Aviation Instructor's Handbook

Chapter 1: Risk Management and Single-Pilot Resource Management

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Safety risk management, a formal system of hazard identification, assessment, and mitigation, is essential in keeping risk at acceptable levels. 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.

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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.

Risk management is the logical process of weighing the potential costs of risks against the possible benefits of allowing those risks to stand uncontrolled.

Risk management is a decision-making process designed to identify hazards systematically, assess the degree of risk, and determine the best course of action.

• A hazard is 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.
• Risk is the future impact of a hazard that is not controlled or eliminated. It is the possibility of loss or injury.
• Safety is 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.

Types of risk include:

• Total Risk: The sum of identified and unidentified risks.
• Identified risk: Risk which has been determined through various analysis techniques. The first task of system safety is to identify, within practical limitations, all possible risks.
• Unidentified risk: Risk not yet identified. Some unidentified risks are subsequently identified when a mishap occurs. Some risk is never known.
• Unacceptable risk: Risk which cannot be tolerated by managing activity. It is a subset of identified risk that must be eliminated or controlled.
• Acceptable risk: Acceptable risk is the first part of identified risk that is allowed to persist without further engineering or management action. Making this decision is a difficult yet necessary responsibility of the managing activity. The decision is made with the full knowledge that it is the user who is exposed to this risk.
• Residual risk: Residual risk is the risk left over 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.

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Four Fundamentals 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 four fundamentals of risk management principles include:

• Accept no unnecessary risk. Everything involves risk. However, unnecessary risk carries no commensurate return in terms of benefits or opportunities.
• Make risk decisions at the appropriate level. Risk decisions should be made by the person who can develop and implement risk controls. In a single-pilot situation, ATC or passengers should not make risk decisions.
• Accept risk when benefits outweigh the costs. In any flying activity, it is necessary to accept some degree of risk. All identified benefits should be compared against all identified costs.
• Integrate risk management into planning at all levels. Risks are more easily assessed and managed in the early planning stages of a flight. Late-arriving changes can be difficult, time consuming, and expensive.

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The 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.

The risk management process requires pilots to:

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.
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.
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

1. 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.
2. Maintain a balance in the process. All steps are important. Allocate the time and resources to perform all.
3. 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.
4. 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.

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Identifying Risk: The PAVE Checklist

Pilots should methodically identify and classify risks to a proposed or ongoing flight by maintaining constant situational awareness. This can be done with the PAVE checklist, which the risks of flight into four categories:

• Pilot in command: The pilot is one of the risk factors in a flight. The IMSAFE checklist, combined with proficiency, recency, and currency, will help determine the level of risk.
• Aircraft: Is this the right aircraft for the flight? Can the aircraft carry the planned load? Does the aircraft have sufficient fuel capacity?
• enVironment: What are current and forecast conditions? What is the terrain along the route? If flying at night, how much of the surface is lit? Does the route cross open water? Is the destination airport open and appropriate? Are there sufficient alternates?
• External pressures: Are the pilot or passengers under any pressure to arrive at the destination on time?

Once a pilot identifies the risks of a flight, s/he needs to decide whether the risk or combination of risks can be managed safely and successfully. If not, the flight should be cancelled. If the pilot decides to continue with the flight, s/he should develop strategies to mitigate the risks.

Managing External Pressures

The key to managing external pressure is to be ready for and accept delays. The use of personal standard operating procedures (SOPs) is one way to manage external pressures:

• 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.

IMSAFE Checklist:

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:

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.

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Assessing and Mitigating Risk

Pilots and (especially) learners should differentiate between a planned low-risk flight and a high-risk flight. They then should establish a review process and develop risk mitigation strategies to address flights throughout that range.

The most basic tool is the risk matrix, which assesses the likelihood of an event occurring and the consequence of that event. In this matrix, a catastrophic result with high probability carries the highest risk. A remote or improbable result with marginal or negligible impact carries the lowest risk.

The likelihood of an event is assessed in these categories:

• 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.

