Train To Mitigate Risk

In the last decade, the general aviation fatal accident rate, which had been decreasing for some time, reached a plateau and has stubbornly resisted industry and FAA efforts to further reduce it. Hovering in the range of 1.20-1.38 fatal accidents per 100,000 flight hours, this safety record is widely considered a deterrent to general aviation growth and may be one of the reasons student starts have continued to decrease. As a community, we may have oversold the benefits of

a new generation of technically advanced aircraft (TAA) to an emerging latent market of individuals who are not traditional enthusiasts and who wish to use these aircraft for safe transportation.

The stagnant fatal accident rate is probably not the fault of the aircraft themselves or a TAAs capabilities, but rather may be due to a faulty training doctrine. The ability to manage risks, and specifically to learn how to more effectively mitigate risks, may be the key to attacking the fatal accident rate.

Readers may recall my assertion (Aviation Safety, July 2010) that ineffective risk management may be a root cause of TAA fatal accidents. The NTSBs probable cause determinations of fatal GA accidents are littered with summary phrases such as “loss of control” or “continued VFR into IMC conditions” but these causalities and factors are really just the final act in a string of contributing factors that are rarely hinted at in the accident summaries. If one delves deeper into the background of individual accidents, it quickly becomes apparent that pilots failed to practice effective risk management before and during the flights in which they came to grief. That is, they failed to identify hazards and risks, properly assess those risks in terms of their likelihood and severity, and then, most importantly, failed to take action(s) that would reduce those risks.

Pilots are unlikely to practice effective risk management if it is not part of their indoctrination and training. As I asserted in the previous Aviation Safety article, our pilot training system is still largely a holdover from an earlier era: Current training doctrine easily can be traced back to the Civilian Pilot Training Program from the period 1939-1941. The current FAA handbooks still trace their roots to the Civil Pilot Training Manual (CAA Bulletin No. 23) and The Flight Instructors Manual (CAA Bulletin No. 5), both written before WWII. The training doctrines found therein are maneuver-oriented, rather than emphasizing how an airplane can be used for practical travel. Its not that the content of these tomes is completely obsolete. Instead, it is what they dont contain that is important. Risk management wasnt such a pervasive concept in that period, when general aviation culture was still in its “white scarf” mode.

The importance of training doctrine cant be overstated. Its useful to review the “triad” of infrastructure that props up our training system, in order to fully understand the concept and its importance.

The first part of the triad, doctrine, includes the entire body of knowledge underpinning the training system and is embodied in publications such as the FAAs Pilots Handbook of Aeronautical Knowledge (FAA-H-8083-25), the Airplane Flying Handbook (FAA-H-8083-3A), the Instrument Flying Handbook (FAA-H-8083-15A), and the Aviation Instructors Handbook (FAA-H-8083-9A). These documents, and others, are the source material supporting FAA standards. Most of these have recently been revised to address TAA issues and the instructors handbook, revised in 2008, and a new Risk Management Handbook (FAA-H-8083-2), issued in 2009, specifically include risk management material, although the coverage is incomplete, with poor coverage especially of risk mitigation.

A second part of the triad-standards-can be found in two places. Although most of us point to the Federal Aviation Regulations as the source of training standards, the knowledge test question banks and the Practical Test Standards (PTS) effectively set the bar for both what and how we train pilots. This can be a good thing, since it usually takes five to 10 years to change FAA regulations, while knowledge test questions and a PTS can be revised in a (relatively) much shorter time frame. Yet, as was pointed out by the NTSB in a special report on TAA safety, issued in March 2010 (see the April and May 2010 issues of Aviation Safety), the FAA has moved slowly or not at all to address TAA issues in the knowledge tests.

The FAA, however, is starting to make some changes in the PTS. For example, FAA revised the Instrument Rating PTS (FAA-S-8081-4E) in January 2010 to include risk management as one element in assessing an individuals single-pilot resource management (SRM). Yet, this revision does not provide specific guidance to the examiner on evaluating the pilots risk-mitigation technique, nor does it really integrate evaluation of risk management performance in the other PTS tasks, especially pre-flight planning and procedures.

