of making decisions. It is a form of analytical decision-making that requires time to evaluate options. The six-steps of the DECIDE process are: 1. Detect a change or hazard; 2. Estimate the need to counter or react to the change; 3. Choose a desirable outcome for the flight; 4. Identify actions that can successfully control the change; 5. Do take the necessary action; then 6. Evaluate the effect of the action. The 3P Model The 3P model offers a simple, structured method for pilots to manage risk during all phases of flight. To use the 3P model, the pilot: 1. Perceives the given set of circumstances for a flight; 2. Processes by evaluating the impact of those circumstances on flight safety; then 3. Performs by implementing the best course of action. Once the pilot has completed the 3P decision process and selected a course of action, the process begins again. Pilots can: Perceive hazards by using the PAVE checklist: Pilot, Aircraft, environment, and External pressures. Process hazards by using the CARE checklist: Consequences, Alternatives, Reality, External factors. Perform risk management by using the TEAM checklist: Transfer, Eliminate, Accept, or Mitigate. Personal Weather Minimums One way a pilot can control risks is to set personal minimums, which act as a buffer between the demands of the situation and the extent of the pilot s skills. When a pilot s experience level changes, he or she should review and, if appropriate, revise his or her personal minimums. Personal minimums should be thought of as the human factors equivalent of reserve fuel. Never attempt a flight that requires the use of skills within your reserve level of piloting ability. Related: Supplements: Personal Minimums Worksheet Situational Awareness Situational awareness is the accurate perception and understanding of all the factors and conditions within the four fundamental risk elements (the pilot, aircraft, environment, and external pressures) that affect safety before, during, and after the flight. Page 4 of 6 My CFI Book
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. Obstacles to Maintaining Situational Awareness Situational Awareness = Experience + Analysis 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 visual scanning. Single-Pilot Resource Management 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 (before and during flight) to ensure the successful outcome of the flight. Related: Fundamentals of Instruction: Techniques of Flight Instruction: Aeronautical Decision Making Technical Subjects: Visual Scanning and Collision Avoidance: Controlled Flight into Terrain Preflight Preparation: Flight Deck Management Appendix: Relationships of Decision-Making Models The 5P s Check The 5P s check provides a way for pilots to understand and deploy SRM. The Plan: The plan (e.g., weather, route, fuel, etc.) should be reviewed and updated several times during the flight. The Plane: The plane consists of the mechanical and cosmetic issues that every pilot can identify with. With technically advanced airplanes (TAAs), the plane also includes database currency, automation status, and emergency backup systems. The Pilot: The traditional I M SAFE checklist. The Passengers: The pilot may feel pressured into continuing a flight into deteriorating conditions. Passengers may not understand the level of risk involved in the flight. When the passengers are pilots, there may be a conflict if no one is designated as PIC and unplanned circumstances arise. The Programming: Glass cockpits, GPS, and autopilots can help to reduce pilot workload and increase situational awareness, but they tend to capture the pilot s attention and hold it for long periods of time. Pilots should plan ahead when lengthy programming will be required. Human Factors Approximately 80% of all aviation accidents are human factors related. Surprisingly, only a tiny percentage of flight training is devoted to human factors training. Accidents that are caused due to human factors may be prevented or reduced by: Increasing training efforts and awareness; Improving student pilot supervision; Auditing training materials; and Developing better piloting skills. Studies of Human Behavior The FAA oversaw an extensive research study on the similarities and dissimilarities of accident-free pilots and those who were not. The project surveyed over 4,000 pilots, half of whom had clean records while the other half had been involved in an accident. Five traits were discovered in pilots prone to having accidents. Version: 0.1.0 Page 5 of 6
Accident prone pilots: Have a disdain for rules; Have a very high correlation between accidents on their flying records and safety violations on their driving records; Frequently have a thrill and adventure seeking personality; Are impulsive rather than methodical and disciplined; and Have a disregard for or tend to underutilize outside sources of information. Frequent Causes of General Aviation Accidents Reference: AIM 7-5-1 The 10 most frequent causes of GA accidents that involve the PIC: 1. Inadequate preflight preparation or planning. 2. Failure to obtain or maintain flying speed. 3. Failure to maintain directional control. 4. Improper level off (i.e., continued descent into terrain). 5. Failure to see and avoid objects or obstructions. 6. Mismanagement of fuel. 7. Improper inflight decisions or planning. 8. Misjudgment of distance and speed. 9. Selection of unsuitable terrain. 10. Improper operation of flight controls. Page 6 of 6 My CFI Book