The severity of an event is assessed in these categories:

• 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

By effectively mitigating known risks to acceptable levels, pilots can complete their planned flights safely or ensure that alternate options are selected for those rare occasions when the planned or ongoing flight cannot be completed.

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Flight Risk Assessment Tools

A Flight Risk Analysis Tool (FRAT) enables proactive hazard identification, is easy to use, and can visually depict risk. It is a tool many pilots use to make better go/no-go decisions.

A risk assessment tool allows pilots to see the risk profile of a flight in its planning stages. A formal process using pen and paper gives a perspective on the entire risk picture and is a good way to make a thorough analysis.

When the risk for a flight exceeds the acceptable level, the hazards associated with that risk may be further evaluated and the risk reduced. A higher risk flight might not be operated if the hazards cannot be mitigated to an acceptable level.

An effective FRAT has at least three possible score ranges. These are often grouped into green, yellow and red sections.

• Red (High: Risk likelihood and/or severity is normally reduced to lower levels before departure. Unless the risks involved in the flight can be mitigated (different crew/adding a copilot, better equipment, delayed launch time...) flight cancellation occurs
• Yellow (Serious): Risk likelihood and/or severity needs reduction to lower levels before departure. Begin by mitigating some of the higher scoring items, and consider consulting with a flight instructor or mechanic if the score remains in the yellow.
• Green (Medium): Flight can depart or continue, but risk severity and/or likelihood may be reduced.

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Three-P Model for Pilots

The Perceive, Process, Perform (3P) model for aeronautical decision-making (ADM) offers a simple, practical, and structured way for pilots to manage risk.

The three steps of the Risk Management Process include identifying the risk, assessing the risk, and finally mitigating the risk. The 3P model parallels those three steps: Perceiving (identifying the risk), Processing (assessing the risk), and Performing (mitigating the risk).

The decision-making process is a continuous loop of perceiving, processing, and performing.

Practicing risk management needs to be as automatic in general aviation (GA) flying as basic aircraft control. Using the 3P model gives flight instructors a tool to teach them a structured, efficient, and systematic way to identify hazards, assess risk, and implement effective risk controls.

Pilot Self-Assessment

Pilots in training should 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.

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 of the Aviation Instructor's Handbook) is an excellent tool for pilots to use in self-assessment.

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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. When situationally aware, the pilot has an overview of the total operation and is not fixated on one perceived significant factor.

Many obstacles exist that can interfere with a pilot's ability to maintain situational awareness, including fatigue, stress, or work overload. A contributing factor in many accidents is a distraction, which diverts the pilot's attention from monitoring the instruments or scanning outside the aircraft.

Fatigue

Two major physiological phenomena create fatigue: sleep loss and circadian rhythm disruption. Characteristics of the flight deck environment, such as low barometric pressure, humidity, noise, and vibration, make pilots susceptible to fatigue.

Extreme fatigue can cause uncontrolled and involuntary shutdown of the brain.

Complacency

Complacency — overconfidence from repeated experience on a specific activity — is a contributing factor in many aviation accidents and incidents. Complacency is harder to recognize than fatigue, since everything is perceived to be progressing smoothly. Instructors should be especially alert to complacency in learners with significant flight experience.

Advanced avionics have created a high degree of redundancy and dependability in modern aircraft systems, which can promote complacency and inattention. Highly reliable automation has been shown to induce overconfidence and complacency.

Operational pitfalls

Operational pitfalls are numerous classic behavioral traps that can ensnare unwary pilots — particularly those with considerable experience. A desire to demonstrate achievements can impose an unrealistic assessment of piloting skills under stressful conditions. Such may bring about dangerous, sometimes illegal, practices that may lead to a mishap.

Operational pitfalls include:

• Peer pressure
• Rigid mindset
• Get-there-itis
• Duck-under syndrome
• Scud running
• VFR into IMC
• Getting behind the aircraft
• Loss of positional or situational awareness
• Operated without adequate fuel reserves
• Descent below minimum en-route altitude
• Flying outside the envelope
• Neglect of flight planning, pre-flight inspections, and checklists

Learners 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.