The third part of the training triad-curricula-is crucial. While the doctrine and standards address the “why” and the “what” elements, the curricula address the “how,” the “when” and the “where.” The curricula and methods of instruction; use of simulators, training devices, and on-line tools-and the methods by which the training system interacts with the customer-actually determine how effectively the doctrine and standards will be applied. The training community, rather than the FAA, is largely in the drivers seat here.

In my last FAA executive job, between 2002 and 2005, I created the FAA Industry Training Standards (FITS) program for the express purpose of catalyzing industry efforts and leadership to modernize the flight training system to address TAA and other safety issues. A number of folks in the training community have accepted this challenge and have created innovative curricula and training business models that have begun to move us into the new century.

A discussion of training “infrastructure” would be incomplete if I did not also acknowledge the “who” of the flight training equation. This business is about people as well as hardware. The flight instructors and pilot schools, designated examiners and courseware providers are the glue holding the system together and, in the absence of FAA leadership, should be leading the charge toward reform.

Its not my intent to condemn the courseware providers and flight training community-or the FAA for that matter-for not having addressed risk management in flight training products and standards. There is a broad emerging awareness of the importance of risk management, yet our collective thinking is still incomplete as to how it should play out. The shortfall is due both to our “go-no/go” mentality and approach, as well as the need to understand human nature and the psychology of risk management, and the current way in which airplanes are used.

Considerable material and courseware have been developed addressing two of the three elements of risk management, notably risk identification and, to a lesser extent, risk assessment. The popular PAVE acronym (pilot, aircraft, environment, external pressures) has spawned a number of tools and training products allowing pilots to identify hazards and risks. The “pilot” element is further dissected with another acronym, IMSAFE (illness, medication, stress, alcohol, fatigue, emotion) to help refine the risks to a given flight.

The PAVE and IMSAFE tools are worthwhile components in our risk management arsenal but I believe they have three critical weaknesses that make them an incomplete solution.

First, they often are based on an arbitrary numerical “score” that reduces the analysis to a simple “go-no/go” result and decision. Such a system, while easy to train for and apply, fails to account for nuances and variables in actual flight scenarios. They also are less likely to be used by pilots in real-world flights, since the weights assigned to the factors can be overly conservative.

Second, many of the tools are cumbersome and therefore are set up to be pre-flight tools only, with limited in-flight utility. This can have undesirable consequences both ways if pilots fail to undertake a flight that could have been made safely with proper risk mitigation or undertake a flight and then fail to conduct effective real-time risk mitigation as conditions inevitably change.

But my main objection to the use of tools such as PAVE and IMSAFE in isolation is they leave you hanging. In other words, they tell you the hazards evaluated may collectively spell “no-go” for a given flight and set of conditions. Now what do I do? We can meekly respect the calculated result and cancel the flight (not likely), try to fudge the figures to give us a better result (probably happens a lot), or we can just ignore it (happens often). Im also just as concerned about a result that says “go” and the pilot then proceeds merrily on his way with his head up his you-know-where and fails to actively reassess his situation as he flies.

The last item above is rife with unspoken issues dealing with human psychology and the reasons that we possess and use airplanes. Most of us are success-oriented and this is particularly true of the kinds of people that buy and use $700,000 and up airplanes. Despite what the light-sport aircraft crowd may want to believe, the biggest latent market for GA airplanes out there is people who want to use their own airplane to get somewhere while avoiding the barbaric and degrading world of airline travel. Value is the issue for them, not cost per se, and they can afford the cost and accept the value proposition if their airplanes turn out to deliver reliable transportation. Therefore, they dont want an arbitrary “no-go” decision made according to a formula. They want the means to evaluate and implement effective risk mitigation so that they can safely complete their planned flight.

