Aviation Instructor's Handbook (FAA-H-8083-9)
Chapter 1: Risk Management and Single-Pilot Resource Management
Introduction
“Pull the throttle back!” Lenore, a flight instructor, ordered the learner, Jennifer, as the revolutions per minute (rpm) climbed past
past 2,000 on engine start. “I did, I did!”
Both Jennifer and Lenore grabbed the mixture and pulled. The engine went from a deafenin g roar to silence . They looked at ea ch
other. “What happened?” asked Jennifer. “I don’t know. Let’s check the engine,” Lenore said.
Ten minutes later, they had removed the cowling from the airplane. A quick engine check gave them the answer. The throttle rod-end
was not connected to the carburetor arm—no bolt, no nut, just air between the rod-end and the arm. Jennifer looked at Lenore. “What
if this had happened in flight?”
“What I want to know,” Lenore said, “is how this happened at all. The annual inspection was signed off yesterday.”
The previous day, the annual inspection had been signed off after a lengthy inspection by a local facility. Several mechanics had been
involved in the inspection, including the owner/learner who had installed a headliner. The mechanic with the Inspection Authorization
(IA) who signed off the annual was supervising several annuals, so most of the maintenance was performed by other mechanics.
After the inspection, the engine had been run-up according to the usual post-inspection procedures. The learner and instructor had
flown the airplane for a half- hour familiarization flight. The next day’s engine start resulted in a runaway engine with the apparent
cause due to the lack of the throttle rod-end hardware being safetied.
Three deficient areas in th is annual inspection were identified by a round-tab le discussion group of aircraft and powerplant (A&P)
mechanics and the learner. These areas were:
⦁ Lack of responsibility
⦁ Checklist misuse
⦁ Complacency
Lack of responsibility—no one took responsibility for the entire inspection. The chances of something being overlooked increase with
an increase in the number of mechanics involved in an inspection. The responsible person is removed from the actual procedure. The
learner remembers hearing the IA ask one of the engine mechanics about the throttle. However, the question was vague, the answer
was vague, and the rod-end was not safetied.
Checklist misuse—Perhaps the throttle rod-end had been disconnected for maintenance after the IA had signed off the
control inspection and marked that item as complete on the maintenan ce checklist. In that case, a discrepancy should have been
entered onto the discrepancy sheet stating, “
reconnect and safety throttle rod-end.”
Complacency—an insidious and hard- to-identify attitude. Each of the mechanics involved in the incident thought someone else had
inspected the throttle rod-end. The IA signed off the annual inspection after asking the mechanics about the items on the checklist,
making frequent visits to the airplane, inspecting some of the various items, and deciding that was good enough. Complacency
crippled the mechanics’ quality of work by removing any thoughts of double-checking each other’s work.
While a definite answer to the question of what happened remains a matter of speculation, professional mechanics heed warning signs
of potential problems. The combination of a lengthy inspection, numerous technicians, an overworked supervisor, a poor checklist,
and vague communication raise a red flag of caution.
This scenario underscores the need for safety risk management at all levels of aviation. Safety risk management, a formal system of
hazard identification, assessment, and mitigation, is essential in keeping risk at acceptable levels. Part of this process is selecting the
appropriate controls to mitigate the risk of the identified hazard. The primary objective of risk management is accident prevention,
which is achieved by proactively identifying, assessing, and eliminating or mitigating safety-related hazards to acceptable levels.
This chapter discusses safety risk management in the aviation community, looking at it as preemptive, rather than reactive. The
principles of risk management and the tools for teaching risk management in the flight training environment are addressed in Chapter
9, Techniques of Flight Instruction.
Defining Risk Management
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 1-1] 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.
Figure 1-1. Types of risk.
Risk management is a decision-making process designed to identify hazards systematically, assess the degree of risk, and determine
the best course of action. Key terms are:
⦁ Hazard—a present condition, event, object, or circumstance that could lead to or contribute to an
unplanned or undesired event, such as an accident. It is a source of danger. For example, a nick in the
propeller represents a hazard.
⦁ Risk—the future impact of a hazard that is not controlled or eliminated. It is the possibility of loss or
injury. The level of risk is measured by the number of people or resources affected (exposure); the extent
of possible loss (severity); and likelihood of loss (probability).
⦁ Safety—freedom from those conditions that can cause death, injury, occupational illness, or damage to or
loss of equipment or property, or damage to the environment. Note that absolute safety is not possible
because complete freedom from all hazardous conditions is not possible. Therefore, safety is a relative
term that implies a level of risk that is both perceived and accepted.
Principles of Risk Management
The goal of risk management is to proactively identify safety-related hazards and mitigate the associated risks. Risk management is an
important component of decision-making. When a pilot follows good decision-making practices, the inherent risk in a flight is
reduced or even eliminated. The ability to make good decisions is based upon direct or indirect experience and education. It is
important to remember the four fundamental principles of risk management:
Accept No Unnecessary Risk
Unnecessary risk is that which carries no commensurate return in terms of benefits or opportunities. Everything involves risk. The
most logical choices for accomplishing a flight are those that meet all requirements with the minimum acceptable risk. The corollary
to this axiom is “accept necessary risk” required to complete the flight or task successfully. Flying is impossible without risk,
but unnecessary risk comes without a corresponding return. If flying a new airplane for the first time, a flight instructor might
determine that the risk of making that flight in low instrument flight rules (IFR) conditions is unnecessary.