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Single-Pilot Resource Management (SRM)

Single pilot resource management (SRM) is the management of all resources available to a single pilot to ensure the successful outcome of the flight. These resources are both onboard the aircraft and from outside sources, and they can be accessed before and during the flight.

SRM includes:

• Aeronautical Decision-Making (ADM)
• Risk Management (RM)
• Task Management (TM)
• Automation Management (AM)
• Controlled Flight Into Terrain (CFIT) Awareness
• Situational Awareness (SA)

The use of available resources such as air traffic control (ATC) and Flight Service replicates the principles of CRM. SRM is all about helping pilots learn how to gather information, analyze it, and make decisions.

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SRM and the 5P Check

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. Risk management sheets that are filled out prior to takeoff form a catalog of risks and turn them into numerical values. These are useful documents for teaching risk factors, but 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 by assessing five risk categories:

• The Plan
• The Plane
• The Pilot
• The Passengers
• The Programming

The 5Ps 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
• IFR: Just prior to the final approach fix
• VFR: Just prior to entering the traffic pattern

The Plan 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.

The Plane includes database currency, automation status, and emergency backup systems.

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.

The desire of the passengers to make airline connections or important business meetings enters easily into this pilot's decision-making loop, creating "Get-There-Itis" pressure. Some passengers may also be pilots who turn out to be useful resources, while other pilot-passengers may be argumentative obstructions. Non-pilot passengers should be aware of the flight's real risks — not zero-risk, but also not unrealistic high risk.

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.

Information Management

Good SRM requires information management — a continuous flow of information in and actions out. SBT plays an important part in teaching the learner how to gather pertinent information from all available sources, make appropriate decisions, and assess the actions taken.

A good strategy for accessing and managing the available information from PFD to navigational charts is to stop, look, and analyze. The goal is for the learner to understand how to monitor, manage, and prioritize the information flow to accomplish specific tasks.

Task Management

A task is a function performed by a human, as opposed to one performed by a machine. Task management (TM) is the process by which pilots manage the many, concurrent tasks that should be performed to safely and efficiently fly a modern aircraft. It includes:

• 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
• Termination of tasks that are completed or no longer relevant

Once the information flow reaches its limit, two alternatives exist: shed the unimportant tasks or perform all tasks at a less than optimal level. SBT helps the learner understand 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. Pilots should know "when to use it and when not to use it." Learns should be able to operate the aircraft, using all the available automation. The learner also should know how and when to operate the aircraft without the benefit of the automation. No one level of automation is appropriate for all flight situations.

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Aeronautical Decision-Making (ADM)

Aviation training and flight operations are now seen as a system rather than individual concepts.

These key principles are often collectively called ADM.

• Aeronautical Decision-Making (ADM)
• Risk management
• Situational awareness
• Single-Pilot Resource Management (SRM)

Aeronautical Decision-Making (ADM) is a systematic approach to the mental process used by aircraft pilots to consistently determine the best course of action in response to a given set of circumstances.

Risk management is a decision-making process designed to systematically identify hazards, assess the degree of risk, and determine the best course of action associated with each flight.

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

Single-Pilot Resource Management (SRM) is the art and science of managing all resources (both onboard the aircraft and from outside sources) available to a single pilot (prior and during flight) to ensure the successful outcome of the flight.

The importance of teaching learners effective ADM skills cannot be overemphasized.

Despite all the changes in technology to improve flight safety, one factor remains the same — the human factor. It is estimated that approximately 80 percent of all aviation accidents are human factors related.

By taking a systemic approach to aviation safety, flight instructors interweave aeronautical knowledge, aircraft control skills, ADM, risk management, situational awareness, and SRM into the training process.

Pilot error means that an action or decision made (or not made) by the pilot was the cause of, or contributing factor to, the accident. The phrase "human factors related" more aptly describes these accidents, since they were a chain of events triggered by a number of factors.

Traditional pilot instruction has emphasized flying skills, knowledge of the aircraft, and familiarity with regulations. However, teaching pilots to make sound decisions is the key to preventing accidents. ADM training focuses on the decision-making process and the factors that affect a pilot's ability to make effective choices.

