The NTSB (or FAA when delegated by NTSB) investigates fatal accidents and the Board issues reports on the probable cause of the accident. The reports also list contributing factors to the accident. Typically, the final reports are peppered with words such as loss of control, controlled flight into terrain (CFIT) and other language describing the final event in the accident sequence and attributing it to one or more other events. But rarely does the report explain the “why” of the accident or the “how” of the pilot’s or other participants’ actions relating to the “why.” For example, in a loss-of-control accident, why did the pilot lose control of the aircraft and how did he or she place themselves in that predicament?
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After the accident reports are issued, the FAA and various industry organizations issue periodic reports analyzing the aggregate data annually or more often and then draw conclusions about what should be done to prevent such accidents in the future. While such analysis is useful as a starting point in getting to the root cause of fatal accidents, it still does not provide the kind of insight that might help us devise effective methods for preventing their recurrence. For example, if a report states that 63 per cent of fatal accidents have pilot-related cause factors, what does this mean? Why did the pilot cause the accident? What actions did the pilot take, or fail to take, to precipitate the accident and how could the pilot have changed the outcome?
Analysis: What Will it Tell Us?
In order to get at the real root causes of fatal accidents, we need to be bolder and dive deeper into the data. More importantly, we need to be willing to speculate reasonably on how outcomes might have changed if the pilot had taken alternative actions that may have avoided the accident. Of course, hindsight is 20/20, but it is still possible for us to test whether different approaches to fatal accident avoidance may be feasible.
It should come as no surprise to readers of my previous articles in this journal that I am a strong proponent of risk management as a key tool in reducing general aviation fatal accidents. It’s fair to ask whether or not there is any data to support my hypothesis. So, to test the hypothesis for this article, I conducted my own analysis of general aviation fatal accidents. To test my hypothesis that risk management plays a key role in general aviation fatal accidents, I looked at a slice of such accidents for the three-year period 2007-2009. The results surprised even me.
I decided to select three general aviation aircraft for my analysis and reviewed NTSB data on all fatal accidents in the data base for the three years in question. I selected the Cirrus SR22 since it represents the quintessential modern technically advanced GA aircraft. I added the Beech V-tail Bonanza (Model 35), which represents a legacy high-performance aircraft. Finally, I selected the “plain Jane” Cessna 172 as representative of simpler GA aircraft. I excluded commercial GA operations, such as Part 135 air taxis, as well as amateur-built aircraft, since neither is representative of mainstream GA safety issues.
For the accident files down-loaded, I excluded those with insufficient data for analysis or for which the data could not reasonably support or refute the hypothesis I wanted to test. These included accidents outside the United States, missing aircraft or other reports with incomplete data. The sidebar on page 10 summarizes my efforts.
For the record, if my analysis revealed a fatal accident that was purely random and/or unpredictable (i.e., sudden internal engine failure in a well-maintained engine, or sudden unpredicted extreme turbulence causing airframe failure), then I did not label it a risk management accident. Similarly, if an accident was completely in the “green” on a risk analysis (i.e., sunny day, no wind, wide and long runway, perfect airplane yet the pilot still kills himself and his passengers during a botched takeoff or landing), then I wouldn’t call it a risk-management accident. If the accident even came close to these categories, I labeled it for what it was, an aircraft-related accident, a pilot-related accident caused by poor basic piloting skills, or some other kind of accident not related to risk management.
The envelope, please…
I’m willing to accept all the caveats that go with this analysis, including small sample size and the assumptions that go into my hypothesis. Yet, I was surprised that more than three-fourths of all fatal accidents met my definition of a risk-management accident. I expected it would be in the 60-70 per cent range. I was especially surprised with the figure for the Cessna 172. I expected that, as a basic aircraft flown by less experienced pilots, traditional pilot skill accidents would be more prominent. The 172’s forgiving nature and the fact that less-experienced pilots are less likely to have learned practical risk management “on the job,” probably accounts for the result of the analysis.