Make Risk Decisions at the Appropriate Level
Anyone can make a risk decision. However, risk decisions should be made by the person who can develop and implement risk
controls. In a single-pilot situation, the pilot makes the decision to accept certain levels of risk, so why let anyone else —such as ATC
or your passengers—make risk decisions for you? In the maintenance facility, an aviation maintenance technician (AMT) may need to
elevate decisions to the next level in the chain of management upon determining that those controls available to him or her will not
reduce residual risk to an acceptable level.
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. For example, in any flying activity, it is necessary to accept
some degree of risk. A day with good weather, for example, is a much better time to fly an unfamiliar airplane for the first time than a
day with low instrument flight rules (IFR) conditions.
Integrate Risk Management into Planning at All Levels
Risks are more easily assessed and managed in the early planning stages of a flight. Changes made later in the process of planning
and executing may become more difficult, time consuming, and expensive. However, safety enhancement occurs at any time
appropriate and effective risk management take place.
Risk Management Process
Risk management is a simple process which identifies operational hazards and takes reasonable measures to reduce risk to personnel,
equipment, and the mission. During each flight, the pilot makes many decisions under hazardous conditions. To fly safely, the pilot
needs to identify the risk, assess the degree of risk, and determine the best course of action to mitigate the risk.
Step 1: Identify the Hazard
A hazard is defined as any real or potential condition that can cause degradation, injury, illness, death, or damage to or loss of
equipment or property. Experience, common sense, and specific analytical tools help identify risks. Once the pilot determines that a
hazard poses a potential risk to the flight, it may be further analyzed.
Step 2: Assess the Risk
Each identified risk may be assessed in terms of its likelihood (probability) and its severity (consequences) that could result from the
hazards based upon the exposure of humans or equipment to the hazards. An assessment of overall risk is then possible, typically by
using a risk assessment matrix, such an online Flight Risk Awareness Tool (FRAT). This process defines the probability and severity
of an accident.
Step 3: Mitigate the Risk
Investigate specific strategies and tools that reduce, mitigate, or eliminate the risk. High risks may be mitigated by taking action to
lower likelihood and/or severity to lower levels. For serious risks, such actions may also be taken. Medium and low risks do not
normally require mitigation. Effective control measures reduce or eliminate the most critical risks. The analysis may consider the
overall costs and benefits of remedial actions, providing alternative choices when possible.
Implementing the Risk Management Process
The following principles allow for maximum benefit from series of steps described above that form a risk mitigation strategy:
⦁ Apply the steps in sequence—each step is a building block for the next and should be completed before
proceeding to the next. If a hazard identification step is interrupted to focus on the control of a
particular hazard, more important hazards may be overlooked. Until all hazards are identified, the
remainder of the process is not effective.
⦁ 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
do the work see them as positive actions. The people who are exposed to risks usually know best
what works and what does not.
Identifying Risk
Hazards and their associated risks can either be obvious or harder to detect. You should methodically identify and classify risks to a
proposed or ongoing flight by maintaining constant situational awareness. To assist this process, it is helpful to apply the simple
acronym PAVE to your risk management process. The acronym stands for Pilot, Aircraft, Environment, External pressures. Use th e
following guidelines and questions to identify risk using the PAVE acronym.
The Pave Checklist
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 an d
successfully. If not, the flight should be cancelled. 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 knot-crosswind component without
additional training. Therefore, the 10 knots crosswind experience level should be that pilot’s personal limitation until additional
training with a flight instructor 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. When considering that risk, a pilot may ask, “Am I ready for this trip?” in terms of
experience, currency, and physical and emotional condition. The IMSAFE checklist (described later in this chapter) combined with
proficiency, recency, and currency helps provide the answer.
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 a 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?
⦁ If the trip includes flying over water or unpopulated areas might there be a loss of visual references?
⦁ Will there be any airspace or temporary flight restrictions (TFRs) along the route of flight?
Night flying requires special consideration:
⦁ Will the trip include flying over water or unpopulated areas?
⦁ Will the flight conditions allow a safe emergency landing at night?
⦁ Are the aircraft lights found to be operational during preflight and is a flashlight available that is
appropriate for intended use before and during flight?
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 (“get-home-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 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, but if they need to arrive by a certain time, they may 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 o n
airlines, driving a car, or taking a bus. The pilot’s goal is to manage risk, not create hazards.
During each flight, decisions should be made regarding events involving interactions between the four risk elements —PIC, aircraft,
environment, and external pressures. The decision-making process involves an evaluation of each of these risk elements to achieve an
accurate perception of the flight situation. [Figure 1-2]
Figure 1-2. One of the most important decisions that the pilot in command makes is the go/no-go decision. Evaluating each of these
risk elements can help the pilot decide whether a flight should be conducted or continued.
IMSAFE Checklist
As mentioned earlier, one of the best ways that single pilots can identify risk associated with physical and mental readiness for flying
is to use the IMSAFE checklist acronym. [Figure 1-3]
Figure 1-3. Prior to flight, pilots may use a checklist to assess their fitness, just as they evaluate the aircraft’s airworthiness.
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. A thorough evaluation of risk accounts for the effects of stress
on performance.
4. Alcohol—Have I been drinking within 8 hours? Within 24 hours? A small amount of alcohol 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. Emotion—Am I emotionally upset? The emotions of anger, depression, and anxiety from such events as a
serious argument; death in the family; separation or divorce; loss of employment; and/or financial problems
not only decrease alertness, but may also lead to taking risks that border on self-destruction. A pilot who
experiences an emotionally upsetting event may choose to refrain from flying until the pilot has
satisfactorily recovered.
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.