Flight instructors should incorporate ADM, risk management, situational awareness, and SRM throughout the entire training course for all levels of learners.

AC 60-22: Aeronautical Decision Making provides background references, definitions, and other pertinent information about ADM training in the general aviation (GA) environment.

The Decision-Making Process

Traditionally, pilots have been well trained to react to emergencies but are not as well prepared to make decisions, which require a more reflective response. During a flight, the pilot has time to examine any changes that occur, gather information, and assess risk before reaching a decision.

The first step in the decision-making process is to define the problem. This begins with recognizing that a change has occurred or that an expected change did not occur.

One critical error that can be made during the decision-making process is incorrectly defining the problem. Fixating on a problem that does not exist can divert the pilot's attention from important tasks.

After the problem has been identified, the pilot evaluates it and will choose a course of action. The expected outcome of each possible action, and its risks, should be considered.

Finally, the pilot must implement the decision and evaluate the outcome. As the flight progresses, the pilot should continue to evaluate the outcome of the decision to ensure that it is producing the desired result.

Factors Affecting Decision-Making

The ability to make effective decisions as PIC depends on a number of factors. Some circumstances, such as the time available to make a decision, may be beyond the pilot's control. However, a pilot can learn to recognize those factors that can be managed, and learn skills to improve decision-making ability and judgment.

Two steps to improve flight safety are identifying personal attitudes hazardous to safe flight and learning behavior modification techniques.

Recognizing Hazardous Attitudes

Flight instructors should be able to spot hazardous attitudes in a learner because recognition of hazardous thoughts is the first step toward neutralizing them.

Attitude can be defined as a personal motivational predisposition to respond to persons, situations, or events in a given manner.

The five hazardous attitudes include:

• Macho
• Anti-authority
• Invulnerability
• Impulsivity
• Resignation

Macho: A pilot may decide to fly in a low or otherwise-unsafe manner to impress others. Antidote: "Taking chances is foolish."

Anti-authority: A pilot may decide that the rules are inconvenient, or that they do not apply to a pilot of his/her abilities. Antidote: "Follow the rules. They are usually right."

Invulnerability: A pilot may accept risks because they've not experienced bad outcomes. Antidote: "It could happen to me."

Impulsivity: A pilot may become frustrated with the airplane's performance in certain conditions and respond with hazardous inputs or decisions. Antidote: "No so fast. Think first."

Resignation: A pilot may not take critical steps to avoid an accident, deciding their actions don't matter. Antidote: "I'm not helpless. I can make a difference."

Stress Management

Learning how to recognize and cope with stress is another effective ADM tool. Performance generally increases with the onset of stress, peaks, and then begins to fall off rapidly as stress levels exceed a person's ability to cope.

One way of exploring the subject of stress with a learner is to recognize when stress is affecting performance. The instructor should also try to determine if there are aspects of pilot training that are causing excessive amounts of stress for the learner.

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Teaching Decision-Making Skills

System safety flight training occurs in three phases.

In Phase l the initial focus is on developing the stick-and-rudder skills required to execute this operation safely. In order to apply the critical thinking skills that are to follow, pilots should develop a high degree of confidence in their ability to fly the aircraft.

Phase II introduces the many factors that come into play during specific phases of flight, such as landings. The tenets of system safety are introduced into the training environment as learners begin to understand 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.

Phase III takes the previously discussed hazards, risks, and considerations, and incorporates them into a complex scenario. The learner may be introduced to more complex scenarios that focus on several safety-of-flight issues.

Thus, scenarios should start out rather simply, then progress in complexity and intensity as the learner becomes able to handle the increased workload.

Scenario-based training (SBT) helps the flight instructor effectively teach ADM and risk management. The learning objective is for the learner to exercise sound judgment and make good decisions. The flight instructor should be ready to turn the responsibility for planning and execution of the flight over to the learner as soon as possible.

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Assessing SRM Skills

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Practical Test Standards: Flight Instructor

Oral Exam Questions