Some other interesting facts were revealed by the analysis. I tallied the primary category of risk for each accident, using the PAVE descriptors. In some accidents there were multiple categories so I recorded 62 risk categories for the 50 accidents. Of this total, the highest risk area was the “environment” (the “V” in PAVE). This category includes weather, terrain and other traffic. It appeared 34 times (55 percent) as a factor. The “pilot” category of PAVE includes factors such as illness, medication, stress, alcohol, fatigue and emotion (IMSAFE), plus non-medical-related factors such as pilot currency, basic qualifications and related competency issues. This category appeared 23 times (37 percent) as a factor. The “aircraft” category of PAVE only surfaced three times and the “external pressures” category only two times. I’m not as confident in the last category, since the NTSB factual reports do not always provide enough information to determine if external pressures were present. I suspect the prevalence of this risk category is higher in GA fatal accidents than the above data indicates.
With respect to “conventional” analysis of this accident sample, the “usual suspects” were all present. This included loss of control and controlled flight into terrain (CFIT) accidents, all of which I attributed to poor risk management based on the available data. Surprisingly, four of the 50 accidents were mid-airs. All occurred in or near a traffic pattern, rather in the random “big sky” en route, and the pilots were all broadcasting their position or receiving air traffic advisories regarding the traffic threat. Hence, I viewed these as risk-management accidents also.
The most striking statistic was that seven of the 24 Cessna 172 risk-management accidents involved intentional low flying away from the airport and two more involved other categories of “cheap pilot tricks,” such as intentional spins with four people on board (outside the aircraft’s center of gravity envelope for intentional spins). We can all be forgiven for writing these off as unavoidable and some of us have publicly stated that we “can’t fix stupid” or that “Darwin rules.” Yet, it’s impossible to ignore the blatant risk-taking that took place in these accidents. Even a cursory risk analysis by the pilot would have shown that “catastrophic” consequences (fatalities and/or aircraft loss) and either an “occasional” or “probable” likelihood of occurring were possible and thus the operation was firmly in the “red” in the risk assessment matrix shown on page 4-2 of the FAA’s Risk Management Handbook (FAA-H-8083-2). This requires mitigation of the risk before further flight.
What does all this mean?
In asking why pilots take these and other risks revealed in my analysis, we have to look to three main reasons. These include the false claims we make about general aviation safety, the safety culture present in most general aviation operations and the pilot training system.
For years, we have told the big lie about general aviation safety to ourselves and potential new members of our community. We say “the trip to the airport is the most dangerous part of the flight.” This is patently absurd when the statistics show that general aviation flying is 7-10 times more dangerous than automobiles. We also raise the old refrain from the poster that goes something like “flying is not inherently dangerous but is unforgiving of errors.” I would modify that one to read “flying is inherently dangerous unless you manage the risks.”
Part of the above thinking is inherent in the general aviation safety culture. Except for the business aviation community, general aviation is made up of and mostly led by enthusiasts. Yet, it tends to breed a safety culture of risk taking, where participants are either ignorant of or choose to ignore known safety risks. Intentionally assuming certain risks may be acceptable to a pilot flying alone over uninhabited areas, but when we assume such risks on behalf of passengers and others, we load the dice against general aviation’s image with the public. I would wager none the pilots in my accident sample had been exposed to risk management techniques during their initial or recurrent pilot training.
Don’t wait for reform
While we wait for the industry to refine its approach to risk management, there is no reason for individual pilots to sit still. Regardless of whether you are a student or a rated pilot, here are some steps you can take to improve your proficiency as a risk manager.
• Supplement your training by taking on-line risk management courses. Ask your pilot school or flight instructor to integrate risk management procedures into your flight training.
• Take an on-line risk management course before your next flight review and ask your instructor to create a flight review around a risk management scenario. The FAA Wings program, which can be a substitute for the flight review, provides credit for risk management courses.
• Assess risk before and during every flight. You may want to use a risk assessment tool, until the process becomes intuitive. You can find such a tool in the FAA’s Risk Management Handbook (page 4-3) or from other sources. Remember, your objective is to mitigate all risks identified as “yellow” or “red” in order to reduce risk likelihood and/or severity to acceptable levels.
Ultimately, the entire GA community will recognize the importance of risk management in reducing the fatal accident rate. But, as an individual pilot, your own initiative will speed this process.
Robert Wright is a former FAA executive and President of Wright Aviation Solutions LLC. He is also a 9300-hour ATP and holds a Flight Instructor Certificate. His opinions in this article do not necessarily represent those of clients or other organizations that he represents.
0312-DRILLING-DOWN-THE-DATA.pdf
0312-PILOT-RELATED-ACCIDENT.pdf