The happy ending to any risk management story is when the protagonist-thats you, the pilot-is able to successfully and safely defeat the elements and complete a flight that otherwise had poor prospects for a happy ending. We do that by mitigating the identified risks to a flight by using any number of tools and methods, some of them intuitive and simple, and others more complex.

The tool I prefer to use is “TEAM,” which is straight out of the FAAs System Safety training course. This isnt exactly a well-known acronym, and the FAAs course material was designed for an airline audience rather than GA, so here is how the four letters apply to the application of effective risk mitigation strategies for the GA pilot. Some of this is strategy, by the way, and not tactics, because it requires the pilot to keep the end goal in mind, which is usually the need to get somewhere. Ill save the detailed discussion of tactical methods for a future article and keep it high-level for now. Here goes.

The “T” in TEAM stands for “transfer.” This risk mitigation strategy is best employed several days before the flight because, no matter what your capabilities or those of your aircraft, there are weather conditions out there beyond the safe envelope of single-engine GA piston aircraft (and sometimes even turbine airliners). Your analysis will probably concentrate on the main hazards that are really no-go, that can be predicted, and for which there is no reasonable mitigation. The outcome here is predictable: you have to be somewhere, so bite your lip and schedule your airline flight. This letter might also be used in those instances where you hire or otherwise bring along a more experienced pilot to take on the flight. This is in line with existing concepts of a “mentor” pilot.

The “E” stands for “eliminate.” This strategy is again best employed in advance and is primarily useful when you dont have to be somewhere; for example, a non-transportation recreation or currency flight. Cancelling a flight you absolutely dont have to make is elegant, intuitive and simple. Do yourself and any passengers a favor and let them know early so everybody can go to Plan B.

“Mitigation,” the “M” is the guts of it. What can you actually do to reduce the risks identified for a given flight down to an acceptable level? Again, the actual tactics employed can be infinitely variable and are beyond the scope of this article, but in some cases they are simple and intuitive. For example, on a recent flight in my Bonanza, from Duluth, Minn., to Mansfield, Ohio, I completely avoided a large area of severe convective activity by flying a dog-leg route. I flew way out over Michigans Upper Peninsula before turning south toward my destination and, at its furthest point, my alternate route displaced me about 120 nm from the direct route. Yet, due to the wonders of geometry, only cost me 56 nm, four gallons and 20 minutes of flight time-and I virtually eliminated the risk associated with the convective activity.

Its worth noting at this point that most pilots tend to be a slave to the GPS-direct magenta line but there is remarkably little cost to being flexible. Yet, how often are such simple techniques taught during typical GA training?

I will conclude the TEAM discussion by admitting that I changed the acronym from TEAM to TEMA, since this is the final step. After transferring, eliminating, and/or mitigating the identified risk, you will always have left what is known as residual risk, an inevitable consequence of being alive. You must be willing to consciously accept this risk-theres the “A”-on behalf of both yourself and your passengers.

I designed and taught the risk management portion of the Eclipse 500 type-rating course while working as the Director of Customer Training for Eclipse Aviation. The TEAM approach to risk mitigation was a core element of this segment and I believe that most, if not all, of our customers agreed with its usefulness and applicability to operating a turbine-powered aircraft as a single pilot.

I dont expect any “big bang” with respect to how we accept the need for and actually teach risk management and, especially, risk mitigation. This issue is both cultural as well as empirical, and involves all elements in the GA training infrastructure previously identified. It will take time for this shift to occur but weve already begun the process.

The actual methods for conducting risk management training will vary but I found the case-study method both effective and interesting for students in the Eclipse 500 course, and I hope former Eclipse students agree with this assessment.

I believe the leadership for changing the methods of GA training will need to come from industry-especially the instructor community-and from courseware providers. The FAA is increasingly distracted by other issues and, while being a necessary player in training reform, needs to follow the training communitys lead.